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The future of the globalphysicians' movementJonathan M. Mann aa François‐Xavier Bagnoud Center for Health andHuman Rights , Harvard School of Public Health , 651Huntington Avenue, Building 4, 7th Floor, Boston,MA, 02115, USAPublished online: 22 Oct 2007.

To cite this article: Jonathan M. Mann (1997) The future of the globalphysicians' movement , Medicine, Conflict and Survival, 13:2, 88-100, DOI:10.1080/13623699708409323

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THE FUTURE OF THE GLOBAL PHYSICIANS' MOVEMENT

The Future of the Global Physicians'Movement*

JONATHAN M. MANN

Harvard School of Public Health, Boston MA 02115, USA

An international physicians' movement should promote and protect health at a societallevel and in a global context. Among the elements of the ethos of medicine underlyingit are: a willingness to accept change when needed; the trust between patient andphysician; respect for human dignity; the physician's privilege of confidence; andhis/her power to specify and seek to relieve suffering. It is proposed that the corpusof Human Rights, as laid down in the Universal Declaration of Human Rights of 1948and elsewhere, provides a key framework underlying the work of such a movement,and this is explored in detail using the issue of domestic violence as an example.IPPNW is clearly placed to provide leadership in this movement.

KEYWORDS Domestic violence Human rightsInternational physicians' movement Public healthIPPNW Society

Paradoxically, during the past decade, at the same time that the public imageof physicians has been suffering - at least in many countries - doctors havebecome important symbols of new global thinking. IPPNW and the 'Frenchdoctors ' movement have actively pioneered and articulated a new global ethicfor physicians and other health workers . IPPNW has demonstrated thetremendous power and influence which physicians united across borders canpotentially command. The 'French doctors' placed action - the relief of suffer-ing - above national borders and political considerations, thereby helping torevitalize the meaning of humanism in medicine. Both movements requiredconsiderable courage, for they challenge the status quo which embedded thephysician so firmly within a national or administrative or organisationalcontext. Both movements required action - action which liberated by plungingthe physician into unfamiliar situations and considerable controversy.

Now, in tu rn ing from the past towards the future, we should firstparaphrase Sir Isaac Newton, who stated that we can all see as far as we cantoday because we stand on the shoulders of the giants who preceded us. Sowith the international physicians' movement: the Lowns and Kouchners - touse one from each movement to represent many - have brought us to thisplace and time, to be able to reflect now on a future so influenced by acollective history, shaped by their inspiration.

* Based on a keynote speech to IPPNW XII World Congress, Worcester MA, 25 July 1996.

MEDICINE, CONFLICT AND SURVIVAL, VOL. 13, 88-100 (1997)PUBLISHED BY FRANK CASS, LONDON

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Each of these leaders - true to their own ideals and with courage andconsiderable charisma - would urge us now to challenge, and then to breakwith, the status quo - of the very movements they helped to create! Not forthe sake of change, but to ensure that organizations and institutions, withtheir weight and momentum, do not inadvertently crush or muffle the creativeaspirations which have emerged precisely because the movement created thespace within which such energies could emerge and flourish.

Yet how, and in what directions, might the international physicians'movement now change? These questions might best be approached not bylisting important global health issues and selecting from among them, butrather by considering the central ethos and values which may distinguish thespecial and even unique nature of an international movement of physicians.

This process - of self-definition and self-awareness - is critical, for how anissue is defined - how a situation is perceived or an identity articulated -determines what will be done. Indeed, definitions predetermine the scopeand shape of the possible, and the description of a movement contains withinit, explicitly and unspoken, a belief about what should and can be done.

Defining an International Physicians' Movement

Four central elements may be proposed in working towards a definition ofan international physicians' movement. First, it is a movement of physicians,which itself raises several key issues. Second, the movement acts at the societallevel, rather than at the traditional medical level of individual patients. Third,it seeks to promote and protect health in its broadest meaning. And finally,it proposes to operate and be relevant in a global context. Thus, it involvesphysicians acting at a societal level to promote and protect health in a globalcontext. Each of these constituent elements merits reflection.

First then, what aspects of the ethos of medicine are most relevant to theevolving self-definition of a global physicians' movement? Five elements couldbe provisionally elaborated upon.

Reality

A first, central, issue is the physician's attitude towards current reality. It isoften assumed that medicine has been, is and will always be an inherentlyconservative profession, drawing to it people who want very much to preservethe social status quo for the rich benefits it brings to them.

Yet most people who decide to become doctors respond to a deep intuitionabout life and their own lives. To become a doctor implicitly places us on theside of those who believe that the world can change - that the chains of painand suffering in the world can be broken! For every medical act challengesthe apparent inevitability of the world as it is, and the natural history of illness,disability and death. Every antibiotic, every surgical intervention, everyconsultation and diagnosis becomes part of an effort to interfere with the'natural' course of events. Thus, at a profound, even instinctual, level - because

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it precedes rational analysis - people become physicians to find a way to say'no' to disease and pain, and to hopelessness and despair - in short, to placethemselves squarely on the side of those who intervene in the present tochange the future.

Trust

A second central tenet involves the uniquely trusting and intimate relationshipphysicians establish with patients. For beyond accurate diagnosis, beyondefforts to cure, and even beyond the ever-present responsibility for relief ofpain, the physician offers something else. The physician agrees to accompanythe patient, to stand by the patient regardless of what happens - through theirsuffering, and even to the edge of life itself. The physician steadfastly remainswith the patient even when the only thing the physician can offer is the factof his or her presence. This is as relevant to public health as for individualpatient care — for public health must engage in difficult issues even when nocure or effective instruments are yet available, and public health physiciansalso must remain with, and not abandon, vulnerable populations. This qualityis the foundation for a trust which makes the relationship with physiciansso unique and so precious. For in the world, perhaps necessarily dominatedby casual, superficial or self-interested relationships, the physician standsthrough his and her avowal and commitment to never abandon the patientor the community.

Dignity

A third principle: physicians respect, promote and sustain human dignity. Theconcept of dignity is at the same time conceptually elusive and highly concrete:it is a commonly used term for which there is no simple definition. Forexample, the Universal Declaration of Human Rights - the core document ofthe modern human rights movement - starts by declaring that all people areequal in dignity and rights - yet while the rights are then listed in the documentin some detail, there is no further elaboration of the specific meaning of dignity.

That physicians, particularly in modern health care institutions andsystems, are frequent perpetrators of violations of dignity does not alter thefact that medicine is dignity-affirming in its essence. For despite theimpersonality of a large hospital, or the constraints of time, physicians havealways had, and have today, a uniquely powerful capacity in their arma-mentarium - that of giving their close, in-the-moment, undivided attentionto the patient. This affirms dignity, and it has the power to uplift, to givecourage, and even to heal. Affirming the dignity of others in their sufferingis a physician's natural act.

Confidence

A fourth, relevant dimension of the medical ethos involves the physician'sspecial privileges of confidence and invasion. Physicians face people who areliterally and figuratively naked; the physician is the stranger who has a right

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to be present at some of the central moments of life - birth, illness, death.Physicians are also allowed, even required, to break the societal rules whichdefine the space around each person which should not normally be entered:from the surgeon who has societal permission and even encouragement tocut and penetrate the body of another, to the psychiatrist who probes secrets,hidden fears and the unconscious. Abuse of this confidence or the privilegeof entering personal space severely violates dignity: used properly, it is a sourceof legitimate and legitimized access to the intimate and sacred dimensions ofthe life of others.

Suffering and Relief

Finally, medicine has the power to name the forms of human suffering andto seek their relief. The history of medicine is composed of such efforts -from the 'love sickness' of the Middle Ages in Europe to modern microbiologywhich differentiated syphilis and gonorrhoea, to the more recent identifi-cation of 'accidents' as 'injuries', thereby transforming personal tragedies intoinjustices. The history of medicine also shows repeatedly that until a healthproblem is named - and adequately described - the problem itself does notexist - at least in a professional or public sense. Take the example of childabuse: until it was described a few decades ago in the medical literature,initially as a 'battered child syndrome' involving severe cases - strange brokenbones, clusters of cigarette burns - and until epidemiological studies werecarried out in a variety of settings which literally ripped away the veil ofsilence and secrecy which hid the universality, frequency and long-standingnature of this severe threat to the health of children, it simply did not existfor medicine, or for society! Another, more recent example is domesticviolence - violence in the household - only recently recognized and acknow-ledged to be a major, pervasive and severe global health problem.

It is clear that we do not yet know all about the universe of human suffering.Just as in the microbial world, in which new discoveries have become thenorm - Ebola virus, hantavirus, toxic shock syndrome, legionnaires' disease,AIDS - physicians are explorers in the larger world of human sufferingand well-being. And our current maps of this universe, like world mapsfrom sixteenth-century Europe, have some very well-defined, familiarcoastlines and territories and also contain large blank spaces, which beckonthe explorer.

Belief in Change

These five elements together suggest the special character and nature ofphysicians working in a global movement. Physicians bring to this challenge:a belief that the world can change, a tenacious commitment to accompanyothers even when no cure or even immediate relief may be available, aconsistent affirming of human dignity, societal authorization to deal with andparticipate in the most private circumstances of human life; and the capacity

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to identify, name, describe, and legitimise forms of human suffering, whilealso seeking their alleviation.

Attention to these unique and powerful elements can help ensure that theevolving global physicians' movement remains true to its own central ethos- the bedrock of authenticity which will allow the movement to evolve inchanged circumstances, with new creative energies, and inspired by newleaders. Remaining true to the physician's identity is vital for publicunderstanding and support; for the public is appropriately sensitive andresistant to efforts by any group to use its credibility in one field - such asmedicine - to speak authoritatively about another domain, in which bothcapacity and credibility may be seriously questioned. Finally, it also helps togo beyond an unfortunate history in which collective discourse by physicianshas too frequently been tainted, if not dominated, by corporatist,professionally self-interested motives.

Society and Health

The second major definitional element of a global physicians' movement,beyond the participation of physicians, is the need to act at a societal level.The necessity for societal-level analysis of threats to health, and the corollaryneed for a societal-level response to these issues, is firmly grounded in whatis known about the determinants of individual and population health. Forthe evidence is abundant, universal and clear: societal factors - not medicalcare or technology - are the major determinants of health status, accountingfor probably two-thirds to three-quarters of the health differential amongpopulations.

However to analyse health problems from a societal perspective, and todevelop societal-level responses, is quite different from the individuallyfocused medical model in which physicians are generally trained. To movefrom individual patients to societal analysis and response is a major personaland professional challenge.

To proceed, it will be essential to have a coherent framework for societalanalysis, in order to identify societal-level cause of preventable illness,disability or premature death or, to put the problem somewhat differently, toidentify the societal conditions for resistance to, or vulnerability towards theseoutcomes. In addition, a consistent and appropriate vocabulary is needed todescribe the deeper societal issues which lie beneath superficially quitedifferent cultural, social and geographic contexts. Finally, a broad consensusis needed regarding the direction of necessary societal change - the prescrip-tion, if you will - regarding steps to relieve or prevent the damage to healthassociated with certain societal features.

In this respect, medicine is stymied. For the scientific framework uponwhich biomedicine has been created was not designed for, nor is it adequatefor, the task of societal analysis and response. Indeed, even public health hasrelatively little to offer - beyond a plethora of discipline-driven approaches

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by the economist, the anthropologist, the sociologist, or the behaviouralscientist - regarding how to identify and respond to the societal conditionsfor health and the societal causes of vulnerability to preventable illness,disability and premature death.

The third defining element for a global physicians' movement is, of course,its focus on health. Yet here also, we recognize the scope of the challenge.Indeed, taking the World Health Organisation definition of health as a stateof not only physical, but also mental and social, well-being underscores howbiomedicine has focused largely on physical maladies. There is relatively littleunderstanding of the constituent elements of physical well-being, let alonemental well-being; and describing and defining societal well-being hasreceived little attention at all in medical circles.

Becoming Global

Finally, the physicians' movement - initially defined as international - mustbecome global to work effectively in a global context. This, as IPPNW knowsfrom intense and direct experience, necessarily engages the tension betweenrespect for diversity and common identity. It is clear that diversity is bestnurtured in the context of internal coherence regarding common goals,identity and strategy; that is, 'acting locally, yet thinking globally'. And inturn, this raised the key question of whether sufficient coherence has thus farbeen articulated to provide the internal consistency needed for a wide andwidening constellation of physicians' movements - local, national andregional. The global physicians' movement must become genuinely global, aglobal network which is much more than a communications system, givingrise to true global thinking.

IPPNW, in its prior focus and work on the prevention of nuclear war,advanced powerfully the idea of an international movement of physicians. Itconcentrated on the physician's role, it worked on the sociopoliticaldimensions and helped create societal-level responses to the challenge, itbroadened the concept of a global health threat and made it profoundlyrelevant to individuals, and it started the difficult process of moving from anational or regional organization towards a global one.

Standing on the shoulders of these giants, of this giant, it is neverthelessclear that in each of these definitional areas - the role of physicians, actingat a societal level, to promote and protect health in a global context - newleadership is needed to articulate and implement the coherence which is theabsolute sine qua non for a true movement - that is, a movement which isgreater than the sum of its parts.

This fundamental coherence must draw upon the ethos of medicine, mustbe capable of analysis and action at a societal level, must be based on a broadconcept of health and well-being, and must have sufficient conceptual,mobilizing and moral character to be universal while at the same timeencouraging and nurturing diversity.

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Human Rights

Fortunately, from entirely outside the domain of public health or biomedicalscience, a powerful series of concepts and a useful framework has beendeveloped, which can help provide the critical conceptual 'glue' for a globalphysicians' movement. This is the modern movement of human rights—arisingin the aftermath of the Holocaust in Europe and born of the deep aspirationto prevent a recurrence of government sponsored violence towards indi-viduals. Human rights provides a coherent conceptual framework for identi-fying and analysing the societal root causes of vulnerability to preventabledisease, disability and premature death, a consistent vocabulary for describingthe characteristics which underlie the specific situation of vulnerable peoplearound the world, and clarity about the necessary direction of health-promoting societal change.

Modern human rights involves the world's first efforts - necessarilyincomplete and partial - to define the societal conditions for human well-being. For this reason, promotion of human rights became one of the fourprincipal purposes of the United Nations, founded in 1945. The UniversalDeclaration of Human Rights, adopted by the UN General Assembly in 1948,provides a list of those societal conditions considered essential for well-being,peace and health.

The Universal Declaration can be thought of as the trunk of the humanrights tree, with the UN charter as its roots. Two major branches - the twomajor International Covenants - on Civil and Political Rights, and onEconomic, Social and Cultural Rights - emerge from, and expand upon thetrunk, with further arborization through many important treaties anddeclarations, such as the Convention on the Elimination of all Forms ofDiscrimination Against Women (CEDAW) and the Convention on the Rightsof the Child (CRC).

These documents describe what governments and societies should not doto people - torture them, imprison them arbitrarily or under inhumanconditions, invade their privacy - and what governments and societies shouldensure for all people in the society - such as shelter, food, medical care andbasic education. When and where human rights and dignity are respected,there will still be rich and poor, Mozarts and people who cannot carry a tune,but all are ensured of a basic minimum in which their individual potentialcan be developed.

The human rights framework offers a more coherent, comprehensive andpractical framework of analysis and action on the societal root causes ofvulnerability to disease, disability and premature death than any frameworkinherited from traditional public health or biomedical science.

Therefore, the aim of a global physicians' movement may become: topromote and protect health by encouraging and promoting societal change- based on analysis of how the lack of respect for human rights and dignitycreates the conditions for preventable disease, disability and premature death,

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or in the larger sense of the WHO definition, how the realization of humanrights and respect for dignity are required to promote and protect physical,mental and social well-being.

This approach provides strategic coherence for work on a wide range ofhealth issues and a large variety of tactical approaches. It is applicable tovirtually all, if not all, issues of relevance to health in different societies, todayand in the future.

An Approach to Domestic Violence

Let us consider what this might mean in concrete and pragmatic terms byexploring a health and human rights approach to a particular problem: suchas the previously mentioned issue of household, or domestic violence.

Domestic violence - to focus on the most common form among adults,which involves violence by a man against a woman - is now recognized to bea major global health problem. In the United States, male partners are themost frequent perpetrators of assault or rape against women, and an estimatedone-fourth to one-third of emergency room visits by women are related todomestic violence. In Papua New Guinea, 54 per cent of urban women and67 per cent of rural women reported being abused and one of five wives havereceived hospital treatment for such injuries, in Nicaragua, 44 per cent ofmen admitted to beating their wives or girlfriends on a regular basis. Yet thenaming of this evil - acknowledgement of domestic violence as a threat tohealth and well-being, physical, mental and social - is relatively recent.

The traditional medical approach to domestic violence starts with caringfor the injured, focusing on the physical, and possibly on the mental, healthmanifestations of this violence. At the public health level, the traditionalapproach will start with epidemiological analysis. Epidemiology is a powerfultool, but it has important underlying assumptions and limits. For applyingclassical epidemiological methods to domestic violence will ensure - willpredetermine - that 'risk' will be defined in terms of individual determinantsand individual behaviour. Epidemiology has thus far been unable to developmodels and methods suited to discovering the societal dimensions whichstrongly influence and constrain individual behaviour.

Thus, the direct translation of epidemiological data on risk behaviour -defined exclusively in individual terms - to the problem of domestic violencewill lead inevitably to activities concentrating on individuals in order toinfluence their risk-taking behaviour - through information, education andservices. This is the traditional public health approach: in essence, to considerdiseases as dynamic events occurring within an essentially static societalcontext. Regarding domestic violence, the issue will be framed as a problemof 'high risk' individuals, their behaviour, and efforts to influence and modifybehavioural patterns.

Medical attention to physical and mental injuries, and public health workto produce epidemiological information about distribution, occurrence and

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identification of individual 'risk factors' for domestic violence are both usefuland important - and will lead to programmes of information, education inschools, and health and social services such as counselling, hot-lines andperhaps 'early intervention' teams.

However, it is clear that unless the societal contest is also addressed, theabove-mentioned approaches will be inherently, and quite limited in thiseffectiveness. To the extent that societal 'factors' are major determinants ofthe phenomenon of domestic violence, societal-level interventions will alsobe required. Thus far, work to address societal factors - governmental, socio-cultural, and economic - has been quite fragmented; the economist, politicalscientist, anthropologist, and social scientist all have their — naturally, quitedifferent - disciplinary perspectives and recommendations.

A human rights perspective would start with the Universal Declaration ofHuman Rights as the principal text of reference. From the UniversalDeclaration, rights can be identified which seem most relevant to two issues:first, the response of society to the occurrence of domestic violence; andsecondly, the rights relevant to the deeper causes of domestic violence towardswomen.

The response to instances of domestic violence engages several importanthuman rights, including:

• the right of non-discrimination, in this case involving how care for acts ofviolence towards women my differ from care for men;

• the right not to be subjected to torture or to cruel, inhuman or degradingtreatment;

• the right to recognition ... as a person before the law, involving specificallyhow the legal system responds to the occurrence of violence towardswomen;

• the right to equal protection of the law; and,• the right to an effective remedy... for acts violating... fundamental rights.

These rights could be advanced concretely by ensuring legal protections forvictims of domestic violence, guaranteeing rapid and fair response by policeand judicial systems to situations of domestic violence, and othergovernmental efforts which demonstrate a commitment to providing careand to enforcing measures to prevent and respond to the phenomenon ofdomestic violence. And if the legal system does not grant women equalprotection and recognition, this more fundamental issue of discriminationmust also be addressed.

An Analysis of Causes

However, a rights analysis also opens issues of root causes, at a societal level.The question could be framed as follows: what do governments in particular,and societies in general, do or not do, which creates vulnerability to domesticviolence? This starts with the right of women to equal rights to marriage,

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during marriage, and at its dissolution. Definitions of partnership andcohabitation will also be important in ensuring that women are granted equalstatus in unions not officially considered to be marriages.

The vulnerability of women to suffering domestic violence and to beingunable to leave an abusive home environment is also created or enhanced bya lack of realisation of the following rights:

• 'the right to work ... and to just and favourable conditions of work ...including equal pay for equal work'; for women who work outside thehome have demonstrably improved capacity to make and effectuate freedecision about their lives.

• 'the right to education, and to non-discrimination in education'; receivingeven an elementary education would give women broadly enhancedsocietal opportunities.

• 'the right to take part in the government of his/her country ... and the rightto universal and equal suffrage'; this would allow women to influence socialnorms through the political process.

• 'the right of peaceful assembly and association'; for it has been demon-strated that organizations of women can powerfully influence public opinionand policy much more effectively than individual women acting in isolation.

Actions to promote and protect these rights-to equality in marriage, to work,to education, to political participation and to association - would work toimprove women's capacity to not become victims of domestic violence, or torespond with a greater and freer range of choices in the event such violenceoccurred.

Actions

Therefore, applying a human rights framework to the problem of domesticviolence can lead to a series of concrete actions by physicians, in concert withthose in each society already striving to improve the respect for human rights.The action by the physicians' organization could include:

• collecting physical and mental health information and using it to helplegitimize the problem of 'domestic violence' as a serious health and socialissue;

• working with human rights groups and other social organisations toidentify priority targets for political action, expressed most often in effortsto change laws and official policies;

• insisting on proper, dignity-affirming health care for victims of domesticviolence;

• contributing energy and expertise at a policy level, including advocatingincreased educational access for women, ensuring non-discrimination inemployment, or removing barriers to creation of grassroots women's non-governmental organizations.

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Thus, a human rights analysis deconstructs or separates the problem of'domestic violence' into a series of health and human rights issues, relevantboth to care of victims and identifying and responding to societal root causesof domestic violence.

A health and human rights approach to domestic violence - like preventingenvironmental contamination, or seeking to end the tobacco plague, or forconflict resolution - clearly engages the central values of physicians. For thestruggle to end domestic violence requires confidence that the world canchange, that the eruptions of violence within a household, extending alsofrom generation to generation, can be ended. It also requires affirmation ofhuman dignity, expressed concretely as universal human rights. It will not bean easy struggle, and accompanying those who suffer domestic violence -even in the absence of any readily available source of relief - will be necessary.Then, to understand the deep roots of domestic violence, physicians will haveto enter the private precincts of families, couples and intimate relationships.Finally, the forms of human suffering which cause, and which result fromdomestic violence remain to be named and described; this also is the specialdomain of medicine.

A Vision for IPPNW

At this moment in history, IPPNW is clearly positioned to provide globalleadership: moving forward, towards a new definition of the role andresponsibilities of a global physicians' movement, will require both articu-lating a vision - a clear sense of common purpose - and acting - developinga concrete plan of work.

The vision of global healing and global health, the tasks of a globalphysicians' movement, reflects both a clear understanding that societal-levelforces are the major determinants of health and awareness of how humanwell-being and human rights protection and promotion are inextricablylinked. This vision, with its implicit justification for physician involvement,provides strategic coherence for actions - local, national or regional - towardsrelevant health threats.

Yet projecting this leadership for global health, linked to promoting andprotecting human rights and dignity, will be difficult. There will be theinevitable accusation that physicians are 'meddling' in societal issues which'go far beyond' their scope or competence. Also, physicians are generallyunfamiliar with human rights concepts and language; human rights are nottaught in schools, and few health professionals - even in the mostgovernmental domain of public health - have received any formal educationor training about human rights. Education about human rights is onlybeginning to become available for health professionals.

In addition, physicians may seek to 'own' the problem; in other words, solong as the discourse around a health problem remains focused on medicine,the pre-eminent role of physicians is assured. To work within a human rights

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perspective requires active collaboration with others, as equals, as well asgreat attention to involvement of people and communities in health.

And, importantly, issues of human rights inherently and inevitablyrepresent a challenge to power - and health professionals are often part of,or direct beneficiaries of, the societal or institutional status quo which ischallenged by the claims of human rights and dignity.

The challenges which IPPNW has faced have always been both historicand enormous. IPPNW is the shoulders of giants who challenged theinevitability of nuclear war and the madness of a public policy which allowedthe unthinkable to be discussed as if it was rational.

Now, the global physicians movement is changing, and must change.Leadership will have to decide on what the global physicians movement is'for' - it is not enough, it is never enough to only be 'against'. This 'for' mustbe broad and clear: personally, I was very attracted by the title of the renamedPSR journal, Medicine and Global Survival, and to the even more positiveidea of 'Physicians for Global Health'.

The new global physicians' movement calls upon physicians, as citizens ofthe modern world, to promote and protect health at a societal level. Itembraces diversity within a movement which recognizes and defines itselfthrough its expression of fundamental physician values. It views human rightsand dignity as the key to coherence in its determination to act directly on thesocietal root causes of illness, disability and death. And it accept that toaccomplish its mission, it will have to work for societal transformation,towards the realization of human rights and respect for human dignity whichdefines the societal essence of well-being.

Changing and evolving is absolutely necessary in order to remain true toits ethos, to the dreams of its founders, to the core values of those who aredrawn and will be drawn to work in this movement because of their deepbelief - beyond sub-speciality, nationality, language, gender or age - that thechains of pain and suffering can be broken, that the world can change, thateach can contribute to the healing of the world.

Creating a global physicians' movement - linking human rights and dignity- is an historic opportunity. Nothing less than a truly global vision will suffice.Education - of ourselves and others; practical and concrete actions; andadvocacy based on clear principles - will all be required. Yet beyond thedifficulties, the obvious problems and barriers, this movement carries thepotential for a revolution of hope. And ultimately, for each physician,participation will offer something truly precious: for in our darkest moments,as in moments of triumph and joy - we will always know with whom we stand- for what, and why!

(Accepted 17 December 1996)

Jonathan Mann is François-Xavier Bagnoud Professor of Health and Human Rightsand Professor of Epidemiology and Public Health, at the Harvard School of Public

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100 J- MANN

Health and Director of the International AIDS Center of the Harvard AIDS Institute.After a degree in history from Harvard College, he qualified in medicine fromWashington University at St. Louis. He founded and directed the international ProjetSIDA in Kinshasa, Zaire, and was founding director of WHO's Global Program onAIDS in Geneva. His current interests are in health and human rights, including theeffects of health policies on human rights, the health impacts of human rightsviolations, and the connection between promoting and protecting health and rights.

Correspondence: François-Xavier Bagnoud Center for Health and Human Rights,Harvard School of Public Health, 651 Huntington Avenue, Building 4, 7th Floor,Boston, MA 02115, USA.

Abstract

Long-term Health Outcomes and Medical Effects of Torture Among US NavyPrisoners of War in Vietnam

By D Stephen Nice, Cedric F Garland, Susan M Hilton, James C Baggett, Robert EMitchell, Naval Health Research Center, San Diego, Department of Family andPreventive Medicine, University of California, San Diego, CA, Naval Aerospace andOperational Medical Institute, Pensacola, FL, USA.

Journal of the American Medical Association 1996; 276: 375-81.

In early 1973 a total of 566 servicemen held prisoner of war (POW) in Vietnam wererepatriated and underwent comprehensive medical and psychiatric examination,which revealed that they had been subject to 'major stressors' such as nutritionaldeprivation, torture, isolation, lack of medical care, political exploitation, over theaverage 5 years' imprisonment. During captivity ropes, ratchet handcuffs, leg ironsand stocks were used to constrict the extremities of POWs. Concern about long-termhealth consequences of this captivity led to a follow-up programme which includeda matched group to allow longitudinal comparisons between the POWs and the controlgroup. The study reported here consisted of a volunteer sample of 70 former POWs(white men aged 47 to 69 years in 1993) and 55 Vietnam veterans who were notPOWs, matched for race, age, marital status, education, rank, year of entry and pilotstatus. POWs were found to have higher incidences of disorders of the peripheralnervous system (p < 0.001), joints (p < 0.006) and back (p < 0.037), and of pepticulcer (p < 0.01).

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