The practice of medicine in relatively affluent countries should not blind a doctor to the global inadequacies of medicine and the suffering of so many millions in low resource countries. Towards this end I have been involved as a member of the Board of the Center for International Health and Cooperation, which was founded in 1992 by my friend and colleague, Kevin Cahill, to promote healing and peace in countries shattered by natural disasters, armed conflicts and ethnic violence. The Center directs its resources and unique personal contacts to stimulate interest in humanitarian issues and to promote innovative educational programs and training. I am also a member of a number of WHO committees dedicated to improving the cardiovascular health of the poorer countries of the world.
The following publications, which are related to humanitarian involvement, are grouped in four categories: first, a series of articles on the tragic damage from land mines; second, articles relating to the imprisonment of doctors and others in Bahrain; third, the measurement of blood pressure in low resource countries, and finally article on miscellaneous aspects of humanitarian involvement.
These articles were published in the nineteen-nineties when the Center for International Health and Cooperation was actively involved in the campaign to have land mines banned from use during warfare.
In 2011 Professor Damian McCormack published a letter in the Irish Times in which he deplored the fate of doctors who had been imprisoned in Bahrain when the wave of prodemocracy protest and revolution—the Arab Spring—engulfed that little island in February 2011. I harboured affection for the Island of Dilmun, which I had visited many years earlier when I had been a member of the academic staff of RCSI. Now that College (and the Royal College of Physicians of Ireland) was prepared to stand by without protest while 47 doctors in Bahrain were imprisoned without trial and subjected to torture. All this might have little interest for Ireland were it not for the fact that some of the imprisoned doctors had been trained in Dublin and were fellows of RCSI, and that RCSI had invested heavily in building and staffing a medical university in Bahrain, known as RCSI-Bahrain. This university had been founded in 2004 on the authority of the Government of the Kingdom of Bahrain and the university campus was officially opened on February 3rd 2009 by His Highness the Prime Minister of the Kingdom of Bahrain, Sh. Khalifa Bin Salman Al Khalifa and the then President of Ireland, Mrs. Mary McAleese.
The largely peaceful protests in February 2011 demanded (in addition to an end to corruption and respect for human rights) not the overthrow of the monarchy but rather the establishment of a “genuine” constitutional monarchy. Indeed, in contrast to so many other Arab states, the essential structures for such a democratic process were in place. In 2002 King Hamad bin Isa Al Khalifa, who had succeeded his father as absolute ruler in 1999 introduced a system that included the establishment of a bicameral parliament with upper and lower houses. The problem with this democratic model is that it is not operated democratically. The upper house of 40 seats is directly appointed by the King, and the lower house (also 40 seats) is filled by an electoral constituency system that ensures that the Shia majority can never win more than 20 of the 40 seats in spite of being 70% of the population; the Government is also directly appointed by the King. Moreover, the Prime Minister, Prince Khalifa bin Salman Al Khalifa, the King’s uncle, has been in office for 47 years, and is the longest serving unelected head of Government in the world. In March 2011 the King declared a state of emergency and invoked the Gulf Cooperation Council security agreements, which led to troops from Saudi Arabia and other gulf states being sent into the country, where they bulldozed public rallying points, including the Pearl Square, which has become a symbol of the protest movement. Among the 47 doctors and nurses arrested, three doctors had received training in Ireland and were fellows of the Royal College of Surgeons in Ireland. On 3rd May, the Military Public Prosecution charged 24 doctors and 23 nurses and paramedics with various offences based on “investigation results” and “confessions by some of the defendants”. It was alleged that in the course of obtaining these confessions, which were video taped, serious violations in contravention of Bahraini and international human rights standards occurred, which included arbitrary arrest and detention, torture, abduction, beating, verbal abuse, being held incommunicado in solitary confinement during which time they were reportedly tortured and ill treated, apparently to force them to confess to the charges levelled against them.
Members of the medical profession in Ireland were particularly disturbed by the failure of both RCSI and the Royal College of Physicians of Ireland (RCPI) to speak out against the repression of doctors. I resigned my fellowship of RCPI in protest against the failure of the president of RCPI, who had been present at the joint conferring of degrees in RCSI Bahrain, to denounce the imprisonment without trial and alleged torture of medical personnel.
Front Line Defenders organised a delegation of concerned individuals from Ireland to visit Bahrain and I was invited as one of the representatives.
My account of the Front Line visit to Bahrain was published in Irish Examiner 20 and The Lancet. Since this visit RCSI, while continuing to justify its stance, has had to retract and apologise for its actions. At least one imprisoned lecturer was suspended from her duties in RCSI-Bahrain. Then RCSI-Bahrain, which is staffed by several eminent academics and clinicians from Ireland, called in students identified in the protests to sign affidavits that they would not participate in political demonstrations and would swear an oath of loyalty to the King. How these students were identified, and by whom, has not been revealed but one must conclude that information passed between RCSI-Bahrain and the government. The Chief Executive Officer of RCSI, Professor Cathal Kelly, has admitted that serious untoward events happened, among which was the demand from senior staff at the RCSI Bahrain that three medical students attending its college swear an oath of loyalty to the Bahraini Royal Family and sign, moreover, a declaration that they would not participate in political protests. RCSI has offered a series of belated platitudes – “we have not lived up to the high standards that we set ourselves in these matters” – “actions were unacceptable and should never have happened” – “actions might appear insensitive and open to misinterpretation” – “questions were wholly inappropriate and inconsistent with our ethos”. The new President of RCSI-Bahrain “unreservedly apologized” to the students who were forced to swear allegiance to the King by staff of RCSI-Bahrain and he has returned to the students the signed and witnessed documents.
It has now been clearly shown by the Bahrain Independent Commission of Inquiry (BICI), that the Public Security Forces violated human rights by forcibly entering and ransacking houses without arrest warrants, and subjecting detainees to blindfolding, enforced standing for prolonged periods, electrocution, sleep-deprivation, and threats of rape with the purpose of obtaining incriminating statements or confessions. Taken with forensic medical evidence the BICI adjudged that torture was common and that such practices were a flagrant disregard both of Bahrain and international human rights law. However daunting these criticisms may be for the security forces’ use of internecine practices, a more worrying aspect for the many doctors and others in Bahrain who still stand accused and who are still being tried, is the serious criticism of the Bahrain judicial system by the BICI, which must call into question the validity of sentences previously passed. The commission viewed the “lack of accountability” of the judicial and prosecutorial personnel in the National Safety Court as “a subject of great concern”, compounded by the acceptance of forced confessions in criminal proceedings in both special courts and ordinary criminal courts. The commissioners went on to recommend that sentences should be dropped, or at least reviewed, for those charged with offences involving political expression, or victims of torture, ill-treatment or prolonged incommunicado detention, and that victims of human rights abuse should be compensated, and that dismissed employees should be reinstated and compensated. This recommendation has not been enacted and the farcical trials of doctors continue.
In 2014 the plight of medical personnel has deteriorated and the repressive regime in Bahrain continues to prevent freedom of expression. The Irish Medical Council visited Bahrain to determine if RCSI-Bahrain met the international standards for medical education and at the time of writing this note, the recommendation of the Council representatives is awaited.
I have written the following articles between 2011 and 2014 to highlight the humanitarian injustices in Bahrain, though my first article on Bahrain, entitled “The Island of Dilmun” dates back to happier time in that country in 1989.
O’Brien E. Hippocratic Oath. Irish Examiner 02.08.2011.p.13 http://www.bahrainjdm.org/2011/08/03/professor-eoin-obrien-writes-in-irish-examiner-on-the-findings-of-the-recent-humanitarian-mission-to-bahrain/
Hypertension in Low Resource Countries
The following articles, written in collaboration with WHO, are directed towards finding cost-effective ways of measuring blood pressure so as to improve the management of hypertension in low resource countries, where the illness in now the leading cause of morbidity and death.
Parati G, Mendis S, Abegunde D, Asmar R, Mieke S, Murray A, Shengelia B, Steenvoorden G, Van Montfrans G, O’Brien E. Recommendations for blood pressure measuring devices for office/clinic use in low resource settings. Blood Press Monit 2005;10:3-10
Parati G, Ochan Kilama M, Faini A, Facelli E, Ochen K, Opira C, Mendis S, Wang J, Atkins N, O’Brien E. A new solar powered blood pressure measuring device for low resource settings. Hypertension 2010;56;1047-1053
Campbell NR, Berbari AE, Cloutier L, Gelfer M, Kenerson JG, Khalsa TK, Lackland DT, Lemogoum D, Mangat BK, Mohan S, Myers MG, Niebylski ML, O’Brien E, Stergiou GS, Veiga EV, Zhang XH. Policy Statement of the World Hypertension League on Noninvasive Blood Pressure Measurement Devices and Blood Pressure Measurement in the Clinical or Community Setting. J Clin Hypertens (Greenwich). 2014 May 8. doi: 10.1111/jch.12336. [Epub ahead of print] PubMed PMID: 24811572.
The following articles refer to general topics relating to humanitarian issues, such as the education of doctors.
O’Brien E. et al. Integrated Management of Cardiovascular Risk. Report of a WHO Meeting. Geneva, 9-12 July 2002. Noncommunicable Diseases and Mental Health. World Health Organization. Pp. 1-35. Geneva. 2003
O’Brien E. Human rights and the making of a good doctor. In: Traditions, Values and Humanitarian Action. Ed. Kevin Cahill. International Humanitarian Series. Fordham Univeristy & Center for International Health and Cooperation. New York. 2003. pp. 136-152