The United States had high avoidablehospitalizations for diabetes and asthma relative to comparisoncountries

Access and Quality

hree countries, the United Kingdom, Sweden,and Denmark, have national health care systems, whereasCanada and Australia have regionally administered universal insur-ance programs. Germany, France, the Netherlands, and Switzerlandhave statutory/mandatory health insurance systems. Only theUnited States has a voluntary, private employer-based andindividual-based system

underinvestment in socialdeterminants of health

Life expectancy in the US was the lowest of the 11 countries at 78.8 years (range for othercountries, 80.7-83.9 years; mean of all 11 countries, 81.7 year

ecessityof the sick and insane persons hopsitals were erected in Muslim Spain asone in Algeziras which was founded in the 12th century21 and another inGranada,22 in 767/1365-6. By the 11th century the Hispano-Muslimshad started the treatment of cancer of the stomach. They had maderemarkable progress in chemistry and pharmacy and had all arrangements that they needed for medical treatment as early as in the Caliphateperiod, although Ibn al-Ahmar (d. 960) the author of a contemporarybiographical work of the Umayyad Caliph 'Abd al-Rahman III al-Na?ir(d. 961) had to travel to India across the I

The medicinal shrubs of Sierra Nevada were better in quality than thoseproduced in India or elsewhere.20 Medicine was commonly preparedfrom dardar (ash tree) grown in Spain. They had invented an instrumentof distillation named alambique, of living plants and prepared liquids andchemical

After al-Razi (856-925 A.C.) of Rayy,

If one takes Islamic Spain out of the equation, European history simply doesnot add up.

epitome of “the Hispano-Muslim style at its greatest splendor.”

Indeed, many people who visit the Chora church or the Hagia Sophia will agree something important is lost whenancient houses of worship, of whatever faith, are hollowed out into museums, full of tourists listening to audio guides.But Christians might argue that the “essential function” of these buildings predated 1453.

And the Greek culture minister sounded alarm with UNESCO to help protect the “universalcharacter” of the Hagia Sophia.

the Avenzoar 26 family ofphysicians which moved to Seville from Talavera in the 5th/11th century.

One preparation may "stimulatethe appetite and strengthen the stomach"; another, a summer dish, was useful"for cooling the body" ; yet another was suitable for the "elderly and those ofmoist temperaments"; another, a winter dish, was for those suffering from"cold ailments"; and so on.

The medieval Arab cookbook was not merely concerned with food forpleasure but also with matters of bodily equipoise.

Since 756, the Umayyads, in their new home in al-Andalus, had acknowledged the caliphate of Baghdad in the Friday prayers in their mosques.

In Ibn H· azm’s

His library was not merely a place to hold books, but an immense royal academywhere virtually every subject could be studied and that attracted scholars from across theIslamic world and even Christian Europe

The Emirate of Granada, along the southern coast of Iberia,remained independent of Christian control.

annexed

The Andalusian acceptance of Murabitun control over al-Anda-lus

When the Christian Reconquista threatened the existence ofMuslim Spain, the Taifa kings called on the Murabitun for help.

Similar to how many Arabs volun-tarily accepted Islam in seventh century Arabia, many Berber tribesvoluntarily joined the Murabitun confederation.

Christianity andJudaism penetrated the peninsula

“There is no god but God, and Muhammad is the mes-senger of God.”

interpretations of the worship of the OneGod, the God of Abraham—whether called Yahweh, Kyrios, Deus,or Allah. Under Islamic rule, these non-Muslim communities livedas dhimmis (“protected peoples”),

Roman/Byzantine and Per-sian empires

lack of on-site health personnel andfacilities at police lockups and court holding cells and suggestthat reliance on emergency departments to provide care forarrestees is inefficient and costly.

Except for those limitations that are demonstrably necessitated by the fact of incarceration

desirable

All prisoners shall be treated with the respect due to their inherent dignity and value as human beings

Trends in U.S. Corrections

dignity

Everyone has the right to seek and to enjoy in other countries asylum from persecution

No one shall be subjected to arbitrary interference with his privacy, family, home or correspondence

No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment

Everyone has the right to life, liberty and security of person

without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.

All human beings are born free and equal in dignity and rights.

should act towards one another in a spirit of brotherhood

Article 1.

treme trauma, f

Perhaps the most devastating health consequences of political violence is that of long-term psychological trauma.

Emotional responses of health professionals may not only be a barrier to rec- ognizing the health consequences of human rights abuses, such responses may: also further traumatize survivors.

ost survivors of human rights violations are poor and have limited or no access to health care. Survivors who are without documentation typically avoid contact with the health care system for fear of deportation, or because health professionals may have participated in their torture

Health professionals have the unique opportunity to recognize the physical, psychological and social health consequences of torture, and with some training, to participate in appropriate treat- ment interventions. De

Among human rights abuses, torture is one of the most traumatic and destructive human experiences.

ealth professionals’ unique knowledge and skills enable them to document evi- dence of violations of international human rights and humanitarian law and to hold violators of human rights responsible for their action

Many refugees have no housing, means of income or transportation, and may in fact be incarcerated on their arrival to a country of asylum. Access to medical or psychological care may be limited or non-existent, and when legal status is in question, work and education opportunities are also precluded.

Nightmares, flashbacks, problems with memory, concentration, anxiety and depression challenge and complicate every- day living

Death and injury caused by armed conflict and political violence are compounded by impairment of infrastructure.

However, health professionals’ conceptual notions of disease and illness have not yet included the health consequences of human rights violations; nor have there been substantial efforts to teach human rights in medical education

These principles, together with more recent bioethical con- cepts of patient autonomy and informed consent,

Since the end of the Second World War

The first, the International Covenant on Civil and Political Rights, recognizes the rights of every human being to life, liberty and security of persons from torture and other forms of cruel, inhuman or degrading treatment. It prohibits slavery, guarantees the rights to a fair trial and protects persons against arbitrary arrest or detention. It recognizes freedom of thought, conscience and religion, freedom of opinion and expression, the right of peaceful assembly and of emigration, and freedom of association. The second, the Interna- tional Covenant on Economic, Social and Cultural Rights, acknowledges the state’s responsibility to promote better living conditions for its people.

they were self-evident and derived from common societal goals of peace and justice and individual goals of human dignity, happiness and fulfillment.

In effect, human rights prescribed conditions for physical, psychological and social well-being by attempting to prevent and alleviate suffering.

“recognition of the inherent dignity and of the equal and inalienable rights of all members of the human family is the foundation of freedom, justice and peace in the world.”

John Locke (1632-1704) introduced the idea of inalienable rights of life, liberty and estate, as natural entitlements by reason of being human. A

Human rights violations are among the most urgent social causes of human suffering for healers to consider given their devastating health consequences.

health professionals have been criticized for their preoccupation with financial interests and control over practice conditions while neglecting the problems of access, quality assurance, cost effectiveness, technology assessment and professional incompetence and malfeasance.

By decontextualizing and reducing suffering to pathophysiology, healers have neglected social conditions which affect health and well-being, and thereby have marginalized their own roles in society.

disease paradigm.

unknowable experiences has failed to acknowledge individuals’ personal suf- fering

science and technology masks human interests which attempt to dominate nature (18) and establish social control (

concept of objectivity

Scientific methods intentionally aim to reduce contextual understandings of everyday life to context-free explanations. Thus, scientists attempt to reduce complex phenomena to objective knowledge by prov- ing the null hypothesis, or that which is not true (

spite a century of technological progress, social inequities, interpersonal violence and environmental threats continue to plague the health of the world community.

Torture, forced disappearance and political killings are systematically practiced in more than ninety countries

Armed conflicts have claimed the lives of more than ninety million people in the twentieth century, and increas- ingly, civilians have become the victims of war

As we enter the twenty-first century, the nature and extent of human suffering has compelled health providers to redefine their understandings of health and the scope of their professional interests and responsibilities

INTRODUCTION

darker side of humanityand the potential for cruelty in this world.

I am also reminded of the extraordinary resilience of the human spirit.

Participating in advocacy work will make the practice of medicine more enjoyable and rewarding and offer importantcontributions towards promoting the health of our society

The fact that more than 43 million Americans remain without health insurance [9] is another advocacy priorityfor physicians here in the US

Advocacy efforts are currently under way promoting alternatives to detention for asylumseekers.

Physicians have a critical role to play in documenting the health consequences of human rights violations.

ince our program began, we have cared for more than1,000 victims of torture and refugee trauma from over 60 different countries. Torture continues to be routine in morethan 90 countries around the world, and it is estimated that as many as 300,000 survivors of torture now live in the US

Such human rights-related problems will only come tolight through effective and empathic communication.

Physicians must take a role in the identification, treatment, documentation, and educationabout the abuses of human rights.

He was interrogated about who his collaborators were, and during this interrogation he was repeatedlybeaten, kicked, and burned with a lit cigarette

This misery was not a tragedy of nature but intentional human-made suffering

I came toappreciate that there was much more to understanding health than what I had learned in pathology.

World Health Organization'sdefinition of health as a "state of complete physical, mental, and social well-being" [2]

disease-oriented model of health and illness

hen human rights are promoted, health is promoted. When human rightsare violated, there are devastating health consequences for both the individual and the community.

advocacy efforts for policies that promote human rights at the local, national, and international levels

Physicians who are aware of various forms of human rights abuses arebetter able to serve and advocate for their patients.

Moral Disengagement

she had thought more about Florentino Ariza than about her dead husband.

On the previous afternoon, under those same branches but in the section on the other side of the wall reserved for suicides, the Caribbean refugees had buried Jeremiah de Saint-Amour with his dog beside him, as he had requested.

hinking as she slept, she tho ught that she would never again be able to sleep this way, and she began to sob in her sleep, and she slept, sobbing, without changing position on her side of the bed, until long after the roosters crowed and she was awakened by the despised sun of the morning without him.

“Get out of here,” she said. “And don’t show your face again for the years of life that are left to you.” She opened the street door, which she had begun to close, and concluded: “And I hope there are very few of them.”

“Fermina,” he said, “I have waited for this opportunity for more than half a century, to repeat to you once again my vow of eternal fidelity and everlasting love.

She prayed to God to give him at least a moment so that he would not go without knowing how much she had loved him despite all their doubts, and she felt an irresistible longing to begin life with him over again so that they could say what they had left unsaid and do everything right that they had done badly in the past. But she had to give in to the intransigence of death. Her grief exploded into a blind rage against the world, even against herself, and that is what filled her with the control and the courage to face her solitude alone.

From her first moment as a widow, it was obvious that Fermina Daza was not as he lpless as her husband had feared.

A reno wned artist who happened to be stopping here on his way to Europe painted, with pathos-laden realism, a gigantic canvas in which Dr. Urbino was depicted on the ladder at the fatal moment when he stretched out his hand to capture the parrot.

Only two of his actions did not seem to conform to this image.

Dr. Juvenal Urbino never accepted the public positions that were offered to him with frequency and without conditions, and he was a pitiless critic of those physicians who used their professional prestige to attain political office. Although he was always considered a Liberal and was in the habit of voting for that party’s candidates, it was more a question of tradition than conviction, and he was perhaps the last member of the great families who still knelt in the street when the Archbishop’s carriage drove by.

Fermina Daza was in the kitchen tasting the soup for supper when she heard Digna Pardo’s horrified shriek and the shouting of the servants and then of the entire neighborhood. She dropped the tasting spoon and tried her best to run despite the invincible weight of her age, screaming like a madwoman without knowing yet what had happened under the mango leaves, and her heart jumped inside her ribs when she saw her man lying on his back in the mud, dead to this life but still resisting death’s final blow for one last minute so that she would have time to come to him. He recognized her despite the uproar, through his tears of unrepeatable sorrow at dying without her, and he looked at her for the last and final time with eyes more luminous, more grief-stricken, more grateful than she had ever seen them in half a century of a shared life, and he managed to say to her with his last breath: “Only God knows how much I loved you.”

He had forgotten that he ever owned a parrot from Paramaribo

But what disturbed him most was his lack of confidence in his own power of reason: little by little, as in an ineluctable shipwreck, he felt himself losing his good judgment.

He was awakened by sadness. Not the sadness he had felt that morning when he stood before the corpse of his friend, but the invisible cloud that would saturate his soul after his siesta and which he interpreted as divine notification that he was living his final afternoons.

But Dr. Juvenal Urbino and his wife left without tasting it, for there was barely enough time for him to have his sacred siesta before the funeral.

He remembered Jeremiah de Saint-Amour, on view at that hour in his coffin, in his bogus military uniform with his fake decorations, under the accusing eyes of the children in the portraits.

This often happened to him, above all with people’s names, even those he knew well, or with a melody from other times, and it caused him such dreadful anguish that one night he would have preferred to die rather than endure it until dawn.

The downpour ended as suddenly as it had begun, and the sun began to shine in a cloudless sky, but the storm had been so violent that several trees were uprooted and the overflowing stream had turned the patio into a swamp. The greatest disaster had occurred in the kitchen.

but bearing up under the misfortune with the invincible smile, learned from her husband, that would give no quarter to adversity.

but the deception he practiced on all of us for so many years.

found himself face to face with the simple incomprehension that had exasperated him for a half a century.

No: that fear had been inside him for many years, it had lived with him, it had been another shadow cast over his own shadow ever since the night he awoke, shaken by a bad dream, and realized that death was not only a permanent probability, as he had always believed, but an immediate reality. What he had seen that day, however, was the physical presence of something that until that moment had been only an imagined certainty.

love as if they had been a diaper, and continued dressing him, item by item, from his socks to the knot in his tie with the topaz pin.

At last he proposed that they both submit to an open confession, with the Archbishop himself if necessary, so that God could decide once and for all whether or not there had been soap in the soap dish in the bathroom.

She headed for the kitchen when she heard him come in, pretending that she had something to do, and stayed there until she heard his carriage in the street.

The truth was they both played a game, mythical and perverse, but for all that comforting: it was one of the many dangerous pleasures of domestic love.

They had just celebrated their golden wedding anniversary, and they were not capable of living for even an instant without the other, or without thinking about the other, and that capacity diminished as their age increased.

That was how the local firemen learned to render other emergency ser-vices, such as forcing locks or killing poisonous snakes, and the Medical School offered them a special course in first aid for minor accidents.

the parrot frightened them with a mastiff’s barking that could not have been more realistic if it had been real, and with shouts of stop thief stop thief stop thief, two saving graces he had not learned in the house.

But he opposed the purchase of a fierce dog, vaccinated or unvaccinated, running loose or chained up, even if thieves were to steal everything he owned

German mastiffs

Dr. Juvenal Urbino, so occupied at that time with his professional obligations and so absorbed in his civic and cultural enterprises, was content to assume that in the midst of so many abominable creatures his wife was not only the most beautiful woman in the Caribbean but also the happiest.

tropical flowers and domestic animal

The fact that the parrot could maintain his privileges after that historic act of defiance was the ultimate proof of his sacred rights.

who did not speak when asked to but only when it was least expected, but then he did so with a clarity and rationality that were uncommon among human beings.

as they attempted to catch the parrot, who had flown to the highest branches of the mango tree

No one ever thought that a marriage rooted in such foundations could have any reason not to be happy.

only a person without principles could be so complaisant toward grief.

Jeremiah de Saint-Amour loved life with a senseless passion, he loved the sea and love, he loved his dog and her, and as the date approached he had gradually succumbed to despair as if his death had been not his own decision but an inexorable destiny.

he had made the irrevocable decision to take his own life when he was seventy years old.

So then you knew!” he exclaimed. She not only knew, she agreed, but she had helped him to endure the suffering as lovingly as she had helped him to discover happiness. Because that was what his last eleven months had been: cruel suffering.

In an attempt to distract him, she invited him to play chess and he accepted to please her, but he played inattentively, with the white pieces, of course, until he discovered before she did that he was going to be defeated in four moves and surrendered without honor.

And then she knew that Jeremiah de Saint-Amour had come to the end of his suffering and that he had only enough life left

Dr. Juvenal Urbino had not often had reason as he did that Sunday to venture boldly into the tumult of the old slave quarter.

In the Plaza of the Cathedral, where the statue of The Liberator was almost hidden among the African palm trees and the globes of the new streetlights, traffic was congested because Mass had ended, and not a seat was empty in the venerable and noisy Parish Café.

Although he refused to retire, he was aware that he was called in only for hopeless cases, but he considered this a form of specialization too.

The scalpel is the greatest proof of the failure of medicine.” He thought that, in a strict sense, all medication was poison and that seventy percent of common foods hastened death.

he left to call on his patients. In spite of his age he would not see patients in his office and continued to care for them in their homes as he always had, since the city was so domesticated that one could go anywhere in safety.

He breakfasted en famille but followed his own personal regimen of an infusion of wormwood blossoms for his stomach and a head of garlic that he peeled and ate a clove at a time, chewing each one carefully with bread, to prevent heart failure.

In his pocket he always carried a little pad of camphor that he inhaled deeply when no one was watching to calm his fear of so many medicines mixed together

He promised to notify the numerous Caribbean refugees who lived in the city in case they wanted to pay their last respects to the man who had conducted himself as if he were the most respectable of them all, the most active and the most radical, even after it had become all too clear that he had been overwhelmed by the burden of disillusion.

Doctor needed to study the unfinished game

I will speak to the Governor.”

circumvent all the legal procedures

the odor in the house was sufficient proof that the cause of death had been the cyanide vapors activated in the tray by some photographic acid, and Jeremiah de Saint-Amour knew too much about those matters for it to have been an accident.

fastidious

eremiah de Saint-Amour was completely naked, stiff and twisted, eyes open, body blue, looking fifty years older than he had the night before.

vaporize the poison.