Geneva Health Forum Archive

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The ‘Rural Surgeon’ of India: A New Paradigm in Surgical Education

Author(s): K. M. Shyamprasad*1, M. Gautham2
Affiliation(s): 1Surgical Education, National Board of Examinations, 2Public Health, Independent consultant, New Delhi, India
Keywords: Rural surgeon, innovative training, skill mix

There is a wide gap between the burden of surgical emergencies and diseases in India and the availability of appropriately skilled surgeons to manage these, especially for the country’s 700 million rural population. On the public health forefront, huge surgical needs exist for management of (1) maternal complications and emergencies that are a leading cause of India’s high maternal mortality rate (407/100,000 live births), and (2) injuries responsible for 11% of deaths, 50 million hospital care seekers, and 17 million hospitalizations. The country needs to develop greater numbers of versatile surgeons able to function independently in resource limited rural settings.


In a significant shift from the Euro-Western model of compartmentalized surgical education, the National Board of Examinations - the MoH’s apex body for post graduate medical education - has developed a 3 year Rural Surgery course. The syllabus emphasizes basic surgical skills and management of traumas and emergencies; it includes Obstetrics and Gynaecology, Anaesthesia, as well as Management of a Rural Health Centre. Problem solving learning principles underlie the pedagogical approach. Nodal and peripheral rural course centres, chosen for their commitment to rural surgical care, provide practical training in cost containment, economics of rural healthcare, functioning within infrastructural constraints, and also inculcate appropriate attitudes and communication skills. Student’s learning material is responsive to local disease burdens and incorporates a variety of e-learning and audiovisual material.


The course was launched in 2007 with 10 students. Periodic reviews are designed to improve upon the basic course design and attract increasing numbers of students.

Lessons learned:

The Rural Surgery course is an innovative, pioneering effort to align surgical education with the public health surgical burden of a low income country. It represents a paradigm shift in the evolution of Indian medical education from a Western model to a locally responsive model.

Emergency Response Plan: Teaching Hospital Anuradhaura, Sri Lanka

Author(s): A. S. Karunarathne*1, P. Gunasena1, M. L. Dassanayake2
Affiliation(s): 1Neurosurgery, 2Orthopaedic, Teaching Hospital Anuradhapura, Sri Lanka
Keywords: Emergency response plan

Teaching Hospital Anuradhapura engages in managing large number of external emergencies. In fact it is one of the hospitals that receive highest number of patients per unit time in Sri Lanka, most probably contributed by the on going war in the north and eastern provinces. During the period of past twelve months from December 2006 to November 2007, there were 18028 admissions to the emergency surgical unit on 16 occasions in clusters of more than 15 patients at each occasion. Working Emergency Response Plan (WERP) of the hospital was initiated in early 2006. At that time there were not many war casualties coming to the hospital. The WERP has neither being updated nor re-evaluated for its efficiency since then, thus formulation of a new efficient plan after evaluating the existing WERP taking in to consideration of the current war situation has been a need for a while.


The objective of this project is to evaluate the existing plan through a questionnaire given to the members of the emergency team of the current plan and design a more efficient and flexible working plan, analysing their responses and studying other presently practiced emergency plans. 45 members from the current emergency plan were provided with the questionnaire and four other presently practiced emergency response plans were reviewed.


Analysis revealed that the existing WERP is not adequate to maintain communication, coordination, using human resource and the infrastructure optimally during the management of mass casualties at present. Considering the weaknesses of the existing plan and acquiring the essentials from the other reviewed plans a new flexible and revisable plan was designed with a view to achieve four second line objectives.

Lessons learned:

New plan is in the process of implementation. A second study is needed once the new WERP is well established, to assess its behaviour in the practical ground of locality.

A Surgeon’s Experience in Haiti

Author(s): M. Assal1
Affiliation(s): 1Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Switzerland
Background: On January 12, 2010, at 16.50, a devastating earthquake of high magnitude (7.0) struck the island of Haiti. Two hundred thousand lives were lost in the first few seconds. Those who survived the initial overwhelming event were left with severe physical and psychological injuries. There were a very large number of crush injuries to the extremities with or without associated fractures, multiple extremity fractures and more rarely axial (pelvic or spinal) fractures, open contaminated wounds, compartment syndromes, and traumatic amputations. The immediate psychological injuries comprised mostly of posttraumatic stress disorders.
The Swiss Humanitarian Aid Unit was rapidly deployed in Port au Price. The first medical team reached Port-au-Prince General Hospital on the 5th day after the earthquake and quickly began surgical activities after just 3 hours on site. The team consisted of one team leader, one orthopaedic surgeon, one general surgeon, two anesthesiologists, two pediatricians, one obstetrician/gynecologist, one anesthesia nurse and three polyvalent nurses. Medical equipment brought to the scene consisted of light equipment (surgical tools, dressing and casting material, some medication), in addition to some material already present in the Port-au-Prince General Hospital (operating tables, some medication, etc.). The team focused on providing medical and surgical care to children and traumatized pregnant women. Orthopaedic surgeons were on the frontline in providing acute care, with fracture stabilization using plaster of Paris, traction, or external fixation. Adequate débridement and delayed primary closure of wounds, fasciotomies, and amputations were also among the major orthopaedic procedures. In addition, all the routine medical and surgical emergencies of daily life needed to be addressed by the specialists of the same team. This was a substantial additional burden placed on our team.

Towards an Ethics of Presence to Support Healthcare Practice in Global Health

Author(s): M. R. Hunt*1, L. Redwood-Campbell2, L. Elit3, L. Schwartz4
Affiliation(s): 1Centre de recherche en éthique, University of Montreal, Montreal, 2Family Medicine, 3Medicine, 4Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada
Keywords: Humanitarian assistance, natural disasters, international development, ngos, health care professionals, ethics

Expatriate health care professionals participate in a range of global health activities in developing nations. Healthcare professionals play key roles in the international response to humanitarian emergencies and natural disasters. Other clinicians participate in development-oriented initiatives to strengthen health systems in developing countries. These practice environments are significantly different from the context of health care delivery in the home countries of expatriate health care professionals. In these settings, human rights, public health, clinical care and ethics intersect in distinctive ways.


In this paper we draw upon three qualitative research studies. These inquiries are based on 45 interviews with Canadian health care professionals who have experience in humanitarian assistance and development work.


The empirical studies identify and illuminate a range of ethical issues and dilemmas experienced by healthcare professionals in humanitarian settings. These include political, structural and organizational challenges; the need to allocate limited resources; questions of professional identity and responsibilities; and social and cultural expectations and realities. These studies also offer insight into how health care professionals experience and respond to the shift of professional, social, cultural and regulatory environments that accompany relief and development projects. We articulate an “ethics of presence” to orient the participation of expatriate clinicians in global health activities. This approach emphasizes the importance of being present to the suffering and vulnerability of others, the shared humanity of those in need of assistance and those in positions to provide it (expressly rejecting a paradigm of victims and rescuers); the opportunity to provide moral voice; and the provision of competent, practical assistance. An ethics of presence is supported by inward orientations of humility and reflexivity, and outward orientations of solidarity and collaboration.

The Sphere Project’s Relevance to Emergency Health Assessments and Interventions

Author(s): A. Nadig1
Affiliation(s): 1The Sphere Project, The Sphere Project, Geneva, Switzerland

Health services in emergencies, HIV and AIDS, Psycho-social issues, Measles Communicable diseases, Non-communicable diseases, Reproductive Health


The Sphere Project’s Handbook (Humanitarian Charter and Minimum Standards in Disaster Response), is recognised as a key reference tool for effective and quality-oriented coordination of emergency interventions. It is a collection of minimum standards in disaster response, covering four technical sectors. One of these sectors is Health Services, which also includes psycho-social health.


The presentation will provide a brief introduction to the Sphere Project, including the rationale behind its inception. It will then turn to the four life-saving sectors included in the Handbook, with special focus on “Health Services” and the linkages between it and the other three sectors (Water and Sanitation, Food and Nutrition, Shelter and Non-food items). The presentation will then turn to the revision process of the current Sphere Project Handbook (2004 edition). By April 2010, the text for the 2010 Handbook edition will be available in draft form and can be shared with the conference participants.


The main focus of the presentation will be on the proposed changes to the chapter content. All those changes are influenced by recent developments in humanitarian action, in particular in the fields of disaster risk reduction, climate change and an evolving understanding of the importance of protection. Cross-cutting issues, in particular psycho-social issues and focus on vulnerabilities, will further shape the new text. The Sphere revision process aims at being broadly consultative and consensus-based, bringing together agreed-upon best practice. Therefore, we can share experiences of concrete application of Sphere in emergency health interventions. The Sphere Project is an NGO initiative, launched in 1997. It aims at improving quality and accountability in disaster response.

Capacity Building for Mental Health and Psychosocial Support in Humanitarian Emergencies: The Challenges of Training

Author(s): C. Colliard1
Affiliation(s): 1Development & Training Department, Centre for Humanitarian Psychology, Geneva, Switzerland
Keywords: Mental health, psychosocial support, humanitarian emergencies, training, psycho-education, capacity building, evaluation, research.

With the growing concern around the impact of climate changes and the potential development of more violence and conflicts to come, and consequently more mass victimization, there will be a growing need for quality training. In recent years, the Sphere Project and the IASC Guidelines on Mental Health and Psychosocial Support in Emergencies have issued principles and good practices(also in the areas of capacity building and training),which have contributed to awareness, better implementation of programs and the growth of a distinct body of knowledge in these fields. However, after evaluating programs on post-disaster scenes (Iran, Sri Lanka, Pakistan&,the speaker has observed a huge gap in the recruitment and training of qualified international and national/local staff after disasters, in both areas of mental health and psychosocial support.


There are many factors involved: countries affected by disasters and conflicts do not always have policies in place in those areas prior to the disaster; training programs have to be created from scratch on an ad hoc basis; local staff are victims themselves and have to be trained into self care alongside attending victims; training in community psycho-education is usually done also on an ad-hoc basis; evaluations and monitoring of training programs are practically non existent. In general, training methodologies in the context of emergencies, both mental health and psychosocial support and education, have been poorly researched and lack scientific validation.
Overall, such programs in post-emergency areas remain quite inconsistent and sketchy, as each humanitarian organisation gives their own training in line with their own objectives. Finally, evaluation and research on mental health and psychosocial training and capacity building in emergencies are still quite thin and lack scientific evidence.


The speaker suggests that trainings should not be a series of one-off and ad-hoc events, but built into a coherent whole, spanning both mental health and psychosocial education practices as complementary fields. This means pre-deployment contingency planning by the international community and governments. Effective training programs would then not only bring more professionalism to national/local staff in emergencies, but also change the communities’ attitudes toward mental illness by extending psycho-education practices that could avoid stigmatisation. Such training programs would also gain strength if there was a coordinating mechanism in the impacted areas, thus avoiding duplication. Furthermore, training programs should be planned in the perspective of sustainable development, by mobilising the communities’ resources, such as primary health care centres, schools, local authorities and integrated into the local culture and community traditions. Evaluation and monitoring tools for mental health and psychosocial education programs in non-western countries should be created and validated. Finally, research into training methodologies and practices in post-emergency contexts should be created in order to build evidence based practices, thus strengthening local professionalism.

Epidemiology of a Cohort of Road Traffic Accidents in Ningbo Area, China

Author(s): X. W. Wang*1, G. Z. G. F. Zhao1, C. W. C. Y. Wang1, C. C. C. J. Cheng1
Affiliation(s): 1Emergency Department, Ningbo No 2 Hospital China, Ning bo, China
Keywords: Road traffic accidents, modern transportation methods, emergency unit

Modern transportation methods, increased number of vehicles and increased vehicle millage per day are considered to be a main causative factor for a development of another new health challenge in our health system “the road traffic accidents (RTA)”. RTA represents a significant amount of admissions and requires a considerable man power and resources. This is becoming a challenge to most critical care units and emergency units in hospitals.


A retrospective observational study based on bed head tickets and hospital records of emergency department and the surgical departments on Road traffic injuries brought to Ningbo No.2 Hospital during 01/01/2009 to 30/09/2009.


Total number of road traffic accident victims brought to the Ningbo No. 2 hospital was 2469 during the study period according to the emergency room data. It represents only 0.039% of the total hospital admissions of the relevant time period. This proportion is unbelievably low. Considering the surgical department data there were 32486 total emergency cases which includes 13968 traffic accident related injuries during the same study period. The number of traffic accident injuries account for 43% in total emergencies according to their data. The main reason for the above difference between emergency department and the whole hospital data is found to be that the number of the transferred patients to other departments were not taken in to account at emergency department documents. Hospital death rate among the road traffic accident victims was 1.122 %.Increasing the severity and number of traffic injuries have imposed and increased work load on the emergency health care workers and having a significant influence in health economics. Approximately 2.15/ 5 of the emergency cases are traffic injuries. According to the existing cadre of the hospital one doctor had attended 1396.8 road traffic accident cases during the study period. That indicates an average day a doctor attends 5.17 road traffic accident victims. A nurse had dealt with 931.2 traffic accident injuries indicating 3.45 cases per day. The cadre need to be corrected considering the increasing the work load. There is a strong necessity of community awareness on prevention of road traffic accident and it should be considered as a part of the preventive health services of the hospital.

GHF2006 – PS18 – Access to Health for People with Disability:A Right or a Favour?

Session outline

Parallel session PS18, Friday, September 1 2006, 11:00-12:30
Chair(s): Félix Bollman, Switzerland, Pierre Perrin, Switzerland
Reduced Access to Health for People with Disability: An Overview of Causes for an Effective Environmental and Human Rights Approach
Patrick Fourgeyrollas, Institut de Réadaptation en Déficience Physique de Québec - IRDPQ, Québec, Canada 
Nicolas Heeren, Department of Programmes, Methods & Techniques, Handicap International, Lyon, France 
Giampietro Griffo, World Council member, Disabled Peoples International - DPI-Europe, Trentola-Ducenta, Italy 

Session Document

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Session Report

Submitted by: Stephanie Berry (ICVolunteers); Contributors: Irene Amodei (ICVolunteers)
"The key point is always to link actions with long-term development processes". Image:

Although the estimated 600 million people with disabilities have formally been recognized, in reality they are still often being overlooked and by no means enjoy the same rights as the rest of the world's population. The goal is to ensure that all people, disabled and able bodied alike, have the same access to all kinds of services in society, in particular health care.

The reason why the disabled are overlooked, claimed Dr. Patrick Fougeyrollas from the University of Laval, Canada, is that the definition of disability is often too narrow. Disabled people are not only those sitting in a wheelchair but also those who are disabled for language reasons or age. Indeed he emphasized that most people are disabled at some stage of their life, which is why it is particularly important to pay attention to the diverse forms in which disability appears.

Ignoring the less able members of society can have several implications, not only for the person concerned, but also for the people around him/her. It can produce secondary, mental disabilities. The person may feel angry or neglected, which makes them become a greater burden for others.

The goal of equal access, regardless of physical ability, can only be achieved if the barriers to equal access are identified and if people with disabilities are included in the planning of public policy and their demands are not overridden.

Dr. Giampiero Griffo from Disabled Peoples' International, Italy, affirmed that we have to adopt a Human Rights approach towards disabled people, without which it is impossible to ensure social inclusion and recognition. This means that disabled people are not to be treated any differently than others. They should be eligible to the same rights and have the same claim to self-determination. During the last week there has been a turning point on this issue. The United Nations (UN) has now finally officially recognized the need to provide more services for persons with disabilities and to work for their integration into society. The UN has affirmed that it will work for the promotion of respect for all disabled people, and in particular for disabled women because they are doubly discriminated against. Dr. Griffo concluded that this will become a reality only if eople with disabilities if they are not truly included in the process and can actively contribute to it: in fact, "nothing for us without us."

A participant from the floor voiced the concern that, although the UN has taken this first step towards an improvement of the situation, in many of the official organizations none of the people actually have disabilities and thus are not sensitive to the problems of those who do. A lot remains to be done in raising awareness about the issues that more vulnerable people face.

Mr. Nick A. Heeren, Former Director of Programmes, Methods & Techniques of Handicap International, France, gave practical examples both in development contexts and emergencies. He began his presentation posing two principal questions:

1) How to guarantee the right of access to aid and services during emergencies for people with disabilities and other extremely vulnerable individuals?

2) How to take into account people with disabilities before, during and after emergencies through anticipated action, direct action of specialized actors and creating "disability-confidence" among generalist emergency actors?

Disasters, wars and crises raise new challenges for all, but people with disabilities are disproportionately the victims of complex emergencies and more impacted by them, because their coping mechanisms are confronted with a new environment while their support system is also dramatically altered. During an emergency, people with disability become more "invisible" than they usually are, because they are excluded from the emergency registration systems; they face communication difficulties and misinterpretation of the situation and, often, they suffer from an inadequate physical accessibility, or lack of mobility aids; not to mention emotional distress and trauma which can have long-term consequences. In order to mitigate the impact of the crisis on people with disabilities, medical attention has to be combined with social and economic interventions, to build so-called "disability-confidence". According to Mr. Heeren, "People with disabilities need special attention, which doesn't only mean the attention of specialists. Disability is in fact a cross-cutting issue that requires a double track (generalist + specialist) and a right-based approach". Time is also an important variant that should be taken into account. "Before the crisis we need awareness and training; planning and risk-and-resource mapping for an efficient early warning system; as well as preparation of local actors and rescue teams by strengthening their capacity building. On the other hand, after the crisis, it is important to deliver disability services, promote partnerships with disabled people's organizations and set-up outreach work. The key point is always to link actions with long-term development processes".

The symposium gave an overview, not only of the issue of disability/diversity, but also of underlying social factors. Strongly defending the right to be different that is the difference to be right.

People with Disabilities at Times of Disaster and Crisis

Author(s): Nicolas Heeren1
Affiliation(s): 1Department of Programmes, Methods & Techniques, Handicap International, Lyon, France
Key issues:

Recent natural disasters in the world (Gujarat, Bam, Kashmir and Yogyakarta) and man-made crises (war in Sierra Leone, Balkans, Iraq, Afghanistan) have unfortunately shown that people with disabilities tend to be disproportionally victims of disaster and conflict. We know that among the poor a much larger part of the population is living in a disabling situation compared to the overall population. An HI study found that 60% of the people with disabilities were overlooked in one specific emergency response. Indeed, disability is often an integral part of emergency situations, and yet it is not taken into account by most of the players in the rush during an emergency. People with disabilities should enjoy the same rights as anybody else. Disability results from a combination of temporary or permanent impairment, and environmental and sociocultural barriers. Existing coping mechanisms of people with disabilities are confronted with a new environment while their support system is also dramatically altered by the crisis. The following list highlights some factors that may make a PWD more vulnerable during an emergency situation: - PWDs tend to be invisible in emergency registration systems. - Lack of awareness and misinterpretation of the situation and communication difficulties (What happened? What do I do? Where is my family?) lead to a lack of comprehension on the part of the PWDs of the disaster and its consequences. - PWDs are often excluded from disaster response efforts and particularly affected by changes in terrain resulting from disaster. - Because of inadequate physical accessibility, or loss or lack of mobility aids or appropriate assistance, PWDs are often deprived from rescue and evacuation services, relief access, safe location/adequate shelter, water and sanitation, etc. - Emotional distress and trauma caused by a crisis situation often have long-term consequences on people with disability. These challenges can be met through anticipated action by both specialised and generalist actors. In the disaster context, two cases have to be differentiated: a) people who were disabled before the actual disaster took place; b) people who have become disabled as a result of the disaster. Whereas, for the latter group, medical interventions and access to health services (including psychological support) have to be organised in the first days after an emergency, for the former group, while medical attention is useful, more often social and economic interventions are necessary. This also means that the many other actors involved in emergency responses should become disability confident. The intervention and debate will focus on practical answers HI has been able to implement in recent crises, both natural and manmade. It will include special needs and issues from the specialisation/mainstreaming debate; disability services; awareness and training; early warning systems; adapted search and rescue; refugee camp management; and the link with long-term development processes. Finally, the special case of psychological trauma suffered by both victims and medical professionals will be addressed.

Meeting challenges:  How to guarantee the right to aid and services during an emergency for people with disabilities? How to take into account people with disabilities before, during and after emergencies through direct action of specialised actors and create disability confidence among generalist emergency actors?
Conclusion (max 400 words):

If we want to reduce the disproportioned impact of disasters on people with disabilities, a combined effort of specialised and generalist actors, both local and international, needs to be developed. In absence of genuine disaster-preparedness, clever mix interventions can reduce greatly the number of people who suffer from crisis and disaster.

GHF2008 – PS16 – Global Health Education in Action

Session Outline

Parallel session PS16, Tuesday, May 27 2008, 11:00-12:30, Room 17
Chair(s): Syed Al Junid, Professor of Health Economics and consultant for public health medicine, United Nations University-International Institute of Global Health, Malaysia, Antoine Hadengue, Head, Division of Gastroenterology and Hepatology, Department of Internal Medicine, University Hospitals of Geneva, Switzerland
People’s Movements for Health: Activist Practice and Learning Needs
Hani Serag, Global Secretariat Coordinator, People’s Health Movement, Egypt 
Academic Involvement in Global Health: Synergy with United Nations in Millennium Development Goal Education
Kendall Ho, Associate Dean, Faculty of Medicine, University of British Columbia, Canada
‘Community-Based Learning: A Foundation for Better Health’ - Experiences from BP Koirala Institute of Health Sciences, Dharan, Nepal
Prahlad Karki, Professor and Head Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Nepal  

Session Documents

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Session Report

Submitted by: Kate Brown (ICVolunteers)

This session focused on the importance of education and training in providing health care for all. The speakers reflected on their experiences of providing training in different contexts, pointing out the importance of integrating rather than marginalizing a focus on the needs of communities, and the enthusiasm that such an approach can stir in students, the 'professionals of the future'.

Opening the session, Professor Syed Al Junid, United Nations University International Institute of Global Health, Malaysia, and Antoine Hadengue, University Hospital of Geneva, introduced the four speakers.

The People's Health Movement (PHM) is a world-wide network built on the understanding that global health justice depends on social movement pressure as well as good policy and professional practice. The PHM's International People's Health University (IPHU), founded in 2004, strengthens such health movements through short course trainings for health activists around the world. The development of a curriculum for this training includes consideration of content, the balanced selection of participants, the appointment of faculty members, teaching and learning methods and post-course activities. Hani Serag, Global Secretariat Coordinator of the PHM, pointed to the need to build on the positive and accumulating experience of the IPHU by sustaining and institutionalizing their work.

Professor Kendall Ho, from the University of British Columbia (UBC) posed the question "How can academia optimally contribute to global health?" He believes that academia can make significant contributions through unique skill sets: translating evidence to action, transmitting knowledge to others, transforming through research and evaluation, and through these actions transcending suffering towards hope. One important path is ensuring the social accountability of medical schools; going beyond the training of medically competent doctors to contribute to the needs of the communities around them. Professor Ho gave the example of UBC's collaboration with Universitas 21, a consortium of universities sharing a common vision of contributing academically to the global health agenda. This alliance is working to create a curriculum on the UN Millenium Development Goals (MDGs) to enable health professional students to understand and live the MDGs.

Founded in 1993, the BP Koirala Institute of Health Sciences aims to improve the health status of the people of Nepal by providing holistic health care through training, service and research. Prahlad Karki, Professor and Head Departement of Internal Medicine, focused on the Institute's experience of community-based learning, which runs throughout their training courses. 50% of students' time is devoted to learning in the community, including activities such as an orientation week, the study of health care delivery systems including the work of NGOs and international organizations, and an internship programme. Through such training, students obtain knowledge, skills and good practice approaches when contacting community residents, and experience to help meet primary health care needs.

Rachelle Saadeh explained that the Lebanese Red Cross (LRC) offers emergency medical services to all Lebanese people, through 44 centres across the country and 2,600 trained volunteers. First Aid teams respond to emergencies of a wide variety, including road accidents and health emergencies in the home. LRC is also involved in transportation (people, blood units and food) and plays an important role in providing medical aid in political conflicts. In 2007 the LRC was involved in 177,053 missions. 2007 saw a new work strategy for the LRC, including a focus on training and a new strategy to standardize training and to train all volunteers.

Much of the general discussion focused around the UN Millennium Development Goals (MDGs). A 2005 UN survey showed that less than 10% of academic institutions were aware of the MDGs. It was recognized that diffusion of such information takes time, and that a critical mass of change agents is needed, through individual efforts and partnership collaborations. To educate people, it is crucial to link the MDGs to specific issues relevant to the target audience. Champions and leaders are also needed, both amongst students and staff and in international organizations.