Vector Volume 11 Issue 1 by The Australian Medical Students' Association

Advisory Board The Advisory Board, established in 2017, consists of academic mentors who provide guidance for the present and future direction of Vector. Dr Claudia Turner Consultant paediatrician and clinician scientist with the University of Oxford & Chief Executive Officer of Angkor Hospital for Children. Professor David Hilmers Professor in the Departments of Internal Medicine and Pediatrics, the Center for Global Initiatives, and the Center for Space Medicine at the Baylor College of Medicine Associate Professor Nicodemus Tedla Associate Professor at the University of New South Wales School of Medical Sciences Dr Nick Walsh Medical Doctor (RACP) & Regional Advisor for Viral Hepatitis at the Pan American Health Organization / World Health Organization Regional Office for the Americas

2017 Vector Committee Editor-in-chief Carrie Lee carrie.lee@amsa.org.au Associate Editors Kryollos Hanna Sophie Lim Koshy Matthew Nic Mattock Aidan Tan Ash Wilson-Smith Sophie Worsfold Danica Xie Publication Designer Lucy Yang Design and layout © 2017, Vector Australian Medical Students’ Association Ltd, 42 Macquarie Street, Barton ACT 2600 vector@globalhealth.amsa.org.au vector.amsa.org.au Content © 2017, The Authors Cover designs by Lucy Yang (University of New South Wales) Vector Journal is the official student-run journal of AMSA Global Health. Responsibility for article content rests with the respective authors. Any views contained within articles are those of the authors and do not necessarily reflect the views of the Vector Journal or the Australian Medical Students’ Association.

Contents Editor’s Note: The Sky’s No Limit

Commentary Rise of Trump/Fall of Health Owen Burton

Anti-vaccination: Separating Fact from Fiction Elissa Zhang

Climate Change and Vector-Borne Disease in Kiribati Erica Longhurst

Features Humanity Lost? Patrick Walker

Redefining Women’s Health: A Noncommunicable Diseases Perspective Charlotte O’Leary

Healthcare in Conflict Zones Michael Wu

Surgery: Luxury or Necessity? Maryam Ali Khan (Pakistan), Zineb Bentounsi (Morocco), Nayan Bhindi (Australia), Helena Franco (Australia), Tebian Hassanein Ahmed Ali (Sudan), Katayoun Seyedmadani (Grenada/USA), Ruby Vassar (Grenada), Dominique Vervoort (Belgium)

Beyond the Horizon and Back Again: Interview with Professor David Hilmers Ashley Wilson-Smith

Reviews PrEP-related health promotion for Aboriginal and Torres Strait Islander Gay and Bisexual Men Alec Hope

Mental Illness Following Disasters in Low Income Countries Rose Brazilek

Factors that Contribute to the Reduced Rates of Cervical Cancer Screening in Australian Migrant Women - a Literature Review Archana Nagendiram Medical Electives in Resource-poor Settings: Are We Doing More Harm Than Good? Gabrielle Georgiou

Conference reports IFMSA - 5 letters with one big mission! Australian Medical Students attend the IFMSA 66th General Assembly in Montenegro Aysha Abu-sharifa, Stormie de Groot, Julie Graham, Justine Thomson Changing Climate, Changing Perspectives: iDEA Conference Report Isobelle Woodruff

Editor’s Note: The Sky’s No Limit Of the many things that come to mind when one thinks about global health, an astronaut is probably not high on the list. The front cover of this first issue of Vector for 2017 is not what we would conventionally expect of a global health journal. And yet, that is precisely the message that this issue conveys – the limitless diversity that global health has come to represent. We are living in an increasingly globalised world, with greater wealth and inequality we have ever encountered. We have made remarkable progress over the past few decades on the frontier of global health, including increased vaccination and access to treatment for diseases such as HIV. However, the agenda is now shifting to focus on new and emerging challenges. Undoubtedly, healthcare in a global context is intrinsically connected to the political, social and cultural phenomena that define today’s world. The rise to power of the United States President Donald Trump raises serious questions and concerns about the future of global health, with his controversial approaches and perspectives towards climate change, refugees and migrants, as well as sexual and reproductive health. Owen Burton (p 2) provides a thoughtprovoking commentary on these issues, and urges Australia to consider our future potential role in leading an alternative direction rather than following the direction set by the US. War and conflict, political stability and human rights also intersect with global health issues, as we see with the distressing increase in targeted attacks on health care facilities, Michael Wu (p 18) offers an insightful perspective into the situation of medical neutrality in conflict zones. In addition to man-made crises, natural disasters also pose a threat to human health and health care systems, with mental health implications a particular concern deserving attention, as discussed by Rose Brazilek (p 32). Climate change is the greatest challenge we are facing in the global health arena. Personal experiences and commentary are provided by Erica Longhurst (p 8). Noncommunicable diseases (NCDs) account for a substantial proportion of the global burden of disease. We are reminded by Charlotte O’Leary (p 14) that we need to question and redefine the approach we take towards this issue, to ensure that women’s health is not limited to reproductive health concerns, but a holistic approach over the entire life course, including addressing the risk factors and burden of NCDs specific to women and girls. Yet whilst our focus often turns to issues “abroad”, there is much to be addressed in global health on a local level. Health promotion amongst key populations in Australia is a particular topic of interest. A comprehensive review article by Alec Hope (p 29) describes issues regarding the promotion of HIV pre-exposure prophylaxis amongst Aboriginal gay and bisexual men in Australia. Migrant women in Australia also have lower rates of cervical cancer screening; the factors and interventions to address this issue are explored in a review article by Archana Nargendiram (p 36).

The recent health policy “No Jab No Play / No Jab No Pay” also raises the issue of vaccination scepticism and conscientious objection, a concerning phenomenon in Australia as well as worldwide. A commentary by Elissa Zhang (p 5) provides an interesting overview of historical events like the Cutter Incident (involving the polio vaccine) and common concerns held by ‘anti-vaxxers’. With so much happening in global health, it is understandable for the general public, and particularly young people, to feel disenfranchised or disempowered. We even become desensitised and apathetic to the problems; such as conflict, mass displacement and natural disasters; that we are constantly exposed to in the media. Patrick Walker calls on us to remember the human side to the tragedies that we see, but also to promote tolerance and understanding with people who hold different views to our own (p 11). An interview by Ashley Wilson-Smith with NASA astronaut, paediatrician and internist Professor David Hilmers (p 26) provides a window into his vast experiences in resourcepoor settings, including recently in the Ebola crisis, and the interview reinforces that global health is not always what we expect it to be. Professor Hilmers is also one of our Advisory Board members, a new initiative aimed at strengthening the academic standard and longevity of Vector Journal. There is a growing community of medical students who share a passion for global health. (Indeed, they are attending conferences around the world, including at Doctors for the Environment Australia (Belle Woody, p47) and with the IFMSA in Montenegro (p44)!) Unlike other medical specialities that have a clear career pathway, global health is a blank canvass. It is hard to define, and that lends a huge amount of potential – global health can be anything that you want it to be. There is “no limit” in that sense! I believe that the contents of this issue speak to the diversity of global health. Not only does it bring attention to some of the greatest challenges, it also celebrates the developments in research, collaboration and policies that pave the way towards new and creative solutions. We hope this issue engages you, inspires you, and challenges your ideas and assumptions about global health. I am incredibly grateful to the Vector Committee, to all of our authors and contributors, to the Advisory Board, AMSA Global Health and many other supporters. Dear Reader, let Vector be a platform for you to launch beyond the horizon into global health. Carrie Lee, Vector Editor-in-Chief 2017 Correspondance: carie.lee@amsa.org.au

Rise of Trump/Fall of Health [Commentary] Owen Burton Owen Burton holds degrees of Bachelor of Biomedical Science (Griffith University) and Masters of Orthoptics (University of Technology, Sydney) While Trump has proven time and time again that he has little regard for females, this blatant attack seems like an extreme first step. People have been protesting the numerous unconstitutional and unethical executive orders streaming from the desk of the White House through large organised protests, rallies at offices of local governmental officials and online petitions. It is vital, however, that this momentum does not weaken: accepting this situation as the new ‘normal’ cannot be allowed to happen. Having to fight constantly is exhausting but essential. Without significant His often-repeated goal during campaigning resistance, it is likely that Trump will be able was to “repeal and replace” Obamacare by push many of these bills through a Republicanrelaxing legislation which prevents exploitation dominated congress and into of the injured by private insurance interests, and These cuts will jeopardise the health law. removing funding for vital of the world’s most at-risk individuals Trump’s executive order to infrastructure in hospitals and by removing access to education freeze funding and support for speciality clinics, as well as and preventative measures against sexual health and Planned sexually transmitted diseases, as well global aid serves to reinstate Parenthood programmes. as all facets of maternal healthcare. and expand Reagan’s 1984 ban on United States (US) Although he has, so far, been foreign aid. All $9.5 billion unsuccessful in repealing USD of American global health funding will Obamacare, he has not given up his crusade be restricted from being available to any nonagainst basic healthcare provisions. government organisations providing or even discussing abortion with patients.[1, 2] These Under Trump’s direct guidance, Tom Price, cuts will jeopardise the health of the world’s head of the Department of Health and Human most at-risk individuals by removing access to Resources, continues to reduce requirements education and preventative measures against for insurance companies to provide essential sexually transmitted diseases, as well as all benefits, and works towards completely facets of maternal healthcare. The World dismantling systems related to women’s or Health Organization estimated that a total of sexual health. Such a removal of support and 225 million women in developing countries shift away from women is concerning, as it were not using contraception, mainly due to appears to indicate the return of deep-seated lack of access and education.[3] With the sexism within governmental institutions which implementation of this gag, it is expected that sets an example for the wider society. these numbers will rise significantly. As Donald Trump took the stage declaring victory as the 45th President of the United States and the Leader of the Free World, I had a sudden chilling realisation. This man, who has spent his entire life ignoring or actively working against the dangers of climate change, progressive social policy and a centralised state control healthcare system, now sits at the head of the American government, which sets the trends in policy and action in the Western world.

Trump has made it clear that he is committed to the promises he made going into the election – promises which have the potential to jeopardise global health. The next step is likely to be severe cuts or the removal of foreign aid funding entirely, as Trump has expressed on Slashing America’s global aid support will only result in detriment for those people already suffering from the consequences of poor support for health services; a rise in disease, poverty and death are to be expected if this policy is to be implemented. multiple occasions that he has no intention of being “president to the world”. By internalising focus, Trump aims to disconnect America from the rest of the world – a process that has started with reduction and removal of aid and is predicted to continue with taxing of overseas goods. The impact this will have on global health programs is not to be underestimated. Slashing America’s global aid support will only result in detriment for those people already suffering from the consequences of poor support for health services; a rise in disease, poverty and death are to be expected if this policy is to be implemented.

and taking a strong stand on healthcare and foreign aid, Australia could become a rally point for other nations – a model for them to work by and therefore improve the lives of millions of people who have already, and will be, affected by the rise of Trump. Acknowledgements None Conflict of Interest None declared Correspondence oburton101@gmail.com References 1. Filipovic J. The Global Gag Rule: America’s Deadly Export. Foreign Policy. 2017 March; 20. 2. Office of the Press Secretary, White House. White House. [Online].; 2017 [cited 2017 May 10. Available from: https://www.whitehouse.gov/the-pressoffice/2017/01/23/presidential-memorandum-regardingmexico-city-policy. 3. Singh S, Darroch J, Ashford L. Adding It Up: The Costs and Benefits of Investing in Sexual and Reproductive Health 2014. Guttmacher Institute; 2014.

Australia has an opportunity, and a responsibility here to intervene. As a country with the wealth and resources to help, we would be passively condoning Trump’s gag policy if we do not aim to lessen its blow on developing nations. By increasing our international aid and presence, as well as encouraging other countries to do so, we can hopefully avoid the rise of neoliberalist nationalism we have seen in America, and help prevent its consequences to global health. Most importantly, Australia needs to stand up against America on this issue. It is time for Australia to take the lead. By changing direction

Anti-vaccination: Separating Fact from Fiction [Commentary] Elissa Zhang Elissa is a 4th year medical student at UNSW. She currently conducts research on parental attitudes towards vaccine policies and media portrayals of vaccine safety at the UNSW School of Public Health and Community Medicine.

Vaccines are indubitably one of the great successes of public health, on par with clean water and basic sanitation. They have saved millions of lives, and even eradicated infectious diseases such as smallpox.[1] Yet, regardless of these achievements, the legitimacy and safety of vaccinations are still questioned. Earlier this year Australian One Nation Senator Pauline Hanson urged parents to take a non-existent “vaccine-reaction test”,[2] and United States (US) President Donald Trump called for a commission into vaccine safety. [3] Furthermore, the recent implementation of stricter childhood vaccination policies (No

Jab No Pay; No Jab No Play) in Australia has raised contentious ethical issues regarding consent and balancing medical paternalism and parental autonomy in the provision of healthcare to children.[4]

Reasons behind vaccination hesitancy For as long as vaccines have been around, there have been those who oppose them. Vaccine opposition began in early 1800s in Europe with the first vaccination mandates. Scientists, doctors, and members of the public questioned the scientific basis of vaccines, even citing that they would disturb with God’s “natural control over the balance between the blessed and the damned”.[5] The modern manifestation of vaccine objection is simply another iteration of this longstanding phenomenon..

Ironically, the great success of vaccinations in dramatically reducing, and even eradicating disease is contributing to their own downfall. As diseases like measles and polio are no longer endemic in Australia, parents no longer directly face the harms of these highly virulent and contagious diseases. Consequently, they

may perceive the risks from vaccinations to be greater than the likelihood of contracting the very diseases they prevent.[5] In fact, surveys of Australian parents show that the primary reason for vaccine hesitancy or objection is concerns about their safety[6] and a third of parents believe children are over-vaccinated. Newer vaccines, like the HPV vaccine, can be perceived to have a lower risk-benefit ratio, as they protect against diseases that are less prevalent or virulent. Older vaccines also face doubts, as the diseases they prevent are less common or even eliminated in the Australia, such as measles. Furthermore, concerns about adverse reactions to vaccination are growing. This could be attributed to the fact that such reactions are perceived to be more common than the diseases that they prevent. Common misconceptions regarding vaccines Rare but severe adverse reactions to some vaccinations attract great public interest, and give rise to misconceptions or over-estimations regarding their harms. For instance, the 1955 Cutter Incident in the USA involved administration of 380,000 doses of incompletely inactivated polio vaccinations to healthy children, which resulted in 40,000 cases of abortive polio (a minor form that does not involve the central nervous system), 51 cases of permanent paralysis and five deaths. It also started a polio epidemic, leaving even more people in the community affected.[7] This event severely undermined public confidence in the safety of vaccinations, even after it prompted the instigation much safer and stricter regulation of vaccines.[7] Incidents such as this undermine trust in vaccine safety, and these fears must be addressed in the community. Commonly, anti-vaxxers also claim that while they are not against vaccinations themselves, they oppose the adjuvants and preservatives that are potentially harmful, like thiomersal.

However, studies have not been able to identify any harmful effects related to thiomersal, and even so, it was removed from all Australian childhood vaccines.[8] One of the most infamous controversies surrounding vaccine safety was Andrew Wakefield’s retracted 1998 paper that linked the Measles, Mumps and Rubella (MMR) vaccine to autism and bowel disease. His study was severely flawed, involving a sample of only 12 children, and Wakefield was deregistered and discredited. In comparison, a Danish retrospective cohort study investigated over 500,000 children who received the MMR vaccine and proved that there was no association between the vaccine and autism.[9] Despite this, many of the general public still believe in the association between the MMR vaccine and autism as a consequence of Wakefield’s study. Vaccine objection in the context of Australian vaccination policies As of January 2016, the nationwide legislation called “No Jab No Pay” has been put into effect, removing conscientious objection from exemption criteria to immunisation requirements for Centrelink childcare payments worth up to $19,000. A press release by then Prime Minister Tony Abbott and Health Minister Scott Morrison stated that “the choice made by families not to immunise their children is not supported by public policy or medical research nor should such action be supported by taxpayers in the form of child care payments”.[10] In contrast, public health experts believe that this policy is may be misplaced in its aims to reduce conscientious objection to vaccination, rather than addressing the more prominent barriers of access to services, logistical issues, and missed vaccination opportunities. [11] A policy such as this could also threaten the validity of a patient’s informed consent, which is outlined in the Australian Immunisation Handbook as being “given voluntarily in the absence of undue pressure, coercion or manipulation”.[12] This has generated a fresh

debate into the ethics of mandating vaccines through paternalistic policy.

Conflict of Interest None declared

Statistics released in July 2016 show that following the implementation of this policy, 148,000 incompletely vaccinated children had caught up, including 5,738 children of parents with previous conscientious objections.[13]

Correspondence elissa.j.zhang@gmail.com References

1. Greenwood B. The contribution of vaccination to global health: past, present and future. Philos Trans Implications as medical professionals R Soc Lond B Biol Sci. 2014;369(1645):20130433. Available from: https://www.ncbi.nlm.nih.gov/pmc/ Public attitudes towards articles/PMC4024226/ DOI: 10.1098/ vaccinations are complex, as As of January 2016, the rstb.2013.0433 2. Australian Broadcasting they are affected by a wide nationwide legislation called “No Corporation. Pauline Hanson joins range of sources, including the Jab No Pay” has been put into Insiders [Internet]. Sydney NSW: media, personal experiences, effect, removing conscientious Australian Broadcasting Corporation; and health providers. A objection from exemption criteria 2017 [cited 2017 May 29]. Available variety of strategies should to immunisation requirements for from: http://www.abc.net.au/insiders/ be implemented to influence Centrelink childcare payments content/2016/s4630647.htm 3. Wadman M. Robert F. Kenndey Jr. such attitudes. For instance, worth up to $19,000. says a ‘vaccine safety’ commission willingness to vaccinate could is still in the works. Science [Internet]. be encouraged by focusing on improving 2017 Feb [cited 2017 May 29]. Available from: http:// awareness of the risks of vaccine preventable www.sciencemag.org/news/2017/02/robert-f-kennedy-jrsays-vaccine-safety-commission-still-works diseases, rather than discrediting or refuting 4. National Centre for Immunisation Research & myths about vaccine dangers. An intervention Surveillance [Internet]. Westmead NSW: NCIRS; 2016. No based on this strategy showed that higher risk jab no play, no jab no pay policies; 2016 [cited 2017 May perception of diseases resulted in an increased 29]; [all screens]. Available from: http://www.ncirs.edu. willingness to vaccinate.[14] It was also shown au/consumer-resources/no-jab-no-play-no-jab-no-paypolicies/ that rates of conscientious objection were 5. Bond L, Nolan T. Making sense of perceptions of reduced in areas with more administrative risk of diseases and vaccinations: a qualitative study barriers to obtaining one. combining models of health beliefs, decision-making and risk perception. BMC Public Health. 2011;11:943. As future health professionals, we need 6. Rhodes A. Vaccination: perspectives of Australian parents [Internet]. Melbourne VIC: The Royal Children’s to develop skills to practise evidence-based Hospital Melbourne; 2017 [cited 2017 May 29]. 6 p. medicine. We need to be able to formulate our Available from: https://www.childhealthpoll.org.au/wpopinions based on verified facts, before helping content/uploads/2015/10/ACHP-Poll6_Detailed-report_ parents to make informed decisions about FINAL.pdf vaccinations. We too can also be influenced by 7. Offit PA. The Cutter incident, 50 years later. N Engl J Med. 2005;352(14):1411-2. the vast amount of facts and misinformation 8. National Centre for Immunisation Research & disseminated about vaccinations in the media. Surveillance. Thiomersal FactSheet [Internet]. Westmead Thus, it is our responsibility to stay up-to-date NSW: NCIRS; 2009 [cited 2017 May 29]. 5 p. Available with the latest literature and separate fact from from: http://www.ncirs.edu.au/assets/provider_resources/ fiction, in order to provide the best care for our fact-sheets/thiomersal-fact-sheet.pdf 9. Madsen KM, Hviid A, Vestergaard M, Schendel D, patients. Wohlfahrt J, Thorsen P, et al. A population-based study of measles, mumps, and rubella vaccination and autism. N Acknowledgements Engl J Med. 2002;347(19):1477-82. Supervisor Prof. Raina MacIntyre, UNSW 10. Abbott T, Morrison S. No jab – no play and no pay r.macintyre@unsw.edu.au for child care [Internet]. Canberra ACT: Parliament of Australia; 2015. 2 p. Available from: http://parlinfo.aph. gov.au/parlInfo/search/display/display.

Climate Change and Vector-Borne Disease in Kiribati [Commentary] Erica Longhurst Erica Longhurst is a third year medical student at the University of New South Wales, passionate about environmental health, and who is a big fan of the great outdoors! Her loves are travelling and learning about people. She is studying in Griffith NSW this year, on clinical placement with my uni. Sheâ&#x20AC;&#x2122;s also super passionate about everything thatâ&#x20AC;&#x2122;s in this edition of Vector!

In February 2016, I went on a New Colombo Plan-sponsored climate change research trip to Kiribati, a nation of low-lying atolls in the Pacific Ocean. The islands of Kiribati are on the equator halfway between Australia and Hawaii. One of the most important things that I learnt was how being sustainable is not that difficult at all, and that the people of Kiribati are absolute professionals at living in harmony with their environment. We travelled to Kiribati to research the social, economic and environmental effects of climate change. However, this trip also taught us much about ourselves and the society that we live in, Australia. It was an opportunity to see how those who contribute nothing to global pollution are suffering from the effects of climate change. There is a large focus in the international community on the environmental implications of climate change. Whilst this is highly significant,

the impact of climate change on the health of local communities also needs to be brought to attention. When I think of this impact on local people, Kiribati is the first place that comes to mind. Climate change is responsible for an array of health issues, primarily the rise in communicable diseases as a result of the climate change-induced El Nino Southern Oscillation (ENSO) effect.[1] Vector-borne diseases such as malaria and dengue fever are particularly relevant. Increase in average global temperatures due to raised levels of greenhouse gases essentially accommodate these epidemics.[2] Without firstly responding to the health issues that these populations face as a result of climate change, many of the other issues cannot be addressed. In Kiribati, it is crucial to take measures to avoid future health consequences such as communicable diseases, as these people are so susceptible to the effects of climate change.

The people of Kiribati are said to be the most vulnerable to the implications of climate change because of the close proximity of the inhabitants to the coastal regions of their islands. The ENSO effect is characterised by irregular warming of the eastern equatorial Pacific Ocean, and is responsible for raising average temperatures and inducing higher rainfall in the Asia Pacific region. Kiribati itself is only two metres above sea level, and so faces challenges in this domain. This is a very significant issue for cooler regions where there is limited experience or resistance to vectorborne infectious diseases.[3] Vector-borne diseases have many factors at play, such as host resistance, the environment, urbanisation and the pathogens themselves. The severity and prevalence of vector-borne diseases depends heavily on the climate, and thus directly correlates with the ENSO climate cycles. Temperature, rainfall and humidity are especially important concerns for vectorborne diseases.[4] According to the ‘The Sting of Climate Change’ report, ‘warmer conditions allow the mosquitoes and the malaria parasite itself to develop and grow more quickly, while wetter conditions let mosquitoes live longer and breed more prolifically’.[5] There is an overall increase in the potential for disease transmission due to the change in the ecology of vectors. This is characterised by quicker mosquito breeding cycle (thus, higher concentrations), increased biting rates, and shortened pathogen incubation periods.[6] If rainfall is excessive, pooled water can form, which creates breeding sites for mosquito larvae. There are many factors that operate in these scenarios, and so there is no one direct link between climate and mosquito populations. For both dengue and malaria, some of the most effective control measures to reduce the burden are long-lasting insecticidal bednets, indoor residual spraying with insecticides, seasonal malaria chemo-prevention, intermittent preventive treatment for infants and during pregnancy, prompt diagnostic testing, and treatment of confirmed cases with effective anti-malarial medicines.[7] These measures have dramatically lowered malaria disease

burden in many Pacific Islander settings over the years. Thus, prevention is limited to vectorcontrol measures, which are very difficult to monitor. Visiting Kiribati gave me insight into the reality of climate change and its current impacts on health. It is clear that there is a distinct connection between climate change and vector-borne diseases. This poses particular challenges for developing nations where consequences of climate change are most pronounced. My experiences in Kiribati showed us raw, personal stories, and we strongly believe it is imperative to take action immediately. Acknowledgements None Conflict of Interest None declared Correspondence e.longhurst1012@gmail.com References 1. Reiter P. Climate change and mosquito-borne disease. Environmental health perspectives; 2011. 141 p. 121 2. Ebi KL, Lewis ND, Corvalan C. Climate variability and change and their potential health effects in small island states: information for adaptation planning in the health sector. Environmental Health Perspectives; 2006, 1957-1963 p. 3. Haines A, McMichael AJ, Epstein PR. Environment and health: 2. Global climate change and health. Canadian Medical Association Journal; 2006, 729-734 p. 4. Woodruff R, Whetton P, Hennessy K, Nicholls N, Hales S, Woodward A, Kjellstrom, T, Human health and climate change in Oceania: a risk assessment. Canberra: Commonwealth Department of Health and Ageing; 2003. 5. Perry M. Malaria and dengue the sting in climate change. Reuters; 2008. Available from: http://www.reuters.com/article/us-climate-diseaseidUSTRE4AJ2RQ20081120 6. Bezirtzoglou C, Dekas K, Charvalos E. Climate changes, environment and infection: Facts, scenarios and growing awareness from the public health community within Europe. Anaerobe; 2011, 2 p. 7. Githeko AK, Lindsay SW, Confalonieri UE, Patz JA. Climate change and vector-borne diseases: a regional analysis. Bulletin of the World Health Organization; 2000. 1136-1147 p.

REFUGEE AND ASYLUM SEEKER UPDATE MARCH 2017 IMPORTANT UPDATE •

The Immigration Department reduced the deadline asylum seekers must apply for protection visas from 1 year to

60 days.1 •

Affects thousands of asylum seekers.1

•

Those who don’t make the deadline may have their claim overturned giving them no right to work or medicare1

•

These applications are up to 60 pages long with complex medical terms in English, requiring legal advice for completion, overloading already saturated legal services1

•

IHMS, contracted to provide primary health care +

•

mental health services on Manus Island and Nauru has been found to be not registered by the PNG

medical board.2 - Therefore, 103 staff working at the centre have been employed illegally.2

Recent Dengue outbreak on Nauru (late Feb).3 Infecting 70 people on Nauru including 10 refugee and asylum seekers. - Unconfirmed reports up to 8 asylum seeker medevaced to Australia mainland for treatment.3 Young male asylum seeker on Manus Island flown to

•

Amnesty International released a report labelling Australia’s offshore detention policy as inhuman and abusive5 o Highlights governments refusal to honour offer from NZ to resettle 150 refugees and asylum seekers5 o Treatment of these people involves

systematic neglect and cruelty designed to inflict suffering5

Australia for treatment 9th Feb following long

standing series of doctors referring the man to get a

pacemaker since August 2016.4 - The man collapsed Feb 1 and was finally transferred. This is another example, just like

that of Faysal Ahmed, of complaints being

ignored for a long time4

Hart, C. (2017, February 26). Asylum seekers’ applications doomed to fail after visa deadline changes, says refugee support service. ABC news. Retrieved from www.abc.net.au/news/2017-02-26/asylum-seekers-issued-with-new-deadline-for-visa-applications/8304766 2 Armstrong, K. (2017, March 3). Manus Island health provider ‘operating illegally for three years’: report. SBS news. Retrieved from http://www.sbs.com.au/news/article/2017/03/02/manus-island-health-provider-operating-illegally-three-years-report 3 Riman, I. (2017, February 28). A physical attack and a Dengue-fever outbreak cause fear among Nauru detainees. SBS news. Retrieved from http://www.sbs.com.au/yourlanguage/arabic/en/article/2017/02/28/physical-attack-and-dengue-fever-outbreak-cause-fear-among-nauru-detainees 4 Booth, A. (2017, February 12). Manus Island asylum seeker with cardiac condition flown to Australia. SBS news. Retrieved from http://www.sbs.com.au/news/article/2017/02/17/manus-island-asylum-seeker-cardiac-condition-flown-australia 5 Jama, H. (2017, February 23). Amnesty critical of Australia’s asylum seeker policy. SBS news. Retrieved from http://www.sbs.com.au/yourlanguage/somali/en/content/amnesty-critical-australias-asylum-seeker-policy 6 Feng, L. (2017, March 8). Hungary toughens laws on asylum seekers again. SBS news. Retrieved from: http://www.sbs.com.au/news/article/2017/03/08/hungary-toughens-laws-asylum-seekers-again 7 Picture: Deacon, L. (2017, February 10). Migrants entering Hungary to be detained in shipping containers on border. Retrieved from http://www.breitbart.com/london/2017/02/10/migrants-entering-hungary-detained-shipping-containers-border/

Humanity Lost? [Feature article] This article was originally published in the Doctus Project (February 2017) Patrick Walker Patrick is a medical student at Monash University, and the Editor in Chief of non-profit health journalism organisation the Doctus Project. He is also the Global Health Policy Officer for the Australian Medical Students’ Association, attended the World Health Assembly recently in Geneva, and late last year completed a policy internship at the Grattan Institute. Health-wise, his interests lie mainly in global health and health policy, and outside of the classroom (or hospital) he’s either reading a novel, writing about something new, or sitting at the piano crunching out a tune or two. This year he is completing a Bachelor of Medical Science (Hons) with the Centre for International Child Health and the Royal Children’s Hospital, looking at oxygen systems and provision of care in low-resource settings. Looking forward, perhaps this line of work might form the basis of a career, though there’s plenty of time for that to change. ‘We started the revolution holding roses. Hoping for support from the international community. Years passed. The roses turned into guns. But the hope for support continues. Still, neither roses nor hope helped.’ - Abdulazez Dukhan, Syrian refugee

Abdulazez Dukhan is one of 4.5 million people who have fled Syria since the current conflict began in 2011. He is one of the countless people whose lives have been destroyed beyond recognition; one of the countless people forced to leave everything behind, in search of a safe place to live. In January, Abdulazez penned a moving letter to the new American president, Donald

Trump, with a simple and powerful message: he wanted to be heard. He wasn’t asking for an end to the conflict in his ‘beloved Syria’. He was simply asking for the West – and its perceived leader, Trump – to acknowledge the human side of the war. He was asking for humanity in the West’s response to his story.

‘Your words matter for us,’ he writes. ‘You might be able to change our future ‘Dear future president, we hope that someone can hear our words. We hope that you do.’ Sadly, his plea has largely fallen on deaf ears.

Just two weeks after Dukhan’s letter was published by Al Jazeera, Trump signed an executive order banning people from seven predominantly Muslim countries, including Syria, from entering the United States (US) for 90 days. The order also placed a blanket ban on all refugees for 120 days, and Syrian refugees indefinitely.

of the highest number of forcibly displaced persons since World War II and unfathomable atrocities occurring throughout the Middle East, northern Africa and many other parts of the world. For many people – most notably the young and highly educated – these events were taken to be a clear marker of racism and an unwillingness to accept difference. But they were also each the result of a free, democratic vote. They reflected the view of the majority. Further, to pass them off as simply racist, or a blip in the global political agenda, would be naive and counter-productive.

The ban is currently suspended thanks to a federal judge temporarily blocking the executive order, but Trump’s message can be heard loud and clear. His response to the Syrian War and the current refugee crisis is to look the other way; to close the doors to those most in need of help.

When I first watched the video of Abdulazez Dukhan’s letter to Trump, I was brought to tears. Dukhan’s poignant words brought the horrors he had endured suddenly to life. For a moment, I felt I was able to gain a tiny glimpse into the harsh reality of life for the millions of Syrians living in a conflict zone.

Perhaps this should not come as too much of a surprise. Trump’s protectionism and stance on immigration are neither novel nor unexpected. Rather, they can be viewed as a symptom of a broader rise in nationalism, in response to a global refugee crisis that continues to worsen. 2016 was a year of many things, but prominent among them were nationalism, division, and an increasingly powerful global Right. Brexit and the rise of an assortment of right-wing parties defined politics in Europe. Across the Atlantic, Trump was elected to the Oval Office on a fervent anti-establishment and pro-US, protectionist agenda. Back home in Australia, we saw the re-emergence of Pauline Hanson and her far-right, anti-immigration One Nation party. All these events occurred in the context

This visceral response is by no means unusual or unexpected. It is the same as the West’s response to the ‘boy in the ambulance’

(five year-old Omran Daqneesh, injured by a blast in Aleppo in August last year) or to horrific images of the dead body of three year-old Aylan Kurdi washed up on a Turkish shore.

want to understand the recent rise of right-wing populist movements, then ‘racism’ can’t be the stopping point; it must be the beginning of the inquiry.’

It is human nature to feel outrage at injustice when it is put in front of us. It is not, however, human nature to react the same way to atrocities removed from one’s own existence and social or political sphere. Without these images and videos that become – for better or for worse – perverse icons of death and destruction, it is all too easy for us to simply turn away.

Rather than labelling the majorities who voted for Brexit, Trump or Hanson as racist or ignorant, we as a society need to understand their motives, and why they have turned to the Right for answers. We need to understand why so many of us are seemingly willing to turn a blind eye to horrors occurring outside of our immediate vicinity. We need to understand why we have lost compassion in our response to the plight of Syria.

This tendency means we often lose sight of the human side of tragic events to which we find ourselves unable to relate. This is exactly what we have seen in our politicians and our leaders. And it is in many cases exactly what we have seen in ourselves. Instead of compassion and unity, we have responded to horrors such as those going on in Syria with disaffection and, at times, apathy. Instead of reaching out to those in need, we have instead turned inwards, creating division and, on the other end, despair. The unprecedented political phenomenon of 2016 is perhaps best encapsulated by social psychologist Jonathan Haidt. In a remarkably insightful and prescient essay entitled ‘When and why nationalism beats globalism’, Haidt unpacks the rise in nationalism we have seen in the past year, and tries to answer the simple question: ‘What on earth is going on in the Western democracies?’ By resisting change and immigration, Haidt argues that nationalists are not, as many believe, being selfish or somehow morally inferior to those embracing change. Far from it. Rather than inciting discrimination, he writes, they are working to preserve their nation and culture. The division between nations that can arise from this attitude is a by-product, rather than an intended consequence. The way to tackle this, then, is not to label nationalist or anti-immigration sentiment as ‘racism pure and simple’. As Haidt notes, ‘If we

2017 can be different from the division we saw in 2016, but only if we resist the urge to vilify the ‘Other’, regardless of who that ‘Other’ is – a Muslim refugee, a status quo conservative, a member of the educated elite, or a right-wing authoritarian. Instead, creating a space of mutual understanding between people of differing opinions may help bridge the gap that has formed between the Right and the Left; the Nationalists and the Globalists; the Educated and the Uneducated; the East and the West. By doing this, we will start on the path towards finding an adequate response to Dukhan’s plea to Trump. And, somewhere along the way, maybe we will find that humanity that seems to have gone missing. Photo credit Abdulazez Dukhan Acknowledgements Doctus Project Conflict of Interest None declared Correspondence patrick.walker@amsa.org.au

Redefining Women’s Health: A Noncommunicable Diseases Perspective [Feature Article] Charlotte O’Leary Charlotte has completed 4 years of medical school at Monash University. She is currently undertaking a Bachelor of Medical Science (Honours) at the Uehiro Centre for Practical Ethics at the University of Oxford. Charlotte undertook a 3-month internship at the World Health Organization in early 2017 in the Global Coordination Mechanism for the prevention and control of noncommunicable diseases (NCDs). Noncommunicable diseases (NCDs) – Nearly two thirds of illiterate people in the mainly cardiovascular diseases, cancers, world are women, and this ratio has remained chronic respiratory diseases and diabetes – unchanged for two decades.[2] Consequently, represent a major challenge for sustainable women have had fewer opportunities to improve development in the twenty-first century. In 2015, their health literacy and equip themselves with NCDs were responsible for 39.5 million (70%) transferable skills that will enable them to be of the world’s deaths, with more than 40% (16 advocates for their own health. million) dying prematurely, or before the age of 70.[1] NCDs affect people of all ages in high, Women face unique challenges accessing middle and low-income countries. In particular, healthcare due to their lower socioeconomic, women and girls face unique challenges in political and legal status compared the growing NCD epidemic due to pervasive gender NCDs have been the to men. The critical importance of inequality, disempowerment and leading causes of death prevention and early diagnosis of discrimination. Without specific among women globally for the NCDs requires regular contact with attention to the needs of women past three decades, and now, the healthcare system. In some and adolescent girls, the impact NCDs account for nearly 65% cultures, the health of a woman is often seen as secondary to the of NCDs threatens to unravel the of female deaths worldwide. health of a man, and she may be fragile health gains made over denied access to healthcare when resources the past decades and undermine future efforts are limited. Even when given the choice, to ensure gender equity and healthy lives for all. women are more likely than men to invest their money in the health of their children and other The problem family members, rather than prioritising their own health. Gender inequality and NCDs NCDs have been the leading causes of death among women globally for the past three decades, and now, NCDs account for nearly 65% of female deaths worldwide. Pervasive gender inequality particularly affects the health of women and girls, influencing their ability to improve their health literacy, access healthcare services, achieve economic empowerment and financial security and live with NCDs free from stigma and discrimination.

Many women may experience financial vulnerability due to high out-of-pocket healthcare costs. Lower access to formal paid employment may deny women the social and financial securities required to insure them against poor health. Additionally, women are too frequently viewed as commodities, and women living with a chronic disease may face alienation 14

and discrimination. This is often due to the emphasis in certain social or cultural settings on a woman’s suitability for marriage and childbearing, which may be affected by chronic diseases.

The caring burden Beyond their personal experiences with NCDs, women are indirectly affected by the increase in the burden of chronic diseases due to their traditional role as carers in families and communities. In a survey of 10,000 women from around the world, half the women were caring for a family member with an NCD, with one in five realising their own economic opportunities were diminished as a result.[3] Another study from the United States revealed that women make 80% of the health care decisions for their families, yet often go without health care coverage themselves.[4] Caregiving responsibilities can threaten or disrupt the education of adolescent girls, and often impacts women in their most productive years. Paid work decreases because of the burden of caring for people living with NCDs and reduces the economic contribution of women. This loss of productivity is felt by the whole society. The large amount of unpaid work undertaken by women in the family and community at all levels of society is highly under-appreciated.

Vulnerability to NCD risk factors Women are uniquely vulnerable to the four major risk factors for NCDs, namely physical inactivity, poor nutrition, tobacco use and excessive alcohol intake. Improved social status and economic empowerment has contributed to an alarming increase in cigarette smoking amongst women and girls. The World Health Organization (WHO) estimates that the proportion of female smokers will rise from 12% in 2010 to 20% in 2025. Deaths attributable to tobacco use amongst women are also projected to increase from 1.5 to 2.5 million from 2004 to 2030.[5] Women’s increasing social and economic status, especially in low and middleincome countries, has made them a prime target for the tobacco industry. This is especially true

in Asia where regulation of tobacco advertising is lacking. Aside from the immoral promotion of health-harming products, the objectification of women is entrenched in tobacco advertising. Women’s bodies are exploited for the sale of cigarettes to men, whilst simultaneously and paradoxically, a message of health and beauty through tobacco consumption is conveyed to women and girls.[5] A similar trend is seen in alcohol consumption, with female alcohol consumption now rivalling male consumption, closing a historic divide. [6] Women and girls around the world are less likely to be physically active than boys and men due to sociocultural, economic and physical limitations imposed on them. In many cultures, women are largely responsible for food preparation. As a consequence, women often eat least and last in the family, compromising their nutrition. Additionally, inhalation of indoor cooking fuels is a well-known risk factor for chronic respiratory disorders, and this risk is borne disproportionately by women.[7] The list goes on. The way forward So how might we move forward at this critical time to ensure that we are effectively addressing the unique needs of women in the NCD epidemic? This problem is evidently complex and multifaceted. Presented here are some possible approaches, to firstly broaden our understanding of women’s health to include NCDs, and secondly to ensure that women are empowered and engaged in their own health.

Defining women’s health One important step forward is to adopt a broader and more holistic definition of women’s health. Historically, the field of women’s health has focused on reproductive health, and consequently, considerable gains have been made in reducing maternal and newborn mortality and morbidity. While these gains are positive and important, it is equally important that the definition of women’s health not be confined to reproductive health. As Norton et al. 15

posit in Women’s Health: A New Global Agenda, the currently narrow approach to women’s health firstly limits opportunities to effectively improve the health of the maximum number of women, and secondly, discriminates against women who do not have children.[8]

communities. One such approach might be to follow up women with gestational diabetes after birth and to provide screening checks and education around good nutrition for mothers and children in order to prevent the development of diabetes. There is growing evidence for the feasibility and effectiveness of health system integration to prevent and control NCDs. [9,10]

In recent years, many international advocacy efforts have thus been made to expand this definition, and encompass a more holistic view Women in medical research of the health challenges faced by women. Such focus areas include, but are not limited to: the There is scope for the broader scientific and burden of NCDs in women, including mental research community to ensure that women are health; the caring roles of women; and sexual equally represented in medical research. It is and interpersonal violence. Additionally, the increasingly apparent that NCDs do not affect health of women must be considered across men and women equally. Women who smoke the whole life course. A reproductive focus have a 25% greater relative risk of ischaemic risks excluding pre-adolescent girls heart disease than men who and older women, all of whom face The impact of educating smoke.[11] Women suffer unique challenges in navigating women has multigenerational worse cardiovascular disease their health in a climate of gender effects due to their central as a consequence of type 2 inequity. Indeed, women who have position in the community, so diabetes than men,[12] and been through menopause have improving women’s engagement women with type 1 diabetes substantially increased risk of with health promotion is a high have a roughly 40% greater risk NCDs. Thus a focus on older women yield intervention. of all-cause mortality than men. should be an integral of a life course [13] However, taking a focused approach to women’s health. biomedical approach is not sufficient to address the burden of NCDs in Integrating NCDs into other health programs women. Medical research must also consider the social and cultural effects of gender There are great opportunities to capitalise on inequity in order to fully appreciate the health existing healthcare services to better address outcomes of women with NCDs. Increasing the needs of women in the NCD epidemic. There attention to gender-disaggregated of research is enormous opportunity to expand existing data has been recognised in the Sustainable reproductive, communicable disease (such Development Goals as an important tool for as HIV and tuberculosis) and sexual health discovering these important gender disparities services to incorporate NCDs. In particular, in illness.[14] maternal and reproductive healthcare services are targeted at women, allowing healthcare Engaging women at every level to be delivered in an environment that is acceptable to, and accessible by, women and Lastly, increasing female participation in adolescent girls. Given the unique challenges decision-making will ensure the challenges faced by women in the NCD epidemic, these faced by women are reflected in policies existing services can be broadened to include for health and sustainable development. health promotion activities around NCD risk Participation happens at every level. In local factors, early diagnosis and screening services communities, women are attuned to the needs of (including breast and cervical cancer screening) other people, and as evident above, make many and referral and treatment services. This will of the health related decisions in the community. ensure that women are empowered to improve There is a huge opportunity to harness their the health of themselves, their families and strength and knowledge to be a driving force 16

for the prevention of NCDs. The impact of educating women has multigenerational effects due to their central position in the community, so improving women’s engagement with health promotion is a high yield intervention. There must be a concerted global effort to remove barriers to female participation in politics and high-level decision-making. Until this is achieved, it will be challenging to ensure that the multifaceted effects of gender inequity are accounted for in national and international policy. Conclusion Noncommunicable diseases are one of the biggest threats to health in an increasingly globalised world. Addressing gender inequity will be a necessary component of the solution. The health of women concerns everyone, and is far more than an economic, political or cultural issue. Ultimately, ensuring every woman and girl has the right to access the utmost level of health and wellbeing is an issue of human rights and justice. Acknowledgements None Conflict of Interest None declared Correspondence charlotte.a.oleary@gmail.com

2014;25(4):1507-13. 5. World Health Organization. Gender, women, and the tobacco epidemic. World Health Organization; 2010. 6. Slade T, Chapman C, Swift W, et al Birth cohort trends in the global epidemiology of alcohol use and alcohol-related harms in men and women: systematic review and metaregression BMJ Open 2016;6:e011827. doi: 10.1136/bmjopen-2016-011827 7. World Health Organization. Household air pollution and health [Internet]. Geneva: World Health Organization. 2017 [cited 27 May 2017]. Available from: http://www.who. int/mediacentre/factsheets/fs292/en/ 8. Peters SA, Woodward M, Jha V, Kennedy S, Norton R. Women’s health: a new global agenda. BMJ Global Health. 2016 Nov 1;1(3):e000080. 9. Chamie G, Kwarisiima D, Clark TD, Kabami J, Jain V, Geng E, Petersen ML, Thirumurthy H, Kamya MR, Havlir DV, Charlebois ED. Leveraging rapid community-based HIV testing campaigns for non-communicable diseases in rural Uganda. PloS one. 2012 Aug 20;7(8):e43400. 10. Janssens B, Van Damme W, Raleigh B, Gupta J, Khem S, Soy Ty K, Vun MC, Ford N, Zachariah R. Offering integrated care for HIV/AIDS, diabetes and hypertension within chronic disease clinics in Cambodia. Bulletin of the World Health Organization. 2007 Nov;85(11):880-5. 11. Huxley RR, Woodward M. Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies 12. Woodward M, Peters SA, Huxley RR . Diabetes and the female disadvantage. Women’s Health (Lond Engl). 2015; 11: 833-839. 13. Huxley RR, Peters SA, Mishra GD, Woodward M. Risk of all-cause mortality and vascular events in women versus men with type 1 diabetes: a systematic review and meta-analysis. The Lancet Diabetes & Endocrinology. 2015 Mar 31;3(3):198-206. 14. United Nations. Transforming our world: the 2030 Agenda for Sustainable Development. Geneva: United Nations. 25 Sept 2015.

References 1. World Health Organization. NCD mortality and morbidity [Internet]. Geneva: World Health Organization. 2017 [cited 27 May 2017]. Available from: http://www.who. int/gho/ncd/mortality_morbidity/en/ 2. The World’s Women 2015. 2015. United Nations Statistics Division [Internet]. Accessed from: https:// unstats.un.org/unsd/gender/chapter3/chapter3.html 3. Insights from 10,000 women on the impact of NCDs [Internet]. Arogya World. 2014. Accessed from: http://arogyaworld.org/wp-content/uploads/2014/12/ Arogya-Full-Report-For-Web.pdf 4. Matoff-Stepp S, Applebaum B, Pooler J, Kavanagh E. Women as health care decision-makers: Implications for health care coverage in the United States. Journal of health care for the poor and underserved.

Healthcare in Conflict Zones [Feature Article] Michael Wu Michael Wu graduated with a B.Pharm from the University of Sydney in 2012 with a major from the Clinical Excellence Commission focusing on IV to Oral Switch Therapy. Since then, my passions have grown from Infectious Diseases to just about everything. It’s a problem. I’d like to work all over the world at some stage, whether in Trauma or Ophthalmology. Introduction Medical neutrality in war-ravaged areas is the cornerstone of healthcare provision in conflict zones. However, weaponisation of healthcare – the deliberate destruction or removal of access to healthcare as a means of hamstringing opponents – has emerged as a concerning and common practice in modern military engagements. Medical neutrality was formalised in 1864 with the inception of the First Geneva Convention, which sought to establish a permanent ‘neutral’ agency that would deliver medical aid and services to sick and wounded combatants.[1] There was consensus amongst governments that armed conflict, no matter how violent, must maintain some semblance of compassion and humanity. This recognition was at the core of the message the Geneva Convention sent; that a line must be drawn in war and conflict. Recent years have seen military forces and governments ignore this sentiment, with clear violations of the Geneva Convention, from deliberate bombings and executions of doctors, nurses, pharmacists, medical students, and pharmacy students in Syria and Somalia, for example. Indeed, it would appear that many countries are either implicated in, or turn a blind eye to, atrocities resulting from violations of the Geneva Convention. Dr Kathleen Thomas has experienced this degeneration in the standard of warfare first-hand. Her story has become a landmark in this field. As an Australian doctor, she was responsible for an Intensive Care Unit at a

Medecins Sans Frontieres (MSF) hospital in Kunduz, Afghanistan, when it was bombed by an American AC130 gunship in October, 2015. MSF had released the GPS coordinates of their hospital to American forces in the region days prior; their location was known. Repeated air strikes resulted in 42 fatalities, including 12 staff, 24 patients and 4 caretakers, with dozens more wounded. MSF maintains that the attack was deliberate and has called for independent investigations by multiple bodies.[2] One must question why American forces, or indeed any government, would condone the attack of healthcare facilities. Similarly, however, it is important to realise that from a military perspective, this weaponisation of healthcare makes sense: it removes a valuable resource to guerrilla forces, that of neutral healthcare. Healthcare and conflict in Syria Syria is now the most dangerous nation in the world according to the Global Peace Index. [3] The Syrian civil war has left much of the country’s population displaced since beginning in 2011. As early as March that year, the country saw its first documented execution of a doctor. Subsequently, the attrition of healthcare in Syria has been the result of direct and violent attacks on health workers, as well as a mass exodus of health workers fleeing persecution. These direct attacks are mostly carried out by pro-government forces, and have manifested as “attacks on health facilities, executions, imprisonment or threat of imprisonment, unlawful disappearance (i.e. kidnapping), abduction, and torture sometimes leading to 18

deathâ&#x20AC;? [4]. According to data from Physicians abandoned their studies, either because there for Human Rights, 796 health workers were are no longer doctors to teach them, or because killed between March 2011 and December there is such an urgent need to replace missing 2016. Of these deaths, shelling and bombing health workers that students are required to accounted for just over provide care. This has amplified the half (55%), followed by potential for suboptimal outcomes, In 2009, Syria had 29,927 shooting (23%), torture with inexperienced doctors and doctors,[8] a figure that has fallen (13%), and execution medical students forced to practice by 15,000 due to persecution and (8%).[5] In addition to outside of their scope of proficiency, war, as reported by Physicians for health worker fatalities, increasing the risk of complications Human Rights in 2015.[9] military forces have also for patients. Indeed, surgical targeted health facilities. complications and infections have This escalated in late September 2015, when become more common, potentially reflecting Russia intervened militarily to provide support shortcomings in medical training.[4] for the Syrian government, with 2016 data showing an 89% increase in verified attacks Responses to healthcare weaponisation on healthcare facilities. The Syrian Network for Human Rights documented â&#x20AC;&#x153;289 attacks on In the face of these atrocities, what is there medical facilities, ambulances and Syrian Arab to do? In keeping with observations regarding Red Crescent bases, 96% of which were by healthcare in conflict zones, particularly in the Syrian or Russian forcesâ&#x20AC;?.[6] In contrast to the context of healthcare weaponisation, health attacks in Afghanistan, such as that of the MSF policy released by The Lancet and American Hospital in Kunduz, these documented attacks University of Beirut (AUB) Commission became so blatant that the United Nations (UN) has explored priorities for maintaining and Security Council condemned them in Resolution promoting healthcare despite the challenges 2286 on May 2016.[7] of conflict. Strengthening accountability with respect to the protection of health workers has In 2009, Syria had 29,927 doctors,[8] a figure been noted as the key priority in combating the that has fallen by 15,000 due to persecution surge in violence towards health workers and and war, as reported by Physicians for Human facilities. Multiple nations and key advocates, Rights in 2015.[9] This vacuum of physicians such as the UN Secretary General and the UN has led to the development of gaps High Commissioner of Strengthening accountability Human Rights, have and deficits in the skills and numbers of healthcare personnel available to serve with respect to the protection of supported and referred the civilian population, which is already health workers has been noted as numerous war crimes under duress from open conflict and the key priority in combating the from the Syrian conflict aerial bombings. However, a deeper look surge in violence towards health to the International at this gap reveals a disparity between workers and facilities. Criminal Court. These government controlled areas and nonattempts have been government controlled areas. In 2015, the obstructed by Russia and China, two of the five non-government controlled region of Eastern permanent members of the UN Security Council. Aleppo had a doctor-to-patient ratio of 1:7000; Indeed, the UN Security Council has issued just 5 years prior, the ratio was 1:800. Research multiple resolutions demanding humanitarian from The Syrian Centre for Policy Research has access and condemning chemical warfare, the demonstrated a gross disparity in healthcare latter of which is particularly pertinent given cover, with 31% of Syrians living in areas with recent chemical attacks in Syria. However, insufficient health workers and 27% living these resolutions have resounded emptily in areas with a complete absence of health due to political and diplomatic obstruction. workers.[4] Fouad et al., publishing under the Lancet/AUB Commission, suggest that responsibility falls Many medical students in Syria have to the civic society and medical community 19

to bring governments and warring factions to account, and to end war crimes against both health workers and civilians. Groups in the Netherlands, Belgium, Spain, France, and Sweden have already had some success in bringing the agenda of health workers in conflict zones to peace negotiations.[4] Other recommendations include supporting health workers in conflict zones with resources, and reinforcing their capacity to deliver a wide range of services beyond trauma management. The Syrian conflict has highlighted the shortand long-term complexities of healthcare in conflict zones, and it is not feasible to allow other domains of care, such as maternal and neonatal care, to suffer as a consequence of conflict, or to allow vaccine-preventable endemics to resurge, as has happened in Nigeria.

populations they serve. Conclusion Fighting against this paradigm shift away from medical neutrality is an arduous and daunting task. Even with strong backing from top UN position holders and many governments, offending parties still roam free of retribution and accountability. Despite feeling like a David vs. Goliath battle, the fate of healthcare in conflict relies upon the empathic and moral consideration of medical neutrality, a responsibility which belongs to every health worker, medical student, and civilian. “The standard you walk past is the standard that you accept” – General David John Hurley (AC).

Acknowledgements None Institutions, including Finally, but perhaps most importantly, military organisations, more research on health workers in should actively encourage conflict is required, with an emphasis Conflict of Interest and promote the concept on developing understanding across None declared of medical neutrality, and multiple nations and conflict zones, work to minimise disruption given the heterogeneity in warfare and Correspondance miwu5665@uni.sydney.edu.au to healthcare services. its effects on healthcare. It must also be realised References that promoting global solidarity with health workers will help to develop an environment 1. Shaw M. Geneva Conventions. In: Encyclopaedia within which protection in times of conflict is Britannica [Internet]. Chicago: Encyclopaedia Britannica more readily achieved. Initiatives such as the Inc; 2004. Available from: https://www.britannica.com/ Safeguarding Health in Conflict Coalition and event/Geneva-Conventions. (Accessed March 30th the Red Cross’ Health Care in Danger Project 2017) 2. Thomas K. What was lost in the Kunduz Hospital should be developed further to prevent targeting Attack [Internet]. Medecins Sans Frontieres; 2016. of health workers, or at least to facilitate early Available from: https://www.msf.org.au/article/storiesmobilisation and response to violence against patients-staff/what-was-lost-kunduz-hospital-attack. health workers and facilities. (Accessed March 30th 2017) Finally, but perhaps most importantly, more research on health workers in conflict is required, with an emphasis on developing understanding across multiple nations and conflict zones, given the heterogeneity in warfare and its effects on healthcare. Such data will allow governments and organisations to draw precedence for future conflicts, and will lend weight to arguments advocating for the protection of health workers and the civilian

3. Institute for Economics & Peace. Global Peace Index 2016 Report. IEP Report 39. 2016. Available from: http://visionofhumanity.org/app/uploads/2017/02/GPI2016-Report_2.pdf. (Accessed March 30th 2017) 4. Fouad F, Sparrow A, Tarakji A, Alameddine M, El-Jardali F, Coutts A, et al. Health workers and the weaponisation of health care in Syria: a preliminary inquiry for The Lancet –American University of Beirut Commission on Syria. Lancet. 2017. DOI: http://dx.doi. org/10.1016/ S0140-6736(17)30741-9 5. Anatomy of a Crisis: A Map of Attacks on Health Care in Syria [Internet]. Physicians for Human Rights. Available from: https://s3.amazonaws.com/PHR_syria_

map/findings.pdf (Accessed 30th March, 2017). 6. Reports on vital facilities attacked August 2014 through December 2016 [Internet]. Syrian Network for Human Rights. Available from: http://sn4hr.org/blog/ category/report/monthly-reports/vital-facilities-monthlyreports/ (Accessed 30th March 2017) 7. United Nations. Security Council adopts resolution 2286 (2016), strongly condemning attacks against medical facilities, personnel in conflict situations [Internet]. 2016. Available from: https://www.un.org/press/ en/2016/sc12347.doc.htm (Accessed 30th March 2017) 8. Annual Report, 2009. Ministry of Health Syria; 2009. Available from: http://www.moh.gov.sy/Default. aspx?tabid=251&language=en-US (Accessed 30th March, 2017) 9. Kupferman S. Syriaâ&#x20AC;&#x2122;s neighbors must let doctors practice [Internet]. Physicians for Human Rights. 2016. Available from: http://physiciansforhumanrights.org/ press/press-releases/syrias-neighbors-must-letdoctors-practice.html (Accessed 30th March 6, 2017)

Surgery: Luxury or Necessity? [Feature Article] Maryam Ali Khan (Pakistan), Zineb Bentounsi (Morocco), Nayan Bhindi (Australia), Helena Franco (Australia), Tebian Hassanein Ahmed Ali (Sudan), Katayoun Seyedmadani (Grenada/USA), Ruby Vassar (Grenada), Dominique Vervoort (Belgium) -InciSioN international team members

InciSioN, the International Student Surgical Network, is a student-led organisation of medical students and young doctors from around the globe with one shared passion, Global Surgery. InciSioN embodies the aim of educating about, advocating for, and performing research in Global Surgery. Among the 33 members of InciSioN, we share 23 countries spanning over 12 time zones, in 5 continents, and speak over 15 languages.

The seminal report published by the Lancet Commission on Global Surgery (LCoGS) in April 2015 highlighted that an estimated 5 billion people continue to lack access to safe and affordable surgical and anaesthetic care when required.[1] Often, surgical care is associated with costly procedures and stateof-the-art equipment. While that might be true for a subset of procedures, there are many lifesaving procedures that are considered basic public health needs and can be performed cost-effectively with a simpler set of equipment. Through domains of research, education and advocacy, the relatively recent movement of Global Surgery endeavours to address and alleviate these vast disparities in surgical equity, particularly in low and middleincome countries (LMICs). Here, we would like to evaluate surgical care on a global scale from a basic public health standpoint. Basic surgical care and safe surgery Surgery is defined by the World Health Organization (WHO) as â&#x20AC;&#x153;any procedure occurring in the operating room involving the incision, excision, manipulation or suturing of tissue that usually requires regional or general anaesthesia or profound sedation to control painâ&#x20AC;?.[2] Surgery is rendered across all disease categories, and is an indispensable component of health care. Essential surgical care is a

distinct concept, meaning surgery necessary to prevent imminent death or disability. Without access to essential surgical care, readily treatable diseases can pose serious threats to health. Safe surgery involves avoiding complications or adverse events that can arise before, during and after surgical procedures. Thus, safety measures are implemented before anaesthesia, before incision, during surgery and in the provision of post-operative care. The WHO estimates that every year almost 7 million surgical patients suffer significant complications, most commonly including infection, bleeding and various complications of anaesthesia. More than half of these adverse events are preventable. In view of this, the WHO has implemented Guidelines for Safe Surgery (2009) to define core safety standards, with 10 essential objectives that can be implemented in any country and any surgical setting. These serve to reinforce the standardisation of safe practices, particularly in developing countries. Cost of basic surgical care Access to safe anaesthesia and surgery, or lack thereof, has a considerable economic impact on both patients and society.

Without sufficient public funding or health insurance, access to surgical services depends on the ability of patients and their family to pay. [3] High death rates for surgically treatable conditions in LMICs are often due the financial barriers of accessing surgical care. Thus affordability, and not necessarily availability, of treatment is a major focus.

health experts, leading to its absence in the Sustainable Development Goals (SDGs). However, since the establishment of the LCoGS in 2015, there has been a shift in this paradigm. With 16.9 million annual deaths (32.9% of all deaths) attributed to surgical conditions, the total burden far outweighs that of tuberculosis (TB), HIV/AIDS and malaria combined.[4] This is because easily treatable surgical diseases such as open fractures and obstructed labour cause significant morbidity and mortality due to lack of access to safe surgical care.

Surgically treatable causes of disease account for 28-32% of the global burden of disease; yet five billion people do not have access to the surgical care they need.[4] There is a common misconception that surgical The LCoGS sheds light on the startling treatment of these conditions is expensive and paucity of surgeries performed in LMICs. It not cost-effective. Beyond the found that a disproportionately incredible impact certain basic low number of surgeries are Surgically treatable causes surgeries, including caesarean performed in LMICs compared of disease account for 28sections and hernia repairs, can to the population size. A third of 32% of the global burden of have on an individualâ&#x20AC;&#x2122;s quality of the worldâ&#x20AC;&#x2122;s poorest population disease; yet five billion people life, their overall monetary cost resides in LMICs, and yet only do not have access to the over time is comparable to other 6% of all surgical procedures surgical care they need.[4] global health initiatives. worldwide are performed in these countries.[4] An additional The cost per DALY averted for basic surgeries 143 million surgical procedures are required is low in LMICs, in both small and large hospitals. annually to overcome this present need. Examples include emergency caesarean sections ($18 USD), elective inguinal hernia Failure to address such basic health and repair ($12.88 USD), and cleft lip repair ($15.44 surgical needs can potentially endanger the USD).[5] In contrast, other widely implemented economic progress of these countries. This public health initiatives can cost much more: is particularly pertinent given the growing oral rehydration therapy can cost over $1,000 population and problem of uneven healthcare USD per DALY averted, and HIV HAART therapy access in LMICs. Each year, 33 million individuals can cost over $900 USD per DALY averted.[5] worldwide face immense expenditures due to out-of-pocket payment of medical and surgical Beyond economic measures, lack of access costs, which can push them into poverty.[4] The to treatment of surgically treatable diseases LCoGS found that workforce losses attributable has a major impact on the lives of patients, their to surgical conditions reduce GDP growth by up families, and their communities. A condition as to 2%, particularly affecting growing nations. If easily addressed as a strangulated hernia can no further is taken to address surgical needs in be life-threatening to an otherwise healthy adult. LMICs, it is estimated that the global economic Such a loss of life or work productivity can have loss in terms of international GDP could soar up devastating impacts not only on the patient, but to $12.3 trillion USD from 2015 to 2030.[4] also on those who financially depend on them. These figures are alarming, and it is of Surgery in low and middle income countries utmost importance to recognise that these are not merely numbers and statistics, but that they In the past, the impact of surgical diseases represent real people affected every day. What has been vastly underestimated by global must be stressed is that although the costs of

providing surgery are high, investing in surgical services in LMICs is affordable, saves lives, and promotes economic growth.[4] To improve the current conditions, there is a great need to gather data, identify gaps in data regarding surgical access, funding and resources, and monitor progress. Global surgery in action Advocacy in recent years has demonstrated new potential for advancements in global surgery. Since its establishment in 2015, the LCoGS has been ground-breaking in demonstrating the many opportunities for improvements in global health and global surgery over the next 15 years and beyond. Progress has also been made in surgical safety. For instance, the sustained use of the “WHO Surgical Safety Checklist” led to continued improvements in surgical processes and reductions in 30-day surgical complications in Moldova, a LMIC, almost 2 years after its implementation.[6] Such improvements were seen despite the absence of continued oversight by the research team, demonstrating the important role that local leaders play in the success of quality improvement initiatives, especially in resource-limited settings. Moreover, opportunities to address health inequity and reset the global health agenda have arisen. These include global commitments to achieve Universal Health Coverage and the establishment of the Sustainable Development Goals. Realisation of the various goals to end poverty, ensure health for all, and promote sustainable economic growth, will be more achievable by ensuring delivery of safe, affordable and timely surgical care.[1] However, more improvements can still be made to further the provision of surgery worldwide. Currently, a global fund for surgery does not exist, and only a few foundations are willing to support surgery. Indeed, it took decades of advocacy to demonstrate the huge disease burden of other global health issues

such as HIV/AIDs, tuberculosis and malaria, and then to develop funding mechanisms for them. With surgeons and leaders in global health advocating for patients in LMICs, we can hope to push for financial support in the coming years in order to improve the infrastructure and access to safe surgical care. In order to improve training and facilitate sharing of resources, there should also be further collaboration between hospitals in high income countries and LMICs (“twinning programs”). [3] However, donor hospitals, surgeons, and all those involved in efforts to redistribute surgical supplies need to exercise due diligence by ensuring that their partner institutions, including hospitals, clinics and medical schools, commit to reaching the poorest populations. Additionally, it is important to integrate vertical surgical programs into broader efforts to improve public health. In doing so, several important questions need to be raised: how effectively are the partner institutions providing care? Are they meeting broader goals of public health and global health equity?[3,7,8] Finally, professional interest groups starting at the level of medical students and residents can foster interest and educate others about surgery in a global healthcare setting. One such entity is the International Student Surgical Network (InciSioN). This international team of medical students and young doctors, began as a small working group within the International Federation of Medical Student Associations (IFMSA) in 2014. Since its initiation, members of InciSioN have been passionately active in global surgery research, advocacy and education. Conclusion Considering the significant economic and disease burden of lack of access to safe surgical care, surgery is truly a necessity and not a luxury. Put simply, essential surgical care should be made accessible and available to everyone in the public sector. Whilst the challenges are huge, progress in global surgery can be made with patience, determination and

devotion to the cause. There is much hope that, through international movements led by various organisations, and with involvement of medical students, doctors, and leaders in global health, the landscape of safe surgical care will change. As members of InciSioN international team, we dream of a world where no life is lost due to lack of access to safe surgery and anaesthesia. References 1. Lancet Commission on Global Surgery. Global surgery 2030 report overview [Internet]. 2015. Available from: https://www.surgeons.org/media/21831010/ Lancet-Commission-Policy-Briefs.pdf 2. World Health Organization. WHO guidelines for safe surgery 2009 [Internet]. World Health Organisation; 2009. Available from: http://apps.who.int/iris/ bitstream/10665/44185/1/9789241598552_eng.pdf 3. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg [Internet]. 2008 Mar [cited 2017 May 28];32(4):533-536. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2267857/ pdf/ DOI: 10.1007/s00268-008-9525-9 4. Meara, JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet [Internet]. 2015 Apr [cited 2017 May 28];386:569-624. Available from: http://www.thelancet. com/pdfs/journals/lancet/PIIS0140-6736(15)60160-X. pdf DOI: 10.1016/S0140-6736(15)60160-X 5. Grimes, CE, Henry JA, Maraka J, Mkandawire NC, Cotton M. Cost-effectiveness of surgery in low- and middle-income countries: a systematic review. World J Surg [Internet]. 2013 Oct [cited 2017 May 28];38:252263. Available from: http://www.brighamandwomens. org/Research/labs/CenterforSurgeryandPublicHealth/ Documents/AGSF/2014/December/Grimes%20 CE%20CE%20of%20Surgery%20in%20LMICs%20 systematic%20review%20WJS%202014.pdf DOI: 10.1007/s00268-013-2243-y 6. Kim RY, Kwakye G, Kwok AC, Baltaga R, Ciobanu G, Merry AF et al. Sustainability and long-term effectiveness of the WHO surgical safety checklist combined with pulse oximetry in a resource-limited setting. JAMA Surg [Internet]. 2015 Mar [cited 2017 May 28];150(5):473-479. Available from: http://jamanetwork.com/journals/jamasurgery/ fullarticle/2207940 DOI: 10.1001/jamasurg.2014.3848. 7. Walton DA, Farmer PE, Lambert W, Leandre F, Koenig SP, Mukherjee JS. Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti. J Public Health Policy. 2004;25(2):137-158. 8. Farmer P. From â&#x20AC;&#x153;marvelous momentumâ&#x20AC;? to health care for all. Foreign Affairs. 2007 Mar;86(2):155-161.

Beyond the horizon and back again Interview with Professor David Hilmers [Feature Article] Ashley Wilson-Smith Prelude The globalisation of medicine, particularly within the last 50 years, has presented both students and practitioners with an exciting yet staggering - amount of career and lifestyle pathways. Be it working with Medecins Sans Frontieres (MSF) in Africa; coordinating a WHO response to a new, virulent disease; or servicing rural-remote populations in outback Australia; the variety of work within medicine is nothing short of astounding. Early life and background Speaking with Professor David Hilmers of the Baylor College of Medicine, this becomes abundantly clear. With rich and varied occupational and academic experience, Hilmers’ pathway into medicine is as fascinating as his career has been since graduation. After growing up in a small town in Iowa, Hilmers moved from undergraduate study to flight school, the United States Marines – during the Vietnam War, no less – and eventually graduate school. Here, he studied electrical engineering and mathematics, giving him a tremendous grounding in scientific practice. Whilst he expressed a desire to practice medicine from as early as childhood, Hilmers was serendipitously given opportunities that initially drove him more towards working with N.A.S.A than working in medicine, as astounding as that may seem. Contextually, the United States space program was still maturing following the peak of the Cold War, with Hilmers’ career progression perfectly aligning with the 1980’s selection period.

In space on IML-1 just before starting medical school

Moving medicine)

into

N.A.S.A

(and

eventually,

Whilst stationed in Japan on his third tour overseas, Hilmers heard that the Marines were offering forward candidates for consideration to the astronaut program. Given that his background was textbook in terms of the desired skillsets - flight/military experience, engineering and mathematics - he placed himself forward. One level after another, he cleared selection and eventually found himself as an astronaut-in-training, something which he considered entirely surprising. After a period of intense long-term preparation, training and eventually four on-orbit expeditions later, Hilmers decided that it was finally time to study medicine. Whilst it would have been incredible to hear more about this journey to N.A.S.A, it is his work following his time in space that really exemplifies the multifaceted nature of medicine and global health.

Medical career and global health research experience After graduation and specialisation in Medicine/Paediatrics at the Baylor College of Medicine, Houston, Hilmers’ career branched out across all realms of medicine. Encompassing on-the- ground experience in disease outbreak areas, applying his engineering knowledge within a medical context, working with large soft-drink distributors (Coca Cola) and then finally more traditional faculty and hospital work, Hilmers’ practice has been anything but conventional. Discussing all he has done in retrospect, he did find it amusing that his background mirrors his life outlook; a “little bit of variety” being his exact words.

The Smart Pod A notable outcome following Hilmers’ return from Liberia, however, was his ensuing attachment to a research team who were in the process of developing a rapidly deployable ‘Emergency Smart Pod’ [1]. This pod is an on-site, versatile management centre and laboratory, with revolutionary potential with regards to disease outbreak and disaster response. Given his background, Hilmers was able to provide highly practical, ongoing advice; this came in the form of refining and redesigning early iterations, and increasing functionality and practicality. The pod, as it stands now, is a feat of modern science and engineering; touting high-tech computer systems with language and literacy programs, screening facilities, crowd control and Ebola-level handling capabilities. Hilmers humorously likened it to a space module. The pods are similar to shipping containers in size, but far lighter and more durable. In fact, they are built entirely from recyclable materials that can withstand extremes both hot and cold, and can be integrated with one another should the need arise. Clearly, the ability to treat, screen and mitigate disaster on-site will strengthen frontline medical workers domestically and abroad. Coca Cola and micronutrient deficiencies

AIDS patient in Romania

Starting his global health journey by touring overseas to Africa with the Baylor AIDS initiative, Hilmers subsequently went on to see AIDSravaged Eastern Europe post-collapse of the Soviet Union, and more recently was the Chief Physician of an Ebola treatment unit in Liberia during the outbreak. Whilst acknowledging the saddening reality of AIDS treatment and outcomes in the early days, Hilmers remarked that the experience was immensely educational and worthwhile. Indeed, it inspired him to continue his work with AIDS sufferers in local Houston.

In terms of more typical research, Hilmers has been involved in a number of studies on health inequalities, with some interesting pieces focussing on effective delivery of micronutrients to nutrient-deficient communities. This work interestingly includes working with Coca Cola, given their not-so-surprising ability to source fresh, clean water for their drinks in even the most remote locations. The importance of this becomes clear with a bit of thought; considering Coca Cola’s highly efficient sourcing and distribution system, there is an opportunity to integrate fortified beverages into their product line. This has enabled access to otherwise inaccessible communities overseas, and disadvantaged communities domestically. This was notable, given the medical community’s overwhelming condemnation of Coca Cola’s

soft-drinks in day-to-day practice. It’s a case that speaks to the astounding intricacy of global health work, and the manner with which problems can be solved in the most unconventional of ways. Life experience and medicine - how does everything relate? One of the things that became apparent to me regarding Hilmers’ work is an ability to extract the positive attributes needed in previous work, and apply them to his current setting. He credits his military training with giving him a “coolness under fire”, his engineering and mathematics background with a logical thought process, and finally his N.A.S.A flight experience with a systematic, step-by-step approach to problem solving - all experiences that have shown themselves to be invaluable. Therein lies a lesson for all students: take on board every opportunity to grow your skillset, as it will lend itself in ways that may not yet seem apparent This is, in fact, one of Hilmers’ central advocacy arguments for continued work on the International Space Station, that space exploration and experimentation confers benefits to medical practice that are not foreseeable, and vice versa. For example, treatments that are developed to deal with the marked muscle atrophy, bone loss and vision impairment associated with long-term space travel, can then be applied to everyday medical practice. Going forward - individual practitioners and the profession So, what advice did Hilmers have for future medical practitioners as we move into our practicing years? Principally, it is important to work in a practice or organisation that allows you to follow your passion. Be that working solely within the W.H.O or Medecins Sans Frontieres, or perhaps academia with concurrent research and clinical duties, there is a balance that every person needs to figure out for themselves. Indeed, Australia is unique in the tremendous scope of medical opportunities available.

Depending on your location, you can experience tropical disease in the far north states, noncommunicable disease in the mid-states, and the reality of disadvantaged communities in rural-remote locations. This does beg the question as to whether global health lends itself more to international health, as it seems to be viewed traditionally, or universal well-being within your own context or circumstance. There are no borders, rules or regulations as to what constitutes “global health”, only the limits of our imagination and creativity. Regardless, if you want to work in global health, the first step is finding an area of medicine you have a burning passion for – the rest will follow as natural sequelae.

Ebola protective gear

As the mid-century approaches, the threat of climate change, antibiotic resistance and the management of ethical conundrums – such as gene editing and healthcare equity – are all very real problems that our generation will have to face. It was saddening to hear Hilmers recall scenes of polluted, diverted or dammed lakes from space, of burning forests and haze hovering over cities, but that is the reality we live in. It does, therefore, imply that we hold at least part of the solution to the problems we face. In what form the specific solution will take, however, only time can tell. It is, however, abundantly clear that in going forward we should learn from leaders like Professor David Hilmers, whose experience is entirely unique and profound.

PrEP-related health promotion for Aboriginal and Torres Strait Islander gay and bisexual men [Review] Alec Hope Alec is a 4th year medical student at the University of New South Wales who is conducting qualitative research into the health promotion of PrEP to Aboriginal and Torres Strait Islander gay and bisexual men. Alec’s research interests include immunology, sexual health, and health inequality. He is looking forward to completing his last two years of medical school in Wagga Wagga.

Abstract Aboriginal and Torres Strait Islander peoples experience significantly poorer health compared to the general Australian population. This health inequality is highlighted in comparisons between Indigenous and non-Indigenous sexual health. Pre-exposure prophylaxis (PrEP) is a new HIV prevention technology that protects gay and bisexual men. Social, economic, cultural and historical barriers may exist that prevent Aboriginal and Torres Strait Islander gay and bisexual men from accessing PrEP, and therefore widen the sexual health inequality that already exists. Introduction Aboriginal and Torres Strait Islander (hereafter ‘Indigenous’) peoples living in Australia have significantly poorer health than non-Indigenous Australians,[1] inextricably linked to a history of disempowerment and oppression through colonialism.[2, 3] Indigenous Australians are often identified as a priority population for public health interventions due to their generally lower health status.[4] Discrepancies between Indigenous and non-Indigenous sexual health have been recontextualised as a human rights issue to draw awareness and urgency to the matter of inequity of sexual health between Indigenous and non-Indigenous Australians.[5] HIV and Indigenous Australians Human immunodeficiency virus (HIV) is a retroviral infection that is both blood-borne and sexually transmissible. HIV exhibits epidemiological differences between Indigenous and non-Indigenous Australians. Sexual contact between men is responsible for 75% of HIV notifications for nonIndigenous Australians, compared to only 51% of HIV notifications amongst Indigenous peoples. [6] Twenty-one percent of Indigenous HIV notifications are attributable to injecting drug use and 16% to heterosexual contact.[6,7] Worryingly, since 2011, the age-standardised rate of Indigenous HIV notifications has been steadily rising despite nationwide slowing of HIV notifications in the general population.[8] In 2015, the age-standardised rate of new HIV notifications in Indigenous people was more than double that of non-Indigenous people (6.8 per 100,000 vs 3.1 per 100,000).[6] Men who have sex with men (MSM) are at elevated risk

of becoming infected with HIV compared to the general population. It is unclear how many Indigenous Australians identify as gay or bisexual, and many Indigenous MSM may not identify as gay or bisexual, sometimes due to stigma.[9] A survey of Indigenous youth aged 16 to 29 found 6% of male respondents identified as gay, 2% as bisexual, and a small but significant number as transgender.[10] Indigenous gay and bisexual men (GBM) and other MSM may be at increased risk of contracting HIV compared to non-Indigenous GBM. Indigenous peoples experience higher rates of sexually transmitted infections (STIs), namely gonorrhoea and chlamydia, particularly in remote areas. [6] The presence of an STI predisposes individuals to HIV infection.[7] Furthermore, Indigenous GBM report higher rates of risky sexual behaviours compared to non-Indigenous GBM.[11, 12] Rates of unprotected anal intercourse with casual partners are higher in Indigenous GBM compared to non-Indigenous, a known risk factor for HIV infection. [13] Likewise, illicit drug use before or during group sex was reported at higher rates in Indigenous GBM compared to non-Indigenous GBM.[11, 14] Coupled with the worrying epidemiological pattern of HIV notifications among injecting drug users and heterosexual people, these elevated rates of risk factors among Indigenous people could increase the risk of HIV transmission for Australia’s Indigenous peoples. [11] Indeed, steady increases in Indigenous HIV notifications and an elevated age-standardised rate of Indigenous HIV notifications are causes for concern (Figure 1).[6] A pill a day to prevent HIV Antiretroviral (ARV) medications have been used since the 1990s as an effective treatment for HIV. More recently, at-risk individuals have used ARVs as an effective HIV 29

prevention method.[15] At-risk individuals can take one pill daily containing two antiretroviral medications, preventing replication of the virus within the body so that viral exposure is not seroconverted, thus preventing HIV infection.[16] Randomised control trials have found that ARVs taken as pre-exposure prophylaxis (PrEP) can prevent 40-99% of HIV infections when taken more than four times a week.[17-21] PrEP implementation trials are currently being run in New South Wales, Queensland, Victoria, South Australia, and the Australian Capital Territory. These trials are supported and funded by state health departments, allowing free or heavily discounted access to expensive drugs that cannot be accessed as PrEP via the Australian Pharmaceutical Benefits Scheme (PBS).[22] In New South Wales, the Kirby Institute runs the Expanded PrEP Implementation in Communities (EPIC) trial in conjunction with NSW Health. After a year of recruitment, over 5000 at-risk individuals have been enrolled and given access to PrEP. Most of these participants are GBM, identified as being at high risk of HIV exposure.[13] This represents a major expansion from a small pilot study to a large demonstration trial. Are Indigenous gay and bisexual men accessing PrEP? Studies in the United States (US) have found that identified priority populations, including Black (African-American) men who have sex with men, may have difficulty in accessing PrEP compared to the general population. This may be due to lack of awareness about PrEP,[23] stigma,[24] poor healthcare coverage,[3] or lack of culturally-appropriate services providing access.[25] Indeed, Black men who have sex with men in the US were successfully recruited, engaged and retained in PrEP programs that employed “culturally-tailored techniques”.[26] Research shows that in order to target interventions like PrEP to Indigenous communities, culturally-appropriate services owned and governed by the community are in the best position to deliver positive health outcomes.[27-29] Likewise, health promotion materials should be designed and produced by the community for the community, and should avoid blocks of text and overly technical terminology.[30] Therefore, Aboriginal community-controlled health services (ACCHSs) may be best placed to help promote and educate PrEP to at-risk members of the community, facilitating referral to specialised sexual health clinics for assessment and preventative methods that may or may not include

PrEP. ACCHSs provide holistic care, and are well equipped to focus on prevention and primary healthcare.[31] ACCHSs are considered manifestations of self-determination and autonomy for Indigenous communities.[29, 32] Self-determination in Indigenous Australian health services The United Nations has identified ACCHSs as best practice models of self-determination,[29] and the United Nations Declaration on the Rights of Indigenous Peoples advocates for the right of all peoples, especially Indigenous, to be able to “freely determine their political status and freely pursue their economic, social and cultural development”. [33] However, self-determination in healthcare alone cannot improve health outcomes. Secure, long-term funding coupled with equitable partnerships between Aboriginal communitycontrolled and mainstream health services is required to address the gap between Indigenous and non-Indigenous health.[29, 32] Facilitating community empowerment reduces the rates of HIV and STIs in female sex workers (FSWs) in low- and middle-income countries.[34, 35] Community empowerment in Australian FSWs during the initial years of the HIV epidemic was essential in enshrining effective HIV prevention focused on universal condom use among FSWs. [36] This case study could be applicable to the Indigenous population, and similar community empowerment in the form of well-funded ACCHSs may allow the gap between Indigenous and non-Indigenous health. Furthermore, Aboriginal Sexual Health Workers administer culturally-appropriate health services throughout Australia, increasing the involvement of Indigenous people in the healthcare workforce.[28, 37] However, Indigenous peoples need to be consulted and involved in the decision-making process and not just in the delivery of health services.[38, 39] Conclusion PrEP is touted as a crucial part of the HIV eradication strategy throughout the world. However, efforts to prevent HIV transmission may be hampered by a failure to engage priority populations, including Aboriginal and Torres Strait Islander Australians. PrEP implementation projects such as EPIC need to ensure adequate coverage of at-risk Indigenous peoples through culturally-appropriate health promotion and security of access to medication. This would be facilitated through the involvement of Indigenous Australians in the decisionmaking process. Further research will explore PrEP-related health promotion to Indigenous peoples and communities, and attempt to identify any gaps or facilitators.

Figure 1. The age-standardised rate of new HIV notifications by Indigenous status.[8]

Acknowledgements Dr Bridget Haire, The Kirby Institute b.haire@unsw.edu.au Conflict of Interest None declared Correspondence alecjulianhope@gmail.com References 1. Commonwealth of Australia. Closing the Gap Prime Minister’s Report 2017. Canberra: Department of the Prime Minister and Cabinet; 2017. 2. Anderson I. Indigenous Australia and health rights. Journal of Law and Medicine. 2008;15(6). 3. Zambas SI, Wright J. Impact of colonialism on Māori and Aboriginal healthcare access: a discussion paper. Contemporary Nurse. 2016;52(4):398-409. 4. Australian Government. National Aboriginal and Torres Strait Islander Health Plan 2013-2023. Australia: Commonwealth of Australia; 2013. 5. Thompson SC, Greville HS, Param R. Beyond policy and planning to practice: getting sexual health on the agenda in Aboriginal communities in Western Australia. Aust New Zealand Health Policy. 2008;5(1):3. 6. The Kirby Institute. Bloodborne viral and sexually transmitted infections in Aboriginal and Torres Strait Islander people: Annual Surveillance Report 2016. Sydney: The Kirby Institute; 2016. 7. Ward J, Costello-Czok M, Willis J, Saunders M, Shannon C. So far, so good: Maintenance of prevention is required to stem HIV incidence in aboriginal and torres strait islander communities in Australia. AIDS Education and Prevention. 2014;26(3):267-79. 8. Institute TK. HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2016. UNSW Australia, Sydney NSW 2052: The Kirby Institute; 2016. 9. Australian Federation of AIDS Organisations. National Indigenous Gay and Transgender Consultation Report. 1998. 10. Ward J, Bryant J, Wand H, Pitts M, Smith A, Delaney-Thiele D, et al. Sexual Health and relationships in young Aboriginal and Torres Strait Islander people: Results from the first national study assessing knowledge, risk practices and health service use in relation to sexually transmitted infections and blood borne viruses. Alice Springs: Baker IDI Heart & Diabetes Institute; 2014. 11. Lea T, Costello M, Mao L, Prestage G, Zablotska I, Ward J, et al. Elevated reporting of unprotected anal intercourse and injecting drug use but no difference in HIV prevalence among Indigenous Australian men who have sex with men compared with their Anglo-Australian peers. Sex Health. 2013;10(2):146-55. 12. Lawrence CG, Rawstorne P, Hull P, Grulich AE, Cameron S, Prestage GP. Risk behaviour among Aboriginal and Torres Strait Islander gay men: Comparisons with other gay men in Australia. Sex Health. 2006;3(3):163-7. 13. Cooper D, Grulich A. Impact of the rapid expansion of pre-exposure prophylaxis (PrEP) on HIV incidence, in a setting with high HIV testing and antiretroviral treatment coverage, to achieve the virtual elimination of HIV transmission by 2020: a NSW HIV Strategy implementation project. The University of New South Wales: The Kirby Institute; 2016. 14. Lawrence CG, Rawstorne P, Hull P, Grulich AE, Cameron S, Prestage GP. Risk behaviour among Aboriginal and Torres Strait Islander gay men: Comparisons with other gay men in Australia. Sexual Health. 2006;3(3):1637. 15. Therapeutic Goods Administration of Australia. Public Summary for Australian Register of Therapeutic Goods #107072 (Truvada). Australia: Therapeutic Goods Administration of Australia; 2016. 16. Therapeutic Goods Administration of Australia. Truvada Product Information V.15. Australia: Therapeutic Goods Administration of Australia; 2016. 17. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L, et al. Preexposure Chemoprophylaxis for HIV Prevention in Men Who Have Sex with Men. N Engl J Med. 2010;363(27):2587-99. 18. Eisingerich AB, Wheelock A, Gomez GB, Garnett GP, Dybul MR, Piot PK. Attitudes and Acceptance of Oral and Parenteral HIV Preexposure Prophylaxis among Potential User Groups: A Multinational Study. PLoS One. 2012;7(1):e28238.

19. Thigpen MC, Kebaabetswe PM, Paxton LA, Smith DK, Rose CE, Segolodi TM, et al. Antiretroviral Preexposure Prophylaxis for Heterosexual HIV Transmission in Botswana. New England Journal of Medicine. 2012;367(5):423-34. 20. Molina J-M, Capitant C, Spire B, Pialoux G, Cotte L, Charreau I, et al. On-Demand Preexposure Prophylaxis in Men at High Risk for HIV-1 Infection. New England Journal of Medicine. 2015;373(23):2237-46. 21. McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic openlabel randomised trial. The Lancet. 2015;387(10013):53-60. 22. Winsor B. Three ways to get PrEP in Australia. SBS Sexuality [Internet]. 2017. Available from: http://www.sbs.com.au/topics/sexuality/ agenda/article/2016/08/30/three-ways-get-prep-australia. 23. Brooks RA, Landovitz RJ, Regan R, Lee SJ, Allen VC, Jr. Perceptions of and intentions to adopt HIV pre-exposure prophylaxis among black men who have sex with men in Los Angeles. Int J STD AIDS. 2015;26(14):1040-8. 24. Miller M, Serner M, Wagner M. Sexual diversity among black men who have sex with men in an inner-city community. Journal of Urban Health. 2005;82(1):i26-i34. 25. Cairns G. US PrEP study achieves high levels of engagement and adherence among black men who have sex with men AIDSMap2016 [Available from: http://www.aidsmap.com/print/US-PrEP-study-achieveshigh-levels-of-engagement-and-adherence-among-black-men-who-havesex-with-men/page/3080023/. 26. Hucks-Ortiz C. Successful Engagement of Black MSM into a Culturally Relevant Clinical Trial for PrEP. 2016 International Aids Conference; 20 July 2016; Durban, South Africa: HIV Prevention Trials Network; 2016. 27. Ward J, McGregor S, Guy RJ, Rumbold AR, Garton L, Silver BJ, et al. STI in remote communities: Improved and enhanced primary health care (STRIVE) study protocol: A cluster randomised controlled trial comparing ‘usual practice’ STI care to enhanced care in remote primary health care services in Australia. BMC Infectious Diseases. 2013;13(1). 28. Thomas DP, Heller RF, Hunt JM. Clinical consultations in an Aboriginal community-controlled health service. A comparison with general practice. Australian and New Zealand Journal of Public Health. 1998;22(1):86-91. 29. Mazel O. Self-determination and the right to health: Australian aboriginal community controlled health services. Human Rights Law Review. 2016;16(2):323-55. 30. Hill PS, Murphy GJ. Cultural identification in Aboriginal and Torres Strait Islander AIDS education. Australian Journal of Public Health. 1992;16(2):150-7. 31. Ward J, Akre SP, Kaldor JM. Guarding against an HIV epidemic within an Aboriginal community and cultural framework; lessons from NSW. N S W Public Health Bull. 2010;21(3-4):78-82. 32. Taylor J, Dollard J, Weetra C, Wilkinson D. Contemporary management issues for Aboriginal Community Controlled Health Services. Australian health review : a publication of the Australian Hospital Association. 2001;24(3):125-32. 33. International Covenant on Civil and Political Rights, (1966). 34. Blanchard AK, Mohan HL, Shahmanesh M, Prakash R, Isac S, Ramesh BM, et al. Community mobilization, empowerment and HIV prevention among female sex workers in south India. BMC Public Health. 2013;13(1):234. 35. Kerrigan D, Kennedy CE, Morgan-Thomas R, Reza-Paul S, Mwangi P, Win KT, et al. A community empowerment approach to the HIV response among sex workers: effectiveness, challenges, and considerations for implementation and scale-up. The Lancet. 2015;385(9963):172-85. 36. Bates J, Berg R. Sex Workers as Safe Sex Advocates: Sex Workers Protect Both Themselves and the Wider Community From HIV. AIDS Education and Prevention. 2014;26(3):191-201. 37. Davidson PM, MacIsaac A, Cameron J, Jeremy R, Mahar L, Anderson I. Problems, Solutions and Actions: Addressing Barriers in Acute Hospital Care for Indigenous Australians and New Zealanders. Heart, Lung and Circulation. 2012;21(10):639-43. 38. Anderson I, Davis G. The hard conversation: Indigenous voices on public policy. Meanjin. 2016;75(2):68-82. 39. Lock MJ, Thomas DP, Anderson IP, Pattison P. Indigenous participation in an informal national Indigenous health policy network. Australian Health Review. 2011;35(3):309-15.

Mental illness following disasters in Low Income Countries [Review] Rose Brazilek Rose Brazilek is a PhD candidate studying through the Australian Centre for Blood Disease at the Alfred Hospital. She has a keen interest in translational medical research and blood disorders. In the future, she hopes to specialise in haematology with a special interest in thrombosis and haemostasis. Abstract Disasters test the capacity of health infrastructure to act in a well-coordinated and adaptable manner, due to the unique nature of each event. While immediate provision of healthcare focuses on the physical consequences, the long term mental health ramifications of such events are often forgotten, and services are ill-equipped to deal with the mental illnesses arising from them. The inherent challenges to the public health response are compounded by the limitations experienced by Low to Middle Income Countries (LMIC). These countries may lack the fiscal resources to fund such interventions and have unstable socio-political environments, which may further complicate disaster response. It is by consideration of these limitations, risk factors specific to such countries, and cultural sensitivity then that effective, long-standing mental health interventions can be implemented. This paper will review the predisposing factors to mental illness development following disaster, particularly in respect to at-risk subpopulations, the impact of socio-political climate and low GDP on disaster response, and the development of effective, culturally-specific interventions. The intersection between low national GDP and poor mental health infrastructure often translates to poorer mental health outcomes following disaster. Women, people of low educational status and low income are especially predisposed to development of mental illness. Common mental health disorders include Post Traumatic Stress Disorder, depression and anxiety

Introduction In Low and Middle Income Countries (LMIC), mental health care considerations of disaster survivors have taken a proverbial back seat, as the establishment of basic needs take priority.[1] Unfortunately, overwhelming evidence of causality between natural disasters and mental health issues has confirmed that provision of culture-specific mental health care is an integral part of the public health response following massive loss of life and injury to minimise longterm recovery ramifications, and a lack of these services negatively impacts survivors.[2] Psychosocial and mental health support programmes are increasingly being recognised as a crucial component of the humanitarian response to disasters.[3] However, disaster response coordination is notoriously complicated with numerous factors to consider, and lack of funding and resources in low income countries further limits health responses.[4] This paper will examine the predisposing factors to the development of mental illness in those affected by disaster in LMIC, and suggests potential preventative actions. Common mental health disorders arising from disasters Poor mental health in the immediate aftermath following disasters is to be expected in most survivors, the degree of suffering is affected by the nature of the experience, support networks, coping skills and the community response.

[4] This suffering includes distress –situations in which the individual feels anger, fear, sadness or shame – emotional dysregulation, or emotional numbing, however these typically resolve without long-term consequences.[5] It is when they are sustained, and impact on daily functioning, that they are defined as a ‘mental illness’. The most common of these are the anxiety disorders, particularly Post Traumatic Stress Disorder (PTSD), in which the individual experiences heightened arousal, avoidance of triggers, and flashback episodes.[5] Other mood disorders commonly experienced include abnormal grief reactions and depression. Due to the decreased utilisation of health services, particularly mental health services around the world and especially in Low to Middle Income Countries (LMIC), individuals may attempt to self-medicate with alcohol and other substances.[4] This may lead to substance use disorders as a way to deal with stressors, by avoiding or displacing difficult emotions associated with disasters. This is especially common in patients with a history of substance use disorder in remission, as relapse is common following stressful events. Somatisation disorders also show increased incidence following disasters; a way for survivors to express emotional distress.[2] They are more likely to occur in individuals with other concurrent mental health diagnoses, such as PTSD. Various cultures approach emotional distress as irrational, and thus there are a number of culture-specific disorders that manifest in this way.[3] These include Latah, 32

a condition originating in Southeast Asia in which individuals have an abnormal startle reaction; Koro, significant anxiety surrounding recession of genitalia; or Susto, a cultural variation of panic attacks originating in Latin America.[6] Knowledge and sensitivity surrounding these diagnoses may dramatically increase utilisation and efficacy of mental health programs in disaster areas. Predisposing factors to mental health disorder diagnosis There is a complex interplay between social dynamics and mental health diagnoses, and alteration for cultural context is an important consideration for any mental health intervention to be effective. Disasters have the potential to have a greater impact than initially considered because of the fear regarding the loss of long-held traditions that define the culture and community of those affected.[7]

Gender Of people impacted by disaster in LMIC, females have been shown to have a higher overall likelihood of developing mental health disorders, particularly depression.[8, 9] Recognition of the specific cultural challenges that females face following a disaster may reduce the impact of events on their recovery. Females in LMIC often occupy roles of household responsibility, and women may therefore feel guilty regarding their lack of ability to tend to basic domestic tasks. Practical consideration may also mitigate some impact of the trauma; though shelters often offer gender-segregated areas, nursing mothers may be reluctant to feed in public spaces. Women may suffer additional mental strain or sexual harassment if they are obliged to use public toilet services, or if they are seen in wet clothing in traditionally modest countries. These considerations must be kept in mind for established relief facilities to be effective, particularly in the case of foreign aid provision.

Low income The correlation between low income in LMIC and increased propensity towards poor mental health may be explained by the ‘reserve capacity model’.[5] This model states that as individuals have increasing background worries – for instance uncertainty regarding income and food shortages – their capacity to deal with additional stressors, as in the case of disaster, diminishes accordingly. It is well established that those of low Socio-Economic Status (SES) have poorer mental health, and often have the least access to services, either because lack of funding or locational difficulties.[10] Recognising low SES as a risk factor for the development of mental illness following disaster may allow more targeted relief efforts to be initiated.

Formal education Education and financial stability may also influence recovery and disease development.[10] One of the key areas preventing development of LMIC is the lack of formal education of its citizens. This may also influence coping capacity following a disaster. On a practical level,

educated individuals have an increased ability to cope with documentation demands, applications and resource seeking. This accordingly reduces the stress and impact of coping following disasters. Similarly, financial status may impact individuals at every stage of disasters. Those with lower incomes may have poorer quality of life and less safe dwellings, and are thus most predisposed to damage in the event of disasters.[11] Additionally, poor financial reserves may make it difficult to repair houses, and thus affects post-disaster recovery as well as the reserve capacity of individuals. At-risk subpopulations

Children Children are amongst the most vulnerable groups to disasters.[12] Negative long-term effects on paediatric wellbeing include increased incidence of PTSD, depression, and life dissatisfaction. Children may lose one or both parents due to disasters, potentially leaving them without a primary caregiver in areas with inadequate infrastructure such as education to meet their needs. Such events have been showed to have a deleterious impact on school performance, particularly in young males. [13] In countries where education level has a direct correlation with lifetime health quality, lack of access to education may drastically alter an individual’s life course, as well as the overall poverty level of the affected country. Schools, if still operational, may provide invaluable facilities for mental health support for students following natural disaster events in LMIC. Schools provide a relatively stable environment for observation and continued support, and they may bring a sense of normalcy back to areas ravaged by disaster.[14]

Aid workers A specific challenge is to assess and care for the first responders and aid workers who assist in relief work following a disaster. All rescue workers have a higher risk of chronic distress following exposure to an incident; although several elements, such as years of experience, perceived locus of control and social support; may mitigate development of disease.[15] These factors are important as responders are often foreign aid workers, operating without existing infrastructure and in unfamiliar environments devoid of a support network. Though they are often briefed beforehand and may receive training to prevent long-term mental health consequences, such workers are often volunteers with minimal experience. There is also some degree of stoicism amongst these volunteers, as their degree of suffering is judged to be far less than that of the people they are assisting. Specific considerations in LMIC The impact of disasters in LMIC appears to be far greater, in part due to the fragility of their existing infrastructure, and the lack of significant financial reserves to rebuild and support affected communities.[3] It is expected that encroaching urbanisation and industrialisation of developing counties will 33

increase the incidence of disasters – both man-made and natural – and that developing countries will be most affected in terms of number and severity. It has been shown that the risk of PTSD also rises proportionate to increase in severity and frequency of such events.[15] Several factors worsen the impact of disasters. Houses are often of inferior build quality, which reduces the ability to withstand severe forces.[7] Slums and communities experiencing poverty are also likely to be built in disasterprone areas such as flood plains because their inhabitants are unable to obtain property in safer areas. In the immediate aftermath of these events, LMIC may struggle to adequately treat the problems of their citizens due to limited training and capacity of healthcare and aid professionals.[10] The World Health Organization has recognised the role of unskilled aid workers in assessing mental health conditions and have devised a framework to use in these circumstances.[16] Untrained or poorly-organised humanitarian aid and destruction of primary infrastructure may also constitute secondary stressors following natural disasters and may compound the initial trauma of the event. Improper, or lack of, information dissemination may lead to anxiety and depression about food distribution, with negatively impacts on community wellbeing.[3] Determinants of effectiveness of public health responses One of the difficulties surrounding mental health disaster response is the changeable nature of the assistance required. Systems required in the immediate aftermath to aid those dealing with loss, physical impairment and adaptation to a different way of life are vastly different as some people return to their original occupations and homes.[3] Pre-disaster planning should involve a multidisciplinary team of healthcare professionals, infrastructure experts and politicians to create lasting policies that are effective and easily implemented. Disparities in the availability, accessibility and quality of mental healthcare due to ethnicity are well-documented. This may be due to language barriers, fears regarding insurance and monetary constraints, geographical difficulties (especially in rural communities), mental health stigma and lack of education.[7] Addressing these barriers may increase uptake of such services and reduce the incidence of mental health-related decrease in quality of life for those most at risk. Solutions include the validation and normalisation of distress reactions, so individuals feel they are experiencing legitimate reactions, rather than moments of weakness. [7] It is important to recognise the role of communities and to establish programs which value interdependence rather than independence in such situations. Promoting community action and initiatives will increase community resilience and realisation of the true impact of shared events. Cultural competence and sensitivity in foreign aid workers is essential to effective integration of support services, as well as the recognition that cultural competence is an

ongoing learning process rather than an end-state.[16] It is important to identify the causes of potential stigma and mistrust in order to properly engage minorities in healthcare. Rituals and traditions from the cultures of those affected may also be utilised and integrated into care solutions, thus using innovative interventions to circumvent such difficulties. Finally, it is critical that aid workers and all stakeholders advocate, facilitate and conduct research into the incidence of mental illness and effective treatment solutions for mental illness in affected populations to increase efficacy of interventions in the future.[1] Disaster-derived perspective

mental

illness:

contemporary

Disasters today are often man-made, as in the case of conflict. There is scarce research into the impact of such political conflict in LMIC. Of the research exists, it has been shown that women and people with a past history of mental illness have the greatest risk of developing mental disorders post-event.[17] Higher levels of constant political terror – measured on a scale that stratified countries according to the frequency of politically-motivated crises – directly correlated with higher rates of PTSD and depression.[18] Resource limitation directly impacts on the quality and quantity of care provided because LMIC must allocate fiscal resources frugally. They often chose to apportion money only to the most severely-affected populations, where the greatest benefit would be attained. This, in addition to the deterioration of healthcare services in wartime, culminates in a dearth of services for all but the most severely affected. The current global political climate, with the rise of nationalism and the unprecedented numbers of people displaced by conflict worldwide, also raise a number of considerations with respect to disaster preparedness. [19] There are more people displaced by conflict than ever before, seeking relocation in countries with greater stability and economic opportunity. The mental health of refugees is also influenced by the circumstances in the country of their resettlement. For example, a study of Latino and Asian refugees arriving in America found that those who experienced discrimination, unemployment or who experienced uncertainty due to unpredictable health insurance had lower self-rated mental health.[19] These post-settlement factors had a greater impact on their mental health than pre-settlement trauma, including war-related trauma.[19] This reflects the detrimental effect of hostile attitudes from the host country towards displaced individuals, and should be considered in the provision of mental health services for these affected communities. The impact of political instability on disaster responses in LMIC was also demonstrated following the earthquake in Nepal’s Gorkha region. Nepal has a GDP of only $20 billion USD, and an extremely limited capacity to fund disaster relief operations. Political instability and slow constitutional development following abolition of the region’s monarchy has prevented ratification of rigorous governance surrounding disaster prevention efforts, such as building codes, which may have reduced the impact of such an event. 34

Conclusion Considerations regarding the provision of mental health support to people in LMIC following disasters rely on a complex interplay between existing culture, socio-political climate and financial constraints hindering relief and prevention efforts. This review has identified that potential avenues for improvement of mental health services in disaster responses include: identification of most at-risk subpopulations including low SES; active integration of cultural sensitivity in in the provision of mental health support; and measures to address barriers in uptake of care. Though further research is needed into the impacts of disaster in LMIC, governments must actively engage in policy development before these events occur and learn from previous experiences to protect their citizens from long-term mental health implications of disasters.

14. Thapa K. Mental Health in Post-Earthquake Nepal. Nepal Journal of Epidemiology.5(4):520-1. 15. Marmar CR, Weiss DS, Metzler TJ, Delucchi KL, Best SR, Wentworth KA. Longitudinal Course and Predictors of Continuing Distress Following Critical Incident Exposure in Emergency Services Personnel. The Journal of Nervous and Mental Disease.187(1):15-22. 16. Zhang Y, Baik SH. Race/Ethnicity, disability, and medication adherence among medicare beneficiaries with heart failure. Journal of general internal medicine. 2014;29(4):602-7. 17. Ostadtaghizadeh A, Soleimani SV, Ardalan A. Health Consequences and Management of Explosive Events. Health in Emergencies and Disasters Quarterly.1(2):71-8. 18. Charlson FJ SZ, Degenhardt L, Chey T, Silove D, Marnane C. Conflict in Libya on Population Mental Health: PTSD and Depression Prevalence and Mental Health Service Requirements. PLoS ONE.7(7):e40593. 19. Kim I. Beyond Trauma: Post-resettlement Factors and Mental Health Outcomes Among Latino and Asian Refugees in the United States. Journal of Immigrant and Minority Health.18(4):740-8.

Acknowledgements None Conflict of Interest None declared Correspondence rose.brazilek1@monash.edu References 1. Galea S, Brewin CR, Gruber M, Jones RT, King DW, King LA, et al. Exposure to hurricane-related stressors and mental illness after Hurricane Katrina. Archives of general psychiatry. 2007;64(12):1427-34. 2. Treatment CfSA. Trauma-Informed Care in Behavioral Health Services. 2014. US. 3. McFarlane AC, Williams R. Mental health services required after disasters: learning from the lasting effects of disasters. Depression research and treatment.1:970194. 4. Norris FH, Friedman MJ, Watson PJ. 60,000 disaster victims speak: Part II. Summary and implications of the disaster mental health research. Psychiatry: Interpersonal and biological processes. 2002;65(3):240-60. 5. Gallo LC, Bogart LM, Vranceanu AM, Matthews KA. Socioeconomic status, resources, psychological experiences, and emotional responses: a test of the reserve capacity model. Journal of personality and social psychology.88(2):386-99. 6. Fergusson DM, Horwood LJ, Boden JM, Mulder RT. Impact of a major disaster on the mental health of a well-studied cohort. JAMA psychiatry. 2014;71(9):1025-31. 7. Norris FH, Alegria M. Mental health care for ethnic minority individuals and communities in the aftermath of disasters and mass violence. CNS spectrums. 2005;10(2):132-40. 8. Kar N, Bastia BK. Post-traumatic stress disorder, depression and generalised anxiety disorder in adolescents after a natural disaster: a study of comorbidity. Clinical Practice and Epidemiology in Mental Health. 2006;2(1):1-7. 9. Nahar N, Blomstedt Y, Wu B, Kandarina I, Trisnantoro L, Kinsman J. Increasing the provision of mental health care for vulnerable, disasteraffected people in Bangladesh. BMC public health.14:708. 10. Lima BR, Pai S, Santacruz H, Lozano J. Psychiatric disorders among poor victims following a major disaster: Armero, Colombia. J Nerv Ment Dis.179(7):420-7. 11. Sathyanarayana Rao TS. Managing Impact of Natural Disasters : Some Mental Health Issues. Indian Journal of Psychiatry.46(4):289-92. 12. Catani C, Jacob N, Schauer E, Kohila M, Neuner F. Family violence, war, and natural disasters: A study of the effect of extreme stress on childrenâ&#x20AC;&#x2122;s mental health in Sri Lanka. BMC Psychiatry. 2008;8(1):1-10. 13. Kar N, Jagadisha, Murali N. Post-traumatic stress disorder in children following disaster. Kerala Journal of Psychiatry. 2001;16.

Factors that contribute to the reduced rates of cervical cancer screening in Australian migrant women - a literature review [Review] Archana Nagendiram Archana is a fourth year medical student from James Cook University with interests in global health and women’s health.

Abstract AIM: This literature review presents factors that have led to decreased cervical cancer screening rates in Australian migrant women. It also evaluates past interventions that have been implemented to solve this issue in screening. METHODS: A wide range of peer reviewed articles from databases such as CINAHL and SCOPUS were analysed to determine factors that have led to migrant women having a lower cervical cancer screening rate in comparison to the general Australian population. This review also analysed the reference lists from these articles. RESULTS: The factors that have led to this reduction in screening rates include cultural differences, limited acculturation, modesty, and logistical issues. Specific cultural issues such as female genital mutilation and the use of Ayurvedic medicine in certain ethnic groups may also contribute. There have been interventions aimed at increasing screening rates, including ethnic media campaigns and education of health professionals, such as doctors and nurses who work in these communities. However, their effectiveness is uncertain due to a lack of evaluation after implementation. CONCLUSION: Whilst research has provided a basic understanding of the reasons that have contributed to the difference in screening between these two populations, there have been insufficient strategies applied to remedy it. Moreover, there has been inadequate appraisal of current interventions and discussion of the cultural appropriateness of current programs.

Introduction This year, the Australian government has renewed the National Cervical Cancer Screening Program (NCSP) to incorporate updated screening protocols in accordance to new research. Hence, it is important to assess the value of the previous screening protocols in underscreened populations such as Australia’s migrant women. From 20122013, 58.2% of the target population partook in the NCSP and since the introduction of organised cervical cancer screening in Australia, cervical cancer mortality has fallen by 44% (95% CI 0.51-0.62).[1,2,3] Whilst migrant women have benefited from screening, the results have not been as favourable in comparison to the general population. The incidence of cervical cancer is higher in migrant women from countries with higher incidence of cervical cancer, including Sub-Saharan Africa, Central America, South East Asia and Melanesia.[1] Consequently, this paper will examine relevant literature since the current NCSP’s introduction in 1991. It will analyse the factors that have caused lower screening rates in migrants, at the level of both the individual and the health system. It will also analyse past and future interventions that may reduce these disparities evident in the rates of cervical cancer screening in Australian migrant women.

Methods This literature review used various online databases to source information. It concentrated on articles that surveyed Australian migrant women, however some larger international studies were also used to provide global context. CINAHL was searched with keywords “cervical cancer AND migrant women”, and SCOPUS was searched with the key words “cervical cancer AND migrant AND Australia”. Only peer reviewed journal articles were used, and opinion papers were excluded in the search. Relevant articles since 1991 were analysed, from the implementation of the NCSP in Australia. Additionally, reference lists of relevant articles were examined using similar inclusion criteria. What is a pap smear? Pap smears are the recommended primary screening tool for cervical cancer by the NCSP. During the procedure, the doctor collects a cytological sample from the ectocervical and endocervical canal of the uterus, which is then analysed to see if any pre-cancerous or cancerous changes are present. If a cytological abnormality is identified, the patient will then be referred for colposcopy.[4] Pap smears are routinely used in general practice and account for approximately 1.7 of 100 consultations.[5] Disease incidence and burden is reduced in Australia through organised screening for cervical 36

cancer. A key strategy lies in general practitioners instigating accessible screening, recall systems and opportunistic screening in their practice.[6] Factors that prevent regular screening

Lack of Knowledge Prior to living in Australia, many migrant women from developing countries had never heard of cervical cancer screening or understood the risk factors associated with the disease.[7] This is the result of a lack of organised screening programs in countries such as Ghana and Vietnam, as their health systems lack the appropriate human resources and infrastructure to support such programs.[8,9,10] Hence, Australian general practitioners are key in providing health education to new migrant women about the NCSP. A qualitative study of 21 West African women in Australia showed that they became informed about pap smears via public health campaigns and from antenatal care during pregnancy in Australia. After this initial point of contact, they had their first pap smear after their pregnancy and then received reminders every two years.[8] Although migrant women of reproductive age were educated through these campaigns, post-menopausal women who have a greater risk of cancer with age were neglected.[11] Even with health education on cervical cancer, it appears that migrant women still have a misconstrued understanding about the NCSP or why they require a pap smear.[8,12] The surveyed West African migrant women believed that they did not require a pap smear without a family history of cervical cancer.[8] Thai and Chinese migrant women also had misconceptions about the risk factors of cervical cancer which included promiscuous behaviour, karma or having a sexual partner who had unhygienic genitalia.[7,13] Some Chinese migrant women did not understand the role of pap smears as a screening tool and none of the surveyed women were aware of the role of Human Papillomavirus (HPV) in cervical cancer.[7] Furthermore, these migrant women believed they did not require a pap smear as they were asymptomatic, had no family history and only had one sexual partner.[7,8]

Cultural Factors Language is a common barrier for women from non-English speaking backgrounds (NESB). Migrant women have a strong preference to see a doctor who speaks their native language, regardless of their English proficiency, as it allows for clearer articulation of their concerns, particularly regarding intimate procedures.[7] However, a study of migrant women from NESB portrayed that 75.1% of the surveyed women would prefer female health providers to male practitioners to conduct their pap smear, and only 36.4% would travel a large distance to see a doctor who spoke their own language.[14] Another study of Thai immigrant women analysed that 61% would prefer a female general practitioner to perform the pap smear due to embarrassment.[13] This implied that modesty was important to migrant women from a NESB, especially as the newer migrant population often were from very conservative

cultures in the discussion of sexual and reproductive health is surrounded by stigma.[8] Additionally, cultural beliefs about maintaining purity may also affect cervical cancer screening, with Assyrian migrants believing that unmarried women should not have pap smears as premarital sex is prohibited. [15] Throughout the literature, it appears that migrant women feel vulnerable and embarrassed during their pap smears and would ideally prefer a female doctor who spoke their language to assist them.[7,8,12] Moreover, there are factors that are culturally specific, such as female genital mutilation (FGM) and the use of Ayurvedic medicine. Approximately 130 million females worldwide have experienced FGM, mainly in Asia, the Middle East and Africa. [16] Migrant women with FGM may not wish to undergo pap smears due to pain, both physical and psychological, and the reminder of the initial traumatic experience.[8] Ayurvedic medicine is practised throughout Asia. A study of Thai women in Brisbane showed these women saw a variety of alternative medical practitioners; including naturopaths, chiropractors, herbalists and traditional Chinese healers; both in Australia and Thailand.[13] As these women would often rely on these traditional methods for medical care, they were less likely to present to their general practitioner for ailments and thus have a reduced chance of undertaking opportunistic cervical cancer screening. Finally, the time since migration to Australia is directly proportional to a womanâ&#x20AC;&#x2122;s probability of having regular pap smears.[7] As acculturation occurs, the individuals becomes more integrated into the Australian community and start to adopt health preventative behaviours.[13] Single migrants or those who are married to other migrants took the longest time to adjust to the health system. On the other hand, migrants who married an Australian or had a catalytic health event, such as the birth of a child, had a faster trajectory to health acculturation.[12]

Other Factors Various factors further contribute to the lower participation of migrant women in cervical cancer screening. Several migrant women from Asia and the Middle East hold a fatalistic view of health and believe that screening is superfluous, as they have no control over their destiny.[19] Migrant women from Yugoslavian and West African communities describe their fear of their results and do not wish to start looking for problems that did not exist.[8,20] Similar to women in the general population, Chinese Australian women describe how previous negative experiences have deterred them from having regular pap smears.[7] Additionally, they may simply forget or have logistical barriers that prevent regular pap smears, such as lack of transportation or childcare.[7,20] Interventions From 2002 to 2011, the Australian Research Council (ARC) spent 7.8% of their funding for people-related research on the migrant population; insufficient considering migrants comprise over a quarter of the Australian population. [21,22] Moreover, the lack of funding for migrant research 37

does not allow for the provision of strongly evidencebased interventions into migrant health, especially as data is not available as to the amount of ARC funding allocated specifically to cervical cancer screening.[22] Nonetheless, using available Australian data supplemented with some international publications, the following conclusions can be drawn about the effectiveness of past interventions and discussion of what is required for future success.

Educational Campaigns Migrant women state that they largely receive information about cervical cancer from health professionals and public media campaigns. Therefore, the lack of awareness about pap smears must be targeted in both health and community settings; through general practice, migrant resource centres and community centres.[8] General practitioners play a key role in advocating for cervical cancer screening in consultations and through reminder letters, as migrant women who have never had a pap smear may not be comfortable asking for the test.[7,8,23] Similarly, the use of nurses in community, refugees health, womenâ&#x20AC;&#x2122;s health, and child and family health is key in facilitating discussions regarding cancer screening amongst the migrant population.[8] The Ethnic Communities Council of Queensland (ECCG) created the Pilot Cancer Screening Education Program (PCSEP) which identified cervical cancer screening levels in various migrant populations before and after their program. In this program, 76% of participants participated in cervical cancer screening and this increased to 91% after the PCSEP. [24] Yet as this result was not statistically significant, we cannot confirm that this target program would be successful in increasing cervical cancer screening rates in migrant populations.

Cultural Sensitivity As cultural factors play a key role in the decreased screening rate amongst migrant women, it is essential for Australian doctors to undertake cultural sensitivity training. This may improve understanding of factors affecting women from certain cultures such as modesty and fatalistic views of health.[7] This will allow health practitioners to appropriately tailor their consultations and the way that they promote cervical cancer screening with their migrant patients. There may also be reduced rates of cancer screening referrals from migrant doctors to patients of their own nationality. A study of Korean American doctors showed that there were reduced referral rates of colorectal cancer screening for their Korean patients. This was because they understood the cultural sensitivities surrounding cancer screening and perceived that compliance would be lower amongst their Korean patients.[25] It is key for doctors providing carer to patients of the same nationality to undergo training in cancer screening. The significance of bilingual health practitioners cannot be underestimated, as migrants prefer to see practitioners of the same nationality.[7,23] In the Vietnamese community, information sessions for bilingual practitioners about cervical cancer has been documented,

but the effectiveness of this intervention has not been assessed.[23]

Use of ethnic media Previous interventions have used ethnic media as a health promotion strategy to increase cervical cancer screening in various migrant populations.[23,26] Between 1991 and 1994, Pap Test Victoria conducted three sets of interventions in ethnic media outlets for over 12 migrant groups including Vietnamese, Chinese, Arabic and Turkish populations. During these interventions, the respective ethnic media outlets conducted live interviews, paid announcements and competitions with prizes. These three interventions led to an increase in screening compliance by 6.7% (95% CI 4.4-9.2). [26] As ethnic media can be utilised for health promotion and appears to be an effective method of increasing screening uptake, funding should be allocated for a nationwide ethnic media campaign on cervical screening. Conclusion Lower rates of cervical cancer screening in migrant women is a multifaceted issue. Factors contributing to these lower rates include lack of knowledge, cultural differences, limited acculturation and logistical issues. While research has been undertaken to understand the cause of the decreased participation of migrant women in regular pap smears, there have not been sufficient evidence-based interventions to address the issue. Although the government has redesigned the NCSP to reflect current medical research, there has been little evaluation of the cultural appropriateness of the current NCSP and the effectiveness of previous interventions to increase participation amongst the migrant population. The renewal of the NCSP should parallel the increased number of research projects that occurred during its initial implementation, as this is necessary to provide updated information on cervical cancer screening to migrant women. This will then allow for the application of evidencebased interventions to increase pap smear rates in this underscreened population. Acknowledgements None Conflict of Interest None declared References 1. Aminisani N, Armstrong BK, Egger S, Canfell K. Impact of organised cervical cancer screening on cervical cancer incidence and mortality in migrant women in Asutralia. BMC Cancer. 2012;12(1):491-501. 2. Australian Institute of Health and Welfare. Cerivcal screening in Australia 2012-2013. [Internet]. 2015 [updated 2015 May 1; cited 2017 May 20]. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset. aspx?id=60129550872. 3. Simonella L, Canfell K. The impact of a two- versus three-yearly cervical screening interval recommendation on cervical cancer incidence and mortality: an analysis of trends in Australia, New Zealand, and England. Cancer Causes Control. 2013;24(9):1727-1736. doi: 10.1007/s10552-0130250-9. 4. Shader RI. The PAP test and the pap smear. Clin Ther.

2015;37(1):1-3. doi: 10.1016/j.clinthera.2014.12.002. 5. Australian Institute of Health and Welfare. General practice activity in 2009-10. [Internet]. 2010 [updated 2010 Dec 8;cited 2017 May 5]. Available from: http://www.aihw.gov.au/publication-detail/?id=6442472433. 6. Munro A, Pavicic H, Leung Y, Westoby V, Steel N, Semmens J et al. The role of general practitioners in the continued success of the National Cervical Screening Program. Aust Fam Physician. 2014;43(5):293-296. 7. Kwok C, White K, Roydhouse JK. Chinese-Australian womenâ&#x20AC;&#x2122;s knowledge, facilitators and barriers related to cervical cancer screening: a qualitative study. J Immigr Minor Health. 2011;13(6):1076-1083. doi: 10.1007/s10903-011-9491-4. 8. Ogunsiji O, Wilkes L, Peters K, Jackson D. Knowledge, attitudes and usage of cancer screening among West African migrant women. J Clin Nurs. 2013;22(7-8):1026-1033. doi: 10.1111/jocn.12063. 9. Sankaranarayanan R, Nessa A, Esmy PO, Dangou JM. Visual inspection methods for cervical cancer prevention. Best Pract Res Clin Obstet Gynaecol. 2012;26(2):221-232. doi: 10.1016/j.bpobgyn.2011.08.003. 10. Lesjak M, Hua M, Ward J. Cervical screening among immiagrant VIetnamese women seen in general practice: current rates, predictors and potential recruitment strategies. Aust NZ J Public Health. 1999; 23(2): 168-173. 11. White MC, Holman DM, Boehm JE, Peipins LA, Grossman M, Henley SJ. Age and cancer risk: a potentially modifiable relationship. Am J Prev Med. 2014;46(3 Suppl 1):S7-15. doi: 10.1016/j.amepre.2013.10.029. 12. Terry D, Ali M, Le Q. Asian migrantsâ&#x20AC;&#x2122; lived experience and acculturation to Western health care in rural Tasmania. Aust J Rural Health. 2011;19(6):318-323. doi: 10.1111/j.1440-1584.2011.01229.x. 13. Jirojwong S, Manderson L. Beliefs and Behaviors About Pap and Breast Self-Examination Among Thai Immigrant Women in Brisbane, Australia. Women & Health. 2001;33(3-4):53-73. doi: 10.1300/ J013v33n03_04. 14. Henderson S, Kendall E, See L. The effectiveness of culturally appropriate interventions to manage or prevent chronic disease in culturally and linguistically diverse communities: a systematic literature review. Health Soc Care Community. 2011;19(3):225-249. doi: 10.1111/j.13652524.2010.00972.x. 15. Ussher JM, Rhyder-Obid M, Perz J, Rae M, Wong TWK, Newman P. Purity, Privacy and Procreation: Constructions and Experiences of Sexual and Reproductive Health in Assyrian and Karen Women Living in Australia. Sexuality & Culture. 2012;16(4):467-485. doi: 10.1007/s12119-012-9133-6. 16. Allen B, Oshikanlu R. Female Genital Mutilation: A practical guide for health visitors and school nurses. Community Pract. 2015;88(12):30-33. 17. Taylor RJ, Mamoon HA, MOrrell SL, Wain GV. Cervical Screening in Migrants to Australia. Aust NZ J Public Health. 2001; 25(1): 55-61. 18. Wain G, Morrell S, Taylor R, Mamoon H, Bodkin N. Variation in cervical cancer screening by region, socio-economic, migrant and Indigenous status in women in New South Wales. Gynecol. Oncol. 2001; 41(3): 320-325. 19. Aminisani N, Armstrong BK, Canfell K. Cervical cancer screening in Middle Eastern and Asian migrants to Australia: a record linkage study. Cancer Epidemiol. 2012;36(6):e394-400. doi: 10.1016/j.canep.2012.08.009. 20. Fernbach M. Exploration of factors linked with high cervical cancer rates in women from the former Yugoslavia in Victoria, Australia. Ethn Health. 2002;7(3):209-220. doi: 10.1080/1355785022000042033. 21. ABS. 3412.0 - Migration, Australia (2013-2014). website. http:// www.abs.gov.au/ausstats/abs@.nsf/mf/3412.0. Published 2015. 22. Renzaho A, Polonsky M, Mellor D, Cyril S. Addressing migrationrelated social and health inequalities in Australia: call for research funding priorities to recognise the needs of migrant populations. Aust Health Rev. Jul 13 2015. doi: 10.1071/AH14132. 23. Cheek J, Fuller J, Gilchrist S, Maddock A, Ballantyne A. Vietnamese women and pap smears: issues in promotion. Aust NZ J Public Health. 1999. 24. Cullerton K, Gallegos D, Ashley E, et al. Cancer screening education: can it change knowledge and attitudes among culturally and linguistically diverse communities in Queensland, Australia? Health Promot J Austr. Jun 29 2016. doi: 10.1071/HE15116. 25. Jo AM, Maxwell AE, Rick AJ, Cha J, Bastani R. Why are Korean American physicians reluctant to recommend colorectal cancer screening to Korean American patients? Exploratory interview findings. J Immigr Minor Health. Aug 2009;11(4):302-309. doi: 10.1007/s10903-008-9165-z. 26. Mitchell H, Hirst S, Mitchell JA, Staples M, Torcello N. Effect of ethnic media on cervical cancer screening rates. Aust N Z J Public Health. 1997; 21(2). 265-267.

Medical electives in resource-poor settings: Are we doing more harm than good? [Review] Gabrielle Georgiou Gabrielle is a final-year medical student (VI) at the University of New South Wales. She has a particular interest in global health and medical education.

Abstract Medical students from around the world desire ever-increasing global health experiences and education, particularly from international medical electives. However, while elective experiences offer a number of potential benefits for students and sending institutions alike, recent evidence suggests that significant practical, social and ethical challenges may result, specifically in resource-poor settings. Ideally, there should be an opportunity for students to engage with elements of a global health program or some form of pre-departure training prior to undertaking a medical elective, with the aim being to engage with social determinants of health, and aspects of service learning. Furthermore, additional research is required to ensure that medical electives do not detract in any way from the pursuit of global health equity and the provision of care in these locations.

Introduction Interest in international medical electives is burgeoning, with medical students from around the world desiring global health content in their curricula,[1] and greater discovery traversing international socio-cultural borders.[2-8] In the United States, for example, of ninety-six medical schools surveyed, 87% reported availability of international clinical electives, 45% offered preclinical research abroad, and 61% offered international opportunities over school holidays. [9] Here in Australia, international health is often explored in medical schools through compulsory elective terms, which typically occur over a period of 6-8 weeks and may take place in developing countries.[1] Medical electives may involve experiences in developing nations with pronounced inequities in health and socioeconomic development.[1, 10] Such electives have been described in the literature with various terms - from ‘international medical experiences’, ‘global health programs’, ‘medical electives’, and ‘global health experiences’, to the use of other, more controversial definitions, such as “medical voluntourism”, “fly-by medical care”, or “duffel-bag medicine”. [6] While elective experiences offer potential benefits for medical students and sending institutions alike, recent evidence suggests the potential for significant practical and ethical challenges, exacerbating global health inequities.[2-4, 7, 8, 11-14] Motivations Certain factors appear to influence student involvement in medical electives. These include altruistic intent, curiosity,

having a sense of adventure and hopes of language development, as well as the allure of the opportunity to experience medical practice outside the scope of one’s normal hospital and community setting.[15] Other benefits which may result from experiencing a medical elective include the prospect of improving clinical skills, enabling personal transformation,[12] increasing tropical medicine knowledge, gaining cross-cultural competency, and improving overall confidence, independence and resourcefulness levels.[5] Benefits Electives may offer an ideal setting for students to engage with preventative health measures that are utilised around the world.[9] Students can develop a greater understanding of effective resource management and public health strategy implementation, improve their awareness of the social determinants of health, and improve their competency as global health advocates.[5] There is also evidence that students’ increase their willingness to assist underserved populations and levels of social responsibility when they experience medicine in another country, particularly in the developing world.[9, 16] International medical experiences are also said to facilitate the process of service learning- that is, a structured learning style incorporating community service, experiential learning, as well as adequate preparation and reflection.[9, 17] Consciousness-raising, self-efficacy, and networking capability, are three notable outcomes which may be facilitated by this service learning style.[14] Institutions hosting medical students may also benefit through improved international partnerships, promoting 40

a potential workforce of international health workers in the future, reciprocal training opportunities for local staff and students to work abroad, equipment donation, and/or potential financial compensation.[5] Concerns Nonetheless, medical electives have the potential to cause serious ethical breaches, particularly those resulting from a medical student practising medicine beyond their level of competency.[4] There have been growing concerns that students are utilising elective opportunities to practise skills, enhance their resumes, and to travel to ‘exotic’ places, which can result in vulnerable communities serving as a means for students to merely fulfill selfish ends, as opposed to students serving to address the needs of the community. [7, 14, 16] Some have argued that electives in resource-poor settings are being used as a glorified form of tourism, with no known sustainable benefits for the receiving community. [13] Furthermore, any form of pre-departure training or global health education as a pre-requisite for such an elective is often missing, limited, or narrow in focus.[15] For the student specifically, there may be health risks involved, substantial costs assumed, the potential for cultural shock, and the likelihood of experiencing ethicallychallenging situations, which may include pressure to exceed the student’s role, and also perform procedures without adequate supervision.[5] There may be uncertainty about how best to contribute, working beyond the student’s scope of practice, navigating through unknown medical cultures, and leaving a subsequent gap in care provision when the student returns home. There are various other issues which may result, including failure to obtain truly informed consent due to language, cultural or other barriers, lack of adequate medical knowledge, and a lack of cultural awareness, which can all potentially lead to patient harm.[5] In the case of elective work in Honduras, for example, medical tourism is considered harmful, entrenching paternalism and inequitable relationships.[14] It is argued that while educational and social benefits may potentially occur, they are not natural consequences of these international experiences, but instead, examples of practical outcomes which must be nurtured and developed through significant education, reflection, and long-term relationship building.[14] Recommendations Healthcare practitioners may provide effective input during a short-term medical elective only if they have adequate knowledge, skills and ethical preparation prior to their departure.[18] There must be a shift in focus from the illprepared student who faces significant ethical dilemmas in global health on an international medical elective, to greater provision of support by teachers and institutions, prior to such an experience, given they ultimately have a responsibility to provide global health training and awareness of potential challenges.[4, 15, 19, 20] Students should be given pre-departure training, which

may involve reflecting upon potential ethical challenges and discussing issues regarding resource shortages and other cultural or professional differences.[17] There should be an opportunity for students to engage with elements of a global health program prior to their undertaking of a medical elective, with the deliberate aim being to engage with social determinants of health.[7, 12, 13, 15] This may encourage students to question social inequities and shift the experience of a medical elective into a period of transformative learning. [19] This may in turn contribute to social change within the medical realm - which is a vital need for improving global health.[15] Further, student-led groups, databases and/or forums could be utilised to facilitate conversation, mentoring opportunities, and more personalised pre-departure training. Discussion amongst students who have been on an elective previously may allow for reflection upon these experiences and any challenges faced, as well as the sharing of knowledge with future cohorts who have not yet undertaken their placements. A global health curriculum would ideally examine ethical issues associated with working with vulnerable populations, and incorporate potential health and personal safety challenges associated with working in resource-poor environments.[3, 4, 20, 21] Experiential data suggests that ethical dilemmas are often part of medical electives and that, in most cases, medical students are not adequately trained to negotiate their way through ethically-troublesome situations.[19] There is a clear necessity for training so that students are able to recognise when to ‘say no’ during such experiences, and are able to learn from challenging situations.[3, 4, 16] The Working Group on Ethics Guidelines for Global Health Training (WEIGHT) has developed a set of guidelines regarding ethical issues and best practice for global health training. It simultaneously encourages efforts to continuously assess and evaluate the potential benefits and harms of programs being undertaken worldwide.[2] Trainees must understand their personal responsibility during a global health experience, to ensure it is a primarily positive one, and to recognise that their actions and behaviours can have farreaching long-term implications.[2] Evidence suggests that one of the most effective ways of teaching skills relating to global health - such as ethical and cultural competency - is through service learning.[17] Service learning incorporation relies on increased academic programming, fostering sustainable hospital partnerships, and encouraging mentorship and reflection for students involved, prior to, during and after their elective experiences. [21] Reflecting on the purpose of their volunteer experience, as well as their capacities and goals, will inform a more culturally-appropriate provision of care abroad, and will allow the student to recognise that good intentions alone are not necessarily sufficient preparation or justification for volunteering or working overseas.[20] Thus, the application of a simulation-based approach to global health ethics education prior to an elective may be useful in dealing with 41

the tensions which exist between service learning and the respect of patient rights and well-being.[17] Social justice-oriented approaches to service learning, coupled with active critical reflection, also serve viable pedagogical approaches for learning the health advocate role.[10] This means that students should be able to better recognise and address relevant ethical and professional issues, with a greater understanding and appreciation of altruism, social justice, autonomy, and integrity as a result.[10] When a student does undertake an elective in a developing country, such experience leads to higher levels of community health knowledge on return, a greater sense of what it means to be vulnerable, a heightened awareness of the social determinants of health, and an appreciation of the importance of socially responsible approaches for community engagement and health advocacy.[10] Another important consideration is to enable bi-directional flow of medical students through formal partnerships between university institutions. This can facilitate more positive elective experiences through sustainable relationships and effective involvement in medical care, as well as encouraging an international medical workforce in the future.[5] Along with fostering such connections, skills building in crosscultural effectiveness, long-term sustainability planning, and local capacity building may help to produce more effective overseas opportunities with meaningful outcomes.[7] Discussion Overall, there is a clear need for individuals who wish to undertake medical electives in the future to reflect upon ethical and best practice guidelines prior to departure,[2] and to subsequently decide whether the experience is right for them.[12] It would also be of benefit to engage in conversation with previous cohorts about their elective experiences, enabling a baseline understanding of any challenges that lie

ahead. Pre-departure, students should aim to gain as much contextual knowledge as possible in relation to their host country, including the language, the specific local needs, the details of the participating institution and the work being carried out. Students must recognise the possible ethical consequences of the work being done, and appreciate the potential impact they might have during such an experience. [12, 16] By incorporating a greater emphasis on learning and on reflection prior to, during, and after an international medical elective experience, students will be better placed to question their values, assumptions, and beliefs to help mitigate the potential harms which their placement may cause. [15] Students must actively question themselves and their surroundings, consider the ways in which healthcare is being delivered, and engage with potential ethical dilemmas and broader social, political and economic concerns underlying their medical provision, without necessarily being engaged in the direct provision of medical care.[11] Indeed, practising beyond one’s capabilities as a medical student is central to the potential harm which may result during an overseas elective in a resource-poor environment, particularly when this is coupled with a lack of adequate supervision. Education and planning are essential in minimising harm to host communities. It is necessary to have well-defined objectives and structured clinical experiences in place for students while abroad, which may be promoted by institutions and educators through mandatory global health education to ensure medical electives are carried out to the highest ethical standards.[8, 19] At all stages, electives must be completed in a way that acknowledges any underlying power balances, ethical challenges, and resource differentials to provide community-led efforts which are focused on sustainable development and community health gains.[7] There is an undeniable need for more global health

Global Health Programs Abroad 1. University of Saskatchewan, Canada: the ‘Making the Links’ program provides an opportunity for undergraduate medical students to participate in a local student-led inner-city clinic, a Northern Aboriginal community health initiative and a long-standing service-learning project in Mozambique over two years. This includes the provision of a supplementary clinical curriculum, guided and facilitated reflections, as well as a complementary global health course and language courses.[15] 2. University of British Columbia, Canada: ‘First, Do No Harm: Global Health Initiatives, Ethics and Social Responsibility’ is a piloted series of interactive workshops.[16] Participants analyse case studies exploring different ethical dilemmas. Results have indicated that this approach to learning and reflection is necessary before participating in a global health initiative, and that problem-based learning is effective in teaching students to engage in the process of identifying and addressing ethical issues.[16] 3. University of Arizona, United States: a four-week immersion program undertaken by students prior to an overseas placement covers a range of international health topics.

education to be incorporated into the curriculum for medical students around the world, with rubrics containing detailed expectations and outcomes that are applicable to global health experiences.[21] Educators have a responsibility to their students to facilitate the development of skills in cultural competency, compassion, and public health, as well as encouraging them to understand the potential ethical challenges they may encounter.[9] Additional qualitative research is required to ensure that the expectations, attitudes, and experiences of healthcare institutions accepting elective students are clearly understood. Recognising the benefits and concerns of elective programs in resource-poor settings in greater depth will ensure that electives do not detract in any way from the pursuit of global health equity and the provision of care in these locations.[6] Acknowledgements None

13. Snyder J, Dharamsi S, Crooks VA. Fly-by medical care: conceptualizing the global and local social responsibilities of medical tourists and physician voluntourists. Globalization and health. 2011;7(1):1. 14. McLennan S. Medical voluntourism in Honduras: ‘Helping’ the poor? Progress in Development Studies. 2014;14(2):163-79. 15. Hanson L, Harms S, Plamondon K. Undergraduate International Medical Electives: Some Ethical and Pedagogical Considerations. Journal of Studies in International Education. 2011;15(2):171-85. 16. Dharamsi S, OseiTwum JA, Whiteman M. Socially responsible approaches to international electives and global health outreach. Medical education. 2011;45(5):530-1. 17. Logar T, Le P, Harrison JD, Glass M. Teaching Corner: “First Do No Harm”: Teaching Global Health Ethics to Medical Trainees Through Experiential Learning. Journal of Bioethical Inquiry. 2015;12(1):69-78. 18. Asgary R, Junck E. New trends of short-term humanitarian medical volunteerism: professional and ethical considerations. Journal of medical ethics. 2013;39(10):625-31. 19. Petrosoniak A, McCarthy A, Varpio L. International health electives: thematic results of student and professional interviews. Medical Education. 2010;44(7):683-9. 20. McCall D, Iltis AS, editors. Health Care Voluntourism: Addressing Ethical Concerns of Undergraduate Student Participation in Global Health Volunteer Work2014: Springer. 21. Stoltenberg M, Rumas N, Parsi K. Global health and service learning: lessons learned at US medical schools. Medical education online. 2012;17.

Conflict of Interest None declared Correspondence gabbygeorgiou@gmail.com References 1. Fox GJ, Thompson JE, Bourke VC, Moloney G. Medical students, medical schools and international health. Medical Journal of Australia. 2007;187(9):536. 2. Crump JA, Sugarman J, the Working Group on Ethics Guidelines for Global Health T. Ethics and Best Practice Guidelines for Training Experiences in Global Health. The American Journal of Tropical Medicine and Hygiene. 2010;83(6):1178-82. 3. Banatvala N, Doyal L. Knowing when to say” no” on the student elective; students going on electives abroad need clinical guidelines. British Medical Journal. 1998;316(7142):1404-6. 4. Shah S, Wu T. The medical student global health experience: professionalism and ethical implications. Journal of medical ethics. 2008;34(5):375-8. 5. Bozinoff N, Dorman KP, Kerr D, Roebbelen E, Rogers E, Hunter A, et al. Toward reciprocity: host supervisor perspectives on international medical electives. Medical education. 2014;48(4):397-404. 6. DeCamp M, Enumah S, O’Neill D, Sugarman J. Perceptions of a short-term medical programme in the Dominican Republic: voices of care recipients. Global public health. 2014;9(4):411-25. 7. Melby MK, Loh LC, Evert J, Prater C, Lin H, Khan OA. Beyond Medical “Missions” to Impact-Driven Short-Term Experiences in Global Health (STEGHs): Ethical Principles to Optimize Community Benefit and Learner Experience. Academic Medicine. 9000;Publish Ahead of Print. 8. Ketheeswaran P. Good intentions with unknown consequences: understanding short term medical missions: SCHOOL OF MEDICINE Thesis GOOD INTENTIONS WITH UNKNOWN CONSEQUENCES: UNDERSTANDING SHORT TERM MEDICAL MISSIONS by PAVINARMATHA KETHEESWARAN BS, University of Florida; 2015. 9. Ackerman LK. The Ethics of Short-Term International Health Electives in Developing Countries. Annals of Behavioral Science and Medical Education. 2015;16(2):40-3. 10. Dharamsi S, Richards M, Louie D, Murray D, Berland A, Whitfield M, et al. Enhancing medical students’ conceptions of the CanMEDS Health Advocate Role through international service-learning and critical reflection: A phenomenological study. Medical Teacher. 2010;32(12):977-82. 11. Wallace LJ. Does Pre-Medical ‘Voluntourism’Improve the Health of Communities Abroad? Journal of Global Health Perspectives. 2012;1:1-5. 12. Citrin DM. “Paul Farmer Made Me Do It”: A Qualitative Study of ShortTerm Medical Volunteer Work in Remote Nepal: University of Washington; 2011.

IFMSA - 5 letters with one big mission! Australian Medical Students attend the IFMSA 66th General Assembly in Montenegro [Conference report] Aysha Abu-sharifa (University of Notre Dame Fremantle), Stormie de Groot (University of New England), Julie Graham (James Cook University), Justine Thomson (University of Wollongong)

The International Federation of Medical Students Associations, or IFMSA, was founded in 1951 in response to the overwhelming global challenges following World War II. Committed to the ideals of the Alma Ata Declaration and “Health for All” (2007), the founders believed that medical students should not be passive bystanders, but rather, use their ability to create lasting and meaningful change through collaboration and innovation. Today, the organisation represents over 1.3 million medical students from over 122 countries worldwide, with the Australian Medical Students’ Association (AMSA) having been part of the organisation for many years. The IFMSA is involved in a wide range of global health advocacy, public health, primary health and clinical health projects. This encompasses training arms, medical student exchange programs and collaborative public health projects. There are several standing committees working within specific areas of global health, including Public Health (SCOPH), Sexual and Reproductive Health (SCORA), Medical Education (SCOME), Human Rights and Peace (SCORP) and Professional and Research Exchanges (SCOPE/SCORE). The IFMSA is also divided into regions which allow for effective collaboration across geographically similar areas, such as the Asia Pacific Region, of which AMSA is a member. The IFMSA offers the opportunity for all Australian medical students, through AMSA, to be involved in student activities on an international scale. Most recently, AMSA sent a team of 14 Australian delegates to attend the IFMSA’s 66th General Assembly (GA) in Budva, Montenegro, from March 2-8, 2017. The team was led by

Julie Graham, AMSA Global Health’s Vice Chair International and acting IFMSA Australian President, along with Liz Bennett, AMSA Global Health’s Chair. The General Assembly is likened to an international version of an AMSA Council in which policies are discussed and debated, changes to operational processes are made, new member states are voted in and prepared statements are read. Most of these processes take place in plenary sessions, where Julie and Liz represented Australia on issues relating to medical education and general global health.

Charlotte O’Leary presents youth declaration on NCDs Along with the plenary sessions, each standing committee also conducts their own parallel SCORA sessions for members. The Australian members were divided between many of these half-day standing sessions, which allowed the Australian team members to think about being part of the global health community and how IFMSA projects could open many doors on this level. Other key components of the program include joint sessions between standing committees, National Member Organisation meetings and plenaries, where delegates participate as guests to support and advise the delegation leaders. 44

This year’s GA was marked by several significant achievements by the Australian team. Most notably Australian student Charlotte O’Leary was responsible for the NonCommunicable Disease (NCD) Youth Caucus, which lead to the creation and adoption by the IFMSA of the “Budva Youth Declaration: A Call to Action on Non-communicable Diseases”. Charlotte has just completed a 3-month internship at the World Health Organization (WHO) in Geneva and was appointed by the IFMSA to organise and moderate the NCDthemed events. AMSA Global Health Chair, Liz Bennett, was also one of the panellists amongst many prestigious speakers and discussed the linkage between nutrition, food systems, and NCDs. The Youth Caucus formed the key components of the themed events on NCDs. It was opened at the IFMSA GA opening ceremony by Dr Bente Mikkelsen, Head of the WHO Commission on NCDs, and was followed by two panel discussions.

Prerna Diksha AMSA was also represented at the IFMSA GA Activities Fair, where over 150 projects worldwide were featured and discussed with delegates. Three Australian projects were presented, including Project Burans, presented by Prerna Diksha of Melbourne University, Crossing Borders, a National Project of AMSA Global Health, presented by Aysha Abu-sharifa, and AMSA’s Newcastle NewGHC presented by Adelaide Pratt (Logistics Convenor, AMSA 2016 Newcastle Global Health Conference). Project Burans is a philanthropic mental health initiative of the Emmanuel Hospital Association, the largest non-governmental provider of

healthcare in India. It won second place for founder Prerna Diksha and other members of Melbourne University, out of almost 150 other entries! Participation in both policy writing and review represents a significant opportunity for involvement in any IFMSA GA. Julie Graham, delegation leader, was a member of the Policy commission team for the IFMSA Rural Health Policy, along with 2 other international team members. This policy received input from around the world prior to the GA, including ample suggestions from Australian medical students. The Rural Health Policy was one of 12 propositions that were successfully passed during the plenary policy session. The Pre GA provides a great opportunity to work with and get to know a smaller proportion of students attending the GA. Medical science student, Stormie de Groot attended a Pre-GA workshop, “Transforming Our World by 2030: Reaching the Sustainable Development Goals (SDGs)”, which focused on how and why the SDGs were developed, their purpose, and how medical students could work towards achieving them.

“It was insightful and humbling to see the work that was already being achieved by National Medical student Organisations (NMOs) around the world, amongst various social, cultural and political contexts. Overall, it challenged all of us to adopt the SDG framework into our existing AMSA Global Health Projects and beyond through our AMSA Sustainable Development Policy (2016).” -Stormie de Groot, University of New England. The activities of the Sexual and Reproductive Health stream within the IFMSA represent a key area for involvement for Australian medical students, many of whom are engaged, interested and skilled in this field. Justine Thomson, Education Officer for AMSA Global 45

Health, was involved in presenting a session within the SCORA streams on Comprehensive Sexuality Education.

discriminatory health care for sex workers in the Netherlands.” Aysha Abu-sharifa, University of Notre Dame Freemantle.

“As a health and physical education teacher prior to medical school, I enjoyed the opportunity to take part in the General Assembly and share my knowledge in [sexual health]. My experiences within the general SCORA sessions were excellent and the guest speakers were highlights, particularly Dr Lale Say from the Department of Reproductive Health and Research, WHO, speaking on Female Genital Mutilation, and new guidelines in this space.” -Justine Thomson, University of Wollongong.

The March General Assembly in Montenegro was an encouraging reminder of the need for global collaboration from Australian medical students. This year’s delegates agreed that not only is there a lot to learn from like-minded students, but there is also a great deal to contribute. The IFMSA conference is only one of the many platforms in which individuals can get involved.

Dr Elijah Painsil, from the Yale School of Medicine, also presented a keynote address around the challenges of children and adolescents living with HIV. In addition to the significant academic opportunities, the IFMSA General Assembly allowed the Australian team members to grow and develop on a personal level through their interactions with other delegates. It was not hard for the team to truly believe the foundational philosophy of the IFMSA: that with collaboration and partnership, it is possible to have an impact on health challenges of the world. For delegation member Aysha Abu-sharifa, the highlight was the personal interactions with other delegates, and being challenged by various cultural perspectives on polarising issues. The Human Rights and Peace stream offered insights into human rights law versus humanitarian law, health inequalities in an intersectional context, and the effects of discrimination on the paediatric population. “[Another] highlight this year was the Activities Fair where projects ranged from medical students mentoring orphans in Baghdad, to signlanguage proficiency training for healthcare workers in Athens, to the advocacy of non-

Act now: • Join the mailing lists of the IFMSA to learn about all the great opportunities (www.ifmsa. org) • Email julie.graham@amsa.org.au to found out more about getting involved with AMSA’s international opportunities, including IFMSA exchanges. Photo credit Jasper Lin & Jessica Yang Acknowledgements None Conflict of Interest None declared Correspondence julie.graham@amsa.org.au References:

1. Baum F. Classics in Social Medicine; Health for All Now! Reviving the spirit of Alma Ata in the twenty first century: An Introduction to the Alma Ata declaration. Social Medicine. 2007;2(1):34-41.

Upcoming events: 1. IFMSA August General Assembly in Tanzania: Pre GA 28 July-1 August; GA 1-7 August; Post GA 7-10 August 2. IFMSA Asia Pacific Regional Meeting (APRM) in Japan: Pre- September 15-17; APRM September 17-21

Changing Climate, Changing Perspectives: iDEA Conference Report [Conference report] Isobelle Woodruff Isobelle is a third year Doctor of Medicine student at UNDS, currently completing her clinical years in Melbourne. She is also the AMSA Code Green Co-National Project Manager and is passionate about empowering people to mitigate the health effects of climate change. Her other areas of interest include mental health and wellbeing, nutrition and behavioural change strategies. The iDEA conference is an annual national conference of Doctors for the Environment Australia (DEA). Run over two days with over 35 world-renowned speakers; engaging breakout workshops; and entertaining social nights with gourmet, ethically-sourced food; iDEA is the centrepiece of environmental health education and inspiration. iDEA unites medical professionals and students from around Australia “with one common goal – to address the human health impacts of the environment and climate change”,[1] with a 2017 theme of “Global Problems, Local Solutions”.

effects of climate change; droughts, bushfires, allergies, asthma”. Similarly, Dr Simon Judkins, President-Elect of the Australian College of Emergency Medicine, asserted that “climate change means that we are seeing bigger and more frequent large scale disasters, and emergency physicians are front and centre when it comes to responding to those events”.

Global Problems Throughout the weekend, I was reminded of why our changing climate is indeed “the biggest global health threat of the 21st century”,[2] affecting health both directly and indirectly. The widely cited 2009 paper “A Commission on Climate Change” in The Lancet outlines the direct effects of climate change to be, namely; increased heat stress, floods, drought and increased frequency of intense storms.[2] In a panel of College Presidents at iDEA17, Dr Bastian Seidel, President of the Royal Australian College of General Practitioners, outlined the direct impacts of climate change on human health through referencing his everyday experiences as a general practitioner; “General Practitioners (GPs) are true climate change witnesses. As a GP in Southern Tasmania, there is not a single day that patients don’t come in and tell me about the

L to R: Dr Scot Ma (ANZCA), Prof John Middleton (UK FPH), Dr Simon Judkins (ACEM), Dr Bastian Seidel (RACGP), Dr Kym Jenkins (RANZCP)

In addition to the direct impacts of climate change on human health, there are also subtler, insidious, indirect effects. Some of these include air pollution, the spread of vector-borne diseases, food insecurity and under-nutrition, displacement and an increase in mental illness.[2] Dr Helen Szoke, CEO of Oxfam, directed our attention to the recent WHO report on pollution and child health, a landmark study which found that more than 1 in 4 deaths of children under 5 years of age are attributed to unhealthy environments. Additionally, climate change could drive 122 47

million more people into extreme poverty by 2030 through its impact on increasing vectorborne diseases, food insecurity, increasing the number of climate refugees and respiratory disease through air pollution.[3]

these nations have had since leading the way in renewables and why it makes economic sense for Australia to follow suit.[6] Focusing the light on Australian shores, Dr Roger Dargaville from the Melbourne Energy Institute outlined the need for robust policy and strategic direction for the Australian energy market, if we are to move towards renewables and avoid further energy demand issues like the recent South Australian energy crises.

Dr Alessandro Demaio, Medical Doctor for the World Health Organization (WHO) and cofounder of NCD-Free, addressed the connection between obesity and climate change. This is a potentially hidden link, but one not to be ignored: if food waste were a country, it would be the Changing Perspectives and Summary third largest CO2 emitter.[4] He emphasised the importance of collaboration on global I took away a bigger picture of how we issues such as obesity and climate change, conceptualise climate change, and left thinking “when it comes to NCDs and climate change, that we need to change our perspective to opportunities for co-mitigation are profound and achieve true change. What makes climate unprecedented. Inaction cannot be an option.” change so difficult to comprehend is the lack He urged us to think laterally on of a clear, single perpetrator; the topic – both issues have What makes climate change so it doesn’t have a face. Without similar causes and solutions, difficult to comprehend is the lack oversimplifying complex issues, so how can we address them of a clear, single perpetrator; it it is clear that, for example, when together through lobbying, policy doesn’t have a face. we want to blame someone for change and targeted public the obesity epidemic we think health strategies? of big corporate companies like Coco Cola or McDonalds. When we want to Local Solutions blame someone for displaced people and mass migrations, we think of war and governments. In the face of impending “climate chaos”, as it was colloquially referred to throughout With climate change, it isn’t as easy to play the conference, it is easy to feel overwhelmed the blame game. We can’t easily point the finger by the reality of climate change. Despite this, at someone or something and say “this is the the speakers provided messages of hope and reason why; this is the cause”. Because we can’t inspired action and empowerment through local readily shift the blame onto something easily solutions. identifiable, it makes the issue less tangible and more challenging to connect with. There is Coming from a refreshingly non-medical nowhere to direct the anger and frustration at perspective, Tim Buckley, one of Australia’s top the catastrophic changes we are seeing around financial energy analysts, provided an overview us, the natural response is to either disconnect of the progress our neighbours in India and with the issue, or to feel overwhelmed with China are making in the renewable energy despair and subsequently be driven to inaction. market [5]. He outlined the importance of knowing your audience – the motivation behind In truth, we should be pointing the finger at these nations’ transition to renewables wasn’t is ourselves. As was made abundantly clear for health reasons, but economic reasons in at the conference and in countless articles India (considering renewables cost 80% of and reviews presented by the wider scientific what it costs to import fuel) and populationcommunity, the evidence overwhelmingly driven air quality concerns in China. Buckley indicates that climate change is largely human highlighted the financial stability and success driven, and thus we must take responsibility.[7]

Yes, we are a large part of the cause. But if I learned anything over the weekend, it is that we can also drive the solution. In the words of Dr Helen Szoke, “the mission that you sign up to when you become a doctor means that you have a responsibility to assist humanity climate change is a big part of that.” There needs to be a shift of focus from the negative outcomes of climate change, towards the positive ways we

as doctors, we have an obligation to talk and act on climate change”. Photo credit Mack Lee Acknowledgements None Conflict of Interest None declared Correspondence isobelle.woodruff@amsa.org.au References 1. Doctors for the Environment Australia. iDEA17 Conference DEA2017 [Available from: https://www.dea.org.au/

iDEA17 delegates can address it. We need to stop seeing it as an issue and start seeing it as a potential for change and act in the infinite ways the speakers outlined at iDEA. While it is the biggest threat to our species and planet, climate change could also be “the greatest global health opportunity of the 21st century”.[8] The evening before the conference commenced, I was honored to hear from human rights lawyer Julian Burnside AO QC, who eloquently stated; “to remain silent is as much a political act as to speak out”. This simple idea is as applicable to climate change and human health as ever; the health impacts of climate change are direct and indirect, immediate and long term, both overt and subtle. We must have a global perspective on the issue, but also the willingness to act locally to create sustainable and tangible change to protect the health of our planet and our people. It is our responsibility as informed, ethically-minded health professionals to act now. In the words of Dr Stephen Parnis, exAMA Vice President “prevention and mitigation is always better than reaction and recovery –

idea2017/. 2. The Lancet. A Commission on climate change. The Lancet. 2009;373(9676):1659. 3. Inheriting a sustainable world? Atlas on children’s health and the environment. Geneva: World Health Organisation, 2017. 4. Food and Agriculture Organization of the United Nations. Food wastage footprint; impacts on natural resources (summary report). Natural Resources Management and Environment Department, United Nations, 2013. 5. Buckley T. IEEFA Update: China Is Now Three Years Past Coal. IEEFA, 2017 Feburary 28, 2017. Report No. 6. Tan JAMH. Economics: Manufacture renewables to build energy security. Nature. 2014;513(7517). 7. McMichael AJ. Globalization, Climate Change, and Human Health. The New England Journal of Medicine. 2013;386:1335-43. 8. Nick Watts et al. Health and climate change: policy responses to protect public health. The Lancet. 2015;386(10006):1861 - 914.

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