Vector Volume 11 Issue 2 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

Thank you to the Vector Journal peer reviewers for 2017: Dr Phil Baker Dr Denton Callander Professor Nicholas Crofts Dr Greg Fox Dr Alexandra Gibson Dr Max Hopwood Ms Alexandra Jones Dr Erik Martin

Dr Bridianne O’Dea Dr Dominique Martin Professor Geetha Ranmuthugala Dr Mitchell Smith Dr Adrienne Torda Dr Leonie Watterson Professor Bridget Wills

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 design image accessed from https://pixabay.com/p-2349893/?no_redirect 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: Turning Up the Heat

Features Non-Health for Non-Persons: Rohingya Muslims in Crisis Jumaana Abdu

LGBTIQ people’s experiences of and barriers to healthcare Salwa Barmaky and Alex Lee

Commercial surrogacy in Australia: the benefits of harm minimisation through legalisation Keyur Doolabh and Emily Feng-Gu

Polio vs Politics: The Case of Pakistan Jeanine Hourani

Turning up the heat Tara Kannan

Coal mining, climate change and the global impacts on health: examining Adani’s proposed Carmichael coal mine

John E Morgan Paddling upstream: Experiences from a medical placement in rural Papua New Guinea Nicholas Snels

Reviews Sugar tax: a sweet solution for obesity? Saiuj Bhat

Drug control in Australia: where to next? Raquel Maggacis

Dengue in the Pacific Islands Madeleine Marsland and Dunya Tomic

Conference reports AIDA 2017 - Family, Unity and Success Narawi Foley Boscott

World Congress on Public Health Michael Au, Ka Man Li, Helena Qian, Michael Wu

Commentary Welfare cuts to refugees AMSA Global Health Crossing Borders National Managers Sibella Breidahl, Jasmine Sekhon

GHC 2017 Start where you are, use what you have, do what you can - Adelaide Global Health Conference 2017 Closing Address 52 Liz Bennett, AMSA Global Health Chair 2017 GHC Competition Winner: “Where to now?” Helena Qian

Book review A walk to remember Anna Marie Plant

Editor’s Note- Turning up the heat Global health is intrinsically linked to the changing social, economic, cultural and political environment. Political leaders powerfully shape responses to global health, whether in a positive or negative way. Historically, when health issues have risen on the political agenda, they received greater media attention, and importantly, funding – the HIV/AIDS epidemic exemplifies this. The change in leadership in the World Health Organization under the new Director-General Dr Tedros offers new opportunities to advocate for issues such as universal health coverage, women’s health and rights, and climate health. However, like many others, I find myself disappointed by the lack of political will to assist refugees and people seeking asylum. This is an ongoing problem, in Australia with the recent welfare cuts to refugees, described by Sibella Briedahl and Jasmine Sekhon (pg 2) , and internationally, with the plight of the stateless Rohingya people fleeing persecution in Myanmar, in a feature article by Jumaana Abdu (pg 50). Over the past year, controversial policies have dominated public health discourse on both a national and international scale. Non-communicable diseases continues to rise on the agenda. A tax set to cut sugar-sweetened beverage consumption takes a step towards tackling Big Sugar in the footsteps of movements against Big Tobacco, as covered in a review by Saiuj Bhat (pg 29). In Australia, we have also seen pushes for safe injecting rooms and pill testing at festivals. Does this reflect the global shift in attitudes from criminalisation towards harm minimisation, with decriminalisation in Portugal providing successful proof-of-concept? Raquel Maggacis overviews drug control approaches worldwide, arguing that Australia should adopt a harm minimisation approach (pg 34). Global health does not obey borders, and health policies have far-reaching effects. Infectious diseases certainly require no passport to spread from country to country, and Madeleine Marsland and Dunya Tomic highlight the importance of strong regional surveillance systems and prevention strategies (pg 38) Moreover, so long as one child has polio, all countries remain at risk, as described by Jeanine Hourani (pg 19). However, polio eradication in Pakistan, one of the last remaining polio-endemic countries, is incredibly complex due to political instability and competing agendas. Local policies certainly have broader international consequences, and Keyur Doolabh and Emily Feng-Gu explore issues around commercial surrogacy such as exploitation in countries where surrogacy is cheaper or poorly regulated (pg 10). Similar to drug control approaches, a harm minimisation approach may offer a better alternative to regulate processes and protect the rights of parents and children.

will have significant implications both now and in the future. With the recent postal vote, the mental health and wellbeing of LGBTIQA+ people could not be of more relevance. However, as Salwa Barmaky and Alex Lee write, LGBTIQA+ people also face barriers in access to healthcare, including discrimination from the medical profession itself (pg 5). Aboriginal and Torres Strait Islander people also experience discrimination within the health care system, as Narawi Foley-Boscott explains (pg 44). So what then is the way forward for such issues? Both authors emphasise the importance of educating medical professionals to be culturally sensitive, to be open to learning, and to be aware of the structural factors that contribute to discrimination. Evan Morgan (pg 21) argues that the Adani coal mine endangers our health and the environment and is a poor investment for tax-payers. It hinders Australia’s ability to fulfil its global commitments under the Paris Agreement to reduce carbon emissions and temperature rises. Divestment offers a solution to climate change: take money away from the fossil fuel industry. We, as medical societies and the future medical profession, have an important role to add to this social movement, as thoughtfully argued by Tara Kannan (pg 17) The title of her article, “Turning up the heat”, captures the energy that connects the articles in this issue, a panoramic range of contemporary and controversial issues. It calls on us to take action and to challenge the paradigm of seeing health as purely a biomedical issue, but one inherently connected to regional and international social and political forces. As medical students, we are well-placed to educate and upskill ourselves to contribute to global health in the future. Attend conferences (Australian Indigenous Doctors’ Association, pg 44 World Congress of Public Health, pg 47. Take elective placements in developing countries, and prepare yourself with pre-departure training (Nicholas Snels, pg 26 ). As yourself, what can we do about these global health issues? (Helena Qian, pg 54) One of the statements that left a lasting impression on me from this year’s Global Health Conference was from the AMSA Global Health Chair, Liz Bennett: “It is not enough to be inspired... We do not have the luxury of apathy and you cannot afford to waste time thinking that you are too small to make a difference.” (pg 52). I am continually amazed and grateful to the incredible work of the authors, editorial team, peer reviewers and Advisory Board. It has been a privilege and a half to lead Vector Journal this year and hope that this issue inspires you and challenges you to take action. Carrie Lee Editor-in-chief, 2017

Other contentious topics in Australia include the Adani coal mine and the postal vote for same sex marriage. These 1

Non-Health for Non-Persons: Rohingya Muslims in Crisis [Feature article] Jumaana Abdu Jumaana is currently finishing her first year of medicine at the University of New South Wales. She aims to find a career path which combines her passion for medicine and human rights. She also hopes her future involves as a side-profession of writing, fiction or otherwise.

In a tightening spiral of human suffering that winds back five decades, the Rohingya have come to be mentioned as a customary precursor to the phrase “most persecuted minority in the world”. The long-disowned nationals of Myanmar are estimated at a population of 1.2 million,[1] stateless victims of humanitarian violations so comprehensive and extensive that the world’s empathy can only be directed towards a vague fog of injustice. However, as flagbearers of the right to health and human dignity, healthcare professionals must be able to shine a torch into the fog and discern the faces within. Current Situation While systematic persecution of the Rohingya Muslims has been noted since the stripping of voting rights and the military “purges” of the 1970s, events within the past year have seen violence escalate dramatically. A border attack by a group of radicalised Rohingya Muslims on

Myanmar’s police last October resulted in an estimated 10 casualties. Extremist violence is unacceptable and unhelpful, though one can see the desperation, injustice and generations-worth of marginalisation from which this radicalisation was inevitably born. Since the attack, disproportionate and indiscriminate military retaliation has resulted in hundreds of deaths and torrents of Rohingya fleeing Myanmar’s northern Rakhine state, where the situation is worst. The United Nations (UN) reports that from the last week of October 2017 to the first week of September 2017 alone – just two weeks – 270,000 people fled to Bangladesh for safety.[2] The humanitarian crisis in which the Rohingya find themselves is undeniable. Officially stateless, access to basics such as healthcare, education, employment, security and freedom is often impossible. Tragically, these deprivations are far less confronting than other reasons for which the Rohingya have been forced to flee. With UNHCR reports documenting common experiences 2

In 2015, another study investigated the general health conditions of Bangladesh’s largest Rohingya refugee camp, Nayapara.[1] With a population of 18,777, the camp was attended by only four trained doctors and six nurses. The infant mortality rate was 45.4 per 1000 livebirths and one quarter of the population was UNHCR interviews with children, most of whom were born Rohingya refugees detail random Hopelessness was the common theme, in a camp. Additionally, the study shooting at crowds who were fleeing houses, schools, mosques with one Rohingyan interviewee asking, reported widespread stunting due and markets that had been set “Our future has been spoiled, but what to malnutrition (57%), anaemia alight by Myanmar’s army, police will happen to the future of our children?” (49%), and a high prevalence of respiratory (46.9%), endocrine and occasionally civilian mobs.[4] (21.9%) and cardiovascular Destruction of food, livestock and disorders (14.8%). Mental health food sources; cases where the army or Rakhine civilians conditions were ubiquitously poor; 18.7% of camp have trapped an entire family, including the elderly and injuries were caused by self-harm, and in Bangladesh’s disabled, inside a house and set it on fire “killing them all”; other major camp, 43.3% of Rohingya refugees were mothers assaulted by “security” forces while being forced diagnosed with a psychotic disorder. to watch their babies stabbed and killed – words cannot do it justice.[4] Importantly, health conditions in registered refugee camps far surpass those of the many unregistered camps Recent news reveals that Burmese officials have in countries neighbouring Myanmar. These makeshift planted landmines along the Bangladesh border, posing shelters, which house twice as many Rohingya as the a lethal threat to Rohingya peoples fleeing atrocities. registered camps, are conferred no security or support Deemed unlawful for their inability to distinguish between from the already-drowning NGOs servicing the area. civilians and militants, children and adults, landmines have This, however, is still favourable to staying in the northern been banned in many countries under the 1997 Mine Ban Rakhine state of Myanmar where health conditions are Treaty. Not a signatory to this, Myanmar officials continue so abysmal that, for example, mortality in children under 5 to use them against Rohingya civilians, protected by the has reached 224 per 1000 livebirths.[6] unsurprising denial by the Burmese government that such landmine plantings have taken place. Role of Health Professionals in Social Justice An assortment of condemnations have been offered In situations where political and military injustice by the UN; crimes against humanity,[3] genocide, ethnic seem impenetrable, often the most basic human cleansing. The UN High Commissioner for Human right affordable is emergency medical care, but is the Rights Zeid Ra’ad Al Hussein, concludes his report on assumption that medical aids are exempt from political the Myanmar atrocities by despairing, “What kind of and military violence still applicable today? As seen ‘clearance operation’ is this? What national security in reports of hospitals targeted in Syria by Western goals could possibly be served by this?”.[3] As Hussein military, it seems that medical neutrality is no longer a seems painfully aware, these words fall on deaf ears. guarantee. Combined with the Myanmar government’s notoriously uncooperative relationship with humanitarian Medical Crisis organisations, one must ask what responsibility healthcare professionals are expected to bear in the Humanitarian agencies are floundering, desperately realm of human rights. attempting to provide emergency care for the monsoonal influx of Rohingya refugees, most of whom have a variety In 2014, Médecins Sans Frontières was banned of physical and psychological conditions. Studies of the in Rakhine, and a month later, when humanitarian aid health conditions within Bangladesh’s two main registered agencies were attacked by Buddhist anti-Rohingya refugee camps present unsurprisingly dire findings. radicals, Myanmar’s government only further restricted humanitarian aid.[6] This ban has since been lifted One psychiatric study surveyed a group of registered but access is now parlous again due to the Myanmar Rohingya refugees and reported experiences of torture government’s “formulated and disseminated accusations (39.9%), sexual abuse (12.8%), rape (8%), forced against the UN and international NGOs, denial of required abortions (2.4%), PTSD (36%), depressive symptoms travel and activity authorisations, and threatening (89%), suicidal ideations (19%) and deaths of friends or statements and actions by hardline groups”.[7] Also family due to illness or starvation while fleeing (22.4%). recently, the UNHCR High Commissioner Hussein has [5] Hopelessness was the common theme, with one struggled with repeated government restrictions on Rohingyan interviewee asking, “Our future has been humanitarian access to the worst affected regions of spoiled, but what will happen to the future of our children?” Rakhine, and bans on UN investigative officials entering of “mass gang-rape, killings, including of babies and young children, brutal beatings, disappearances and other serious human rights violations by the country’s security forces”, returning to Myanmar is not an option.[3]

Rohingyan regions of Myanmar. Forced to work within the law, the UN can only deploy officers to the Bangladeshi border.[2] These tensions between humanitarian aid and the state beg the question: in health emergencies and human rights violations as staggering as those experienced by the Rohingya Muslims, should human rights and healthcare organisations bend to the will of unjust – even criminal – governments? It is a problem the UN and its subcommittee, the World Health Organization, still grapple with. Do they obey their mandate to respect the sovereignty of their member states? Or do they perform their constitutional role of helping member states “respond to... emergencies with public health consequences”?[8] How can they, when the member state itself is perpetuating the emergency? Additionally, the aforementioned lack of confidence in medical neutrality makes it unsafe for health workers to stand against government and military opposition.

with the desperate masses in any way possible. History paints a picture of peaceful generations of Rohingya living in Myanmar. Their future seems increasingly uncertain, although ideally it involves them returning safely home. One and a half million people await a saving grace, security for their children, medicine, clean water. If international global health organisations cannot work within Myanmar’s policies, then they must find a conclusive alternative. It is unacceptable that there is still not a light at the end of this half-a-century long tunnel. Photo credit EU/ECHO/Pierre Prakash Accessed from https://www.flickr.com/photos/eu_ echo/17337141093/in/photostream/ Conflicts of interest None declared

The only solution where a full response to this

Correspondance jumaana.a6000@gmail.com

... should human rights and healthcare organisations bend to the will of unjust – even criminal – governments?

References

humanitarian crisis can be appropriated lies in either cooperation with Myanmar’s government – which seems unlikely – or direct actions against the government by UN member states. Ideally, the Burmese government would grant the Rohingya some form of internationally recognised citizenship, allowing for better organisation of refugee status and resettlement programs for the Rohingya in neighbouring countries. Sanctions intended to force the Burmese government’s hand have failed in the past,[6] but if the global community can unite with harsher repercussions for the continued persecution of Rohingya Muslims, surely the situation can only improve. Conclusion The Rohingya peoples are born into a cycle of poor health outcomes that begin with low birthweight and continue with dismal access to healthcare. Timid international responses to the systematic abuse, torture and dehumanisation of this minority have allowed for the continuation of historical persecution. The 2015 election of Nobel Prize laurate Aung San Suu Kyi as Myanmar’s Prime Minister presented an opportunity for a Myanmar government to end their denial and dismissal of decades of Rohingyan suffering. However, as stated by her aide, it seems she has “other priorities”,[6] which probably includes avoiding conflict with her majority-Buddhist supporters and the hugely politically influential Burmese military. For now, Rohingya Muslims will have to continue to relying on NGOs who are drowning under resource insufficiencies and legal restrictions, attempting to deal

1. Milton, A. H., Rahman, M., Hussain, S., Jindal, C., Choudhury, S., Akter, S., ... & Efird, J. T. (2017). Trapped in Statelessness: Rohingya Refugees in Bangladesh. International Journal of Environmental Research and Public Health, 14(8). 2. United Nations (2017). UN scales up response as 270,000 flee Myanmar into Bangladesh in two weeks. Retrieved from http://www.un.org/apps/news/story.asp?NewsID=57480#. WbZ6eK2B3Vo 3. United Nations (2017). UN report details ‘devastating cruelty’ against Rohingya population in Myanmar’s Rakhine province. Retrieved from http://www.un.org/apps/news/story. asp?NewsID=56103#.WbZ4w62B3Vp 4. OHCHR Zeid Ra’ad Al Hussein (2017). Interviews with Rohingyas fleeing from Myanmar since 9 October 2016. Retrieved from http://www.ohchr.org/Documents/Countries/MM/ FlashReport3Feb2017.pdf 5. Riley, A., Varner, A., Ventevogel, P., Taimur Hasan, M. M., & Welton-Mitchell, C. (2017). Daily stressors, trauma exposure, and mental health among stateless Rohingya refugees in Bangladesh. Transcultural Psychiatry, 54(3), 304-331. 6. Mahmood, S. S., Wroe, E., Fuller, A., & Leaning, J. (2017). The Rohingya people of Myanmar: health, human rights, and identity. The Lancet, 389(10081), 1841-1850. 7. Médecins Sans Frontières (2017). Myanmar: International humanitarian access to Rakhine State must urgently be permitted. Retrieved from http://www.msf.org/en/ article/myanmar-international-humanitarian-access-rakhinestate-must-urgently-be-permitted 8. Kennedy, J., & McCoy, D. (2017). WHO and the health crisis among the Rohingya people of Myanmar. The Lancet, 389(10071), 802-803.

LGBTIQ people’s experiences of and barriers to healthcare [Feature Article] Salwa Barmaky and Alexander Lee Salwa is a fourth year medical student at the University of New South Wales. and a public health enthusiast, especially interested in health disparities and programme interventions. Alexander is an undergraduate medical student currently studying at the University of New South Wales. His interests include improving healthcare access for marginalised populations including gender and sexuality diverse groups and reproductive health. Introduction Increasing data on sexual orientation and gender identities in large scale social studies has revealed that significant portions of the Australian community are sexuality and/or gender diverse. In the 2014 ABS General Social Survey, 3% of the Australian population identified as not heterosexual,[1] and whilst Australian data is unavailable, a study of 8500 New Zealand secondary school students revealed that 1.2% identified as transgender.[2] LGBTQIA+ refers to lesbian, gay, bisexual, transgender, queer and questioning, intersex, asexual and aromantic individuals, with the ‘+’ connoting other diverse sexualities, sexes and genders. LGBTQIA+ Australians continue to face significant barriers to care which in turn impact individuals’ help seeking behaviours. [3, 4]

group advocating this practice. Many intersex individuals have also been subjected to risky, non-consensual genital mutilation surgery as infants in a bid to ‘normalise’ them.[10] Furthermore, some clinicians expressly feel awkward treating LGBTQIA+ individuals.[11] Hence, to effectively advocate for greater inclusivity and equity, it is paramount that health professionals understand both current and historical healthcare barriers as well as the specific health concerns of LGBTQIA+ communities As such, this article will outline: 1) Effects of individual, interpersonal and structural social determinants of health on healthcare access for LGBTQIA+ individuals; 2) Key health issues affecting LGBTQIA+ individuals; and 3) Recommendations for improving access. Social determinants of healthcare access for LGBTQIA+ individuals

Until 1973, homosexuality was considered a mental Despite the acronym LGBTQIA+ construing disorder. Similarly, transgender and gender diverse (TGD) homogeneity, LGBTQIA+ communities are distinctly identities were classified as ‘gender identity disorder’ heterogeneous. Individuals may have different until the 2013 edition of the Diagnostic & Statistical experiences of their identity and come from different Manual (DSM-5) [4] and continues to social contexts such as ethnic be listed as such by the World Health background or socioeconomic Whilst questions such as Organization’s International Statistical class.[12] However, they do share a Classification of Diseases and “do you have a boyfriend/ continued exposure to societal stigma Related Health Problems (ICD-10).[5] girlfriend?” seem innocent, they associated with their diverse identities. Furthermore, access to hormonal and/ carry value judgements on what This stigma plays into all levels of the or surgical intervention largely remains social determinants of health which in tied to gatekeeper models requiring is considered ‘normal’. turn impact both individuals’ health and TGD individuals to be ‘diagnosed’.[6, 7] healthcare access. These include individual internalised shame, interpersonal discrimination and ignorance and Despite having been widely condemned as ineffective structural legal, administrative and systemic challenges. and causing significant psychological harm,[8, 9] These determinants limit LGBTQIA+ Australians’ pseudoscientific ‘gay conversion therapy’ continues to confidence in our healthcare system. persist. Most recently, a New South Wales GP appearing in a ‘Vote No’ television campaign against same-sex marriage was identified as a founder of a ‘family values’ 5

Individual and interpersonal While accessing healthcare, LGBTQIA+ individuals face interpersonal barriers in the form of clinicians’ lack of knowledge and discrimination as well as their own individual internalised homophobia.

DSM-5 now allows for self-identification as asexual as an alternative to diagnosis with ‘hypoactive sexual desire disorder’ or ‘female sexual arousal/interest disorder’ [25], historically, a lack of interest in sex has been pathologised by Western medicine.[26]

Many practitioners have limited training and Internalised homophobia may manifest as a further awareness around the importance of comprehensive, barrier to seeking healthcare services. Consequently, non-judgmental sexual history taking. Clinicians’ during periods of illness, individuals turn to pharmacies unconscious biases often result in LGBTQIA+ clients and only seek health services when self-medication has being forced to ‘out’ themselves in response to questions been unsuccessful.[27] that assume heterosexuality and do not recognise gender diverse or intersex experiences (e.g. asking a Structural trans woman about birth control). This exacerbates LGBTQIA+ communities also face a myriad of existing awkwardness around sexual and mental health structural barriers to quality healthcare. and is associated with significant discomfort, which may contribute to patients’ decisions Australia is currently the only not to disclose their sexuality or gender LGBTI people in Australia Western country which requires TGD identity.[13] Additionally, some GPs did not are five times more likely to adolescents to gain Family Court understand different sexual practices and ‘approval’ to access hormones. felt uncomfortable broaching the topic. attempt suicide in their lifetimes Despite the time-sensitive nature of [14] One third of LGBTQ* Australians hormone therapy, the legal process still hide their sexuality or gender identity can take up to 10 months, and cost when accessing healthcare.[15] In youths, half did not tens of thousands of dollars.[28] However, this is currently disclose.[16] This not only impacts individuals’ ability to under review by the Family Court.[29] build trust with healthcare providers but also undermines the provision of targeted health services such as human TGD communities, especially non-binary individuals, immunodeficiency virus (HIV) testing in men who have sex also face inaccurate medical record keeping that do with men (MSM). not reflect individual’s chosen names, genders and/or pronouns and a lack of gender-neutral bathroom access. Healthcare providers’ lack of knowledge regarding [18, 23] Moreover, TGD individuals experience discomfort TGD identities and unique health needs is a common in gendered spaces such as gynaecologists’ clinics [23] theme.[17-20] Having to educate healthcare providers and heightened discomfort surrounding pap smears and breast checks.[18, 22] The relegation of TGD services to was found to be a key contributor to negative GP the realm of expensive private healthcare[15] is at heads encounters in Australia.[17] A lack of sensitivity [19, 20] with their increased risk of poverty, underemployment and with practitioners asking invasive or offensive questions housing instability.[18, 19, 23] [17] and misgendering clients through the use of incorrect pronouns or old names [15, 21] contributes to these barriers. Clinicians not working in TGD-specific fields often have little knowledge on the issue, resulting in these clients’ exclusion from mainstream health services. [2, 15, 21] Even clinicians regularly engaged with TGD clients enlist gatekeeping behaviours which restricts access to hormonal and surgical intervention.[17, 22] This discourages TGD individuals from raising mental health concerns and many find this process of “assessment” to be degrading and pathologising.[21] Moreover, rigid, binary views of gender results in non-binary individuals feeling invisible and unwelcome to services.[23] Additionally, the view of LGBTQIA+ identities as inherently pathological by some providers is discriminatory. [13, 21, 24] TGD individuals may face clinician discomfort, disgust, ridicule, contempt and even refusal of treatment. [19, 21-23] One participant of the Australian and New Zealand TranZnation report was told by their doctor that she was ‘the filthiest, most perverted thing on earth’ while another was informed they ‘needed to find god not hormones’.[21] Asexuality is also pathologised. While

Furthermore, unconscious bias can also manifest in the distribution of research funding and practitioner training. Compared to the relative visibility of gay men’s health around the HIV/AIDS epidemic, TGD health as well as queer women’s health have largely been ignored.[13]

Sexual health LGBTQIA+ individuals may also experience poorer sexual health. There is evidence to suggest that women who have sex with women (WSW) are at higher risk for cervical cancer.[32] Both patients and clinicians lack awareness around sexually transmitted infection (STI), specifically human papilloma virus (HPV), transmission during cisgender woman to woman sexual contact. Consequently, WSW are less likely to have Pap or other cervical smears.[33] Key LGBTQIA+ health issues Besides issues of access, LGBTQIA+ individuals have specific healthcare risks, needs and concerns. Pertinently, LGBTQIA+ individuals have significantly poorer mental and sexual health. They also have higher incidence of certain chronic diseases such as cardiovascular disease, asthma and diabetes.[30]

Mental health Poorer mental health is one of the ways that stigma affects LGBTQIA+ individuals’ wellbeing. Compared to the general population, LGBTI people in Australia are five times more likely to attempt suicide in their lifetimes and more specifically, TGD-identifying individuals are eleven times more likely.[31] LGBT people are also twice as likely to be diagnosed and treated for mental health disorders, and 24.4% of LGBT people aged 16 and over currently meet the full criteria for a major depressive episode.[31] Reasons for poorer mental health are also based in internalised, inter-personal, organisational and structural stigma and discrimination.[31] These include: bullying at schools, lack of bullying laws, ostracism from families and faith communities, fear of employment and economic stability, and inner conflict and internalised phobia about their respective identities. LGBTQIA+ individuals also have higher risk for poor coping mechanisms and substance abuse.[32]

In addition, MSM have greater incidence of HIV. In Australia, HIV transmission occurs primarily through male-to-male sex with 68% of new HIV diagnoses in 2015 having been attributed to male-to-male sex.[34] Besides the greater susceptibility of anal mucosa, this increased incidence arises from the concentration of HIV within MSM sexual networks in Western nations.[35] Receptive anal intercourse in male-to-male sex may also increase risk of hepatitis B, HPV and herpes.[32] In NSW, MSM are also more likely to report ever having had an STI, particularly chlamydia, pubic lice, genital herpes, syphilis, anal warts and gonorrhoea.[36] As some of these STIs are risk factors for anal cancer, MSM are also at greater risk for anal cancer.[32] However, MSM are also more likely than any non-MSM to be tested for STIs.[36] Furthermore, poor data collection means that the sexual health of TGD populations in Australia remain poorly understood. The tendency to collapse TGD experiences into a single ‘third gender’ category ignores the vast differences in risk associated with different gender identities, sexual orientations and partners. For example, the Kirby Institutes’ 2016 annual report on STIs recorded sex as ‘male’, ‘female’ and ‘transgender/ missing’.[37] This is particularly disappointing in the context of trans women in particular being significantly overrepresented in global HIV prevalence.[38]

Aging Owing to Australia’s aging population, the issue of older

Key messages • LGBTIQA+ people face barriers to healthcare access, historically influenced by discrimination from the medical profession • Health disparities exist between LGBTIQA+ individuals and the general population, particularly in the areas of mental health, sexual health and chronic disease • Further research and education, a collective effort to treat LGBTIQA+ people with individual respect, and a willingness to learn, will help to reduce health inequalities

*In certain parts of this article, terms to refer to the sex, sexuality and gender diverse individuals may change dependent on the groups of people being researched in the various research articles cited.

LGBTQIA+ individuals is topical. LGBTQIA+ individuals in aged care have specific care needs such as ongoing HIV/AIDS treatment and hormone therapy. Having lived through the criminalisation of homosexuality, many may be impacted by an internalised need to go ‘back into the closet’ for fear of discrimination.[39]

Improving access To reduce the aforementioned barriers and risks, various areas can be improved. Institutionally, education around LGBTQIA+ issues of sexuality, gender diversity, access and risk should be integrated into the medical curriculum. Trainees should be taught to adopt non-judgmental approaches to history taking and communication.[16, 40] Whilst questions such as “do you have a boyfriend/girlfriend?” seem innocent, they carry value judgements on what is considered ‘normal’. Instead, more inclusive terminology should be encouraged to enable clinicians to invite discussion around sexual health without assuming heterosexuality or gender binaries. Encouragingly, previous efforts in introducing LGBTQIA+ content through lectures and clinical simulations have been effective in decreasing at least clinician discomfort in providing LGBTQIA+ related care.[41-44] Clinicians should also create environments of inclusiveness. This includes respecting patients’ chosen pronouns and names, and keeping open minds about their relationships. This is imperative to building trust. Introducing intake forms that include diverse gender identities and LGBTQIA+ specific signage or educational brochures also increase patient comfort.[40] Additionally, revision of current data collection systems would enable more targeted healthcare delivery for TGD populations. This could be aided through mandatory recording of both sex assigned at birth and current gender identity which would enable the disaggregation of different TGD experiences.[45] Conclusion LGBTQIA+ people face on-going barriers to healthcare on individual, interpersonal and structural levels and have an increased risk of mental, sexual and chronic illnesses. Thus, in order to improve health outcomes, barriers to access should be targeted on both interpersonal and structural levels. Ultimately, treating LGBTQIA+ people with individual respect and a willingness to learn will go a long way in in reducing these inequities. Acknowledgements The authors acknowledge and thank Gale Chan for their contributions to the drafting and revising of this article. Photo credit ©2008 laverrue, accessed from https://www.flickr. com/photos/23912576@N05/2942525739

Ryan melaugh, accessed from https://www.flickr.com/ photos/120632374@N07/13974181800 Conflicts of interest None declared Correspondance salwasayeed70@hotmail.com alexanderlee193@gmail.com References

1. Australian Bureau of Statistics. General Social Survey: Summary Results, Australia, 2014 2014 [cited 2017 September 9]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/ mf/4159.0. 2. Clark TC, Lucassen MFG, Bullen P, Denny SJ, Fleming TM, Robinson EM, et al. The health and well-being of transgender high school students: Results from the New Zealand Adolescent Health Survey. Journal of Adolescent Health. 2014;55:93-9. 3. Mulé NJ, Ross LE, Deeprose B, Jackson BE, Daley A, Travers A, et al. Promoting LGBT health and wellbeing through inclusive policy development. International Journal for Equity in Health. 2009;8(18). 4. Potter J, Goldhammer H, Makadon M. Clinicians and the care of sexual minorities Potter J, Goldhammer H, Makadon M, Mayer K, editors. Philadelphia: American College of Physicians; 2008. 5. World Health Organisation. International Statistical Classification of Diseases and Related Health Problems 10th Revision 1992 [updated 2016. 10:[Available from: http://apps. who.int/classifications/icd10/browse/2016/en#/F60-F69. 6. Australian and New Zealand Professional Association for Transgender Health. Standards of Care [Available from: http://www.anzpath.org/about/standards-of-care/. 7. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender and gender nonconforming people 2011 [Available from: http:// www.wpath.org/site_page.cfm?pk_association_webpage_ menu=1351&pk_association_webpage=3926. 8. Mayers L, Chow K. Same-sex marriage survey: Petition to deregister Pansy Lai, doctor in No campaign ad, taken down. ABC News. 2017. 9. Daniel H, Butkus R. Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians. Annals of Internal Medicine. 215(163):135 — 7. 10. Minto CL, Liao L-M, Creighton SM, Woodhouse CRJ, Ransley PG. The effect of clitoral surgery on sexual outcome in individuals who have intersex conditions with ambiguous genitalia: A cross-sectional study. Lancet. 2003;361(9365):1252 — 7. 11. Smith D, Mattews W. Physicians’ attitudes toward homosexuality and HIV: a survey of a California medical Societyal of Homosexuality. Journal of Homosexuality. 2007;52(3/4):1 — 9 12. Ard KL, Makadon HJ. Improving the health care of lesbian, gay, bisexual an transgender people: understanding and eliminating health disparities. Boston, Massachusetts: The Fenway Institutee; 2012. 13. Australian Human Rights Commission. Resilient Individuals: Sexual Orientation, Gender Identity & Intersex Rights 2015. 14. Hinchliff S, Gott M, Galena E. ‘I daresay I might find it embarrassing’: general practitioners’ perspectives on discussing sexual health issues with lesbian and gay patients. Health & Social Care in the Community. 2005;13(4):345.

15. Leonard W, Pitts M, Mitchell A, Lyons A, Smith A, Patel S, et al. Private Lives 2: The second national survey of the health and wellbeing of gay, lesbian, bisexual and transgender (GLBT) Australians. Melbourne: The Australian Research Centre in Sex, Health & Society, La Trobe University; 2012. 16. Robinson KH, Bansel P, Denson N, Ovenden G, Davies C. Growing Up Queer: Issues Facing Young Australians Who Are Gender Variant and Sexuality Diverse. Melbourne Young and Well, Cooperative Research Centre 2014. 17. Riggs DW, Coleman K, Due C. Healthcare experiences of gender diverse Australians: a mixed-methods, self-report survey. BMC Public Health. 2014;14(1):230. 18. Roberts TK, Fantz CR. Barriers to quality health care for the transgender population. Clinical biochemistry. 2014;47(1011):983-7. 19. Safer JD, Coleman E, Feldman J, Garofalo R, Hembree W, Radix A, et al. Barriers to healthcare for transgender individuals. Current opinion in endocrinology, diabetes, and obesity. 2016;23(2):168-71. 20. Snelgrove JW, Jasudavisius AM, Rowe BW, Head EM, Bauer GR. “Completely out-at-sea” with “two-gender medicine”: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Services Research. 2012;12(1):110. 21. Couch M, Pitts M, Mulcare H, Croy S, Mitchell A, Patel S. TranZnation: A report on the health and wellbeing of transgendered people in Australia and New Zealand Melbourne Australain Research Centre in Sex, Health & Society, La Trobe University 2007. 22. Pitts M, Couch M, Croy S, Mitchell A, Hunter M. Health service use and experiences of transgender people: Australian and New Zealand Perspectives Gay & Lesbian Issues and Psychology. 2009;5(3):167-76. 23. Mogul-Adlin H. Unanticipated: Healthcare Experiences of Gender Nonbinary Patients and Suggestions for Inclusive Care. United States, Connecticu: Yale University; 2015. 24. Transgender and Gender Diverse Health and Wellbeing: Background paper. Victoria Gay, Lesbian, Bisexual, Transgender and Intersex Health and Wellbeing Ministerial Advisory Committee, ; 2014. 25. Bogaert A. Asexuality: What It Is and Why It Matters. The Journal of Sex Research. 2015;52(4):362-79. 26. Gupta K. “And Now I’m Just Different, but There’s Nothing Actually Wrong With Me”: Asexual Marginalization and Resistance. Journal of Homosexuality. 2017;64(8):991-1013. 27. Alencar Albuquerque G, De Lima Garcia C, Da Silva Quirino G, Alves MJH, Belém JM, Dos Santos Figueiredo FW, et al. Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review. BMC international health and human rights. 2016;16(2):22. 28. Taylor J. Chief Justice vows change to ‘traumatic’ court process for transgender children. ABC News. 2016. 29. Ryan E. Access to justice for young transgender Australians: Laywers Weekly 2017 [Available from: https://www. lawyersweekly.com.au/opinion/21101-access-to-justice-foryoung-transgender-australians. 30. Bolderston A, Ralph S. Improving the health care experiences of lesbian, gay, bisexual and transgender patients. Radiography. 2016;22:207 — 11. 31. Alliance NLH. Snapshot of mental health and suicide prevention statistics for LGBTI people. National LGBTI Health Alliance; 2016. 32. Lee R. Health care problems of lesbian, gay, bisexual, and transgender patients. The Western Journal of Medicine. 2000;172(6):403 — 8. 33. Curmi C, Peters K, Salamonson Y. Lesbians’ attitudes

and practices of cervical cancer screening: a qualitative study. BMC Women’s Health. 2014;14(153). 34. The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia. The Kirby Institute; 2016. 35. Amirkhanian YA. Social Networks, Sexual Networks and HIV Risk in Men Who Have Sex with Men. Current HIV/AIDS reports. 2014;11(1):81-92. 36. Richters J, Zou H, Yeung A, Caruana T, O de Visser R, Rissel C, et al. Sexual health and behaviour of men in New South Wales 2013–2014. School of Public Health and Community medicine 2015. 37. The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2016. Sydney, Sydney NSW 2052: The Kirby Institute 38. Groves A. Transgender women and HIV: A footnote to the epidemic. HIV Australia. 2012;9(4):30-2. 39. Australian Department of Health and Aging. National Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI): Ageing and Aged Care Strategy. 2012. 40. Ard KL, Makadon HJ. Improving the Health Care of Lesbian, Gay, Bisexual and Transgender People: Understanding and Eliminating Health Disparities Boston, MA: The National LGBT Health Education Center; 2012. 41. Arora M, Walker K, Duvivier RJ, Wynne K. Transgender health delivery and education in the Hunter New England local health district. ANZPATH 2017 Biennial Conference; Sydney, Australia2017. 42. Canty J, Gray L. The last taboo? Teaching skills for clinical consultations with sex/gender diverse people in medical education. . ANZPATH 2017 Biennial Conference; Sydney, Australia2017. 43. Grosz AM, Gutierrez D, Lui AA, Chang JJ, Cole-Kelly K, Ng H. A Student-Led Introduction to Lesbian, Gay, Bisexual, and Transgender Health for First-Year Medical Students. Family Medicine. 2017;49(1):52-6. 44. Safer JD, Pearce E. A simple curriculum content change increased medical student comfort with transgender medicine. Endocrine Practice. 2013;19(4):633-7. 45. Sizemore LA, Rebeiro PF, Mcgoy SL. Improving HIV Surveillance Among Transgender Populations in Tennessee. LGBT Health. 2016;3(3):208-13.

Commercial surrogacy in Australia: the benefits of harm minimization through legalisation [Feature Article] Emily Feng-Gu and Keyur Doolabh Emily is an enthusiastic fourth year medical student at Monash University. She is completing a Diploma of Liberal Arts (Philosophy), and hopes to complete a Bachelor of Medical Science next year in her area of interest: bioethics. In her spare moments, she can be found with a coffee in one hand and a book in the other. Keyur is a medical student with an interest in philosophy. He enjoys writing, and is particularly interested in poverty, climate change and animal welfare. Surrogate /sʌrəɡət/ A substitute, or someone or something that represents another person or thing in their stead.[1]

The status quo There is much controversy around surrogacy in Australia. We have what is known as ‘altruistic surrogacy,’ whereby a woman cannot be compensated beyond reasonable expenses for gestating a baby intended for someone else. Even the name puts our moral intuitions at ease. Altruistic. Contrast this with the term ‘commercial surrogacy’, which makes many of us instinctively recoil. So what is it about commercial surrogacy, where a woman is paid to gestate a baby, that we take issue with? The most common type of surrogacy is gestational surrogacy, wherein the commissioning parent(s) uses IVF to create an embryo from their own or donor gametes and transfer it into the uterus of the gestational surrogate. With this method, the surrogate mother does not provide any genetic material. People that seek out surrogacy commonly include infertile heterosexual couples and homosexual couples desiring children of their own. The demand for surrogacy has heightened in recent years following changes to child protection policy, which lead to drastic falls in the number of children for adoption and stricter criteria implemented by overseas countries regarding the age and family types who can adopt. For example, none of Australia’s current international adoption agreements allow same-sex couples to adopt.[2] The status quo in Australia (except

the Northern Territory) only allows altruistic surrogacy, where one must not compensate the surrogate mother beyond out-of-pocket expenses like medical cost, travel, and time off work. The options are further limited by the fact that surrogacy is illegal for single people and samesex couples in certain states like Western Australia and South Australia. The increasing number of roadblocks to accessing surrogacy has left many desperate couples resorting to offshore commercial surrogacy. But even this option is becoming more restricted now that Thailand, Cambodia, India, and Nepal have banned foreigners from commercial surrogacy following the notorious “Gammy scandal” in 2014.[3] Objections to commercial surrogacy Commercial surrogacy commonly encounters several types of objections. Some think it is inescapably a form of exploitation of women, reducing the surrogate to her base reproductive capability, and effectively turning her into a walking incubator. Certainly, the idea of a class of ‘breeders’ is eerily reminiscent of Margaret Atwood’s classic novel The Handmaid’s Tale, which could be interpreted as a cautionary tale warning against the harms of surrogacy. In a similar vein, some argue that pregnancy belongs in a special moral realm, and that by bringing market forces into the arena we degrade the intrinsic value of creating life. Maybe there are some things in life which simply should not come with a price tag.

Certainly, the idea of a class of ‘breeders’ is eerily reminiscent of Margaret Atwood’s classic novel The Handmaid’s Tale

Commercial surrogacy also raises objections that intersect with other ethical and societal issues. Some assume that a child is best raised with both a father and a mother figure, and therefore believe that enabling same-sex couples to access surrogacy would be harmful for children. However, existing Australian law allows same-sex couples to adopt, and it is difficult to see why, on the grounds of concern for the child, surrogacy would be different. Furthermore, the assumption that samesex parenting is harmful to children is not borne-out in the evidence,[4] and so we do not see this as a relevant argument against commercial surrogacy.

Undesirable consequences

The supply of altruistic surrogates in Australia falls well short of demand, driving Australian couples to search for surrogates overseas. Most are travelling to countries like India or Thailand where the process was until recently legal, cheaper, and poorly regulated. It is this scene that has become inextricably associated with commercial surrogacy. The transnational surrogacy market operating out of developing countries has been widely criticised in popular media,[7,8] and rightly so. Women who become surrogates in these countries tend to be poorly educated, have low incomes, and may even Another objection to commercial be coerced into surrogacy by family Banning commercial surrogacy members or intermediaries seeking to surrogacy is that it would change the nature of the family unit by involving the domestically has created a turn a profit.[9] Often, very little of the surrogate as a third parent figure. But transnational black market of money actually reaches the surrogate these changes to the more ‘traditional’ commercial surrogacy that does herself. There are some surrogacy family unit are already common in not protect the best interests of agencies which effectively imprison society. Take for example adoption, surrogates, controlling their diet, sleep, the surrogate, the child, or the sexual activity, and contact with the where both biological and adoptive parents may be involved in the child’s intended parents outside world. All this is done under the life. It is also possible for women to guise of antenatal care, which is in truth become single parents through the help scant and inadequate.[9] It is difficult to of donor sperm and IVF. In neither case has disruption see how informed consent could truly be said to exist in of the ‘traditional’ family unit been viewed as reason for this environment.[10] prohibition, and it would be inconsistent ban commercial surrogacy on these grounds. Even if the surrogacy results in a liveborn child, the challenges do not necessarily resolve. The lack of These ethical objections may be why Australia has enforceable contracts between commissioning parents made commercial surrogacy illegal. But given that no one and surrogates, combined with issues of legal citizenship has ever been prosecuted on these grounds,[5] the legal and parentage, can create a veritable labyrinth if threat is a poor deterrence.[6] For people desperate to conflict arises or if commissioning parents change their have a baby of their own, but who are otherwise unable minds and no longer want the child. Case examples of to, the risks of commissioning illegal surrogacy can pale transnational surrogacy debacles abound in the media. in comparison to the intoxicating notion of holding a fleshFor example, commissioning parents have divorced and-blood child. before the surrogacy was complete, leaving the child

with an uncertain future.[11] Another case saw a baby left stranded with no identity or legal papers for as long as two years.[11] Fortunately, Australian laws allow a child born from an international surrogacy arrangement to be given Australian citizenship, provided that at least one parent is an Australia citizen and a parent-child relationship is proven with DNA testing, although other measures of ‘parent’ can be used. If ineligible, commissioning parents may be required to apply for a permanent visa or an adoption visa. Despite being lengthy and difficult for parents to navigate, these processes and laws minimise the risk of children born internationally via surrogacy being left stateless.[12,13] Australia’s current approach is to prohibit commercial surrogacy because it is regarded as immoral, but is this policy helping the situation or making it worse? At present, Australians for whom altruistic surrogacy is simply not feasible appear to be turning to transnational surrogacy. In 2011, only 21 births by altruistic surgery were recorded in Australia.[14] In the same year, it is estimated over 270 babies were born via transnational commercial surrogacy arrangements.[6] Banning commercial surrogacy domestically has created a transnational black market of commercial surrogacy that does not protect the best interests of the surrogate, the child, or the intended parents; the process is expensive, risky, poorly regulated, and is largely a profit-making exercise for overseas surrogacy agencies. Despite being designed to prevent exploitation, our current system might in fact ironically be encouraging it. Harm minimisation Simply prohibiting a behaviour on the basis of its supposed immorality is not necessarily an effective strategy. Data shows that in Australia and overseas, drug use and morbidity increased under policies of prohibition, and decreased with decriminalization and regulation.[15] Harm minimisation is a principle we see being used more often in Australia’s approach to illicit

drug use and prostitution. It recognises that prohibition can be counterproductive in achieving its overarching goal of improving the lives of Australian citizens. Instead, our laws regulate the potentially damaging behaviour or substance in a way that realistically protects the people involved. So why not apply a similar harm-minimization approach to surrogacy? Given that our prohibitive model is failing to protect Australian couples seeking surrogacy, and instead funnelling business into exploitative transnational surrogacy agencies, we should instead look to harm minimisation to guide how we approach the issue at hand. This could be best accomplished through the decriminalisation of commercial surrogacy in Australia. Decriminalisation and the establishment of a strictly regulated system would better enable us to protect the interests and rights of the intending parents, surrogates, and children. But what should these regulations actually look like? A suggested solution Ideally, a reformed system in Australia would be carried out by a centralised institution that could oversee the entire process, from psychological screening and matching, to counselling, and support services. This centralised institution could be national, state-run or notfor-profit. Strict criteria of eligibility could then more easily be applied, screening out individuals who are unsuitable for surrogacy arrangements due to medical, social, or psychological reasons. This assessment could draw on existing assessment processes for adoption.[16] The relationship between the surrogate and intending couple appears to be the most crucial factor affecting satisfaction with the experience and the likelihood of conflict regarding parentage of the baby.[17] In fact, some studies suggest the most common reason for a surrogate to want to keep the baby is being unsure of the commissioning couples ability to provide adequate care. [17] With this in mind, matching surrogates and intended parents with similar values and desired levels of contact,

as well as facilitating educated discussion about the possibilities of chromosomal abnormalities or multifetal gestation, would also mitigate conflict. Antenatal and postnatal support, including mental health checks, could also be provided through this system. The exclusion of profiting intermediaries increases the likelihood that the interests of all parties would be equally considered, rather than sacrificing the surrogate’s health and experience in favour of maximising profits. Moreover, any surrogacy arrangements would still be constrained by Australia’s existing common law and family law. This ensures that the surrogate maintains all the decisionmaking powers throughout the pregnancy, including her rights to access termination of pregnancy and to bodily autonomy. In terms of the appropriate compensation, it seems prudent to set both a minimum and a maximum limit. Pregnancy is unavoidably risky for a woman, and gestating a growing fetus is no easy task. Why should it not, like many other jobs, receive recompense proportionate to the task? Moreover, pregnancy is intrinsically care-based ‘women’s work’, which is still insidiously undervalued even in modern times. Conversely, to titrate the price of surrogacy to the intensity of a commissioning couple’s desire for a child is hardly ethical. The US can shed light on what prices may look like in an uncapped surrogacy market; the estimated reimbursement for surrogates advertised by leading US agency Circle Surrogacy, not including medical or otherwise associated expenses, is US$30,000.[18] Most couples experiencing infertility would struggle to pay this price, which does not include medical and legal costs. The aim of setting both minimum and maximum limits on a surrogate’s compensation is to strike a balance between the interests of the surrogate and the commissioning parents - or more simply put,

ensuring fair pay for fair work. Furthermore, a centralised agency would also offer benefits for children born from surrogacy arrangements. There would exist a database through which children could later in life track down their surrogates should they choose to, just as adopted children can request information regarding their birth origins after turning 18. The laws regarding surrogacy should be standardised across all Australian states and territories. At present, the laws are fractured and discordant, diverging on points including whether same-sex couples should be eligible to be intended parents, the legality of advertisement for surrogacy, as well as that of seeking overseas surrogates. The murky legalities of surrogacy make it confusing for surrogates without deterring commissioning parents; if they are willing to pay tens of thousands of dollars for surrogacy, they would probably be happy to travel to states with more favourable laws.[6] Challenges of decriminalisation of commercial surrogacy One might argue that by decriminalising commercial surrogacy in Australia, we simply shift the burden of exploitation from overseas to our own shores. The concern is that commercial surrogates will be uneducated and disempowered, and have little informed choice in the matter. If we assume that the demographic of paid surrogates in Australia would resemble that of the US, then this concern does not appear to be relevant.[17, 19] Small studies of commercial surrogates in the US have suggested the while surrogates do tend to have lower incomes and less education than commissioning parents, they are generally not of a vulnerable population. In one study, most had gone to college, or at least finished high

school, were from middle income earning families, and were in long-term relationships.[17,20] Furthermore, their primary motivation was not the money, but rather to help a couple start their families. While self-report studies do have limitations, perhaps we are too quick to assign altruistic and commercial surrogates into two camps: those who are doing it purely for selfless reasons and those who are doing it for money. The move may also be politically unpopular, with possible public resistance making the implementation slow and difficult. Moreover, creating a system which successfully protects commissioning parents, surrogates, and children born from surrogate arrangements would be a time-consuming and expensive exercise, fraught with pitfalls. Unless it is well-designed, decriminalising commercial surrogacy could perpetuate the very consequences it was designed to mitigate.

Why should it not, like many other jobs, receive recompense proportionate to the task? Conclusion Our approach is not to judge the morality of surrogacy, neither promoting or undermining its value as a reproductive option relative to other methods such as adoption. The problem is a thorny and possibly intractable one, and requires careful consideration of racial politics, gender and income inequality, and human rights. Even in a moral grey zone, however, there are things which are arguably more morally reprehensible than others. Australian couples are resorting to the unregulated and deeply unethical commercial surrogacy market in developing countries, as a result of the failure of our current system. Working towards a safer, more regulated model of surrogacy should be on the Australian and international agenda. Acknowledgements The authors would like to acknowledge the contribution of ideas and research from their fellow medical students, Su Ern Poh and Eli Ivey. Photo credit http://maxpixel.freegreatpicture.com/PregnantPregnancy-Pregnant-Woman-M-Mother-2640994 https://www.pexels.com/photo/pregnancy-pregnantmotherboard-parenthoof-57529/ http://www.publicdomainpictures.net/view-image. php?image=54223&picture=man-holding-newborn Conflicts of interest: None declared Correspondance keyurd12@gmail.com

References

1. Company H. The American Heritage Dictionary entry: surrogate [Internet]. Ahdictionary.com. 2017. Available from: https://www.ahdictionary.com/word/search.html?q=surrogate 2. Australian Institute of Health and Welfare. Adoptions Australia 2011-12. Canberra: AIHW; 2012. Contract No.: CWS 42. 3. Baby Gammy case reveals murky side of commercial surrogacy [Internet]. The Conversation. 2014 [cited 1 October 2017]. Available from: https://theconversation.com/ baby-gammy-case-reveals-murky-side-of-commercialsurrogacy-30081 4. Crouch S, Waters E, McNair R, Power J, Davis E. Parentreported measures of child health and wellbeing in same-sex parent families: a cross-sectional survey. BMC Public Health. 2014;14(1). 5. Stuhmcke A. The regulation of commercial surrogacy: The wrong answers to the wrong questions. Journal of Law and Medicine. 2015;23:333. 6. Everingham SG, Stafford-Bell MA, Hammarberg K. Australians’ use of surrogacy. The Medical Journal of Australia. 2014;201(5):270-3. 7. Alford P. Surrogacy Scandal Widens with Southeast Asia Infant Trafficking Operation Exposed. The Australian. 2014 9 August 2014. 8. Murdoch L. Australian couples’ baby plans in limbo as Cambodia bans commercial surrogacy. The Sydney Morning Herald. 2016 4 November 2016. 9. Saxena P, Mishra A, Malik S. Surrogacy: ethical and legal issues. Indian Journal of Community Medicine. 2012;37(4):211. 10. Deonandan R, Green S, van Beinum A. Ethical concerns for maternal surrogacy and reproductive tourism. Journal of Medical Ethics. 2012;38(12):742-5. 11. Trimmings K, Beaumont P. International surrogacy arrangements: legal regulation at the international level: Bloomsbury Publishing; 2013. 12. Fact sheet - International surrogacy arrangements [Internet]. Border.gov.au. [cited 1 October 2017]. Available from: http://www.border.gov.au/about/corporate/information/factsheets/36a-surrogacy#offshore 13. Birth, adoption and surrogacy [Internet]. Smartraveller.gov. au. [cited 1 October 2017]. Available from: http://smartraveller. gov.au/guide/all-travellers/birth-death-marriage/pages/birthadoption-and-surrogacy.aspx 14. Macaldowie A, Wang YA, Chambers GM, Sullivan EA. Assisted reproductive technology in Australia and New Zealand 2010: AIHW; 2012. 15. Wodak A. The failure of drug prohibition and the future of drug law reform in Australia. Australian Prescriber. 2015;38(5):148-9. 16. Review of the Adoption Act 1984. Melbourne: Victorian Law Reform Commission; 2015. 17. Busby K, Vun D. Revisiting The Handmaid’s Tale: Feminist theory meets empirical research on surrogate mothers. Can J Fam L. 2010;26:13. 18. Circle Surrogacy. Anticipated Costs for Gestational Surrogacy [Available from: http://www.circlesurrogacy.com/ costs. 19. Jadva V, Murray C, Lycett E, MacCallum F, Golombok S. Surrogacy: the experiences of surrogate mothers. Human Reproduction. 2003;18(10):2196-204. 20. Ciccarelli J, Beckman L. Navigating Rough Waters: An Overview of Psychological Aspects of Surrogacy. Journal of Social Issues. 2005;61(21):21-43.

Polio vs Politics: The Case of Pakistan [Feature Article] Jeanine Hourani Jeanine has just completed her first year of the Master of Public Health at the University of Melbourne, having come from an Immunology & Microbiology background. She is particularly interested in refugee and migrant health as well as the effect of warfare on Public Health. Her previous work includes ‘As Syria Bleeds’ which explores the effect of the Syrian Crisis on the health system. Polio is a highly infectious disease caused by poliovirus which predominantly infects young children by invading the nervous system and can result in paralysis. [1] Polio reached epidemic proportions in the early 1900s but was brought under control after the introduction of effective vaccines in the 1950s and 1960s.[1] Despite the progress that has been made, as long as a single child remains infected with poliovirus, children in all countries are at risk of contracting the disease.[2] This is because poliovirus can easily be imported into poliofree countries and subsequently spread, potentially resulting in as many as 200,000 new cases every year. There is no cure for polio, it can only be prevented by the polio vaccine which, if administered correctly, can protect a child for life.[2] As such, vaccination programs are key to achieving global polio eradication. War and civil unrest have a destructive effect on population health. In particular, conflict increases the prevalence of vaccine preventable diseases and decreases the success of vaccination programs.[3] For instance, Pakistan is one of the few countries in the world where polio is still endemic [1, 4, 5] and this is largely due to its geopolitical and socioeconomic challenges. [6] In 2006, Taliban insurgency intensified in Pakistan and the resulting political insecurity has been directly associated with the rise in polio transmission.[7] Failure to achieve polio eradication in Pakistan demonstrates the importance of non-health sector issues, such as barriers to access in war and conflict zones [6].

Conflict and insecurity in Pakistan is clustered in Khyber Pakhtunkhwa (KP) and Federally Administered Tribal Areas (FATA) which are home base to the Taliban and al-Qaeda.[5, 7, 8] The conflict and insecurity in KP and FATA has led to a dramatic rise of reported paralytic polio cases in Pakistan with more than 85% of the global polio cases coming from these regions.[7, 9] The establishment of KP and FATA as major polio reservoirs is undeniably linked to active conflict and insecurity in these regions.[7-10]

It is clear that global health programs can no longer isolate themselves from economic, security, and political interests.

Polio eradication in Pakistan jeopardises worldwide efforts aimed at eradicating polio.[6] In 2013, polio strains originating in Pakistan were detected in sewage samples in Egypt, Israel, the West Bank, the Gaza Strip, Syria, and Iraq.[1, 7] The first subsequent polio case occurred in Syria in October 2013, resulting in 35 children being paralysed by November.[1] The first Iraqi polio case was confirmed in March 2014.[1] Polio has spread from Pakistan in South Asia to countries in the Middle East that have been polio-free for decades, unraveling progress that has been made on a global scale [1, 7] and confirming that polio eradication is no longer solely Pakistan’s problem, but a global one. Fueling this problem is the United States’ involvement in Pakistan. In 2011, the CIA attempted to obtain DNA samples from the children in KP as part of the search for Osama bin Laden. In order to do this, the CIA conducted a fake vaccination program against hepatitis B, leading to an erosion of public trust in immunisation.[1, 7-9] The use of aid workers for intelligence purposes and the use of health initiatives to advance security and

foreign policy motives has undermined global healthcare initiatives aimed at polio eradication, jeopardising longterm global health goals.[7] Recent fatal attacks on polio vaccination workers in politically fragile parts of Pakistan pose a further threat to the global eradication of polio.[11] It is believed that the international attention paid to polio eradication may have led terrorist groups to believe that they can achieve some of their aims by interfering with its eradication. [11] As such, the Pakistani Taliban announced in June 2012 that it would place a ban on all vaccinations until the United States ended drone strikes.[9] Since then, the Taliban have orchestrated targeted attacks on immunisation teams that have tragically killed over 40 vaccinators.[1, 7] This includes the killing of Abdul Ghani (who was the head of the government’s vaccination campaign) by a road-side bomb after upon his return from a meeting with tribal elders to dispel rumours that vaccination is a U.S. conspiracy to sterilize their children. [5] To this day, vaccination program staff remain under threat of kidnappings, beatings, harassment, and even assassinations in conflict zones.[9] It is believed that the actions against polio workers may be driven by two objectives; to terrorise local populations and government workers, or to stop the house-to-house movement of polio workers who some terrorist groups suspect of carrying out US surveillance activity (brought about by the fake hepatitis B campaign).[11] Regardless of the reason, it is clear that polio eradication has evolved into a war tactic resulting in an environment of fear and anarchy. Global health initiatives are becoming increasingly intertwined with diplomatic, foreign policy, and security interests.[7] This is not limited to Pakistan: earlier this year, six Red Cross Aid workers were killed in Afghanistan [12], and healthcare in Syria has been transformed into a target of war.[13] It is clear that global health programs can no longer isolate themselves from economic, security, and political interests.[7] The recent portrayal of polio as the new battleground between Western forces and terrorist groups illustrates the importance of efforts to depoliticise polio activities.[11] We can no longer allow security or foreign policy motives to undermine polio eradication and thus compromise the wellbeing of the 7.5 billion people living on earth.

Photo credit Sanofi Pasteur / Almeena Ahmed / Sanaullah Afridi, accessed from https://www.flickr.com/photos/sanofipasteur/29837040256/in/album-72157673062558422/ Conflicts of interest None declared Correspondance

jeaninehourania@live.com.au References

1. Akil L, Ahmad HA. The recent outbreaks and reemergence of poliovirus in war and conflict-affected areas. Int J Infect Dis. 2016;49:40-6. 2. WHO. Does polio still exist? Is it curable? 2017 [Available from: http://www.who.int/features/qa/07/en/. 3. Glatman-Freedman A, Nichols K. The effect of social determinants on immunization programs. Hum Vaccin Immunother. 2012;8(3):293-301. 4. Afzal O, Rai MA. Battling polio in Pakistan: breaking new ground. Vaccine. 2009;27(40):5431. 5. Ahmad K. Pakistan struggles to eradicate polio. The Lancet Infectious Diseases. 2007;7(4):247. 6. Nishtar S. Pakistan, politics and polio. Bull World Health Organ. 2010;88(2):159-60. 7. Hussain SF, Boyle P, Patel P, Sullivan R. Eradicating polio in Pakistan: an analysis of the challenges and solutions to this security and health issue. Global Health. 2016;12(1):63. 8. Roberts L. Fighting Polio in Pakistan. Science. 2012;337. 9. Chang A, Chavez E, Hameed S, Lamb RD, Mixon K. Eradicating Polio in Afghanistan and Pakistan. A Report of the CSIS Global Health Policy Center. 2012. 10. Shah M, Khan MK, Shakeel S, Mahmood F, Sher Z, Sarwar MB, et al. Resistance of polio to its eradication in Pakistan. Virol J. 2011;8:457. 11. Abimbola S, Malik AU, Mansoor GF. The Final Push for Polio Eradication: Addressing the Challenge of Violence in Afghanistan, Pakistan, and Nigeria. PloS Med. 2013;10(10):1-4. 12. SBS. Opinion: Aid workers are not a target, and never should be 2017 [Available from: http://www.sbs.com.au/news/ article/2017/02/17/opinion-aid-workers-are-not-target-andnever-should-be. 13. The Guardian. Syria ‘the most dangerous place on earth for healthcare providers’ 2017 [Available from: https:// www.theguardian.com/world/2017/mar/15/syria-conflict-studycondemns-weaponisation-of-healthcare.

Key Messages • The persistence of polio in Pakistan jeopardises worldwide efforts aimed at eradicating the disease. • Global health initiatives are becoming increasingly intertwined with the diplomatic, foreign policy, and security interests • With the portrayal of polio as a battleground between Western forces and terrorist groups, greater effort should be made to depoliticise polio activities

turning up the heat [Feature Article] Tara Kannan Tara Kannan is a first-year MD student at the University of Newcastle. Passionate about global health, she represents AMSA’s 2017 Code Green portfolio within her university’s global heath group. She believes that a major way forward in advancing medicine on the world stage is through nursing our environment back to good health. Aside from that, when she’s not busy dissecting Guyton’s diagrams, she enjoys perusing news articles online and loves her Cadbury.

American environmentalist and journalist, Bill McKibben, offers a simple yet revolutionary proposition in the climate debate: “Leave oil in the soil, coal in the hole and gas under the grass”. The birth of an idea Divestment is a very simple idea. You just remove your money from companies that are involved in extracting fossil fuels. It’s a novel movement in the climate debate that is different from your traditional change-yourlightbulb kind of ideas.

So, while as individuals we could make some adjustments such as changing our lightbulbs and switching from car use to public transport, if companies continue to dig up and burn their reserves, these measures will prove rather insignificant. This is where divestment comes in - a movement about shifting your money away from the problem and towards the solution. Turning back time In history, divestment has been shown to be a powerful political tool in several major movements.

Its underlying basis is that to avoid catastrophic In the latter half of the 20th century, a time when South global warming, we will need to reduce our carbon dioxide Africa’s Apartheid was our world’s largest moral issue, emissions. There are three key numbers that explain two prominent figures created massive change. Nelson this. First, 2˚C is the maximum global temperature rise Mandela and Desmond Tutu suggested a revolutionary this century that is aspired to in the Paris Agreement.[1] tactic to help counter institutionalised racial segregation Secondly, we have a ‘carbon budget’ of 565 gigatons and white supremacy, imploring Western institutions which is essentially the amount of carbon dioxide that to cut their economic ties with companies backing can safely be released into the atmosphere while still the Apartheid regime. Experts often deem this as the complying to our 2˚C rule.[2] Most importantly, the third model of symbolic pressure as it raised awareness and number to know is 2795 gigatons. This is the amount embarrassed many American businesses.[4] of carbon dioxide that will be released if all of the documented fossil fuel reserves Then, through the 1990s, a were burned.[2] So, while as individuals we could make movement against the tobacco some adjustments such as changing our industry took place to shun the Addressing a sixfold rise lightbulbs and switching from car use to industry’s negative impacts on in energy demand in the last 50 years, fossil fuels provide public transport, if companies continue health. Along with regulation and roughly 80% of the energy we to dig up and burn their reserves, these taxation, tobacco divestment had a sizeable impact on society, need through coal, gas and oil.[3] measures will prove rather insignificant. shrinking the industry and Yet, the money-making industry smoking rates.[4] releases greenhouse gases into the atmosphere and thickens Earth’s blanket of air pollution which led to 3.7 million deaths in 2012 due to pneumonia, asthma, heart disease, stroke and cancer. [3] Needless to say, carbon dioxide is a tiny molecule with a big bite.

Most recently, divestment has had a role in the Darfur genocide - the first genocide of the 21st century. Darfur divestment involves removing money away from companies with ties to the Sudanese government. Some

Western institutions including Brown University divested; however, other investors interested in the nation’s valuable resources simply filled their place. Drawing from this rather unsuccessful campaign, fossil free activists are encouraged to consider how their actions could lead to the success or failure of the divestment movement. More specifically, it is important to weigh the impact of divesting from a company relative to giving up your voice as a shareholder. Fuelling a movement Nevertheless, the balance scales show that divestment is well worth the bet. Major goals of the fossil fuel divestment campaign can be captured in the following:[4] a) leverage the power of investors and institutions to make strong political statements and influence policy change b) raise awareness of the impact of the fossil fuel industry in our society c) lead the market to consider the effects of climate change when evaluating any investments d) drive capital investment into clean energy and other climate mitigation strategies Above all else, divestment stigmatises the fossil fuel industry, eroding its social license to operate and posing the largest threat to these companies.

Back home, Australian universities are making bold statements with the help of several fossil free organisations on campus. La Trobe University, Swinburne University and the Queensland University of Technology pledged to divest their A$40 million, A$150 million and A$300 million portfolios from fossil fuels respectively. [7] Recently, both Monash University and the Australian National University have partially divested.[8] But sadly, Westpac, ANZ, NAB and the Commonwealth Bank – which make up the ‘big four’ banks of Australia — have failed to divest, instead funding the industry to the tune of A$5.5 billion in 2015.[7]

the ‘carbon bubble’ has its underlying roots in the fact that our financial markets maintain an extraordinary overvaluation of fossil fuel reserves that has the potential to burst. Pop goes the bubble From an economic point of view, fossil fuel divestment is falsely thought to come with financial uncertainty and major repercussions. Addressing this, a key argument in the fossil fuel divestment campaign is that returns will, in fact, improve once investors have divested – an

And, if you have not figured it out yet, the fossil fuel divestment campaign is not a normal movement. There are no great leaders. There is no Gandhi or Martin Luther King Jr. of the climate movement. But, establishing firm roots in society, the fossil fuel movement is set to be colossal with or without a figurehead.

...divestment stigmatises the fossil fuel industry, eroding its social license to operate and posing the largest threat to these companies. Blossoming ideas Since its initial conception in 2010, the idea of fossil fuel divestment has been spreading like wildfire. The campaign celebrated its first major victory in mid-2014 when Stanford University committed to divesting its US$18.7 billion endowment from the industry.[5] Later that year, the campaign inspired the People’s Climate March where a 400,000-strong crowd flooded Manhattan’s streets, demanding U.N. action on global warming.[4] By 2015, around 2500 investors representing US$2.6 trillion in assets had divested, including major organisations such as the Rockefeller Brothers Fund and the Canadian Medical Association.[6]

Figure 1: Global health groups are leading the fossil fuel divestment game with eight societies having divested; while, only three medical societies have divested so far.

argument based on a concept called the ‘carbon bubble’ – named by the Carbon Tracker Initiative. Much like the US housing bubble of 2009, the ‘carbon bubble’ has its underlying roots in the fact that our financial markets maintain an extraordinary overvaluation of fossil fuel reserves that has the potential to burst.[4, 8] The problem here is that all reserves simply cannot be burned if we intend to comply with the ‘carbon budget’, or else, there’s no doubt that we will find ourselves amidst catastrophic climate change. More importantly, with increasing pressure from pollution regulations, competition from renewables and one of history’s fastest growing stigmatisation

...the fossil fuel divestment campaign is not a normal movement. There are no great leaders. There is no Gandhi or Martin Luther King Jr. of the climate movement. campaigns, the value of fossil fuels is already diminishing. [4,8] Last year, energy use emissions grew less than 1% for the third consecutive year.[9] Oxford University researchers and commercial analysts are predicting that fossil fuels are likely to become ‘stranded assets’ which cannot be used, rendering them worthless to investors. [8, 9] It follows that investors should prepare for such a scenario by selling their assets now rather than after the ‘carbon bubble’ bursts when investors are likely to lose money.

Preparing accordingly, investors in Wall Street banks, such as HSBC and Chase, have demanded that fossil fuel companies discuss the risks of the bubble; while, oil companies, including Shell, are now committed to disclosing their asset portfolios and discussing the bubble.[4] Similarly, with major financial news venues such as Bloomberg and the Financial Times now backing the movement, we are beginning to achieve one of our primary aims: influencing the economy’s thinking on climate change.[4] In fact, as of September 2017, US$5.53 trillion has been divested by almost 800 institutions.[7] Renewable energy: a brave new world of investment So, you move your money away from the fossil fuel industry and then what? Many experts have shown that investing in ethical funds such as the renewable energy industry will have financial returns similar to, if not better than, the fossil fuel industry.[10] Renewable energy has made ambitious headlines around the world. For instance, China recently became home to the world’s largest solar farm at 27-squarekilometres which can produce 850 mega-watts of power - enough to supply around 200,000 households.[11] However, even though renewable technology needs to be used by all, it’s only accessible to those who can afford it. Addressing this gap, many grassroots movements are committed to providing renewable energy to developing nations. For instance, one such foundation, Liter of Light, teaches communities to recycle plastic bottles and use locally sourced materials with the aim of illuminating their homes – a strategy which has received much recognition and is often adopted for use in UNHCR camps.[12]

Figure 2: the committee of the University of Newcastle’s global health group, Wake Up!, proudly put their W’s up to celebrate their divestment win. Congrats Wake Up!

Key messages • Fossil fuel divestment is a very simple idea: a global movement focussed on shifting money away from a problem and towards a solution. • Divestment has been shown to be historically successful • Establishing firm and expansive roots in our society, divestment now sets out to radically influence the world’s thinking on climate change

The power of smaller players Speaking of smaller players making big waves, medical societies and faculties, are major targets of the fossil fuel divestment campaign. As highly regarded entities within universities, they are large enough to matter but small enough to have an influence on. Now, more than ever, we are seeing Australian medical university groups divesting (Figure 1). Most recently, the University of Newcastle’s global health group, Wake Up!, switched from the Commonwealth Bank to Newcastle Permanent – a major win in our medical scene (Figure 2). Although divestment will not cripple the fossil fuel industry overnight, this strategy can still operate effectively, conveying a loud and clear message of disapproval – an objective we are closer to achieving thanks to societies like Wake Up! One of divestment’s main jobs is to draw attention and challenge the status quo – a powerful opportunity to be noticed, and be remembered, in times of tragedy and turbulence. It’s a movement that inspires students, banks and universities alike to make ethical commitments and invest in a sustainable future. With global warming looming large, now is the time to blaze trails and boldly transform the climate debate.

2015; 82:913-37. 5. Carroll R. Major University Divests $18 Billion Endowment From Coal Companies [Internet]. HuffPost. 2017 [cited 15 September 2017]. Available from: http://www.huffingtonpost. com/2014/05/07/stanford-university-divesting_n_5276899. html 6. Rowe JK, Dempsey J, Gibbs P. The Power of Fossil Fuel Divestment (And its Secret). The University of California eScholarship. 2016. 7. Go Fossil Free. Divestment Commitment [Internet]. Go Fossil Free. 2017 [cited 15 September 2017]. Available from: http://gofossilfree.org/commitments 8. Ansar A, Caldecott B, Tilbury J. Stranded assets and the fossil fuel divestment campaign: what does divestment mean for the valuation of fossil fuel assets?. Smith School of Enterprise and the Environment. 2013. 9. Brahic C. Living with climate change: Have we reached peak emissions? New Scientist. 2017; 234: 32-4. 10. De George R. Ethics, corruption, and doing business in Asia. Asia Pacific Journal of Economics and Business. 1997; 1: 39–52. 11. Phillips T. China builds world’s biggest solar farm in journey to become green superpower #GlobalWarning [Internet]. The Guardian. 2017 [cited 15 September 2017]. Available from: https://www.theguardian.com/environment/2017/jan/19/chinabuilds-worlds-biggest-solar-farm-in-journey-to-become-greensuperpower 12. Liter of Light. Liter of Light - About Us [Internet]. Liter of Light. 2017 [cited 15 September 2017]. Available from: http:// literoflight.org/about-us/

Conflicts of interest None declared Correspondance taranikita@hotmail.com References

1. United Nations Framework Convention on Climate Change: Adoption of the Paris Agreement. 21st Conference of the Parties, 2015: Paris, France: United Nations. 2. 350.org. Do the Math [Internet]. Math.350.org. 2017 [cited 15 September 2017]. Available from: http://math.350.org/ 3. Perera F. Multiple Threats to Child Health from Fossil Fuel Combustion: Impacts of Air Pollution and Climate Change. Environmental Health Perspectives. 2017; 125: 141-8. Doi:10.1289/EHP299 4. Apfel DC. Exploring Divestment as a Strategy for Change: An Evaluation of the History, Success, and Challenges of Fossil Fuel Divestment. New School for Social Research.

Coal mining, climate change and the global impacts on health: examining Adani’s proposed Carmichael coal mine [Feature Article] John E Morgan John Morgan is a fourth year medical student at James Cook University. He is passionate about advocacy, climate change and issues facing the developing countries within our region. He is a member of Doctors for the Environment and AMSA’s Mental Health Campaign. Based in Cairns, he loves bushwalking and camping (and so far hasn’t had any crocodiles up close). Introduction The proposed Adani-owned Carmichael coal mine in central Queensland is currently in the final stages of planning with the support of both the Queensland and Australian governments. It is in the interest of human health, locally and abroad, for the medical profession to advocate on behalf of the community and lobby our legislators to reject this project.

population health through greenhouse gas emissions, waterway damage and land clearing. A report recently published in The Lancet has condemned the planned Adani Carmichael project as a “public health disaster”, arguing that the health impacts and environmental damage will be significant for Australia and its regional neighbours.[5]

The net effect of obtaining and using coal from the Carmichael site is estimated to release 4.7 billion tonnes of greenhouse gas emissions,[6] which will contribute The Carmichael site will be the world’s largest export to climate change. This will result in increased human coal venture and the biggest mining site in Australia, exposure to pollen, moulds and air pollution, reducing consisting of six open cut pits and five underground air quality and increase the incidence of respiratory mines. Mined in the Galilee Basin, 160km north-west diseases.[7] Ambient pollution in Australia is primarily of Clermont, coal will then be transported on a new derived from fossil fuel powered electricity generation, railway network before connecting to shipping terminals heavy industry and wood or coal based home heating.[8] bound for India via the Great Barrier Reef Marine Park.[1] Annually, 3000 Australians die due to urban air pollution, Adani has stated that it plans to mine 60 million tonnes more than the national road toll.[9] In its current state, of coal every year over the expected 60 year lifespan the air pollution problem is already being insufficiently of the Carmichael mine site.[2] The estimated annual addressed. Additionally, exposure to ozone is linked with average emissions of the proposed Adani coal mine are increased hospital admissions for respiratory diseases equivalent to the annual emissions of Malaysia, Vietnam amongst both children and the elderly.[10] Our legislators or Sri Lanka.[3] must act decisively and commit meaningful action to reduce the impact of climate change as it will affect the The Carmichael mine is health of future generations and a highly politicised topic with A report recently published in The our present vulnerable elderly widespread implications. This article considers some of the Lancet has condemned the planned population. impacts on Australia’s economy, Adani Carmichael project as a “public Currently, 5% of the our natural environment (and that health disaster” population will experience an of our regional neighbours), and allergic respiratory response to crucially; the seriousness of the airborne moulds during their lifetime.[11] Changes in Carmichael mine’s contribution to climate change and global precipitation are likely to increase the prevalence its effect on human health. of airborne moulds.[7] Additionally, ambient air pollutants and allergens are most likely to exacerbate respiratory Health Implications on a Global Scale disease in individuals with pre-existing respiratory conditions.[12] Climate change associated air pollution The World Health Organization (WHO) has said that will undoubtedly worsen the quality of life of patients climate change is the greatest threat to human health living with chronic airway diseases. this century.[4] This gigantic coal mine is set to contribute significantly to climate change. It will adversely affect 21

Coal combustion affects the water as well as the air. Rising water temperatures linked to climate change will cause further aerosolisation of marine toxins, thereby increasing respiratory disease prevalence globally.[7] Asthmatics exposed to the harmful algal bloom Karenia brevis’ marine aerosols on the south east coast of the United States of America (USA) experienced respiratory symptoms after just one hour of exposure. Inland residents experienced an average of 3.49 symptoms, more than coastal residents, who experienced an average of 2.24 symptoms.[13] This suggests that aerosolisation of marine toxins will increase respiratory morbidity as climate change related aerosols proliferate and distribute further afield.

[22] This emerging group of environmentally displaced people will need support to cope.[23] Climate change has the potential to create disasters beyond the capacity of developing nations’ public health systems.[24] Action must be taken to reduce the impact of climate change for the sake of public health. The global community is interconnected and each nation has the responsibility to reduce its contributions to climate change. Consequently, the impact of the planned Carmichael mine site and its extensive environmental damage will have substantial impact on human health into the future. Locally, coal worker’s pneumoconiosis has reemerged in Queensland with at least 20 cases recently diagnosed, highlighting the lack of appropriate health protection within the Queensland coal industry.[25] If the Queensland and Australian governments can’t manage these Occupational Health and Safety issues at home, how can they contribute to the ‘safe’ delivery and burning of this coal in Adani’s power stations in India – a country where air pollution already kills an estimated 1.1 million people annually.[26] If the mine proceeds, the flow on effects of poor governing locally will with long term have detrimental health impacts on a high levels of global scale.

The cardiovascular burden of disease will worsen in the future if action is not taken now to reduce the impacts of climate change.[7] Airborne particulate matter is associated with compromised heart function, atherosclerotic disease, deep vein thrombosis,[14] and pulmonary embolism.[15] The particulates contributing to air pollution include black carbon, sulphates, nitrates, a complex mixture of metals and other byproducts from the incomplete combustion In areas of fossil fuels.[16] In areas with long term exposure to exposure to high levels of particulate matter particulate matter air pollution, air pollution, it was found that an increase Environmental Implications of just 10 ug/m3 is associated with a 70% it was found that an increase of The establishment of the increase in DVT risk.[15] Ozone is another just 10 ug/m3 is associated with proposed Carmichael coal mine key pollutant - exposure to a 10g/m3 a 70% increase in DVT risk. and its shipping impact will damage increment has demonstrated an increase vital ecosystems and reshape the lives and health of the in the risk of cardiopulmonary mortality by 1.014 times. people reliant on waterways and reefs. More than 500 [14] Both particulate matter and ozone type air pollution million people around the planet rely on coral reefs for cause adverse cardiovascular outcomes. food, income and storm protection.[29] Climate related Increased global temperatures will exacerbate heat changes in waves, ocean circulation, cyclone frequency, related deaths due to an increased frequency of heat temperature and precipitation will impact fisheries in stress events.[7] Untreated heat exhaustion can progress tropical Queensland and further north.[30] Additionally, to heat stroke,[17] of which 15% of cases are fatal.[18] fisheries in our region may be contaminated by chemicals Heat related health events typically occur on the same released into seawater by the mine and from increased day as initial exposure.[19] Emergency departments (ED) shipping traffic. This will have economic, social and in Brisbane have demonstrated that during days ≥35°C, health implications and affect the productivity of the elderly patients were 1.9 times as likely to present seafood industry in Australia and surrounding nations, to the ED and 3.75 times as likely to present due to especially those that rely on it as a major industry and heat-related complications specifically.[20] Based on cultural cornerstone.[30] Climate change associated current modelling of Brisbane’s population growth, ED contamination of food staples is also likely to impact on presentations on days ≥35°C and the projected climate nutrition and human development.[7] In parallel, the social change related temperature increases, it is predicted to aspects of recreational fishing are also highly sensitive cause a 125-2065% increase in excess visits by 2060. to climate change.[30] Thus, along with the state of the [20] Consequently, political inaction now will continue to environment, multiple social determinants of health are worsen the burden on public ED services. at risk of declining for our coastal communities. The psychological impacts of climate change are generally indirect and have only recently been considered as part of the widespread impacts of climate change on health. Extreme weather events can lead to mental health disorders associated with loss, displacement and social disruption. This can increase anxiety about the future, with already-disadvantaged communities most likely to suffer the most severe consequences.[21] Two hundred million people will be displaced by climate change by 2050.

Implications for Australia In Central Queensland, the proposed Adani mine will see more than 10,000 hectares of native bushland cleared from around the Galilee Basin. Combined with the Carmichael mine’s generous water licence enabling unlimited groundwater use from the Great Artesian Basin,[31] this has huge potential for irreversible environmental damage. 22

The Great Artesian Basin is a drought-prone area that is critically responsible for supplying an estimated 200 towns and settlements with irrigation and drinking water. [31] The construction of the world’s largest coal mine at this site could risk the livelihoods and lives of Australian primary producers in this region. The importance of water security in drought-prone areas is tantamount and supporting this mine renders these remote Australians even more vulnerable. Australians living in rural and remote settings already have a lower standard of health service provision and are more likely to suffer worse health outcomes as a consequence of their social determinants.[32] The health impacts from the proposed mine are likely to impact rural Australians to an even greater magnitude. Massive quantities of coal will be shipped overseas through the Great Barrier Reef.[3] It is feared that this will exacerbate the already extensive coral bleaching. This will impact Australian coastal communities as the Great Barrier Reef and other coral reefs provide protection from wave and storm damage.[33] Implications for Australia’s regional neighbours Climate change is projected to slow economic growth, erode food security and hinder poverty reduction. The negative effects will be most felt by those who are already disadvantaged.[34] This is especially pertinent for our regional neighbours, predominately developing countries.

prevent the temperature associated rises in sea levels in order to prevent their nations going underwater. A 2°C goal requires a 40-70% reduction in greenhouse gas emissions compared with 2010 levels, whereas a 1.5°C increase will require a 70-95% reduction.[28] As one of the most influential developed countries in our region, Australia has a responsibility to support the continuing development of our regional peers. This begins with supporting their call for action to reduce the global temperature rise to 1.5°C. There is simply no room for the proposed Carmichael coal mine and its extensive pollution in a sustainable future – a future that needs action now. Economic and Political implications The proposed Carmichael mine project has struggled to achieve financing. Nineteen banks (including Australia’s ‘Big Four’) have refused to fund the venture due to ethical concerns, environmental policies, or the likelihood that renewable energy will outprice fossil fuels over the proposed life of the mine. The use of Australian mined coal in Indian power plants will also inevitably become economically foolhardy.[37] Both the Australian and Queensland governments should not continue to support this proposal as it will create few lasting jobs and crucially it will increase the loss of human life and burden of disease locally and abroad.

Many of our regional neighbours are already suffering from the effects of climate change. Bangladesh has experienced increased temperatures, swollen rivers and sea level rises; all which threaten infrastructure, livelihoods and homes and undermining the region’s development. [35] Climate change is now making cyclones on many of our neighbouring Pacific Islands even more powerful and destructive. In 2016, Tropical Cyclone Winston hit Fiji, affecting more than half a million people and decreasing its national GDP by one-fifth.[36] As a developed nation, our government has a responsibility to contribute to the prosperity, safety and health of our region by supporting these developing nations. This begins with reducing our carbon footprint by stopping the expansion of our fossil fuel industry, including the proposed Carmichael coal mine. The climate impacts of the proposed Carmichael coal mine go against Australia’s international commitment to promote a sustainable future by limiting increases in global temperatures. The United Nations Framework Convention on Climate Change (UNFCCC) promotes the work of the Paris Agreement to limit a global temperature rise this century to below 2°C above pre-industrial levels. [27] Many of our regional neighbours do not believe this goes far enough. The “1point5toStayAlive” movement by the Caribbean and their partner states is fighting to

The continued approval of Adani’s Carmichael mine by the Australian and Queensland governments is unwise as the economic return on taxpayer investment 23

is questionable. The Northern Australia Infrastructure Facility (NAIF) has proposed a $1 billion AUD loan to Adani for the North Galilee Basin Rail Project – a 310km rail link from the mine site to the Abbot Point export terminal. Despite widespread coverage, little information was publicly available at the time of writing; only four documents were published on NAIF’s website, with none focussing explicitly on coal mining in the Galilee Basin. [38-41] Both Adani and the former Minister for Resources and Northern Development have suggested that the loan is “not critical” and consequently the mine should be ineligible for NAIF funding.[42] Other requirements for NAIF funding include public benefit and commercial viability, both of which are questionable.[42] Adani continues to claim that the Carmichael mine will create 10,000 direct and indirect jobs. However, reef industries threatened by the mine provide approximately 69,000 jobs.[43] The proposed “10,000 jobs” is even more questionable because Adani has, under oath, stated only 1,464 jobs will be created.[42] A loan of this magnitude seems wasteful for taxpayers. In September 2016, the Minister for Resources and Northern Australia Matthew Canavan stated that opening the Galilee Basin for coal mining would “not damage the environment”.[38] The political mismanagement and fabrications surrounding the Carmichael mine site are a disservice to Australian taxpayers. The lifespan of the proposed Carmichael coal mine is 60 years.[2] Australian coal is expected to be burnt in India, a country where the Power Minister plans to ban coal imports. India’s draft National Electricity plan states that until 2022, India will not require an increase of coal from its current rate of supply.[44] India is also a signatory to the Paris Agreement and has declared commitment to utilising emerging “cleaner sources of energy” as they become feasible.[45] The long term profitability of Adani’s Carmichael coal mine is even more questionable as there is growing public discontent in India with coalbased power sources and its resulting air pollution. Whilst there was an absolute increase in the use of coal in India, renewable generation grew at over six times the rate of conventional sources. Between April-October 2016, 28% of Indian energy production came from renewable resources.[44] This demonstrates that the global trend towards increasing utilisation of renewable energy sources is extending to India and the coal industry is declining. The United Nations (UN) recognises that climate change is a threat to human health and rights.[4] In 2016, Australia ratified the Paris Agreement with a declaration to work towards combatting climate change. Yet due to the export nature of the proposed Adani Carmichael coal mine, these Australian sourced emissions will not count as part of our Intended Nationally Determined Contributions. The UN’s Committee on Economic, Social and Cultural Rights (CESCR) stated that Australia’s increasing carbon footprint is “at risk of worsening in the coming years”[46] which would undermine the vision of the Paris Agreement and its predecessor, the Kyoto Protocol, both of which we are signatories to. The CESCR’s panel of international

human rights experts has recommended Australian politicians “review (their) position in support of coal mines and coal export”.[46] In light of the USA’s recent withdrawal from the Paris Agreement, it is of increased importance for Australia and other developed countries to consider the impact of our carbon footprint beyond our national border. Conclusion The real cost of Australia enabling the continuing burning of coal will be measured in health impacts, hunger and humanitarian disasters. Therefore, the Australian and Queensland governments must act now to preserve the health of Australian and global citizens into the future. The medical profession has a long and proud history of protecting public health. We must add our voices to the wave of protest to stop the construction of the world’s largest coal mine, and for the sake of our patients’ health, to make coal history. Acknowledgements Doctors for the Environment Australia Photo credit Julian Meehan, accessed from https://www.flickr.com/ photos/takver/31283359832 Conflict of Interest None declared Correspondance evan.morgan@my.jcu.edu.au References

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Mar [cited 2017 Oct 15];18:496-503. Available from: http://www.flinders.edu. au/medicine/fms/sites/southgate/documents/events/2014/Understanding%20 rural%20and%20remote%20health_a%20framework%20analysis%20for%20 Australia.pdf 33. Guannel G, Arkema K, Ruggiero P, Verutes G. The power of three: coral reefs, seagrasses and mangroves protect coastal regions and increase their resilience. PLoS One [Internet]. 2016 July 13 [cited 2017 Aug 28]; 11(7): e0158094. Available from: http://journals.plos.org/plosone/article?id=10.1371/journal. pone.0158094 34. Working Group II Contribution to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. Fifth Assessment Report – Impacts, Adaptation and Vulnerabilities [Internet]. New York USA: Intergovernmental Panel on Climate Change; 2014 [cited 2017 Oct 10]. Available from: https://www.ipcc.ch/ report/ar5/wg2/ 35. Glennon, R. The unfolding tragedy of climate change in Bangladesh [Internet]. New York USA: Scientific American; 2017 Apr 21 [cited 2017 Aug 28]. Available from: https://blogs.scientificamerican.com/guest-blog/theunfoldingtragedy-of-climate-change-in-bangladesh/ 36. United Nations Office for the Coordination of Humanitarian Affairs. Tropical Cyclone Winston – Feb 2016 [Internet]. New York USA: ReliefWeb; 2016 [cited 2017 Aug 28]. Available from: https://reliefweb.int/disaster/tc-2016-000014fji 37. Climate Council of Australia. Risky business: Health, climate and economic risks of the Carmichael coalmine [Internet]. Sydney NSW: Climate Council of Australia; 2017 [cited 2017 Sep 21]. Available from: https://www. climatecouncil.org.au/uploads/5cb72fc98342cfc149832293a8901466.pdf 38. Ministers and Assistant Ministers for the Department of Industry, Innovation and Science [Internet]. Canberra, ACT: Australian Government; 2016 Sep 30. Canavan’s Speech to CEDA; 2016 Sep 30 [cited 2017 Oct 20]. Available from: http://www.minister.industry.gov.au/ministers/canavan/speeches/speechceda 39. Sharon Warburton, Chair, Northern Australia Infrastructure Facility. Speech – Developing Northern Australian Conference [Internet]. Cairns, QLD: Northern Australia Infrastructure Facility; 2017 June 19 [cited 2017 Oct 20]. Available from: https://naif-gov-au.industry.slicedtech.com.au/wp-content/ uploads/2017/06/Speech-Sharon-Warburton-DNA-final-for-web.pdf 40. Australian Government. Our north, our future: White paper on developing northern Australia [Internet]. Canberra, ACT: Australian Government; 2015 [cited 2017 Oct 20]. 200p. Available from: http://northernaustralia.gov.au/files/files/ NAWP-FullReport.pdf 41. Australian Government. Northern Australia audit – infrastructure for a developing north [Internet]. Canberra, ACT: Australian Government; 2015 Jan [cited 2017 Oct 20]. 306p. Available from: http://infrastructureaustralia.gov.au/ policy-publications/publications/files/IA_Northern_Australia_Audit.pdf 42. Swann, T. Don’t be so naif; Adani and Governance of the Northern Australia Infrastructure Facility (NAIF) [Internet]. Canberra ACT: The Australia Institute; Mar 2017 [cited 2017 Oct 15]. Available from: http://www.tai.org.au/sites/ defualt/files/P318%20Dont%20be%20so%20naif%20FINAL.pdf 43. Deloitte Access Economics. Economic Contribution of the Great Barrier Reef [Internet]. Townsville Qld: Great Barrier Reef Marine Park Authority; Mar 2013 [cited 2017 Oct 15]. 52p. Available from: http://www.environment.gov.au/system/ files/resources/a3ef2e3f-37fc-4c6f-ab1b-3b54ffc3f449/files/gbr-economiccontribution.pdf 44. Burton B, Fernandes A. Is the Indian coal domino about to fall? [Internet]. Australia: Renew Economy; Dec 2016 [cited 2017 Oct 15]. Available from: http:// reneweconomy.com.au/indian-coal-domino-fall-91973/ 45. United Nations Framework Convention on Climate Change. Paris Agreement – Status of Ratification [Internet]. New York USA: United Nations; Dec 2015 [updated Apr 2017; cited 2017 Oct 15]. Available from: http://unfccc.int/ paris_agreement/items/9444.php 46. United Nations Committee on Economic, Social and Cultural Rights. Concluding observations on the fifth periodic report of Australia [Internet]. Geneva Switzerland: United Nations Office of the High Commissioner; 2017 July 11 [cited 2017 Aug 28]. Available from: http://tbinternet.ohchr.org/_layouts/treatybodyexternal/ Download.aspx?symbolno=E%2fC.12%2fAUS%2fCO%2f5&Lang=en

Paddling upstream: Experiences from a medical placement in rural Papua New Guinea [Feature Article] Nicholas Snels Nick is a final year medical student from Griffith University. Throughout his degree he has been interested in gaining clinical exposure in a variety of settings, ranging from a rural experience in Warwick to furthering an interest in global health in Papua New Guinea and India. the words ‘common things occur commonly, therefore, I sit in an office on my GP rotation. My insides burn, this is probably tuberculosis or malaria’ heard at least courtesy of my morning doxycycline. The patient, who once per ward round. Ascites was probably due to has come in with fever and a sore throat, coughs. I flinch. abdominal seeding of tuberculosis, a headache was My eyes fly across the room, searching for a face mask. probably due to cerebral malaria. We quickly learned to Then I remember I am back in Toowoomba, and not appease the ward doctor by suggesting tuberculosis as every fever is likely due to an unpronounceable parasitic the cause for nearly every presenting infection. This is perhaps a slight complaint. The range of tropical dramatisation of my GP block, however, ...the words ‘common things diseases surpassed my expectations, I cannot help but cast my mind back to when a cough could signal something occur commonly, therefore, from tuberculosis, malaria and this is probably tuberculosis or malnutrition, to less common cases of far more sinister than an URTI. malaria’ heard at least once severe AIDS and Buruli ulcers. I was even exposed to diseases I had not I was recently given the opportunity per ward round. even fathomed I might see, such as to spend six weeks at the Kiunga toxic epidermal necrolysis as a result District Hospital in rural Papua New of leprosy medications. Guinea (PNG) as part of the Griffith Rural Medical Education program. Every rotation block, Our time in the general ward consisted of a morning four students are given the opportunity to spend six ward round followed by jobs, and it was eye-opening weeks in Kiunga hospital. For those as unfamiliar with to see how health care could be limited by a lack of Papua New Guinean geography as me prior to my visit, resources. Intramuscular antimalarials often ran out, Kiunga is a town in the western province of PNG, on meaning that oral antimalarials had to be followed by the banks of the Fly River. The hospital serves a town an ondansetron chaser. There was no adrenaline in the of approximately 13000 people, in addition to being emergency room, meaning it was necessary to trawl the a referral centre for the region, with approximately 45 hospital to find some before it was needed. A lack of beds spread over numerous wards (medical, surgical, funds for staff meant the occupants of the tuberculosis women’s), as well as a pathology lab and an emergency ward were at the far end of the general ward, placing department/outpatient department (OPD). The wards the rest of the patients at risk of nosocomial infection. are managed by a physician and a surgical/obstetrics Consequently, we soon learned that ward rounds began and gynaecology doctor, health extension officers, by applying appropriate PPE as soon as we entered the community health workers and nurses. As medical building (Figure 1). students we were well accustomed to being at the bottom of this hierarchy; however, in PNG we were given One patient made a particular impression on me. M far greater responsibility. was a 7-month old female admitted due to malnutrition. Throughout the week, she slowly gained weight and General Ward started to take an interest in the strange pale humans trying to make her smile with a toy koala, and was Common things occur commonly. This phrase had eventually discharged. The next week she returned with been thrown at me all throughout my clinical years. Most a cough, initially thought to be viral in origin. However, coughs are probably not cancer, most sore throats are common things occur commonly, and imaging suggested not the harbinger of quinsy. However, the medical ward M had tuberculosis. While unable to pinpoint the exact showed us just how context-specific this phrase is, with 26

expected to step up and start to manage situations ourselves. In the maternity suite births were usually facilitated by one midwife, and if something went wrong, the focus was on looking after the mother. This meant that care of the neonate typically came after the motherâ&#x20AC;&#x2122;s situation was controlled.

Figure 1. Students in PPE cause, it was possible that her long stay on the ward could have been the source. It was incredibly frustrating knowing that if the hospital had funding, these incidents could be prevented. Nonetheless, the case of M is not an isolated one, and the lack of resources was evident in all the areas of the hospital during our stay. Surgical Ward Having heard of other elective experiences, I expected that surgery in a developing country would be exceptionally hands-on, however, this was not what I experienced. The reasons for this were unique. A number of issues, such as the surgeon having malaria, or the building having no functioning water with which to sterilize equipment, resulted in my group having relatively few surgeries to attend. Something I was exposed to, however, was overcoming challenges in a resource-poor setting. In the absence of K-wire cutters, garden pliers were sterilised with alcohol wipes; on another occasion, an abdominal drain was secured in place with a tongue depressor snapped and taped together. The persistence shown by the staff to make the most of what was available was inspiring, especially given they face these challenges continually.

Therefore, on a number of occasions, a routine birth would end with the midwife handing a limp neonate to two medical students. Prior to coming to PNG, I was aware of the debate regarding medical students overstepping their boundaries while on elective. However, in that moment we had to make a choice to either stand by and watch the neonate die due to a lack of resources and staff, or give it the best chance it could have in the circumstances by applying pre-departure training in neonatal resuscitation. It is hard to imagine the situation where there are no medical students to assist, but sadly due to lack of staffing that is the situation this hospital faces every day. We were involved in three such scenarios during my time in PNG, and I am thankful for the training we received on resuscitation prior to departure. In saying that, the unsuccessful resuscitations were amongst the most confronting moments in medical school, but I am glad we were present to intervene when no one else was available. Not all births were intense, and even in uncomplicated births we were routinely supported by the midwives to assist the mother in delivering the child. The midwives in PNG are incredible, managing most births without intervention of a doctor, and even performing procedural skills such as perineal repair and vacuum-assisted delivery. Emergency and Outpatient Department

Although other areas of the hospital were perhaps more confronting, I felt most out of my depth in the OPD. We were expected to independently see patients and prescribe medications, with no guidance offered unless Womenâ&#x20AC;&#x2122;s Ward required. While the OPD allowed us to practice our Pidgin, the language barrier remained a significant issue. In my third year, I was placed in a rural hospital in Personally, I felt very uncomfortable prescribing antiAustralia which did not see a huge amount of obstetrics. malarials according to a guideline You could say I was unprepared for I did not know well, to a 4-year-old obstetrics in Kiunga. In an Australian setting, we are used whose parents I could not explain Caesarian sections were an to working under the guidance of a anything to, a situation I found uncommon event, meaning that we senior team member, especially in a high- myself in on our first day in the witnessed births which probably intensity situation. However, in PNG we hospital. The staff were probably would not have happened in were expected to step up and start to annoyed by my constant questions, however, I was worried about Australia. Examples of this include manage situations ourselves. overstepping my boundaries as a mother with malaria struggling to a student and potentially causing give birth due to severe lethargy, or significant harm. In saying that, the the two breech births occurring during my six weeks. range of presentations was diverse (although malaria was exceptionally common), and the chance to practice In an Australian setting, we are used to working under our newly-acquired language skills was excellent. the guidance of a senior team member, especially in a high-intensity situation. However, in PNG we were

Similar to the obstetric department, we were forewarned that if resuscitation needed to be performed, we would potentially be in charge. Even with this in mind, I certainly did not expect to be performing compressions one Sunday afternoon while wearing thongs and board shorts. Due to a lack of staff on this particular weekend, three medical students who had been playing soccer with the local kids were now attempting to resuscitate a man who had been in the ED since the morning. Eventually the doctor arrived to take control, but it is hard to imagine students in Australia ever being in such a situation. Social Aside from the clinical experience, one of the highlights of the placement was the chance to become involved in the local community. We stayed in a house a close walk away from the hospital, meaning that we often had spare time in the afternoons/weekends. Most afternoons we played sport with the local kids, and every Sunday we played a movie for them at the hospital. Not all of the children were so keen, however, as one particular girl started crying as soon as she saw us, a sobering reminder that foreign faces are still uncommon in such parts of the world.

how aware students must be before embarking upon such an elective, and to have these issues in their minds while on the placement to avoid overstepping their scope of practice. Such difficulty is exacerbated by the challenges of healthcare provision in resource-poor settings, and this placement was invaluable in showing me how it differs compared to Australia. The shortage of staff, medications and equipment was evident throughout the hospital, and it was clear that the entire health system could be improved by further funding. It was confronting seeing individuals suffer because the medication they needed was not available, however, it was inspiring to see the ways staff attempted to overcome these barriers. Additionally, the attitude of the staff continually stayed positive, even in the face of these challenges. Finally, it was evident to me throughout the placement that global health challenges in developing nations are changing. While infectious and tropical diseases were rife, the impact of chronic conditions such as cardiovascular disease, hypertension and diabetes was evident during my time in Kiunga. These conditions were often poorly managed due to lack of proper medications and monitoring. Their increasing prevalence coupled with the lack of resources to manage these conditions mean students doing a similar placement in the future will face a host of different conditions.

One of the most surreal experiences was going to a local club and listening to Justin Bieber while meeting locals over Papua New Guinean beer. A local gentleman At times it seemed like the health care In summary, this elective was adamant Justin was in fact a workers were battling their way upriver was an excellent experience. Papua New Guinean artist, but in his against a tide of financial constraints and Not only for the clinical defence the local brew was quite potent. At the end of the night we poor government support, however, the exposure, but also for the were even offered a lift home by enthusiasm and dedication shown towards chance to see how healthcare functions in a resource-poor the police chief, provided we let him the people of Kiunga was inspiring. setting. At times it seemed finish his drink first. Another highlight like the health care workers was being shown wild birds of paradise by a guide who had taken David Attenborough were battling their way upriver against a tide of financial to see them years ago. The people were exceptionally constraints and poor government support, however, the welcoming, often stopping on the street or in the markets enthusiasm and dedication shown towards the people of Kiunga was inspiring. Additionally, the chance to to talk to us and see how we were finding the experience. experience life in a rural town in PNG was a highlight in Reflections itself. This placement has, undoubtedly, been one of the most motivating placements of medical school, and I There were a few main lessons I took away from this strongly urge anyone considering something similar to experience in regards to students experiencing a global take the opportunity. health elective. The most striking point was the issue regarding medical students on electives in resource-poor Acknowledgements settings. This issue deserves a review unto itself, but QRME and Graeme Hill for continual support of this suffice to say it became very apparent to me how easy program; Aisha, Ryan and Emily for sharing the experience it could be for an overconfident medical student to abuse and for support throughout difficult times. the level of trust placed in them by the local population. Particularly, in a poorly-resourced setting with a lack of Conflicts of interest None declared supervision, students may be placed in situations that are beyond their level of knowledge. However, in certain Correspondance circumstances, capable students, and especially those in nicholas.snels@griffithuni.edu.au their final year, may be able to have a positive impact on their chosen placement. Such an experience highlighted

Sugar tax A sweet solution for obesity? [Review] Saiuj Bhat

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Saiuj is a first year medical student at the University of Western Australia with a passion for understanding the social and commercial determinants of health. He also has an interest in tissue engineering, in particular organoid technology, and the promising that holds for many aspects of medicine in the future. He graduated last year with Honours in pharmacology. Abstract Background: The rising prevalence of obesity and obesity-related illnesses parallels the increase in sugar consumption across the globe. To limit consumption of sugar and tackle obesity, the World Health Organization has recommended that member states implement a tax on sugar. Such a tax is envisioned to reduce sugar consumption at a societal level, generate stable revenue for governments, and drive product reformulation. However, at present there is insufficient evidence to suggest any beneficial effect of a sugar tax on the incidence and prevalence of obesity. Aim: This review examines the effectiveness of a sugar tax as an obesity prevention strategy. Methods: A qualitative review of modelling and observational studies investigating the link between sugar tax and obesity, and conducted over the past ten years, was carried out. Findings: Modelling studies suggest that a tax on high-sugar foods and beverages is likely to have beneficial effects on obesity as increased price of taxed items leads to reduced consumption. However, observational studies suggest little benefit of a sugar tax on actual obesity rates in a population. Taxes in combination with other policy and regulatory approaches, for example health food subsidies and education campaigns, might be more effective than a tax on its own. Conclusion: A tax on sugar is likely to be a step in the right direction as it would raise public awareness of the negative health effects of excess sugar and de-normalise consumption of excess sugar.

Introduction The obesity epidemic Over the past few decades, overweight and obesity have risen to epidemic proportions all over the globe. In 2014, more than 1.9 billion adults were overweight and 600 million were obese.[1] In 2013, 42 million children under the age of five were either overweight or obese, and this is predicted to increase to 70 million by 2025.[2] The growing prevalence of childhood obesity is particularly alarming given that it is a predisposing factor for lifelong obesity.[3] Obesity, defined as having a body mass index (BMI) greater than or equal to 30, is a major risk factor for non-communicable diseases such as cardiovascular disease, diabetes, cancer, and mental illness. [4] Since non-communicable diseases were responsible for 68% of all deaths in 2012, [5] it is apparent that the health burden of obesity is high. Obesity is a complex heterogenous disease that arises from an interplay between our genes and the environment we live in. Highly energy-dense diets combined with a lack of adequate physical activity leads to a positive caloric balance and hence weight gain in genetically susceptible individuals. Our diet and physical activity are increasingly

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shaped and driven by broader social, cultural, economic, and political landscapes that are often beyond individual control and awareness.[6] The modern obesogenic environment, which provides easy access to calorie-rich processed food and encourages sedentary lifestyle, is mismatched to human physiology that evolved to survive in an environment of food scarcity.[7] At a population level, obesity can be viewed as a manifestation of a global economic system that currently prioritises wealth creation over health creation.[8] Obesityâ&#x20AC;&#x2122;s sweet tooth

In recent decades, the rising prevalence of obesity has closely paralleled the burgeoning consumption of sugar all over the world.[9] Sugar is recognised as one of the biggest risk factors for obesity,[10-15] and the leading source of sugar in the diet is sugar sweetened beverages (SSBs).[15] Therefore, the current review will focus on SSBs as a proxy for sugar and the discussion about policies aimed at limiting sugar intake (i.e. sugar taxes), will predominantly revolve around SSBs. SSBs are non-alcoholic beverages with added sugar and include soft drinks, fruit drinks, sports drinks, energy drinks, 29

iced tea and coffee, and lemonade. SSBs are becoming increasingly popular in low- and middle-income countries, with Latin America and Asia leading the world in consumption.[16] The worldwide impact of SSBs on the burden of adiposityrelated cardiovascular disease, cancer, and diabetes is estimated at a total of 8.5 million (95% CI: 2.8 – 19.2) disability-adjusted life years (DALYs) [17].

The success of an SSB tax as an obesity prevention strategy remains controversial. The plethora of studies investigating the link between sugar taxation and obesity prevention demonstrate conflicting results. There is currently no consensus regarding the best approach to implement a sugar tax. Furthermore, existing meta-analyses on the topic show inconsistent findings and are “obesity can be viewed as a manifestation unable to include many primary of a global economic system that currently studies in their analysis owing to methodological inconsistencies.

Limiting the intake of free sugars to less than 10% of total daily energy consumption is strongly recommended by the prioritises wealth World Health Organisation and the creation.” US Dietary Guidelines Advisory Committee.[18, 19] For every additional serving of SSB per day, the likelihood of a child becoming obese increases by 60% over the course of two years.[20] The energy obtained from SSBs is added to an individual’s total energy intake rather than displacing other sources of calories due to the poor satiating properties of sugar in liquid form.[21] The net increase in calorie consumption is likely to contribute to an increase in body mass. Given the high burden of obesityrelated illnesses on healthcare systems [17] and the strong evidence linking excess consumption of SSBs to obesity in children and adults,[15, 22] a reduction in SSB consumption is warranted. A decrease in consumption is especially pertinent as the major SSB consumers are children, adolescents and poorly educated individuals from lower socio-economic strata of society who may be less aware of the harmful effects of added sugar.[10] Sugar tax as an obesity prevention strategy? Population health interventions aimed at curbing the consumption of excess sugar are pertinent to curtail the obesity epidemic. Price is one of the key factors influencing food purchasing behaviour. People tend to reduce consumption of unhealthy foods in response to increased prices of such products.[23] To discourage purchase of SSBs and address the growing burden of obesity, countries such as France, Mexico, the UK, and Hungary, and several jurisdictions in the USA, have implemented a tax on sugar.[10] Following implementation of a €0.11 per 1.5 L excise tax on SSBs, which translated to a 6% price increase, France saw a 6.7% decline in demand for cola in the first two years.[24] SSBs are a sensible target for a sugar tax as they have a high calorie density with no additional nutritional value [10, 25] and can be clearly defined for policy implementation.[2] A number of assumptions underscore the success of an SSB tax [26]: first, the tax must be passed onto consumers, leading to an increase in cost; second, SSBs follow the law of demand; and finally, the tax leads to a significant net reduction in energy intake despite substitution by consumers, for example by increasing consumption of fruit juices with comparable caloric content.[27] While a tax on sugary drinks may not be the silver bullet for obesity on its own, it has the potential to slow the epidemic. For this reason, recommendations to implement diet-related taxes should be taken seriously.[28, 29]

creation over health

Recognising these limitations, this review provides a brief overview of the current literature on the effectiveness of a sugar tax as an obesity prevention strategy. Given that existing studies have been performed in both developing and developed nations, this review adopts a global perspective on the issue of sugar taxation. The theoretical basis of a sugar tax, its economic feasibility, and effectiveness with regards to obesity prevention will be examined. Alternative strategies for curbing the obesity epidemic, such as regulation of advertisements and food labels, are beyond the scope of this review and will not be explored. Methods Electronic databases (PubMed and Web of Science) were searched for relevant journal articles between 1 January 2007 and 1 July 2017. The year 2007 was chosen to ensure included studies were relevant to modern dietary habits and practices. The following search strategy was used: (tax* OR price* OR economic* OR financial*) AND (sugar OR sweetened OR beverage* OR drink*) AND (intake OR consumption OR demand OR sale* OR diet OR weight OR overweight OR obes* OR body mass index OR BMI). Searches were limited to articles published in English. Relevant articles were also identified by searching the reference lists of included studies. Abstracts were assessed for suitability of inclusion. Studies that were found to be suitable were read in full and their salient features reported here. Economic feasibility of a sugar tax Consumers do not bear the full costs of their decisions when it comes to high-calorie foods and beverages.[30] It is estimated that an individual with a BMI between 30 and 35 will accumulate 30% higher medical costs than a normal weight individual;[31] this increases to 50% in individuals with a BMI greater than 35.[32] In Canada, obesity-related healthcare costs are close to $6 billion [33] whereas in Australia this figure is close to $10.7 billion.[34] In addition to direct healthcare costs, there are indirect costs to the community associated with absenteeism and obesity-related premature death.[35]

A number of modelling studies have reported substantial healthcare cost savings and stable revenue streams from a tax on sugar.[14, 36-38] For example, annual healthcare cost savings of $23.6 billion (95% CI: 9.33 – 54.9) and annual revenue of $12.5 billion (95% CI: 8.92 – 14.1) have been predicted for a tax of $0.01 per ounce of sugar in the United States (US).[39] Importantly, a sugar tax combined with a fruit and vegetable subsidy is deemed to be poverty neutral,[37] an important consideration given the significantly higher relative cost of fresh produce,[40] especially in rural and remote communities. The revenue generated from an SSB tax can be used to cover the healthcare costs of obesity, support subsidies on healthy food options, and fund public and school education campaigns promoting childhood nutrition and obesity prevention.

“a sugar tax combined with a fruit and vegetable subsidy is deemed to be poverty neutral, an important consideration given the significantly higher relative cost of fresh produce, especially in rural and remote communities.” Effectiveness of a sugar tax for preventing obesity Of various taxes on “unhealthy” foods, a tax on sugar was modelled to have the biggest health gain in the Australian population, equating to 270,000 DALYs (95% CI: 250,000 – 290,000) averted.[37] The effect of a sugar tax on BMI was found to be modest, equating to a BMI reduction of 0.1 in males and 0.06 in females, and a decline in obesity prevalence of 2.7% in males and 1.2% in females [36]. In a study modelling the German population, a 20% SSB tax was shown to reduce the prevalence of obesity by 4% in males aged 20 to 29.[41] Similarly, a modelling study by Cancer Research UK estimated that a 20% tax on SSBs could prevent 3.7 million people from becoming obese by 2025. Significant, albeit small, inverse associations between SSB taxes and weight gain have been reported by other modelling studies.[15] These could represent important changes over time and alter the prevalence of obesity at a population level. [42] Importantly, reductions in energy consumption were more pronounced in low- and middle-income groups.[38, 41, 43] One of the biggest limitations of these studies is that they are population models.[37] They rely on national data which may be outdated and assume a linear relationship between weight changes and energy consumption without accounting for substitution behaviour by consumers and often relies on self-reported data.[41] The substitution effect is an obvious confounder in studies that do not classify fruit juices as SSBs, despite juices often containing more sugar than soft drinks. [14] Another limitation of modelling studies is the lack of information on long-term SSB price elasticity that is specific to geographic and economic subgroups.[14] Six months after implementation of an SSB excise tax ($0.01 per ounce), consumption of SSBs decreased in Berkeley, California (–21%) and increased in comparable

neighbouring cities that did not levy a sugar tax (+4%). Of the 124 people who reported changing drinking habits as a result of the tax, 82% reported drinking SSBs less frequently and 40% reported drinking smaller sizes because of the tax.[44] Similarly, following introduction of an SSB tax (1 peso/litre) by the Mexican government, the purchase of SSBs declined by an average of 6% during the first year of the tax and this decline was greater in low income groups.[45] The average Mexican purchased 4.2 litres less taxed beverages than expected during the first year, however, purchase of untaxed beverages increased by 13 litres on average.[45] Whether the increased consumption of untaxed beverages compensated for the reduced caloric intake due to the decline in taxed beverages was unable to be determined, so the effect of the sugar tax on net caloric intake remains to be seen. Given their short time frame, these observational studies provide no indication of the effect of a sugar tax on actual obesity rates in a population. Similarly, surveys investigating consumers’ purchasing behaviour may not necessarily predict their actual purchasing habits.[46] This is critical in light of the fact that a 20% tax on SSBs did not result in an appreciable reduction in consumers’ likelihood to buy SSBs, despite their perception that they were more expensive.[46] Notwithstanding these pitfalls, a review of cross-sectional and longitudinal studies investigating the impact of sugar taxes on weight gain found several studies that demonstrated an inverse association between price increase of SSBs and point prevalence of overweight and obesity.[13] However, the magnitude of change reported in these studies was small.[13] Outlook Reduced consumption of sugar by virtue of an SSB tax may not necessarily translate to decreased body weight, particularly if unhealthy alternatives still exist. A tax on SSBs will only be effective in reducing obesity when there is no substitution with another untaxed high-calorie food or beverage.[47] A tax on sugar-rich foods (e.g. confectionary) in conjunction with a tax on SSBs would reduce the likelihood of substitution and therefore increase the effectiveness of the public health intervention. Taxes on high-fat foods will need to be considered in the future as adjuncts to the sugar tax. Given the complexity of taxing foods high in sugar and fat, and limited research on their effectiveness, this requires further study. In addition to reducing calorie intake through a sugar tax, other aspects of the obesogenic environment that require monitoring and regulation include food labelling, food portions, food advertisements, and plain packaging. A sugar tax on its own is unlikely to be the panacea for obesity prevention. It is widely accepted that taxes have the potential to reduce sugar consumption, drive production reformulation, and generate substantial revenue for governments.[16] While it appears plausible that reduced sugar consumption and product reformulation would be beneficial to tackle obesity, whether this is actually the case remains to be seen. To address the obesity epidemic, a number of other population level policy measures, including advertising restriction, 31

reformulation targets, health star rating systems, promotion of healthy transport choices, and sustained high-impact education campaigns are warranted.[48] While the effect of sugar taxes on SSB consumption and obesity have been carried out in some low- and middleincome groups,[38, 41, 43] there is a paucity of literature from developing nations on the impact of decreasing SSB consumption on obesity rates. This is pertinent given that lowand middle-income nations are disproportionately impacted by obesity and related non-communicable diseases.

“A sugar tax on its own is unlikely to be the panacea for obesity prevention.” Conclusion Obesity and obesity-related diseases are a significant burden on healthcare systems around the world. The global prevalence of obesity has increased and excess consumption of sugar, in particular SSBs, is one of the strongest drivers of that increase. To curb the obesity epidemic, a number of countries have adopted various forms of sugar taxes. While theoretically and economically sound, a sugar tax on its own might be insufficient to curb the obesity epidemic. However, a tax on sugar is likely to be a step in the right direction as it would raise public awareness of the adverse health effects of excess sugar and de-normalise excess consumption. A tax on SSBs can also encourage industry to reformulate its products with lower sugar levels. Taxes in combination with other policy and regulatory approaches, for example subsidies to healthy foods, graphic warning labels, and awareness campaigns, might be more effective to curb the obesity epidemic than a tax on its own. A sustained, focussed, and multi-pronged public health intervention worked in the past against Big Tobacco. There is no reason to believe that similar perseverance will not work against Big Sugar. Conflicts of interest None declared Correspondance saiujbhat59@hotmail.com References

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Drug Control in Australia: Where to next? [Review] Raquel Maggacis

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Raquel Maggacis is a final year medical student at the University of Queensland. She has a keen passion for public health endeavours and hopes to one day intertwine this with a career as a medical physician.

Abstract Substance use and associated disorders are increasingly recognised as a global health issue. As attitudes towards drug use disorders evolve, varying drug control policies worldwide are called into question. Nations such as the United States of America utilise the criminal justice system to place sanctions on those contravening drug control policy, which often results in cycles of incarceration, further drug use, and poverty. In contrast, Portugal has revolutionised its approach to drug control since the turn of the century by decriminalising all drugs to great effect. In view of this wide spectrum of attitudes towards drug control, the future of Australia’s approach to drug control policy is examined.

Introduction The International Classification of Diseases defines substance use disorders as “continuing drug consumption despite severe adverse consequences”.[1] A report by the office of National Drug Control Policy in 2010 outlined the detriments of substance use disorders using a biopsychosocial paradigm (Figure 1).[1, 2] Substance use disorders are managed through three main drug policy approaches: decriminalisation, criminalisation, and harm minimisation. Decriminalisation involves prohibiting and regulating drugs but excluding sanctions from criminal law jurisdiction, whereas criminalisation is the attribution of criminal offences to drug-related activities.[3, 4] Harm minimisation strives to decrease adverse consequences

”

without aiming to reduce consumption.[1] Substance use disorders are perpetuated by social stigma and thus the political context is a key determinant of long-term health outcomes.[3] Benefits and detriments of different policy approaches

Criminalisation of drugs, and the subsequent incarceration of drug users, provides the immediate benefit of removing the individual from an environment that exacerbates their drug use, and prevents the community from being threatened by drug-affected behaviour. Additionally, incarceration allows the government to demonstrate the work being done to tackle drugs in a manner that is tangible and easily understood by the general public. However, punitive drug law enforcement alone may fail to address or even worsen health

Figure 1: The biopsychosocial adverse outcomes related to substance use disorders [1, 2] 34

complications of drug use. It can marginalise populations at risk of poorer health and increase barriers to seeking health services, as illustrated by the growing epidemic of HIV/AIDS and hepatitis C amongst injecting drug users.[5] Moreover, drug law enforcement has minimal impact on the drug market itself, although there is some evidence that it may alleviate a degree of associated harm.[1, 6] Advantages of the harm minimisation approach include curbing the progression of the HIV/AIDs epidemic through safe needle programs and deterring criminal behaviours.[1, 7] This is achieved through demand and supply reduction, prevention campaigns, and improved access to treatment and harm reduction.[8] Critiques of this approach include maintaining demand for the illicit drug market, and ineffectively addressing all biopsychosocial facets of substance use disorders.[8]

“Decriminalisation addresses substance use disorders in a biopsychosocial context and identifies it as a key public health issue”

The main benefit of decriminalisation is that it reframes drug use as a public health problem, which allows for reallocation of funds from drug-related criminal justice proceedings and the prison system to rehabilitation services focusing on long-term health outcomes.[3] This, coupled with a shift in criminal justice focus to high-level drug offenders, ultimately results in less drug use and better long-term health outcomes.[3] Decriminalisation addresses substance use disorders in a biopsychosocial context and identifies it as a key public health issue, both key steps in arresting the perpetuation of stigma which only serves to isolate drug users from health services.[3] Criticisms of decriminalisation include potential for increased accessibility to drugs and a cheaper street value, which could result in increased uptake of drug use.[9] In 2009, Antonio Costa, the executive director of the United Nations Office on Drugs and Crime, affirmed that “drug use should be treated as an illness in need of medical help”, and appealed for universal access to drug treatment.[2] In 2011, the Global Commission on Drug Policy emphasised that it was time to “end the criminalization, marginalization and stigmatization of people who use drugs but who do no harm to others”.[1] The World Health Organization and the United Nations echoed this view in their joint statement published in June 2017, stating that to ignore such a call to “[review] and [repeal] punitive laws...[including] drug use or possession of drugs for personal use” would be to “[violate] the most fundamental human rights protected in international treaties and in national laws and constitutions”.[10] This strong stance against discrimination in health care settings reflects the global shift in attitudes towards drug policy, from incarceration to rehabilitation of drug offenders.

Drug control approaches worldwide

Criminalisation: the United States The United States (US) has a strong stance of criminalisation towards illicit drugs and has a low threshold to prosecute drug offenders.[3] Its prison population has increased by almost 800% since 1980, in marked disproportion to its population growth, with 47% of all inmates imprisoned for drug-related crimes, and many with drug use disorders.[3] In 2010 alone, US $80 billion was spent on continuing incarceration of inmates.[3] Drug users, possessors and traffickers are treated equally in this criminal system, with mandatory minimum prison sentences.[3] Without adequate rehabilitation services or emphasis on drug use and use disorders as a public health issue, the high rates of recidivism are unsurprising, often resulting in a cycle of criminality, incarceration and poverty, with subsequent economic burden on the community.[3] This is an issue fuelled by media sensationalism, portraying drug law enforcement in an enamouring light with dramatic drug busts and arrests, acting only to perpetuate fear within the general population. Where drug courts - legal committees which redirect nonviolent drug offenders from incarceration to treatment - have been trialled in the US, they have proven to decrease crime rates (7-14%) and recidivism (up to 35%), and improving rehabilitation uptake, treatment outcomes and stability of the family unit.[2] Such models are estimated to reduce health care costs related to substance use disorders by US $4 for every US $1 spent.[2]

“This is an issue fuelled by media sensationalism, portraying drug law enforcement in an enamouring light with dramatic drug busts and arrests, acting only to perpetuate fear within the general population.”

While marijuana is considered illicit under US federal law, states are able to make independent laws, which are only disregarded in cases concerning juveniles, cross-border trafficking, or organised crime.[9, 11] Presently, over half of American states have legalised medicinal marijuana, and eight have further allowed recreational use.[9] Given the relatively recent legalisation of marijuana, data on its impact on usage patterns is currently conflicting, and more time is required for reliable assessment.[9] Studies have indicated that diversion of black market marijuana from legalised to criminalised states is likely to decrease marijuana prices, although the degree and impact of this is uncertain.[12, 13] Notably, there are significant economic benefits associated with the legalisation of marijuana.[9] In Colorado, where recreational marijuana use is legal, marijuana tax and licensing fees have been implemented, together generating over US $70 million in the first year alone.[9] This revenue was subsequently funnelled into school construction and youth 35

and substance use programs).[9]

Criminalisation: Central Asia Central Asian countries, such as Tajikistan, Kazakhstan, and Uzbekistan, have adopted an increasingly stringent approach to drugs.[14] In the year following the September 11 attacks, these countries received US $187.5 million from the US government to improve border control, counterterrorism measures and counter-narcotics initiatives.[14] Between 2004 and 2007, a strong criminal justice-based approach was further reinforced in Central Asia with funding from international agencies, other foreign governments and national budgets directed to legal action against drug use. [14] Further, national campaigns in Central Asia often label drug users as evil, increasing the stigma and discrimination which perpetuates cycles of drug use.[15] Little or no rehabilitation or treatment is available for substance users, with such countries preferring a model of criminalisation and incarceration.[14] For example, opioid substitution treatment is prohibited in Tajikistan and Turkmenistan, minimally available in Uzbekistan and Kyrgyzstan, and non-existent in Kazakhstan.[14] The lack of treatment for drug users and increasing accessibility of opiates has resulted in a growing HIV epidemic in Central Asian prison systems with poor longterm health outcomes.[14]

Decriminalisation: Portugal Prior to 2001, drug use was criminalised in Portugal, yet rates of heroin use and drug trafficking continued to increase.[3] Consequently, the Portuguese government drafted a law decriminalising all drugs purchased, possessed or consumed for personal use. This law also had a public health focus towards rehabilitating those with substance use disorders, and a punitive focus towards high-level drug trafficking. This involves a committee of two medicallytrained persons and one legally-trained person, deciding first whether an offence is protected by this law, and then whether the offender is suffering from a drug use disorder.[3] This law only aimed to decriminalise low-level drug offences; strict laws remain against high-level offenders and drug traffickers who propagate this vicious cycle and endanger the general community.[16]

absolute numbers of drug-related deaths by each prohibited substance decreased; the total number of drug-related deaths decreased from 400 in 1999 to 290 in 2006.[18] Importantly, while some speculated that decriminalisation would lead to lower prices of drugs and subsequent higher rates of usage, the cost of drugs did not decrease. [19] In fact, the rates of cannabis and cocaine use after decriminalisation have been three times lower than before. [18] Further, data extrapolations have predicted lower lifetime prevalence rates of drug use for almost all drug categories post-decriminalisation.[18]

Decriminalisation: West Africa West African countries must contend with both international drug cartels and the growing transit of illicit substances to Europe and North America. Consequently, local consumption of illicit substances has increased, especially among younger persons, with significant economic, health and social consequences.[20] While data is scarce, in 2008 it was estimated there were 1.8 million intravenous drug users in Sub-Saharan Africa, of whom 12% were thought to be living with HIV.[20, 21] In 2014, the West Africa Commission on Drugs published a declaration specifically stating that “criminalisation of drug use worsens health and social problems, puts huge pressures on the criminal justice system and incites corruption”, and that “drug use must be regarded primarily as a public health problem”, mirroring the movements of Portugal.[20] Despite these recommendations, there is currently no evidence that any West African countries have been successful in implementing drug decriminalisation policies. Drug policy in Australia and the way forward

In 1985, the Australian Government adopted an official national drug policy of harm minimisation.[1] In the 200203 financial year, the Australian Government allocated $3.2 billion to managing illicit drugs, 75% of which was spent on drug law enforcement, aiming to decrease drug and drugrelated crime, and improve public health and safety.[1, 16] Despite this investment, a staggering 400 Australians die yearly from heroin overdose, and most areas have a demand for substitution products far out-weighing the After this law was passed, supply, notwithstanding the costly Portugal reduced its burden on the co-payment.[1] The methadone “...a staggering 400 Australians die yearly substitution program and syringe criminal-justice system, allowing more funding allocation towards from heroin overdose, and most areas have exchange services available in public health endeavours, including a demand for substitution products far out- Australia have made an impact, yet prevention campaigns, treatment, with a growing affected population weighing the supply” and facilities.[17] Treatment and the root cause unaddressed, uptake consequently increased, the need is largely unmet.[1] resulting in decreasing rates of drug-associated illnesses.[4, Harm minimisation still perpetuates discrimination and 18] During the four years following decriminalisation in 2000 marginalisation of drug users, instead, decriminalisation can to 2006, there was a significant decrease in the incidence reduce stigma and is essential to better health outcomes.[3] of new cases of HIV/AIDS amongst drug users in Portugal, from almost 1400 to 400 persons.[18] Decreased rates of The Australia21 report, published in 2012, was effective new hepatitis B and C infections have also been evident, in initiating a debate on drug reform. The report not only attributed to the improved treatment and rehabilitation illustrated the harmful effects of criminalising possession programs afforded by decriminalisation.[17, 18] Moreover, and personal use on drug-dependent individuals in an 36

Australian context, but also highlighted the potential health benefits of some currently illicit drugs.[1, 8] This report left Australians to decide which legal system would allow for better biopsychosocial health and economic stability for the community with respect to those consuming drugs – rehabilitation or incarceration. Australia should act to follow countries like Portugal that have prospered from revolutionising drug policy with respect to low-level offences and reform to decriminalise all drugs. As supported by the Global Commission on Drug Policy, a move towards decriminalisation of low-level drug offenses in Australia would allow for decreased economic burden on the criminal justice system, reallocation of funds to drug rehabilitation programs, and a sharpened focus on the illegality of high-level drug trafficking offenses.[3] Viewing drug use as a public health problem is the key first step to reducing stigma and consequently improving access to treatment and long-term health outcomes. Conclusion Criminalisation marginalises those afflicted with drug use disorders, who are already burdened with significant health, social and economic disadvantage. Where there is demand, there is supply, and tackling drug use disorders with criminal law is simply too late to create a meaningful impact on the individual or society at large. Poverty breeds poverty; while incarceration may remove the immediate threat from society, it does nothing to address the root cause. Substance use disorders are a medical condition and public health problem, not a moral choice. Epitomised by Portugal, decriminalisation of drugs and rehabilitation fortifies a community, not just immediately, but with long-term positive effects in the workforce and crime rates, spanning generations. Substance use disorders, therefore, need to be reframed from a criminal, punitive problem, to one befitting the biopsychosocial model of health. Fortunately, throughout the world this is increasingly becoming the case. Acknowledgements Sophie Lim, Vector Associate Editor

IDEAS Working Paper Series from RePEc. 2017. 5. Elliott R, Csete J, Palepu A, Kerr T. Reason and rights in global drug control policy. CMAJ. 2005;172(5):655-6. 6. Mazerolle L, Soole DW, Rombouts S. Street-level drug law enforcement: A meta-analytical review. Journal of Experimental Criminology. 2006;2(4):409-35. 7. Webster IW. Managing legal and medical complexities in caring for people with drug and alcohol problems: a call for change. Med J Aust. 2016;204(4):141-2. 8. The prohibition of illicit drugs is killing and criminalising our children and we are all letting it happen. [press release]. Canberra2012. 9. Homel PB, Rick. Marijuana legalisation in the United States: An Australian perspective. Canberra: Australian Institute of Criminology; 2017 June 2017. 10. Joint United Nations statement on ending discrimination in health care settings [press release]. World Health Organisation2017. 11. Adler J. Symposium Marijuana, Federal Power, and the States: Introduction. Case Western Reserve Law Review. 2015;65(3):50512. 12. Caulkins JP, Bond BM. Marijuana Price Gradients. Journal of Drug Issues. 2012;42(1):28-45. 13. Hall W, Weier M. Assessing the public health impacts of legalizing recreational cannabis use in the USA. Clin Pharmacol Ther. 2015;97(6):607-15. 14. Latypov A. Understanding post 9/11 drug control policy and politics in Central Asia. Int J Drug Policy. 2009;20(5):387-91. 15. Wolfe D. Paradoxes in antiretroviral treatment for injecting drug users: access, adherence and structural barriers in Asia and the former Soviet Union. Int J Drug Policy. 2007;18(4):246-54. 16. Willis K. Measuring the effectiveness of drug law enforcement. Trends and Issues in Crime and Criminal Justice. 2011;406(1):1-7. 17. Hughes CE, Stevens A. What Can We Learn From The Portuguese Decriminalization of Illicit Drugs? British Journal of Criminology. 2010;50(6):999-1022. 18. Greenwald G. Drug Decriminalization in Portugal: Lessons for Creating Fair and Successful Drug Policies. Washington, DC: Cato Institute; 2009. 19. Felix S, Portugal P. Drug decriminalization and the price of illicit drugs. Int J Drug Policy. 2017;39:121-9. 20. Drugs WACo. Not Just in Transit: Drugs, the State and Society in West Africa. West Africa Commission on Drugs; 2014. 21. Mathers BMD, Louisa; Phillips, Benjamin; Wiessing, Lucas; Hickman, Matthew; Strathdee, Steffanie A; Wodak, Alex; Panda, Samiran; Tyndall, Mark; Toufik, Abdalla; Mattick, Richard P. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet. 2008;372(9651):1733-45.

Conflict of Interest None declared Correspondance raquel.maggacis@uqconnect.edu.au References

1. Wodak AD. The need and direction for drug law reform in Australia. The Medical Journal of Australia. 2012;197(6):312-3. 2. Madras BK. Office of National Drug Control Policy: a scientist in drug policy in Washington, DC. Ann N Y Acad Sci. 2010;1187:370402. 3. Sapp CE. Rehabilitate or incarcerate? A comparative analysis of the United States’ sentencing laws on low-level drug offenders and Portugal’s decriminalization of low-level drug offenses. Cardozo Journal of International & Comparative Law. 2014;23(1):63-97. 4. Félix S, Portugal P, Tavares A. Going after the Addiction, Not the Addicted: The Impact of Drug Decriminalization in Portugal.

Dengue in the Pacific Islands [Review] Madeleine Marsland and Dunya Tomic Madeleine is a fourth year medical student who is interested in global health and research. She combines these interests in her role as Chief of Editorials and Publications for the Pacific Medical Students’ Association, and is also undertaking research with the Department of Anatomy and Developmental Biology at Monash University. She hopes to pursue global health research and policy.

“

Dunya is a fourth year medical student at Monash University with a particular interest in clinical research and medical ethics. She hopes to one day combine this with a career as a physician.

Abstract Without a fully effective vaccine, prophylactic measures, or sufficient treatment options, dengue has emerged as a significant global health threat. The Pacific Islands are particularly susceptible to dengue as they provide favourable conditions for the Aedes mosquito population, the vector responsible for spreading the virus. Strong public health protocols with an emphasis on vector control are considered to be the best way to combat dengue in this region. However, for a variety of social, economic, environmental and political factors, vector surveillance and control mechanisms are failing. This review seeks to provide an overview on the emergence of dengue in the Pacific Islands, why this region is susceptible due to virus and vector factors, and what has been done and can be done in the future to contain the dengue threat in this region.

Introduction Dengue virus is a vector-borne disease primarily spread by the Aedes mosquito population; it is one of the most significant infectious diseases that remains without definitive prevention or treatment options. Due to a variety of environmental and social factors, the Pacific Islands are particularly susceptible to dengue and other arbovirus.[1, 2] This has significant associated morbidity, mortality and economic cost, particularly when patients contract ‘severe dengue’.[1-3] A diagnosis of dengue can be based on clinical signs and/or laboratory diagnosis, whilst a diagnosis of ‘severe dengue’ is based on serious complications including plasma leakage, severe haemorrhage or severe organ impairment.[3] These clinical manifestations and complications of dengue can cause severe illness, particularly in susceptible patient groups including children.[3] Treatment options are limited particularly in resource poor settings, and thus preventing dengue and recognising outbreaks is critical.[3] Dengvaxia, a world-first dengue vaccine, has recently been approved for use in endemic settings, with the World Health Organization recommending high-risk nations implement it as part of their vaccination program.[4-6] However, the vaccine has variable levels of efficacy, and is not yet considered a cost-effective solution. [5, 6] Whilst dengue remains a growing threat, the Pacific Island region must urgently develop alternative cost-effective

”

diagnostic, detection, treatment and prevention strategies.[4, 7, 8] Methods

The intended focus of this literature review was dengue in the Pacific Island region. An Ovid MEDLINE search was conducted combining the search terms “Dengue”, “Aedes” and “Pacific”. Grey literature and data was also sourced from the World Health Organization (WHO) and other non-profit organisations. Additional resources were identified through analysing the articles retrieved through these searches. Epidemiology

Prevalence Dengue has been reported in several Pacific Island nations since the 1950s, but in the past decade the incidence has grown exponentially.[1, 9] Whilst in 2000 there was only 50 reported cases per 1000 people, by 2012 this had grown to 350 per 1000.[1] It is difficult to determine reliable data on the endemic levels of dengue in the Pacific Islands, as this depends on accurate and timely reporting to the Pacific Public Health Surveillance Network, still under development. [2] However, whilst dengue is not endemic in all Pacific Islands, it is emerging in previously untouched islands including the Solomon Islands and Papua New Guinea.[9] From 2016 to 2017 alone, there has been an unusual increase in dengue

Table 1: Dengue Serotypes and Epidemiology DENV Serotype

Notable related epidemiology and outbreaks

DENV-1

The most prominent serotype in 2012-2013, causing the largest-ever documented outbreak affecting New Caledonia.[21]

DENV-2

Caused recent outbreaks in Tuvalu and a current outbreak in Samoa.[10, 22]

DENV-3

After 18 years of absence, has recently become the dominant serotype in the Pacific islands causing five ongoing outbreaks [23].

DENV-4

Caused one outbreak since 2012, is rare in the Pacific Islands [10].

illness reported in the Solomon Islands, Vanuatu, Fiji and Palau.[10] With this growth, some reports indicate that the vast majority of the Pacific Island population will be infected at some point in their lives.[1] In Samoa, one study showed 96% of the population tested positive for IgG antibodies, indicating prior infection.[11] With 89% of 18-25 year olds testing positive, this demonstrated that most Samoans first contracted dengue during childhood, when dengue illness is more likely to be fatal.[7, 11]

Outbreaks Dengue typically follows an epidemic pattern with 1 of the 4 serotypes causing outbreaks across the Pacific every three to five years. However, the number of outbreaks of concurrent serotypes has been growing.[2] After an outbreak of a single serotype, this strain of the virus tends to circulate throughout the region until the next outbreak of a different strain occurs.[12] A single outbreak can affect a large portion of the population, with the 2009 outbreaks affecting 14 Pacific nations.[13] During such outbreaks, complications increase, placing a burden on hospital resources, with 4% of the Federated States of Micronesia’s population requiring hospitalisation during the Kosrae state outbreak.[14] The frequency of outbreaks appears to be increasing,[4] though this may be due to improved surveillance. The virus Dengue virus (DENV) is a single-stranded, positivesense RNA virus of the Flavivirus genus.[15] There are four serotypes DENV-1 to DENV-4. Though they only share 65% of their genomes, their clinical syndromes are nearly identical, and they all occupy the same ecological niche. [16, 17] Dengue epidemics usually result from introduction of a single serotype from hyper-endemic countries, which will remain dominant in the region for several years.[12,18,19] However, in 2012, outbreaks of all four DENV serotypes were noted in a single year [20]. Each DENV serotype has caused outbreaks or been prevalent in the Pacific Islands at various times (Table 1). Repeated infection of DENV of the same serotype is associated with increase risk of progressing to severe dengue, which is associated with higher morbidity and mortality if left untreated.[24] Those living in endemic areas such as the Pacific Islands are at an increased risk of being reinfected and thus complications are more common.

The Vector Dengue, zika, chikungunya and other arboviruses are transmitted to humans through the bites of infected Aedes mosquitoes.[25] Aedes aegypti is the primary vector in the Pacific Islands and is widespread across the region except for Futuna and other isolated islands.[26,27] Aedes aegypti is associated with human migration and urbanisation, enabling it to be dominant in the region, however, Aedes albopictus, Aedes polynesiensis and nine other potential vectors have also been identified in the Pacific Islands.[27, 28] Aedes mosquitoes begin their transmission cycle upon acquiring the dengue virus from the blood of a viraemic person; the virus then replicates in mosquito midgut epithelium before shedding its progeny into the haemocoel, which then disseminates into secondary target tissues such as salivary glands.[29] During the next feeding event, the mosquito transmits the virus to the host through saliva.[29,30] Aedes aegypti is capable of repeatedly transmitting the virus through this process irrespective of its number of hosts.[30] The introduction of Aedes aegypti into different islands has been spurred by human migration; there have been intense population migrations in the Pacific Islands since European colonization.[31] Though the first dengue epidemic in the Pacific Islands was reported in the 1880s, descriptions of Aedes aegypti didn’t emerge until the 1960s in Fiji and Tonga. [20, 32, 33] Aedes aegypti then spread during World War II, when travel between the Pacific Islands and Asia, Europe, and America became more frequent.[34] Recent studies have now identified genetic variability in nine locations across Fiji, New Caledonia, Tonga and French Polynesia, suggesting a link between human migration and Aedes aegypti populations, possibly related to island isolation and environmental conditions.[25] Several factors influence the transmission of DENV from mosquitoes to humans, including climate.[30] Higher temperatures enable the virus to replicate in higher concentrations, enhancing the vectors’ risk for pathogen transmission and contributing to the high prevalence of dengue infection in the tropical Pacific Islands[30] Globally, climate-induced variations in modelled Aedes aegypti populations were strongly correlated to historical dengue cases between 1958 to 1995.[35] Recent research from New Caledonia, where dengue spread by Aedes aegypti is a major 39

public health problem, showed that the epidemic dynamics of dengue were predominantly driven by climate in the last forty years.[36] Another study found a positive correlation between dengue infection and El Nino southern oscillation in ten countries, with evidence of infection spreading from larger islands to smaller surrounding islands.[37] It is predicted that global warming will increase the latitudinal and altitudinal distribution of Aedes aegypti and subsequently DENV.[38,39] Dengue Surveillance Methods Dengue surveillance and tracking is essential to enable timely epidemic responses.[8] Though representatives from the Pacific Islands believe there is adequate surveillance infrastructure and systems, governments have not emphasised prevention. These systems must be strengthened to more accurately track dengue epidemiological data [8, 40]. Given financial difficulties, this may be better accomplished through alternative mechanisms. One such alternative is the transport of serum and blood samples internationally.[41] When a new serotype emerges in one Pacific country, this is often followed by outbreaks in neighbouring countries [42]; using blood samples to identify emerging serotypes enables surveillance of viral spread across the region. Filter paper (FP)-dried blood spots have minimal health risk and so are not bound by dangerous goods regulations present in several Pacific nations [43]. Blood spiked with cultured DENV can be blotted on FP-cards and the serotype determined using reverse-transcriptase polymerase chain reaction.[44]. The serotype and genotype of DENV can be identified using FP-dried serum even after being transported over thousands of kilometres at tropical temperatures.[41] This method of surveillance particularly useful in the Pacific Islands, where samples may need to be transported over long distances. Another method to monitor dengue levels is the use of international travellers as â&#x20AC;&#x2DC;sentinelsâ&#x20AC;&#x2122;, so that the risk of dengue infection can be estimated through proxies who travelled to particular areas.[45] Patterns of local dengue incidence in the Pacific Islands were shown to be closely correlated with patterns of dengue incidence imported from the Pacific to New Zealand.[46] However, this method is more commonly retrospective and cannot provide an indication of outbreaks.

A combination of both methods could be implemented to cheaply and effectively improve dengue surveillance in the regions. Dengue Prevention and Control, Now and in the Future

Strategies and Policies Many nations have been attempting to meet the WHO infectious disease strategy objectives (Figure 1) by implementing policies that address vector surveillance, health education for vector control and dengue prevention, and emergency response capacity.[8] However, an urgent policy review to combat dengue is needed, with a focus on emphasising dengue in climate change and environmental medicine policies.[48] It is also essential that dengue is classed as a notifiable disease across all Pacific Islands through legislation.[48] A Dengue Vaccine Although several live-attenuated dengue vaccines are undergoing phase III clinical trials, currently Dengvaxia (CYDTDV) is the only vaccine that is licensed and registered for use in individuals aged 9-45 years and living in dengue endemic areas.[40] Modelling has shown that Dengvaxia would only have the highest net benefit and be most cost-effective if the majority of the population is vaccinated in dengue-endemic nations.[52] The WHO has recommended that nations with a high burden of disease, defined as seroprevalence >70% in 9 year-olds, introduce the vaccine.[4, 1] However, many nations worldwide are still debating this, and Dengvaxia is not currently licensed for use in Pacific Island nations.[5, 51] From the two major phase III clinical trials for Dengvaxia, overall vaccine efficacy against severe dengue was 79%, however, this varied by serotype, age at vaccination, and previous dengue infection.[52] For those with a previous dengue infection, vaccination efficacy was 78%, however, it was only 38% for those with no prior infection.[52] In fact, a study has shown that Dengvaxia can also increase the risk of hospitalisation when seronegative individuals are vaccinated and later experience natural secondary dengue infection. [51] The pooled efficacy for those older than 9 years old was higher than those under 9 years of age, who have a higher risk of severe dengue (66% vs 44%).[3, 52] Finally, in terms of serotype, vaccine efficacy was shown to be higher against

Figure 1: Outline of the World Health Organization Infectious Disease Strategy [47] 40

serotypes 3 (72%) and 4 (77%) than for serotypes 1 (55%) and 2 (43%).[52] Further study is ongoing to determine whether dengue illness and hospitalisation has reduced in nations that have implemented Dengvaxia.[53, 54] However, with varying efficacy, and questions regarding long-term safety and cost-effectiveness, it is predicted that vaccination will only be possible in the Pacific Islands if it is priced competitively. [53, 54] Thus, for the time being, vector control will remain the focus of dengue control strategy in the Pacific Islands, with the aim of integrating vaccination once it is more efficacious and cost-effective.[55] At present, it is far more affordable and effective to combat dengue by improving vector control mechanisms, and vaccination will be most useful as an adjunct if appropriate for specific nations.

Vector Control: Currently Used Methods Vector control currently offers the best option for preventing dengue, but delivery of prevention programmes in the Pacific Islands is often inefficient, ineffective or both. [7] Several mechanisms exist in various Pacific Islands to control outbreaks once they occur, however some of the most common efforts, such as pesticide spraying, have limited effectiveness.[56] Factors that increase the risk of dengue transmission have included poor household drainage and hygiene problems, issues that can be addressed by health education programs to build a â&#x20AC;&#x2DC;prevention attitudeâ&#x20AC;&#x2122; among Pacific residents.[57, 58] However, it is believed that improving health education, awareness campaigns and technical support is necessary to ensure successful vector control.[8] Environmental factors such as buckets of stagnant water, allowing mosquitoes to breed, and host larvae and pupae, are other key risk factor which could be targeted through education campaigns. [59] Chemical treatment of breeding sites, insecticide spraying and biological control by introducing predators are mechanisms already utilised by some Pacific Islands which could be further implemented for vector control in the future. [60]

Vector Control: Innovative Approaches Novel vector-based approaches aimed at controlling dengue include the use of obligate intracellular bacterium Wolbachia pipientis,[61] which interferes with reproduction in over 40% of insect species.[62] Although Wolbachia does not occur naturally in Aedes aegypti species, transinfection has been shown to be successful.[63] Recent studies in Cairns, Australia have shown stable transinfection of natural A. aegypti populations with the wMel strain of Wolbachia, rising to near-fixation within a matter of months and remaining established in those field sites unaided.[64] The antiviral activity of wMel has shown to be highly effective in laboratory studies even one year after field release.[65] The evidence supports the long-term stability of Wolbachia against the dengue virus, however, the effects on reduction of human disease in dengue-endemic regions is yet to be established, this is currently under investigation in Indonesia and Vietnam. [61]

Another promising vector control method is the sterile insect technique (SIT), which has historically been successful against a multitude of agricultural pests.[66] In the 1960s, large-scale SIT programs enabled the elimination of A. aegypti from 23 American countries.[67] SIT has recently re-emerged as a vector control strategy due to innovative technological advances including genetic modification of mosquitoes.[68] Using SIT, Cuba has come close to the eradication of A. aegypti [69] and Singapore has kept levels of the mosquitoes down for more than 30 years.[70] Though neither of these methods is currently used widely in Pacific Islands, these innovative strategies are potential costeffective vector reduction methods.

Emergency Response Capacity There is a significant need to grow emergency-response and outbreak-response to combat dengue.[8] Currently, the WHO and Red Cross manage the majority of outbreak control, both logistically and financially[14, 71] The Pacific Public Health Surveillance Network has provided some support in capacity building, and multiagency response teams have successfully been implemented during some outbreaks, but there remains a need to engage Pacific Directors and Ministers of Health to help prepare these multidisciplinary response teams for future outbreaks.[2, 14] Conclusion Dengue remains a significant threat in the Pacific Islands, with prevalence levels and the number of outbreaks continuing to increase. Until Dengvaxia or another dengue vaccine has a proven cost-effective public health benefit beyond the currently calculated values, it is unlikely to be deployed in Pacific Islands.[5, 51] The best hope for containing dengue is by improving region-wide surveillance and cost-effective, sustainable vector control mechanisms [6-8]. This requires Pacific Island governments to integrate dengue prevention into their environmental and public health policy, and work to improve vector surveillance and control methods, which may involve implementing innovative approaches [8, 48]. Another area that requires significant improvement is outbreak response, and upskilling all Pacific doctors to appropriately respond to dengue outbreaks [8, 60]. Ultimately, until the objectives outlined by the WHO are addressed, dengue will remain a growing challenge in the Pacific Islands. [7, 47] These islands must engage with the growing body of organisations working in the region to develop new and innovative surveillance and control approaches and combat dengue in the future.[7] Conflicts of interest None declared Correspondance dtom4@student.monash.edu References

1. Arima Y, Chiew M, Matsui T. Epidemiological update on the dengue situation in the Western Pacific Region, 2012. Western Pacific Surveillance and Response Journal. 2015;6(2):82-89. 2. Roth A, Mercier A, Lepers C, Hoy D, Duituturaga S, Benyon E

et al. Concurrent outbreaks of dengue, chikungunya and Zika virus infections – an unprecedented epidemic wave of mosquito-borne viruses in the Pacific 2012–2014. Eurosurveillance. 2014;19(41):1 - 8. 3. Dengue Guidelines for Diagnosis, Treatment, Prevention and Control [Internet]. World Health Organization (WHO) and the Special Programme for Research and Training in Tropical Diseases (TDR); 2009 [cited 27 July 2017]. Available from: http://www.who.int/tdr/ publications/documents/dengue-diagnosis.pdf 4. Dengue and Severe Dengue [Internet]. World Health Organization. 2017 [cited 11 August 2017]. Available from: http:// www.who.int/mediacentre/factsheets/fs117/en/ 5. Wilder-Smith A, Vannice KS, Hombach J, Farrar J, Nolan T. Population Perspectives and World Health Organization Recommendations for CYD-TDV Dengue Vaccine. J Infect Dis. 2016;214(12):1796-1799. 6. Olivera-Botello G, Coudeville L, Fanouillere K, Guy B, Chambonneau L, Noriega F et al. Tetravalent Dengue Vaccine Reduces Symptomatic and Asymptomatic Dengue Virus Infections in Healthy Children and Adolescents Aged 2-16 Years in Asia and Latin America. J Infect Dis. 2016;214(7):994-1000. 7. Guzman M, Halstead S, Artsob H, Buchy P, Farrar J, Gubler D et al. Dengue: a continuing global threat. Nature Reviews Microbiology. 2010;8(12):S7-S16. 8. Tambo E, Chen J, Zhou X, Khater E. Outwitting dengue threat and epidemics resurgence in Asia-Pacific countries: strengthening integrated dengue surveillance, monitoring and response systems. Infectious Diseases of Poverty. 2016;5(1). 9. Kline K, McCarthy J, Pearson M, Loukas A, Hotez P. Neglected Tropical Diseases of Oceania: Review of Their Prevalence, Distribution, and Opportunities for Control. PLoS Neglected Tropical Diseases. 2013;7(1):1 - 6. 10. Pacific: Dengue Outbreak – Oct 2016 [Internet]. Disasters. ReliefWeb. 2017 [cited 11 August 2017]. Available from: http:// reliefweb.int/disaster/ep-2016-000112-slb 11. Duncombe J, Lau C, Weinstein P, Aaskov J, Rourke M, Grant R et al. Seroprevalence of Dengue in American Samoa, 2010. Emerging Infectious Diseases. 2013;19(2):324-326. 12. Dupont-Rouzeyrol M, Aubry M, O’Connor O, Roche C, Gourinat A, Guigon A et al. Epidemiological and molecular features of dengue virus type-1 in New Caledonia, South Pacific, 2001–2013. Virology Journal. 2014;11(1):61. 13. Dengue in the Western Pacific Region [Internet]. World Health Organization Western Pacific Region. 2017 [cited 26 February 2017]. Available from: http://www.wpro.who.int/emerging_diseases/ Dengue/en/ 14. Taulung L, Masao C, Palik H, Samo M, Barrow L, Pretrick M et al. Dengue Outbreak — Federated States of Micronesia, 2012– 2013 [Internet]. Morbidity and Mortality Weekly Report. 2013 [cited 26 February 2017]. Available from: https://www.cdc.gov/mmwr/ preview/mmwrhtml/mm6228a3.htm 15. Dupont-Rouzeyrol M, Aubry M, O’Connor O, Roche C, Gourinat AC, Guigon A et al. Epidemiological and molecular features of dengue virus type-1 in New Caledonia, South Pacific, 2001-2013. Virol J. 2014;11:61. 16. Sabin AB. Research on dengue during World War II. Am J Trop Med Hyg. 1952;1:30–50. 17. Halstead SB. Dengue virus – mosquito interactions. Annu Rev Entomol. 2008;53:273-91. 18. A-Nuegoonpipat A, Berlioz-Arthaud A, Chow V, Endy T, Lowry K, le Mai Q et al. Sustained transmission of dengue virus type 1 in the Pacific due to repeated introductions of different Asian strains. Virology. 2004;329(2):505-12. 19. Morens DM. Dengue fever: a prevention summary for Pacific health workers. Pacific Health Dialog. 1996;3(1):240-52. 20. Singh N, Kiedrzynski T, Lepers C, Benyon EK. Dengue in the Pacific – an update of the current situation. Pacific Health Dialog. 2005;12(2):111-9.

21. Roth A, Mercier A, Lepers C, Hoy D, Duituturaga S, Benyon E et al. Concurrent outbreaks of dengue, chikungunya and Zika virus infections - an unprecedented epidemic wave of mosquito-borne viruses in the Pacific 2012-2014. Euro Surveill. 2014;19(41):20929. 22. Centers for Disease Control and Prevention (CDC). Dengue outbreak – Federated States of Micronesia, 2012-2013. MMWR. Morbidity and mortality weekly report. 2013;62(28):570-3. 23. Cao-Lormeau VM, Roche C, Musso D, Mallet HP, Dalipanda T, Dofai A, et al. Dengue virus type 3, South Pacific Islands, 2013. Emerg Infect Dis. 2014;20(6):1034-6. 24. World Health Organization. Dengue haemorrhagic fever. Diagnosis, Treatment, Prevention and Control. Geneva (CH); 1997. 92 p. Report No.: 2. 25. Calvez E, Guillaumot L, Millet L, Marie J, Bossin H, Rama V et al. and Phylogeny of Aedes aegypti, the Main Arbovirus Vector in the Pacific. PLoS Negl Trop Dis. 2016;10(1):1-2. 26. Guillaumot L. Arboviruses and their vectors in the Pacific – status report. Pac Health Dialog. 2005;12(2):45-52. 27. Lounibos LP. Invasions by insect vectors of human disease. Annu Rev Entomol. 2002;47(1):233-66. 28. Paupy C, Vazeille-Falcoz M, Mousson L, Rodhain F, Failloux AB. Aedes aegypti in Tahiti and Moorea (French Polynesia): isoenzyme differentiation in the mosquito population according to human population density. Am J Trop Med Hyg. 2000;62(2):217-24. 29. Carrington LB, Simmons CP. Human to Mosquito Transmission of Dengue Viruses. Front Immunol. 2014;5:290. 30. Scott T, Takken W. Feeding strategies of anthropophilic mosquitoes result in increased risk of pathogen transmission. Trends Parasitol. 2012;28(3):114-121. 31. Rallu JL. Tendance recentes des migrations dans le Pacifique Sud. Espace, population, sociétés. 1994;12(2):201-212. 32. Perry WJ. The mosquitoes and mosquito-borne diseases on New Caledonia, an historic account; 1885–1946. Am J Trop Med Hyg. 1950;30(1):103-14. 33. Chow CY. Aedes aegypti in the Western Pacific Region. Bull World Health Organ. 1967;36(4):544-6. 34. Kuno G. Research on dengue and dengue-like illness in East Asia and the Western Pacific during the First Half of the 20th century. Rev Med Virol. 2007;17(5):327-41. 35. Hopp MJ, Foley JA. Worldwide fluctuations in dengue fever cases related to climate variability. Clim Res. 2003;25:85-94. 36. Descloux E, Mangeas M, Menkes CE, Lengaigne M, Leroy A, Tehei T et al. Climate-Based Models for Understanding and Forecasting Dengue Epidemics. PLoS Negl Trop Dis. 2012;6(2):e1470. 37. Hales S, Weinstein P, Souares Y, Woodward A. El Nino and the Dynamics of Vectorborne Disease Transmission. Environ Health Perspect. 1999;107(2):99-102. 38. Hales S, de Wet N, Maindonald J, Woodward A. Potential effect of population and climate changes on global distribution of dengue fever: an empirical model. Lancet. 2002;360:830-834. 39. Jetten TH, Focks DA. Potential changes in the distribution of dengue transmission under climate warming. Am J Trop Med Hyg. 1997;57:285-297. 40. Masahiro U, Sengebau-Kinzio M, Nakamura K, Ridep E, Watanabe M, Takano T. Household risk factors associated with dengue-like illness, Republic of Palau, 2000-2001. BioScience Trends. 2007;1(1):33 - 37. 41. Aubry M, Roche C, Dupont-Rouzeyrol M, Aaskov J, Viallon J, Marfel M et al. Use of serum and blood samples on filter paper to improve the surveillance of dengue in Pacific Island Countries. Journal of Clinical Virology. 2012;55(1):23-29. 42. Cao-Lormeau VM, Roche C, Descloux E, Viallon J, Lastere S, Wiegandt A et al. Lost in French Polynesia: which strategies for a dengue virus to spread? Am J Trop Med Hyg Suppl. 2007;12:111-19. 43. Guidance on regulations for the transport of infectious substances 2011–2012 [Internet]. World Health Organization; 2010 [cited 31 July 2017]. Available from: http://www.who.int/entity/ihr/

publications/who_hse_ihr_20100801/en/index.html 44. Prado I, Rosario D, Bernardo L, Alvarez M, Rodriguez R, Vasquez S et al. PCR detection of dengue virus using dried whole blood spotted on filter paper. J Virol Methods. 2005;125:75-81. 45. Fukusumi M, Arashiro T, Arima Y, Matsui T, Shimada T, Kinoshita H et al. Dengue Sentinel Traveler Surveillance: Monthly and Yearly Notification Trends among Japanese Travelers, 2006– 2014. PLOS Neglected Tropical Diseases. 2016;10(8):1 - 14. 46. Lau CL, Weinstein P, Slaney D. Dengue surveillance by proxy: travellers as sentinels for outbreaks in the Pacific Islands. Epidemiol Infect. 2013 Nov;141(11): 2328–34. 47. Strategy [Internet]. Emerging Disease Surveillance and Response. 2017 [cited 26 February 2017]. Available from: http:// www.wpro.who.int/emerging_diseases/strategy/Strategy/en/ 48. Beatty M, Stone A, Fitzsimons D, Hanna J, Lam S, Vong S et al. Best Practices in Dengue Surveillance: A Report from the AsiaPacific and Americas Dengue Prevention Boards. PLoS Neglected Tropical Diseases. 2010;4(11):e890. 49. Malavige GN, Fernando S, Fernando DJ, Seneviratne SL. Dengue viral infections. Postgrad Med J. 2004;80(948):588-601. 50. Rodriguez T. Dengvaxia Most Effective in High-Transmission Areas [Internet]. Infectious Disease Advisor. 2016 [cited 3 April 2017]. Available from: http://www.infectiousdiseaseadvisor.com/ vector-borne-illnesses/dengvaxia-effective-in-high-transmissionareas/article/579948/ 51. Aguiar M, Stollenwerk N, Halstead S. The Impact of the Newly Licensed Dengue Vaccine in Endemic Countries. PLOS Neglected Tropical Diseases. 2016;10(12):e0005179. 52. Questions and Answers on Dengue Vaccines [Internet]. Immunization, Vaccines and Biologicals. World Health Organization. 2017 [cited 11 August 2017]. Available from: http://www.who.int/ immunization/research/development/dengue_q_and_a/en 53. Hadinegoro S, Arredondo-García J, Capeding M, Deseda C, Chotpitayasunondh T, Dietze R et al. Efficacy and Long-Term Safety of a Dengue Vaccine in Regions of Endemic Disease. New England Journal of Medicine [Internet]. 2015 [cited 3 April 2017];373(13):1195-1206. Available from: http://www.nejm.org/doi/ full/10.1056/NEJMoa1506223#t=article 54. Flasche S, Jit M, Rodríguez-Barraquer I, Coudeville L, Recker M, Koelle K et al. The Long-Term Safety, Public Health Impact, and Cost-Effectiveness of Routine Vaccination with a Recombinant, Live-Attenuated Dengue Vaccine (Dengvaxia): A Model Comparison Study. PLOS Medicine. 2016;13(11):e1002181. 55. Background Paper on Dengue Vaccines [Internet]. 1st ed. SAGE Working Group on Dengue Vaccines and WHO Secretariat; 2016 [cited 3 April 2017]. Available from: http://www.who.int/ immunization/sage/meetings/2016/april/1_Background_Paper_ Dengue_Vaccines_2016_03_17.pdf 56. Masahiro U, Sengebau-Kinzio M, Nakamura K, Ridep E, Watanabe M, Takano T. Household risk factors associated with dengue-like illness, Republic of Palau, 2000-2001. BioScience Trends. 2007;1(1):33 - 37. 57. Noel M. Dengue fever larval control in New Caledonia: assessment of a door-to-door health educators program. Pacific Health Surveillance and Response. 2005;12(2):39 - 44. 58. Morrow GBowen K. Accounting for health in climate change policies: a case study of Fiji. Global Health Action. 2014;7(1):23550. 59. Burkot T, Handzel T, Schmaedick M, Tufa J, Roberts J, Graves P. Productivity of natural and artificial containers for Aedes polynesiensis and Aedes aegypti in four American Samoan villages. Medical and Veterinary Entomology. 2007;21(1):22-29. 60. Chang M, Christophel E, Gopinath D, Abdur R. Challenges and future perspective for dengue vector control in the Western Pacific Region. Western Pacific Surveillance and Response. 2011;2(2):1 - 7. 61. McGraw EA, O’Neill SL. Beyond insecticides: new thinking on an ancient problem. Nat Rev Microbiol. 2013 Mar;11(3):181-93. 62. Zug R, Koehncke A, Hammerstein P. Epidemiology in evolutionary time: the case of Wolbachia horizontal transmission

between arthropod host species. J Evol Biol. 2012 Nov;25(11):214960. 63. Xi Z, Khoo CC, Dobson SL. Wolbachia establishment and invasion in an Aedes aegypti laboratory population. Science. 2005 Oct;310(5746):326-8. 64. Walker T, Johnson PH, Moreira LA, Iturbe-Ormaetxe I, Frentiu FD, McMeniman CJ, et al. The wMel Wolbachia strain blocks dengue and invades caged Aedes aegypti populations. Nature. 2011 Aug;476:450-3. 65. Frentiu FD, Zakir T, Walker T, Popovici J, Pyke AT, van der Hurk A, et al. Limited Dengue Virus Replication in Field-Collected Aedes aegypti Mosquitoes Infected with Wolbachia. PLoS Negl Trop Dis. 2014 Feb;8(2):e2688. 66. Dyck VA, Hendrichs J, Robinson AS, editors. Sterile Insect Technique: Principles and Practice in Area-Wide Integrated Pest Management. Dordrecht: Springer; 2005. 787 p. 67. Soper FL. The elimination of urban yellow fever in the Americas through the eradication of Aedes aegypti. Am J Public Health Nations Health. 1963 Jan;53(1):7-16. 68. Phuc HK, Andreasen MH, Burton RS, Vass C, Epton MJ, Pape G, et al. Late-acting dominant lethal genetic systems and mosquito control. BMC Biol. 2007 Mar;5:11. 69. Kourí G, Guzmán MG, Bravo J. Hemorrhagic dengue in Cuba: history of an epidemic. Bull Pan Am Health Organ. 1986;20(1):24-30. 70. Ooi EE, Goh KT, Gubler DJ. Dengue prevention and 35 years of vector control in Singapore. Emerg Infect Dis. 2006 Jun;12(6):88793. 71. Disaster relief and emergency fund enables dengue outbreak response [Internet]. Fédération internationale des Sociétés de la Croix-Rouge. 2014 [cited 26 February 2017]. Available from: http:// www.ifrc.org/fr/nouvelles/nouvelles/common/disaster-relief-andemergency-fund-enables-dengue-outbreak-response-65371/

Family, Unity and Success - Australian Indigenous Doctors’ Association (AIDA) 2017 [Conference report] Narawi Foley Boscott Narawi completed a Bachelor of Science (Biomed) at the University of Queensland and is currently completing a Doctor of Medicine as well as a Graduate Certificate in Business Leadership. Narawi is pssionate about Badtjala culture and aspiring to improve Indigenous and mental health.

Hunter Valley The Australian Indigenous Doctors’ Association (AIDA) celebrated 20 years strong by holding their annual conference for 2017 in the Hunter Valley, traditionally owned by the Wonnarua people. This four-day long intensive collaboration of keynote speakers, engaging workshops as well as invaluable cultural and networking events created a leading platform to connect and be inspired. The AIDA 2017 conference focussed on “family, unity and success” with the overarching theme of supporting and connecting Aboriginal and Torres Strait Islander medical students and doctors to ultimately improve the health of Indigenous people in Australia.[1] This conference has grown to not only bring Indigenous students and doctors together but also to provide networking opportunities for associate members, medical college representatives, other health professionals and key invited guests, making it an important medical and political event.

“...in the medical curriculum, where education about Aboriginal and Torres Strait Islander culture and cultural safety is often poor, undervalued or realistically done too late to change some attitudes and beliefs.” Family This was the second AIDA conference I have attended as a medical student. I believe many people would underestimate the value of bringing together fellow Indigenous medical students and doctors from across Australia. However, this sense of belonging and knowing you are not alone in medicine, whether it be through sharing stories in the yarning circle 44

or networking in the lunch break, is why I believe the AIDA conference and AIDA itself is so successful. Recently, AMSA Blue Week highlighted conversations regarding the need to do more about the mental health crisis amongst medical students and doctors.[2] Research also shows that mental health disorders are more prevalent amongst Indigenous Australians than their non-Indigenous counterparts [3] and it is well documented that good social support is protective for mental illness.[4] This highlights the importance for Aboriginal and Torres Strait Islander medical students and doctors, in particular, to have a strong support network throughout their medical journey. AIDA provides a support network as a familylike organisation, its members backing each other as they embark on their medical careers and embrace the enormous task of improving Indigenous health. Unity So what do we know about Indigenous health? There is still a lot to do, but as an attendee of the AIDA conference, I was surrounded by people who are already are, or are soon to be, making a real impact on many people’s lives. However, the media continues to portray a narrative that there are only a few well-educated Aboriginal or Torres Strait Islander people. Australia’s history of Aboriginal and Torres Strait Islander people is still poorly taught in schools. Not only this but key Aboriginal and Torres Strait Islander people in the past who have formed a better path for our people are either unheard of or undervalued in our society.[5] This is reflected in the medical curriculum, where education about Aboriginal and Torres Strait Islander culture and cultural safety is often poor, undervalued or realistically done too late to change some attitudes and beliefs.[6]

broader society, particularly in how we value Aboriginal and Torres Strait Islander lives, challenge racism and become more culturally aware. At this year’s AIDA conference, it was encouraging to see many of the medical college representatives understand the need for more Indigenous doctors, and the need for cultural change to challenge racism and improve cultural awareness within their own colleges. Medicare exclusions for prisoners is a key issue that highlights systemic racism and contributes to health disparities. Currently, prisoners in Australia are excluded from Medicare and the Pharmaceutical Benefits Scheme subsidies. This limited access to good healthcare is shortening life expectancy and decreasing the quality of life of many people who are incarcerated.[11] Aboriginal and Torres Strait Islander people are over-represented in prisons and are 13 times more likely to be incarcerated.[12] This is not closing the gap but in fact, widening the existing chasm in health disparities.[13] The beautiful but complex aspect to Aboriginal and Torres Strait Islander people and culture is that there are many communities, languages and cultural protocols; in improving Indigenous health there is no “one size fits all” approach. The best outcomes at a grass-roots level are when a community is meaningfully involved, a lengthy but essential strategy to drive improvements to Indigenous health.[14] Targeting the social determinants of health are also key, however tackling systemic racism, the lack in cultural awareness and creating a cultural change in society to value Aboriginal and Torres Strait Islander lives should be our focus for enduring change. All medical students and medical schools in Australia

The question then arises: is the problem really about the lack of teaching about Aboriginal and Torres Strait Islander culture, when racism (both institutional and interpersonal) is known to be associated with poorer health and poorer health outcomes?[7] Should the curriculum entail teachings on racism, both identifying it and stopping it? This conference asked whether it is the job of Indigenous people to educate non-Indigenous people on racism itself. The term “hidden curriculum” – the values and attitudes that medical students see around them – highlights the importance of lecturers, tutors, administrators and academics in showing strong leadership and changing the culture of our universities to stop racism and strongly value Aboriginal and Torres Strait Islander culture and health.[8] It is not just universities that need to step up. The United Nations (UN) recently described Australia’s progress in Closing the Gap as “woefully inadequate”.[9] Hearing this in a room full of people who are driving positive change and having real impacts on lives can be very disheartening, especially when Aboriginal and Torres Strait Islander people make up only 2.8% of Australia’s population.[10] However, this highlights the importance for all Australians to unite to make Indigenous health an absolute priority amongst many key stakeholders. There needs to be a cultural change in

Painted stethoscope 45

should start talking about the idea that you are not clinically competent until you are culturally competent. This is imperative to reduce existing health disparities and eradicate diseases still present in remote Indigenous communities. AIDA and their supporters are ready to save and improve Aboriginal and Torres Strait Islander peoples lives, but everyone should also feel a sense of responsibility to unite to change the narrative from “woeful” to making real and lasting change. Success One of the most anticipated events of the conference every year is the stethoscope ceremony. This ceremony is where newly graduated Indigenous medical students and newly qualified Indigenous fellows are recognised for their hard work, sleepless nights, sacrifice and often added weight of responsibility by being presented with a handpainted stethoscope. This creates mentorship at AIDA and inspiration that success is possible and very achievable as an Indigenous medical student and graduate. The other most anticipated event (for me anyway) is the cultural excursion on the last day. I had very high expectations after last year, living dangerously and tasting a particular species of ant that tasted like citrus. However, I survived that last year, and can tell you that I thoroughly enjoyed the trip this year when people of the Wonnarua nation took us to Biame cave, the site of a significant piece of rock art in the Hunter Valley. These opportunities to have culture and knowledge shared are invaluable. What I also learnt was about how the traditional owners had worked with the nonIndigenous property owners on which this significant site sits in order to protect it, and make it accessible for those who wish to visit and appreciate its significance - thousands of

“All medical students and medical schools in Australia should start talking about the idea that you are not clinically competent until you are culturally competent. years of culture and knowledge. The Wonnarua people also believe there are many other significant sites around that area. They hope that by setting this as precedent, not only can they work with other property owners in the region, but this can be applied to other significant sites across Australia. So, if you, your family or your friends own a property with an Indigenous site on it, or if you are unsure, please be in contact with your local Indigenous community because there may be thousands of important sites nationwide that need to be protected for generations to come. When talking about medicine today, we often think of just the mind and body, but for many Indigenous people, there is an element of the spirit. It is also important to recognise that before colonisation, traditional healers or Ngangkari looked after our people, probably with the same care and dedication we hope to have as good doctors one day. These Ngangkari included the spirit in healing; some are still around

today treating Indigenous people. So from an Indigenous medical student’s perspective, in a society faced with racism and disparity, perhaps we should put the humanity back into medical school and not just hope, but work hard to create a better world and health outcomes for this nation’s first peoples. Conflict of Interest None declared Correspondance narawi.kefb@gmail.com References

1. Australian Indigenous Doctors’ Association. AIDA Conference 2017 [Internet].[cited 2017 Oct 1] Available from: https://www.aida.org.au/conference/ 2. AMSA mental health. About the Campaign. [Internet]. [cited 2017 Oct 1]. Available from: http://mentalhealth.amsa.org.au/about-thecampaign/ 3. Jorm A, Bourchier S, Cvetkovski S, Stewart G. Mental health of Indigenous Australians: a review of findings from community surveys. Med J Aust. 2012 196 (2):118-121. 4. Ozbay F, Johnson D, Dimoulas E, Morgan C, Charney D, Southwick S. Social Support and Resilience to Stress. Psychiatry (Edgmont). 2007 May 4(5):35-40. 5. NITV. Do our teachers care enough about Indigenous Australia to bring it into the classroom? [Internet]. 2017 May 9 [updated 2017 May 9; cited 2017 Oct 1]. Available from: http://www.sbs.com.au/nitv/article/2017/05/09/ do-our-teachers-care-enough-about-indigenous-australia-bring-itclassroom 6. Durey A. Reducing racism in Aboriginal health care in Australia: where does cultural education fit? Australian and New Zealand Journal of Public Health. 2010 July 34(1):87-92. 7. Larson A, Gillies M, Howard P, Coffin J. It’s enough to make you sick: the impact of racism on the health of Aboriginal Australians. Australian and New Zealand Journal of Public Health. 2007 August 31(4):322-229. 8. Mahood S. Medical education-Beware the hidden curriculum. Can Fam Physician. 2011 September 57(9):983-985. 9. Brennan, B. Australia’s progress on Closing the Gap ‘woefully inadequate’, UN says. [Internet]. ABC News. 2017 September 11 [cited 2017 Oct 2]. Available from: http://www.abc.net.au/news/2017-09-11/closingthe-gap-progress-woeful-un-says/8892980 10. Australian Bureau of Statistics. Census: Aboriginal and Torres Strait Islander population. [Internet]. 2017 June 27 [updated 2017 June 26; cited 2017 Oct 2] Available from: http://www.abs.gov.au/ausstats/abs@.nsf/

Four perspectives on the World Congress on public health [Conference report] Michael Au, Ka Man Li, Helena Qian and Michael Wu

“Leadership is the capacity to translate vision into reality” – Warren Bennis The World Congress on Public Health (WCPH) is held every 2-4 years and organised by the World Federation of Public Health Associations (WFPHA). Attracting between 20004000 delegates from over 80 countries, the main objective of this international forum was to engage diverse voices, ideas, vision and actions of committed professionals and citizens to strengthen and transform the global public health effort and influence decision makers.[1] With a comprehensive academic program, field trips, World Leadership Dialogues, satellite events and meetings, and a glitzy social program, this is truly the ultimate conference for public health inclined peers.

To apply, there was a simple online questionnaire and requirement to volunteer at least 20 hours throughout the conference. As this meant volunteering for four hours per day, I wasn’t able to attend all the academic workshops/sessions. I mainly worked with the media department whereby I sent interesting quotes from plenary sessions to the team for Twitter content. I also had the opportunity to directly converse with speakers in a relaxed setting, after their interview with the media team.

We evaluate the experiences of attending the WCPH, the benefits of meeting like-minded individuals, the sense of optimism in the face of challenge and the problems on financial supports in four different perspectives: a volunteer, a presenter, a medical student and a young researcher. A Volunteer’s Perspective - Helena Qian Helena is a third year medical student at the University of Newcastle with a keen interest in improving global health and aiding underserved communities. She hopes to work with WHO and MSF in the future as a collaborative researcher, advocate, field doctor and volunteer.

“When ‘I’ is replaced with ‘We’, even ‘Illness’ becomes ‘Wellness’.” - Malcolm X As someone passionate about improving public health, I noticed a curriculum gap in which public health was only briefly touched upon. WCPH was the perfect meeting of likeminded individuals, leaders and global health enthusiasts from which I could gain a holistic understanding of public health from a grassroots standpoint to a global perspective. With a registration fee of $770 for students (excluding accommodation and flights) and being on a uni student budget, I opted to attend the conference for free as a volunteer.

Despite the vast array of expertise and interests, discussion points centred around the confluence of global environmental degradation, differing political agendas, civil unrest and widening inequities in health outcomes. Interestingly, despite proven health detriments from excess alcohol, tobacco and sugar consumption, Prof. Mike Daube stated, ‘Where engagement has occurred, it has invariably been counterproductive.’ Hence, a significant barrier preventing implementation of effective public health policies are the industry groups who place private profits over the health of their consumers. As Dr Bronwyn King eloquently encapsulated, “60% of the tobacco industry involves child labour - is there no baseline standard below which we will sink to raise money?” Where negotiations with industry have failed, focus has shifted to the consumer. Exposing the fund managers who invest in these corporations and highlighting that indirect health and environmental costs rest with taxpayers, whereas revenue stays with manufacturers, have resulted in approximately $5 billion AUD being withdrawn from investment in the tobacco industry alone.[2]

Ultimately, the conference epitomised the power of public health to draw connections to unseen patterns of disease, highlighted hidden societal inequalities and served as a platform for marginalised or underserved populations to have a say. Backed by epidemiology and evidence based medicine, public health brings ugly truths to the forefront of discussion and ‘has a duty to speak truth to power’. I’m immensely grateful to have attended as a volunteer and to have met such an inspiring network of public health leaders and fellow peers. As a student, I highly recommend attending as a volunteer, especially as you gain unprecedented access to event organisers and plenary speakers. Hope to see you at the 16th WCPH in Rome 2020! A Delegate’s Perspective - Michael Wu Michael is a second year medical student and current Chair of GlobalHOME at the University of Sydney with a burning passion for health that disregards borders. Like Helena, he dreams of working all over the world with MSF. His heroes include inspirational figures such as Dr Catherine Hamlin. He also enjoys sunsets and hummus. The most palpable feeling one senses at a gathering of minds tackling the most complex social health issues in the world is that of positivity. Despite the clear adversity, there is a strong belief that we have the tools and allies needed to succeed in our agendas. As anyone that is interested in optimising health outcomes and promoting medical equity, the words “World Congress of Public Health” instantly caught my attention when I first heard them. The WCPH was a melting pot of inspiration, edgy research and health reform superstars from all over the world. This gathering does not come cheap but it also comes only once every 2-4 years and can be anywhere in the world. It was an opportunity I couldn’t miss. To pay for my privilege to be a fly on the wall I sought

the assistance of the University. Unfortunately, the Sydney Medical Program only sets aside funds for conferences if you are a presenter, however, the Sydney University Postgraduate Association was more than happy to hear me out. All I had to do was attend a general meeting, provide background information on the event and my interest and how this can benefit their interests then prepare an “ask”. They saw fit

to offer me a grant for $480 to subsidise my registration in exchange for sharing what I learnt with their Women’s Officer and Environmental Officer. This year, the University of Sydney’s Global Health Society - GlobalHOME - committed to numerous key areas of interest, including climate change and the impact on Healthcare. The plenaries for the WCPH not only had this, but also talks about Female Genital Mutilation, First Nations people, Non-Communicable Disease and Tobacco Control. These were talks dedicated to some of the most difficult healthcare issues today, and WCPH would see some of the greatest minds gather to discuss them. With Plain Packaging 2.0, we may start seeing cigarettes marked along their length with the cost to your life expectancy. There was research on the resiliency of health care systems in warzones. One researcher working on his PhD had just returned from Eritrea to add to his pool of data from nine other countries into which he had ventured during active fighting. As a student, it is a little daunting to attend a professional conference out of your direct field but all you need is an interest and passion. I made many connections and took home plenty of key messages. I would encourage anyone looking to attend a professional conference to do so and to not be fazed by a lack of scholarship availability. It would be worthwhile approaching your student council or representative organisation and present to them to secure a bursary of your own making. A Presenter’s Perspective - Michael Au Michael is a fourth year medical student at James Cook University. He is committed towards the promotion of human rights, social justice, and health equity. His interests lie in refugee and maternal health, health systems and the social determinants of health. He is currently completing research investigating refugee health systems in Far North Queensland. Although there is much to celebrate in public health, Dr Margaret Chan at the conference described “new challenges of unprecedented complexities” facing the world in the areas of antibiotic resistance, obesity and chronic diseases. These issues are intertwined with social, political and cultural issues which make them increasingly difficult to address. The status quo is not enough and there is still so much to be achieved in public health. However, many students, including myself, fall into the trap of complacency towards the state of affairs in global health. As Australian students, we view the rest of the world through the lens of a developed country, distorted by daily privileges which we take for granted. The solution? A continual pursuit for truth and information with a high degree of scientific scepticism. This was just one of the few gems I gathered from this conference. With the support of the Royal Australasian College of Physicians (RACP), I was fortunate to be given full registration and travel assistance to attend the WCPH as a John Snow Scholar. The scholarship gave me the opportunity to present research which I had completed as a medical student, entitled 48

“HIV/HCV Prevention in Australian Incarcerated Populations: A Review into Preventative Practices and Outcomes”. My review highlighted the growing disparity in health outcomes between prison populations and the community due to a lack of preventative programs in Australian prisons against infectious blood-borne diseases. I encourage all medical students to consider applying for the John Snow Scholarship. [3] Attending this conference gave me the opportunity to meet with leading academics in my area of research. In addition to bringing together academics from across the globe, both government and private sectors were closely involved. It was my great pleasure to meet with the Australian Capital Territory (ACT) Chief Health Officer who was leading the reform in needle-syringe programs as well as other academics prominent within the field of my research topic. I found this most peculiar and warming, that an event like this is able to bring people together from different parts of the world, addressing a certain issue and to share, foster and inspire other like-minded individuals. Many medical students would have had experience in attending AMSA Global Health and AMSA National Convention events. The WCPH differs to AMSA events in that it is a professional research intensive conference. These events demarcate the knowledge frontier in public health in a setting that aims to create professional networks and expanding partnerships. A Young Researcher’s Perspective - Ka Man Li Ka Man is a final year Biomedical Science student at the University of Melbourne with a strong devotion to furnish approaches for current health concerns: healthy ageing and preventive cardiology. She aims to serve as a part of WHO and WFPHA to optimise global health in the nearest future.

“Pioneering spirit should continue, not to conquer the planet or space... but rather to improve the quality of life.” – Bertrand Piccard As a young researcher, I always dreamt about either standing behind the podium presenting my novel research findings in front of experts in the field, or seeing my name on publications. On the 4th of April this year, my dream finally came true. It all began an hour before a regular Monday meeting with my supervisor. With little progression in my thesis, I did not want to be a disappointment thus I googled an upcoming conference related to my research field. I submitted an abstract in the spur of the moment to this conference. Months later, I got accepted as an orator for my study entitled, “The Effect of Physical Activity, Body Mass Index on Cardiovascular Risk in Australian Older Women”. I was overwhelmed by a cocktail of excitement and anxiety. Weeks before the conference commenced, I spent countless days and nights working on my results for the

presentation, enduring many failures along the way. Numerous times, I had to go back and forth changing the inclusion and exclusion criteria for my literature review, refining the rationale and interpreting my statistical regressions. However, with the support and encouragements from my supervisor and colleagues, I finally finished my results for the presentation. As soon as I arrived at the venue of WCPH, my first international conference, all my doubts, insecurities and anxieties suddenly vanished. I was impressed by the scale, the conference production value and the number of people participating! It was a pleasure to meet with a diverse group of delegates from different professional fields across the globe. We were able to share personal experiences, discuss typical research mistakes and exchange knowledge about improving global health. One of the most memorable highlights was meeting with leading academics, including Dr Michael Moore, President of the World Federation of Public Health Associations (WFPHA) and the CEO of Public Health Association of Australia. Not only did he inspire me with his persistence and belief in research but he also expanded my vision for certain health issues with different perspectives. Ultimately, WCPH was a life-changing conference. I was delighted to achieve my dream at such an early stage of my research career, presenting formally at one of the biggest international conferences. WCPH has certainly reignited my unwavering passion for public health research despite all the challenges. It has given me an opportunity to engage, learn and foster ideas with many like-minded individuals. Although funding is not always available for research students, conferences like WCPH are worth the cost! As Mr Greg Hunt, MP, stated at the opening ceremony, we need more frontier researchers to contribute to and enhance quality of life. We, as tomorrow’s researchers, ought to raise our voices to develop a comprehensive vision to take action and improve global health nationally and globally. Acknowledgements

Sydney University Postgraduate Representative Association (Michael Wu) Royal Australasian College of Physicians (RACP) (Ka Man Li)

Photo Credit Helena Qian, Michael Wu, Michael Au, Ka Man Li Conflicts of interest None declared Correspondance helena.qian@uon.edu.au References

1. WCPH About [Internet] Retrieved on 28th August 2017; Last Updated 2017. Available from: http://www.wcph2017.com/about.php 2. WCPH Program Handbook. Proceedings of the World Congress of Public Health; 2017 Apr 3-7; Melbourne, AU. 2017. 3. John Snow Scholarship Information website [Internet] Retrieved on 10th September 2017; Last Updated 2017. Available from: https://www.racp.edu.au/about/racp-foundation-awards/ division-faculty-chapter-regional-awards/australasian-faculty-ofpublic-health-medicine/john-snow-scholarship

Welfare cuts to refugees, AMSA Global Health Crossing Borders National Managers [Commentary] Sibella Breidahl and Jasmin Sekhon Crossing Borders For Health is AMSA Global Health’s project that aims to advocate for refugees and people seeking asylum. With arms covering Education, Advocacy and Projects we aim to give students a functional understand of the refugee crisis, with a focus on the Australian context, as well as contributing to the advocacy based around creating a fair and fast processing system for people seeking asylum in Australia. Jasmin and Sib are Crossing Border’s 2017 National Project Managers

We live in a society founded on the values of fairness, reciprocity and freedom. Whether you call it a scallop or a potato cake, you’re a millennial or older than Phillip Ruddock, across lines of politics and race, these values hold true.

considering the question of refugees?

Many social and economic factors inform the health and wellbeing of humans. Housing insecurity, job hunting, lack of access to proper medical care, limited education pathways, lack of transport. These things pile up. Not only do refugees face these stresses with no supportive We would all like to think that in our moment of community or family, but also after years need we would be supported by our of trying to get to Australia, often fleeing community. Daily across Facebook and We are great at jumping into horrific wars, genocides and famines.[2] the media, there are countless examples of people proudly going above and action when people need At the time of their greatest need, the beyond for members of their community, help. Why then, are Australians government resolves that the best thing even for complete strangers. The so happy to eschew these to do it to lock them up and throw away #sofaforlondon movement in the wake values when considering the the key. of the London Bridge attack earlier this question of refugees? The government decided in late year is a perfect example of this. People August to cut welfare payments to 100 posted on social media offering beds of the 400 people seeking asylum in Australia that have (and salt and vinegar chips) to strangers who were left come to the mainland from regional processing centres stranded in the attacks.[1] Examples of this exist at for medical treatment.[3] They plan to extend the cuts to home as well, like the overwhelming response after the the other 300 people in this group in the coming months, Victorian bushfires in the last decade. We are great at including pregnant women, 37 babies and 90 children jumping into action when people need help. Why then, who attend school in Australia. This means they will stop are Australians so happy to eschew these values when 50

receiving the paltry $200 a fortnight they have to support their family, and will also be kicked out of supported accommodation. With a name that would not be out of place in an Orwell novel, the “Final Departure bridging E visa” which stipulates these conditions, was given to 100 people with no notice.

It is deeply concerning that post-arrival factors have a worse impact on the outcomes for children seeking asylum, than the trauma of the wartorn countries they come from

As a young, qualified person with an acceptable grasp of the English Language and a good knowledge of the workings of Australian society, I know how hard it can be to find a job. These people who have been transferred to Australia for serious medical illness must find a way to support themselves in just three weeks, with the possibility of being deported at any time, a prospect sure to turn off any employer. To add insult to injury, the government has also stuck by its policy that those over 18 years old cannot access education or training programs, giving them even less opportunity to find jobs. This has huge implications for those at school. Why bother applying yourself and working hard, just to be barred from further education and face a desperate future? Being transferred to Australia in the first place is no mean feat, as we have seen in several cases, such of that of Hamid Kazhei, who died on Manus Island of sepsis from a cut in his foot because the government would not transfer him to the mainland to get the attention he needed. Or the multiple pregnant mothers with preeclampsia who have been refused transfer and have no access to obstetric care. This shows that the group in question who did make it to Australia are extraordinarily resilient and are in genuine need of care. There is strong evidence to show that reduction in funding for welfare has major effects on the health of newcomers. Eroding economic and social conditions negatively impacts on health by reducing access to healthcare, deterioration in mental health and increases domestic violence. [4] The government has already made people seeking asylum vulnerable, through damaging policies that incorporate unnecessarily long processing times, keep people in detention under inhospitable conditions, offer few options for family reunification, deny full work rights and withhold social services. This new policy will further exacerbate the disadvantage that these people currently endure.

It is deeply concerning that post-arrival factors have a worse impact on the outcomes for children seeking asylum, than the trauma of the war-torn countries they come from.[1] A recent study published in the Journal of Paediatrics and Child Health showed that childrens’ environment after arriving in Australia had more impact on their physical health and wellbeing than the process of getting to Australia and the traumas they experienced before arriving.[5] Irresponsible policies like the recent welfare cuts contribute strongly to this observation. The government even went as far as threatening children in their letter about the Bridging E visa, writing to parents “Please remind your children that they will also be required to abide by Australian values and laws. Breaking Australian laws may result in their removal from the community.”[3]

Refugees and people seeking asylum are starting from a point of compromise. It is our obligation as a caring community that values equity to springboard them into starting their lives in Australia The Government is pushing the financial burden to support asylum seekers on community and not-for-profit organisations, straining their already limited resources. Refugees and people seeking asylum are starting from a point of compromise. It is our obligation as a caring community that values equity to springboard them into starting their lives in Australia, rather than holding them back or providing a flimsy safety net. It’s time to say enough is enough and stop them bullying the most vulnerable members of our society. Conflicts of interes None declared Correspondance jasmin.sekhon@amsa.org.au sibella.harebreidahl@amsa.org.au References

1. The Guardian staff and Press Association (2017). #sofaforlondon: residents open their doors in wake of London Bridge attack. The Guardian. 2. Marmot, M., Wilkinson R. (2003). Social Determinants of Health, The Solid Facts. [online] The World Health Organisation. Available at: https://books.google.com.au/

Start where you are, use what you have, do what you can

Adelaide Global Health Conference 2017 Closing Address AMSA Global Health Chair 2017 Liz Bennett

Good afternoon, wonderful GHC delegates. Iâ&#x20AC;&#x2122;m Liz, the Chair of AMSA Global Health and a final year medical student at Flinders. As some of you would have heard yesterday, my experiences in global health have taken me from Adelaide, to Tennant Creek, to Oxford, to Geneva, and to Tanzania, but GHC has always held a special place in my heart and attending my first GHC was one of the first steps on my global health journey. I wanted to start by taking some time to reflect on my time with AMSA Global Health this year. AMSA Global Health is a team of 22 people from around the country who work year round to advocate for, represent and educate medical students like you on global health issues. We focus on refugee and asylum seeker health, climate health, sexual and reproductive health and most recently non-communicable diseases. There have been so many incredible moments this year, from watching Sib, one of our Crossing Borders For Health National Project managers, shine in her first radio interview on refugee and asylum seeker health; to watching Georgia, our Vice Chair Operations seamlessly put the Council agenda together; to reading the amazing divestment action plan for AMSA put together by the

Code Green National Project Managers, the Belles; to seeing Carrie publish the first copy of Vector, our student written, peer-reviewed global health journal, in two years and then watch her guard the hard, print copies with her life! Iâ&#x20AC;&#x2122;ve participated in AMSA Global Health meetings from Byron Bay, from Alice Springs, Darwin, Geneva and most recently using dodgy airport internet in Tanzania, and every single one has been a joy. I would like to thank my AMSA Global Health team for all of the amazing work they have done this year. It has been a privilege to work with each and everyone one of you and it has been incredible to watch your passion grow into tangible products that have benefited so many. At GHC, we are given the chance to learn how phenomenal and passionate individuals - who are often our idols - are making change. We are inspired, challenged and empowered to then go forth and change ourselves. I still remember sitting in plenary hall in Hobart at my first GHC in 2013, listening to Julian Burnside talk about his work in refugee and asylum seeker advocacy. It was one of the first times I actually heard about the impacts of immigration detention and I started crying because I had never heard someone speak so candidly

about its devastating mental health effects. I could not believe that this was happening in our country and that our government was knowingly subjecting vulnerable people to institutionalised torture. After a small period of feeling hopeless, I began to get angry. It was this seed of anger that has fuelled my passion for health inequalities more broadly since then and I think this is a reason why I am up here today.

But it is not enough to be inspired. There is too much to be done. We do not have the luxury of apathy and you cannot afford to waste time thinking that you are too small to make a difference. However, if you had told me then that four years from now, I would have been able to learn about global health research with the George Institute in Oxford, I would have been fortunate enough to spend 6 weeks being inspired by global health babe, Sandro Demaio at the WHO in Geneva, and that I would eventually publish an article with Julian Burnside in the Lancet calling for immediate action on refugee and asylum seeker health, I would not have believed you. But it all started at GHC.

have the luxury of apathy and you cannot afford to waste time thinking that you are too small to make a difference. I encourage all of you to leave here and be productive with the seed of inspiration that has been planted this week. Continue to challenge yourself to make change and always foster inquisitiveness and love of global health. Ensure that you it, watch it grow and share its fruit with those around you. This might be something as simple as starting a conversation with someone using some of the knowledge you gained, it could be putting pen to paper and recording your ideas to share with others, it could be joining a local advocacy group doing great work that you are passionate about in your community, or it could be joining an organisation like AMSA Global Health. Start where you are, use what you have and do what you can. Photo credit Karl Asmussen, Vienna Tran Correspondance liz.bennett@amsa.org.au

And so I would to thank Holly and her amazing team for this fantastic event. Since that first GHC in Hobart, this conference has gone from strength to strength and it would not be possible without individuals like you. This conference has given us the ability to challenge ourselves in many different areas. We have been provided with an opportunity to realise our strengths, as well as our faults and imperfections. But it is not enough to be inspired. There is too much to be done. We do not 53

Where to now?

Vector Journal & GHC Writing Competition Helena Qian Helena is a 3rd year medical student at the University of Newcastle with a keen interest in improving global health and aiding underserved communities. She hopes to work with WHO and MSF in the future as a collaborative researcher, advocate, field doctor and volunteer. What: “We are resolved to free the human race within this generation from the tyranny of poverty and want, and to heal and secure our planet for the present and for future generations.” – The 2030 Agenda for Sustainable Development Society is at a critical juncture in world history whereby a fragile balance exists between global health, effects of modern-life, social constructs, politics and economy.[1] The 2003 SARS epidemic encapsulates how unprecedented population growth and adverse living conditions have facilitated cross-species shift of organisms.[1] Despite incredible medical advances, our exponential increase in knowledge has not matched public health progress as seen with the re-emergence of polio in conflict-affected areas.[2]

Why: “If we see injustice, why can’t we make a change right now?” – Mr Kon Karapanagiotidis GHC 2017 From conversing with Dr Stewart Condon, poor application of knowledge due to differing political/ financial agendas have largely been to blame. These stem from a failure of stakeholders/society to appreciate the ‘complex links between social and economic aspects’ [1] of disease and address health at a world-population level. Contrary to popular belief, there is no shortage of resources to improve global health,[3] only a lack of moral imagination and political will to change long-standing, inefficient healthcare systems and implement strategies to broaden attitudes towards health.

Where to now? “The world is coming to recognise more and more that problems in one country reverberate in another...this is why it is so important to make the most of our collective strengths.” - Ban Ki Moon

As privileged medical students with access to platforms that engage our community, we can challenge the complacency of those who don’t fully comprehend the magnitude of impact every individual has on others less fortunate. As future doctors, we should endeavour to couple excellent care of individual patients to public health programs that more efficiently disseminates information and healthcare. Although the way forward is challenging, it’s not impossible with positive steps such as the creation of the Coalition for Epidemic Preparedness Innovations (CEPI) aiming to efficiently develop new vaccines to prevent epidemics.

“It is because it is so dark that we need to burn the brightest right now.”- Mr Kon Karapanagiotidis GHC 2017 Conflicts of Interest None declared Correspondance helena.qian@uon.edu.au References

1. Solomon R Benatar Global Health: Where to Now? Retrieved 2017, August 19; Last Updated Unknown; Global Health Governance, 2009;11;2 Available from: <http://www.ghgj. org/Benatar_Global%20Health.pdf> 2. Akil L, Ahmad HA. The recent outbreaks and reemergence of poliovirus in war and conflict-affected areas. Retrieved 2017, August 19; Last Updated 2016; International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases. 2016;49:40-46. doi:10.1016/j.ijid.2016.05.025. 3. Benatar, Daar, and Singer, “Global health ethics: the rationale for mutual caring”; Benatar, Gill and Bakker, “Making progress in global health: the need for new paradigms.” Retrieved 2017, August 21; Last Updated Unknown

Moving forward, societal introspection are shifting from a narrow, monetised view of global health to a multifaceted appreciation for an interdependent world that can drive forces for change. Greater emphasis should be placed on collaboration to address health inequalities and social determinants of health. 54

A Walk to Remember [Book review] Anna Marie Plant Anna Marie Plant is a Medical student at the University of Sydney with a strong interest in Global Health. She wishes to pursue a career in surgery with a humanitarian focus and work for an organisation such as Médecins Sans Frontières (MSF) to address the global shortage of safe surgical care, especially in orthopaedics and trauma. Walking Free by A/Prof Munjed Al Muderis with Patrick Weaver. p 336. Allen & Unwin. $22.99

Despite our common motivations and dedication to learning, the journey of each medical student is unique. Despite managing intense study loads, we probably cannot imagine the added stress of living under a brutal dictatorship, as was the experience of Associate Professor Munjed Al Muderis. He began his Medical studies at Basra University in southern Iraq, near the Kuwaiti border that former Iraqi President Saddam Hussein’s forces had invaded a month prior. It was clear from the outset that A/Prof Al Muderis’ journey was never going to be straightforward.

awoken the following morning to the sound of planes overhead and explosions nearby; it was the 17th of January 1991 and the commencement of Operation Desert Storm. After he tended to civilian casualties at his teaching hospital, he made the journey along the war-ravaged Western highway, and passed the Imam Ali Air Base that was under active airstrikes by the US-led coalition, to Baghdad. Al Muderis’ gripping vignette ensures that one will never again complain about long flights or drives to visit family. Fast forward and the young Dr Al Muderis found himself in one of the worst imaginable situations: he had to choose between honouring the Hippocratic Oath by refusing to remove the ears of army deserters, or facing death at the hands of Saddam’s military police. For most of us this is a nightmare situation but sadly it is the reality for some healthcare workers in unstable geopolitical environments.

“the young Dr Al Muderis found himself in one of the worst imaginable situations: he had to choose between honouring the Hippocratic Oath by refusing to remove the ears of army deserters, or facing death at the hands of Saddam’s military police” Midway through his first year of medical school, his parents called one evening and implored him to return home to safety. He was

After the journey to Australia, his stay in Curtin Detention Centre would prove another

major hurdle. As detainee 982 (names were replaced by numbers), his experience was the rule, not the exception: extended periods of solitary confinement, a general lack of privacy, and navigating the complex web of rumours and tensions that a confined environment instigated between detainees. Detainees were constantly reminded that their stay was indefinite and they may never be resettled in Australia, but could return to their country of origin at any time.

Al Muderis has presented the events of his life as actions and reactions, rather than delving into whether his experiences had any long term psychological toll, however in writing your own story you afford to keep some cards close to your chest. Walking Free is the journey of someone who achieved their dreams against the odds of complex, challenging and evolving geopolitical circumstances. It gives a face and story to those on the other side of the fence:

“Al Muderis has presented the events of his life as actions and reactions, rather than delving into whether his experiences had any long term psychological toll” The story only briefly covered Al Muderis’ rise through the medical ranks in Australia, most likely because the day-to-day experiences of surgical training are seemingly mundane in comparison to the preceding journey. Nevertheless, a more in-depth discussion of his pioneering use of osseointegration surgery in Australia would have been appreciated. Despite the seemingly unbelievable events of Walking Free, there are some commonalities about life that hold true irrespective of personal context. Marriage and a newborn child midway through medical school was never an easy undertaking but religious differences and constant interference from both families may ensure any union is doomed. There is the sobering reminder that a bond and later marriage forged through a treacherous boat journey and stay in detention could be broken by the strain of long working hours and constant relocations associated with a surgical career. My favourite anecdotes involve the savviness of Mrs Al Muderis. She managed the family finances during wartime and economic sanctions, she provided USD $22 000 in cash to her son upon hearing his need to flee during a time in which owning US dollars in Iraqi banks was prohibited, and organised legal representation during his stay in Australian detention centres. When family is involved, mothers will always find a way.

locked up, anonymous individuals only seen in glimpses of news reports as the ‘dangerous other’; individuals that are every bit as human as us, but who have been dealt a very different hand in life. As medical students, it can be easy to become entangled in the inevitable drama and competition that surrounds us, and lose sight of why we are pursuing this goal. Walking Free is a humbling reminder that everything can change in the blink of an eye and that no matter how tortuous the journey becomes, there is something to be learnt from every step of the way. Conflicts of interest The author of this book review declares that they have no conflict of interest. Correspondance apla9692@uni.sydney.edu.au