Vector: Issue 12 February 2011

vector www.ghn.amsa.org.au

Issue 12 Febuary 2011

The Official Student Publication of the AMSA Global Health Network

the

Millennium Development Goals issue

THANKS TO ALL OUR SPONSORS

contents 4

EDITORIAL

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Reflections on the 63rd UN DPI-NGO Conference

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GLOBAL HEALTH IN THE NEWS: AN UPDATE

Feature articles

12 MDGs not only for Developing Nations 14

Tipping the Scales

18 One Step on a Long Path to Much More 20 The Pains of Labour 26 Nets, Condoms and Drugs 28 Going Environmental 30 Why can’t we just all get along?

32 Global health, Sustainability and Doctors 34 Student Selective - Welcome to Samoa 36 Global Health Conference 2010 Report

a Window into Global Health A series of powerful photos that visualise and encapsulate the MDGs

Vector: The Official Student Publication of the AMSA Global Health Network GHN Publicity Officer Alyssa Fitzpatrick Editor in Chief Saion Chatterjee Co Editors Maheshie Dayawansa Katherine O’Shea Design & Layout Annjaleen (Anjie) Hansa Web master Rungrueng (Tommy) Kovitwanichkanont

Editorial enquiries:

Email vectormag@gmail.com GHN enquiries: ghn.publicity@gmail.com

or visit www.ghn.amsa.org.au We welcome your written submissions, letters and photos on any global health issue or topic.

Please limit submissions to 500 words or less.

Cover Photography Hiep Pham Graphics Ralph Bergmann

s a i o n chatterjee editor in chief

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m o n a s h university

young child in Ethiopia aspires to become a doctor, engineer, or teacher one day. She dreams of earning an income, owning a house and providing her children with a life she could never have. But this seems like a futile dream. Her family is unable to provide her with an education, as school fees would consume more than one quarter of her family’s income. Despite her parents’ wholehearted efforts to send her to school, the reality of their situation means that she will be entrenched in the perpetual cycle that has encompassed her family;

countries of Sub-Saharan Africa and Southern Asia.

Education has been identified by experts as the most sustainable and expeditious means of economic and social development and to alleviate poverty. With education, employment opportunities are broadened, income levels are increased and maternal and child health is improved.

Countries such as Burundi, the Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Malawi, Mozambique, Tanzania and Uganda have abolished school fees, which has led to a surge in enrolment: in Ghana, for example, public school enrolment in the most deprived districts and nationwide soared from 4.2 million to 5.4 million between 2004 and 20051.

In Kenya, enrolment of primary school children increased dramatically with 1.2 million extra children in school in 2003 alone; by 2004, the number had climbed to 7.2 million, of which 84 percent were of primary school age1. Despite this, the 2nd goal is not on course to reach its target of universal primary education by 2015. Currently, 56 million children could still be out of school in 2015 and girls will still lag behind boys in school enrolment and attendance2.

editorial a nomadic life underpinned by the daily struggle to survive.

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On the other side of town, another child can no longer endure the darkness, waiting for daylight to arrive so she can get ready for school. She lives in a small one room abode, abutted by replicas of her home. Her mother leaves early in the morning to work in the mill and returns in the late hours of night. The child must cook and clean for herself, and make the arduous journey to school every day.

School for her, however, is a secure and nurturing setting, where she can come early and often stay late, and is lovingly equipped with the tools to lead a better life by her teachers.

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Education in Sub-Saharan Africa has prevailed as a ray of hope, in the midst of proliferating political warfare, and the truculence of disease and inequality.

The 2nd Millennium Development Goal - to ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling - has been a key focus in the

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As the 63rd UN DPI-NGO conference occurred in Melbourne late last year, with a large medical student contingent from around Australia putting in their two cents, this issue canvasses the progress and potential pitfalls concerning the Millennium Development Goals (MDGs). The MDGS are a series of resolutions setting a hard target of 2015 to achieve a range of specific quality-of-life benchmarks agreed to by 192 countries and 23 international organizations. We can all play our part to ameliorate our globalised world, whether it be through grass roots action, supporting non-governmental organisations though activism and participation, or influencing health care in developing nations via research and student placements. Medical students must show leadership when it comes to issues such as universal primary education, as factors like this will play an unprecedented role in the burden of disease and quality of life people face, particularly in developing nations, in the years to come.

1. United Nations Development Programme. Achieve universal primary education (Success stories) [Internet]. 2007 [updated 2007 Nov 1; cited 2010 Aug 7]. Available from: http://www.mdgmonitor.org/story.cfm?goal=2/ 2. UNICEF. Press release [Internet]. 2010 [updated 2010 May 17; cited 2010 Aug 7]. Available from: http://www.unicef. org/media/media_53659.html/

IEVE the M CH

arthur ch eu ng university of queensland

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rom 30th August to 1st September 2010, Melbourne hosted the largest United Nations conference in Australia’s history. It was the third time the UN Department of Public Information Non-Governmental Organisation (UN DPI-NGO) Conference was held outside the UN headquarters in New York, and the first time it was held in the Southern Hemisphere.

Medical Students’ Associations, it promised to be a great boost to the level of global health engagement in Australia.

Reflecting on the conference brought mixed feelings.

There is a common belief that we must remain positive about our experiences, to the extent that it makes us uncomfortable to criticise that which needs critique. Regardless, I shall give my honest thoughts on the conference and its proceedings.

There are three main reasons why a productive conference was vital. The first is that while we sat in the Melbourne Convention and Exhibition Centre, people continued to die of preventable causes in the world outside. So any diversion of the attention of the world’s NGO leadership must be for a good reason. The second is that it is extremely rare for such a diverse and comprehensive range of NGOs to come together for the express purpose of

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The theme for the 63rd UN DPI-NGO Conference was global health and achievement of the Millennium Development Goals (MDGs): eradicate extreme poverty and hunger, achieve universal primary education, promote gender equality, reduce child mortality, improve maternal health, combat communicable diseases, ensure environmental sustainability, and access to essential medicines.

With a large contingent of Australian youth in delegations including those from the World Medical Association and the International Federation of

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reflections on the 63rd UN DPI-NGO Conference

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However, I was both dismayed and frustrated at the lack of direction, co-operative spirit, forward movement and learning in the majority of the plenary roundtable discussions. Many delegates distracted the conference with questions and comments that showed a disregard of the topics at hand, the dire nature of the problems we are trying to address, and where their contribution sat within the larger picture of global health efforts as a whole.

To ask a roundtable of world leaders in the MDG campaign to comment on whether the conference should be held with Esperanto as the official language is inappropriate. To ask off-topic predrafted questions merely to practice public speaking or to assert your NGO’s presence at the conference is inappropriate. To have speakers misunderstand the few questions that were on topic due to lack of interpreters is farcical.

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It was great that there were so many new NGOs, youth, and others less experienced in global health at the conference. However, we must let the more experienced NGOs/WHO/UN have productive discussion. Pushing of individual agendas only serves to undermine meaningful discussion of the relevant topics and stall progress on the overall objectives.

If this is the state of world affairs, it seems our generation has a lot to fix.

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idea sharing, collaboration and co-ordination. We therefore must make maximal use of such immense potential to secure the future of our world through successful pursuit of the MDGs, a duty all the more important in light of the UN General Assembly Summit on the MDGs that was held later in 2010.

The third is the many youth who were present at the conference, who hoped to experience an inspirational and informative conference, and to gain a glimpse into the world and NGO community they will inherit.

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To ask a roundtable of world leaders in the MDG campaign to comment on whether the conference should be held with Esperanto as the official language is inappropriate

It should be recognised that perhaps it was a unique set of circumstances that resulted in a less productive UN DPI-NGO conference than is usual.

The uncertain political situation in Australia postelection prevented a number of high-profile UN officials and Australian politicians from attending.

This undoubtedly led to a lack of clear leadership and vision, and a lesser sense of urgency and importance that productive discussion need take place.

So did I regret attending the conference? No. There were undoubtedly some exceptional delegates present, and the conversations which resulted (on topics from the mundane to philosophical, from policy issues ranging from Indigenous health and access to essential medicines to reproductive health education) was undoubtedly of great benefit to the delegates personally, and therefore also to the people their organisations help. The time allowed for networking was certainly a useful insight into the breadth of global health activities, from the Global Alliance for Vaccines and Immunisation, to the work of the Burnet Institute based in Melbourne. The growing recognition that addressing non-communicable diseases and climate change is fundamental to achieving the MDGs is a positive step.

The consistent advocacy for strengthening health systems over running vertical aid programs focussed on specific diseases was great to see. The observation that everyone wants to coordinate, but no one wants

while educating a girl educates a family; the MDGs are donor driven and over-sell the significance of international aid (aid does not progress the MDGs when funds flow to developed-world contractors rather than building local capacity); the MDGs focus on aggregate measures and averages and are poor indicators of equity; the MDGs do not cover all issues important to global health; and prevention is not only better than cure, but is also cheaper.

The MDGs should not be an end-point in and of themselves, but a benchmark for measuring the success of initiatives that develop local capacity.

The MDGs are merely a communication tool used in assessing progress on our commitment to health as a universal human right. It is important to remember that the MDGs are both a moral imperative, and achievable.

What of the MDGs, and our strategy beyond 2015?

A few observations were especially influential: you cannot save the most vulnerable infants and children without first ensuring the health of their mothers; educating a boy educates an individual,

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The point made here is that good process is important to good outcome. Our activities must have clarity of purpose, and strong leadership to steer discussion and ensure we stay on task. Should I be criticised for criticising the conference? As was emphasised at the 6th Annual Nossal Institute for Global Health Forum held immediately after the UN DPI-NGO Conference, evaluation is a crucial aspect of running aid. The appropriate response to a fear of donors withdrawing support due to deficiencies identified by evaluation of aid programmes (or, similarly, voter support for government initiatives) is not to neglect critique.

It is to educate donors that evaluation is vital to improving and following evidence for better practice.

Indeed, improvement, not the outcome per se, should be the framework under which we measure success.

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to be coordinated, is a poignant indictment and call for action. To hear Che Guevara’s daughter speak of the Cuban health and medical education system was inspirational, if not embarrassing when she suggested that Cuba train Indigenous doctors free of charge so that they may return to benefit our communities in Australia. If the plenaries reached that level of discussion, it would be a hugely productive conference indeed!

The observation that everyone wants to coordinate, but no one wants to be coordinated, is a poignant indictment and call for action.

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1. the battle against AIDS The AIDS pandemic is almost 30 years old. Sixty million people have been infected with HIV. However, since the pandemic peaked in 1999, safer-sex education and widespread condom use have brought down the number of new infections by 19 percent, according to a state-ofthe-pandemic report just issued by UNAIDS, the United Nations agency charged with leading the fight against AIDS.

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child health

8

mil

estimated number of children under five who die every year

maternal health

358 , 000

estimated number of women who die each year in pregnancy and childbirth

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HIV/ AIDs

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67%

ear er y nd p s ath -ha 0 de second 1% 0 0 an by 00 an 6 caused more th eaths h t e d Mor ide are this is these f w o d ) l wor e (SHS 165 000 ldren. k i smo deaths. g ch n o m a ll are of a

of HIV infections are in subSaharan Africa

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what’s been

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A new speedier test for tuberculosis has been endorsed by the World Health Organization. The test will shorten diagnosis time from months to a few hours. Currently TB spreads and kills faster than it can be diagnosed.

global health in the news - a quick overview

http://www.good.is/post/which-countries-are-making-the-most-progress-on-the-millenium-development-goals/

Countries around the world are working hard to achieve the Millennium Development Goals (MDGs). The Overseas Development Institute’s Millennium Development Goals Report Card: Measuring Progress Across Countries, recently ranked the countries that have made significant progress on key targets of the first, fourth, and fifth goals. The rankings are in terms of absolute progress toward the targets, meaning that countries that have improved by the largest margins (from first measurement), regardless of initial conditions (and distance from the targets).

4. needle for meningitis ‘Tis the season for meningitis in SubSaharan Africa. Starting December and running through June, the seasonal drought will once again put more than 450 million people across Burkina Faso, Mali, Niger, Chad, Sudan, and Ethiopia at risk of developing meningitis.

But this year, doctors have a new weapon in their fight; a new vaccine that works against the group A meningitis strain that causes more than 8 out of 10 cases on the continent.

Moreover, it costs less than 50 cents a dose.

5. Cancun clinches a climate consensus For the first time the pledges by developing and developed nations to cut pollution have been brought under a UN agreement, despite vigorous opposition from Bolivia.

A multi-billion dollar Green Climate Fund was established for poorer countries to deal with climate change and progress was made on deforestation and clean energy technology.

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h a p p e n i n g

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Goal 1: Eradicate extreme poverty and hunger

photo by

jeremiah stanley vector FEB 2011

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Miguel Angel Leonardo, 6, licks clean a spoonful of Incaparina, a powdered supplement distributed by food-aid organizations to prevent malnutrition in infants and children. Even so, Guatemala has the highest rate of chronic malnutrition in the western hemisphere, and continues to have the highest rate of chronic malnutrition, according to a report from United States Agency for International Development.

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hy should Australia be interested in the Millennium Development Goals (MDGs)?

Despite the fact that focus is indeed on developing nations, Aboriginal & Torres Straight Islander (ATSI) communites have health statistics comparable to poorer countries. So there is much that is relevant especially with our poor track record in improving ATSI health and, not only that, when this country is faced with an unsustainable health system there is much to be learnt from some of the successes of the approach.

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The initiative was launched in September 2000, building upon a decade of major United Nations conferences and summits where world leaders came together at the United Nations Headquarters in New York to adopt the United Nations Millennium Declaration, committing their nations to a new global partnership to reduce extreme poverty. It is important to note the time for planning and gaining a commitment compared to how long this country takes to plan and implement health interventions. A series of time-bound targets were set with a deadline of 2015. Such long term planning and goals are impossible in Australia thanks to our electoral cycle and the short term funding of health projects.

The eight goals were assessed for progress and further resources were allocated to countries that

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were clearly not going to achieve their goals without extra support.

Australia set the National Health Goals and Targets in 19941]. What happened to them? We seemed to have moved to measuring activity leaving the question open as to whether the activity promotes the health of all Australians.

This is the appeal of the MDGs in that they are focussed on populations as opposed to individuals.

This is consistent with the well known aphorism of Dr Geoffrey Rose2, ‘... a preventive measure that brings large benefits to the community offers little to each participating individual.’ In Australia the focus is on the customer with a disease and no cost is spared to bring the benefits of the latest technology to bring a cure or to palliate. This has led to inverse care law being alive and well in that the provision of cutting-edge health services is located where the need is least 3,4.

Many strategies included in the MDG approach are synonymous with the social determinants of health, ten of which were identified by Wilkinson and expatriate Professor Sir Michael Marmot (visit http://www.who.int/social_determinants/en/). He also emphasised the importance more recently of

MDGs not only for

Dr Bret Hart, Head of Public Health Unit , Nort vector FEB 2011

the need for interventions to be proportionate to the degree of disadvantage, and hence applied in some degree to all people, rather than applied solely to the most disadvantaged5.

The impact of comparatively modest interventions can be seen by reviewing some of the strategies employed so far in reaching the MDGs. For example the first goal is to ‘halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day’. Imagine the impact of developing a program that doubles a person’s income to two dollars a day. Now reflect on the difference an extra dollar a day would make to you. This prompts another law to be considered: the law of diminishing returns.

Applied to Australian health the law suggests that the more we reach health actualisation (apologies to Maslow and his hierarchy of needs), the more the cost to achieve a marginal gain in personal health and no improvement in population health - in fact there is the potential for a net loss because of the opportunity cost associated with the provision of boutique health services as opposed to providing basic health care to those who need it most.

Another lesson for us is that when global threats to health become more manifest during this decisive decade, there is the need to emulate the multidimensional approach to ensure that the factors that determine health are enhanced and strengthened. Many of these factors included in the MDGs are summarized in a recent extension of the Dahlgren and Whitehead model to include the environmental influences on health[6,7.

The challenges for health systems across the world are great but, ironically, it is the developed world where the dominance of tertiary services has led to an exponential and unsustainable increase in costs.

Thanks to the MDGs we are likely to see enormous health gains from investing in the determinants of health and in primary health services and hopefully the Australian medical leaders of the future will take note of where they need to focus their efforts to achieve the greatest impact on the health of Australians.

1. National health goals and targets: summary of draft reports. Canberra: Department of Human Services and Health; 1994 2. Rose G. The strategy of preventative medicine. Oxford University Press; 1992.

3. Hart JT. The inverse care law. The Lancet 1971 Feb 27; 1(7696):405-12.

4. O’Dea JF, Kilham RJ. The inverse care law is alive and well in general practice (Editorial). Med J Aust 2002; 177:7879.

5. Health equity: an election manifesto? (Editorial). The Lancet 2010; 375(9714):525.

6. Dahlgren G, Whitehead M. Tackling inequalities: a review of policy initiatives. Tackling inequalities in health: an agenda for action. London: King’s Fund Institute; 1995 7. Barton HAGM. A health map for the local human habitat. J R Soc Promot Health 2006; 126(6): 252-261.

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developing nations

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3

MDG promote gender equality & empower women

Tipping 1. UNDP. Goal 3: promote gender equality and empower women. [Internet] 2010 [updated 2010; cited 2010 November 18]; Available from: http://www. undp.org/mdg/goal3.shtml.

2. UN. The Millennium Development Goals Report. New York; 2010 3. UNSD. Millennium Development Goals: Gender equality and women’s empowerment progress chart 2010. New York; 2010.

4. UNDP. Keeping the promise: united to achieve the Millennium Development Goals. United Nations 2010 MDG Summit; New York.

K E Y FA C TS

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MDG 3 seeks to promote gender equality and empower women. The empowerment of women has been linked to long term financial and social stability in communities across the globe. This is reflected in the 2000 Millennium Declaration, which states that the empowerment of women is an “effective way to combat poverty, hunger and disease and to stimulate development that is truly sustainable1.”

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The achievement of the MDG is reflected in three key indicators, including the ratio of girls to boys in primary, secondary and tertiary education, the proportion of women employed in the non-agricultural sector, and the share of seats held by women in the national parliament1.

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he 2010 MDG Review Summit, held in New York in September, held a spotlight on the progress made towards achieving equality for and the empowerment of women. It provided a chance to reflect on what has been achieved thus far, and the barriers which remain towards achieving the full political, financial and social involvement of women on the world stage.

Equality for women, however, is more than just an end in itself. Kofi Annan, former Secretary-General of the United Nations, stresses that it is a precondition for meeting the challenge of reducing poverty, promoting sustainable development and building good governance.”In short, not much will happen until women have the chance to be equal on the playing field.

Since 2000, documented progress has been made in achieving the third Millennium Development Goal, as reflected in greater gender parity in primary education in some nations. While the greatest advances have been made in Southern Asia, SubSaharan Africa, Western and Northern Africa have also documented improvement in female participation in the education sector1. Sadly, in Oceania, which in conjunction with Sub-Saharan Africa and Western Africa, has the poorest record of gender equity, there has been a slight reduction in parity in enrolment in primary education1. Similarly, the percentage

of women who share in employment in the nonagricultural sector remains at worryingly low levels in many African and South Asian nations2.

Long-held cultural views of the secondary role of women in society provide a major barrier to the active participation of women in educational, financial and employment sectors. Drought, food shortages, conflict, failure to register births, child labour and the rise of HIV/AIDS further cripple progress by impeding school involvement and denying girls the opportunity to gain an education1.

Beyond immediate crises, however, women are unable to achieve equal participation in society in the absence of appropriate infrastructure to

unable to break the cycle of poverty and become active participants in the labour market3. Where women are denied an education, they are unable to make choices about the use of contraception, key to controlling the spread of HIV/AIDS and in enabling women to choose the timing of their children3. And where women are not empowered to become active decision makers, their needs continue to be unheard and unaddressed.

alyssa fitzpatrick

university of adelaide support their ongoing development. For example, in communities where water is not available by pipeline, girls are twice as likely as boys to be required to collect water, completing multiple long-distance trips and sacrificing time that could otherwise be used for education and employment.3 Women’s economic involvement provides a conduit for improved livelihoods for themselves and their families, and improved health and educational opportunities for the children3. Where women are denied ownership and control of resources, they are

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investing in women and girls has a multiplier effect on productivity, effiency and sustained economic growth review summit 2010

The 2010 Review Summit reiterated its commitment to promoting women’s social and economic involvement, stressing that investing in women and girls has a multiplier effect on productivity, efficiency and sustained economic growth” and thus that a focus on women is key to ensuring continued progress and meaningful improvements in quality of life4. The 2010 Review Summit placed an emphasis on the continuing need to target gender equality through the launch of the Gender Equality and Women’s Empowerment Progress Chart. Highlighting the promising increase in aid directed at improving parity in women’s involvement in recent years, it nonetheless called for further contributions to address this core concern3. However, the Summit also emphasised the need to ensure good sanitation and nutrition, and to combat HIV/AIDS, to facilitate women’s empowerment. It additionally reiterated the reciprocal dependency of achieving MDG 3 and realisation of the other core targets embodied in the Millennium Development Goals to achieve improvements in quality of life for all. At the heart of it, however, is the deep understanding that without equal opportunity for women, there will be continued barriers to achieving long-lasting and meaningful development.

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Goal 4: Reduce child mortality rate

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Reducing child mortality is not as simple as increasing immunisation rates. A burn like this one can mean a life of disability, and increased susceptibility to other diseases. It's important to recognise the importance that rehabilitation also plays in helping those children who have suffered a serious illness or injury to remain free of further problems.

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Zhi Lin Kang

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4

MDG reduce child mortality

ONEStep on a long path university of melbourne

towards much

T

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he story of what is today global or international child health had its beginnings in the aftermath of the violence of World War II. Much as the War abolished and redefined borders, the boundaries of responsibility for the world’s children were to progressively expand. The United Nations International Children’s Emergency Fund (UNICEF) was created in 1946 by the United Nations General Assembly to provide relief to children affected by World War II; and this heralded an approach that called for international collaboration to improve the health of children.

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The 4th Millennium Development Goal, to reduce the rate of child deaths (expressed as deaths per 1000 live births) in each country by 2/3 of what it was in 1990 by 2015, is a continuation of approaches adopted over the last three decades. The idea is that most child deaths are preventable. Despite advancement in the science of medicine, pharmaceuticals and technology, the major killers of children are still pneumonia, malaria, malnutrition, diarrhoeal diseases, and complications of birth or infections of the newborn. In the 1980s, UNICEF introduced the GOBI initiative, focussing on trying to ensure every child has their basic needs of medical care.

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G OB I i n i t i a t ive ( 19 8 o ) : • growth monitored • oral rehydration solution access if diarrhoeal disease occurs • breast feeding • immunisation

This had remarkable results, and emphasised an important lesson: what needs to be done is already known, and the majority of child deaths can be averted by focussing on a few simple, highly effective interventions, and doing them well.

It would be simplistic to assume that MDG 4 is sufficient for improving child health. We know that health is much more than preventing deaths.

Children need a safe environment to prosper in, a future and the chance to become what they aspire to, without being hindered by race, gender or place of birth. If we achieve MDG 4 – which would be the case for most countries in Latin America and some countries in South East Asia – that would be encouraging, but still not enough.

Today, the greatest determinant of a child’s future is the country they are born in. Addressing this inequity requires more than reducing death rates.

it can target high density areas, and neglect scattered rural communities.

Such details will never be reflected by one national figure for child mortality.

The Millennium Development Goals are a remarkable step forward. But we do need to be cognisant of their constraints. What is the problem with focussing on reducing national death rates? The most obvious problem is data. Most developing countries do not have vital registration systems, i.e., no population records of births and deaths. Therefore, indicators, like child mortality, are calculated using indirect methods, such as surveying a representative sample (much like political opinion polls).

The inaccuracies in these methods are obvious when we compare mortality rate estimates from say WHO and UNICEF, which can be significantly different depending on the methods used to derive the estimate.

There is much to be hopeful about.

For one, the annual number of child deaths has dropped from 12.5 million in 1990 to 8 million in 2009. We are in an era of increasing global awareness to the plight of people in every corner of the globe, and increasing interest by health professionals in engaging in global health. The science of just how to reduce child deaths, support the development of health systems and work towards health is gradually improving. However, it is important to always emphasise that MDG 4 is the right step on a long path towards much more.

annual number of child deaths has dropped from 12.5 million in 1990 to 8 million in 2009

1.UN. Summit on the Millennium Development Goals. [Online]. 2010 [accessed 1st November 2010]. Available from: URL http://www.un.org/millenniumgoals/ 2.UNICEF. The State of the World’s Children. New York: United Nations Children’s Fund; 1984 3.UNICEF. Progress for children: MDG4. [Online]. 2007 [accessed 1st November 2010].

Available from: URL:http://www.unicef.org/progressforchildren/2007n6/index_41799. html 4.You D, Jones G, Hill K, Wardlaw T, Chopra M. Levels and trends in child mortality, 1990-2009. The Lancet. 2010; 376(9745):931-33

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The more worrying problem is equity.

Within every society, there are the rich and poor; the privileged and underserved. But within the under-served, there is a continuum. A country can reduce its mortality rates by targeting a large population of marginally disadvantaged groups, neglecting smaller populations of extremely disadvantaged minority groups. Or

And then there is sustainability, and the effect that global support for particular areas can have on the health system. Generous external donors can identify HIV and malaria as a problem, and fund initiatives to address these at a scale that engulfs other ongoing health programs. And hence, the bigger picture can become clouded with multiple, well funded diseasespecific programs that are highly dependent on external support and management.

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MDG improve maternal health

K E Y FA C TS MDG 5 focuses on maternal health and has two targets. The first is to reduce by 他 between 1990 and 2015 the Maternal Mortality Ratio (MMR), defined as the number of deaths of women who are pregnant, giving birth, or up to 42 days postpartum, per 100,000 live births1. The second is to achieve universal access to reproductive health care.

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the Pains of Labour 20

samantha sundercombet

university of sydney

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MDG5 is the worst performing MDG2. Since 1980, the world MMR has declined 1.3 percent (CI 1.0-1.5) annually to 251 deaths/100,000 live births in 20083.

Similarly, there has been a 1.5 percent annual decline in the gross number of deaths, from 526,300 to 342 900 (CI 302 100-394 300)3. These figures are smaller than the 3 percent annual decline necessary to meet the MDG5 target between 1990 and 2015.

Over half the maternal deaths in 2008 occurred in just 6 countries: India, Nigeria, Pakistan, Afghanistan, Ethiopia and the Democratic Republic of the Congo. Afghanistan has the highest MMR, at 1575/100,0003]. For comparison, Australia’s MMR is 5/100,0003.

Maternal mortality progress from 1980-20083

Reasons for high maternal mortality: The most common immediate causes of maternal death are post-partum haemorrhage, sepsis, hypertensive disorders, unsafe abortion, and obstructed labour4. The majority of deaths occur around labour, delivery, and 5-48 hours post-partum5.

Broader socio-economic factors contributing to maternal deaths include poverty6, which is improving2, disempowerment of women, and HIV3, 5.

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Progress to date:

MDG 5 is the worst performing millenium development goal

World Global Monitoring Report 2010

Access to modern contraception is an effective primary prevention strategy against unsafe abortion, which causes 8 maternal deaths an hour[9, and maternal mortality generally 10. Modern contraceptive use has increased in all regions11], however remains so low that 76 million unintended pregnancies occur each year12: 41 percent of pregnancies globally are unwanted and 22 percent result in induced abortion13.

Access to safe, legal abortion has been shown to reduce abortion mortality10.

In India, a scheme where women are given cash incentives to deliver their babies at health facilities has increased the number of in-facility births14. If adopted globally, this scheme could reduce maternal deaths due to poverty.

Women are gradually becoming more empowered.

Girls were attending primary school at the same rate as boys in almost 2/3 of developing countries by 20052]. Educated women marry later, have greater decision-making power in households, and have fewer, healthier and better-nourished children15.

Furthermore, more women than before are able to earn income through access to small business loans, known as microfinance.

Maternal mortality progress from 1980-20083

Solutions:

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Ensuring access to skilled attendance at delivery, and emergency obstetric care for birth complications, can potentially prevent 250,000 maternal deaths per year7. A strategy where women deliver their children in a health facility attended by midwives, with other attendants such as doctors available if complications arise, is the ‘best bet’ for reducing maternal mortality8.

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Results from the UN MDG summit: At the UN MDG Summit 20-22 September 2010 the Global Strategy for Women’s and Children’s Health was launched16. This document encourages governments, NGOs, universities, health workers, philanthropists and business partners to join forces to integrate and scale-up interventions and services proven to work. It emphasizes supporting country-led health plans, delivering packages of integrated care and building capacity in health workforces.

More investment is needed to meet MDG5 - US 26 billion dollars in 2011. More than 40 million dollars was pledged at the summit. If implemented successfully, the strategy will provide access to modern contraception for 43 million more women, and enable 19 million more women to deliver their children safely, with a skilled birth attendant by 2015.

This will prevent 33 million unwanted pregnancies, and save 570,000 women who would have otherwise died of birth or pregnancy complications.

The 6 countries in which half the maternal deaths in 2008 occurred, with number of national maternal deaths (in 1000s)3

68.3% 15.4% 18.2% 36.7% 20%

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20.1%

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[1.] United Nations General Assembly. United Nations Millennium Declaration. A/RES/55/2. New York: United Nations, 2000 [2.] World Bank. Global Monitoring Report 2010. The MDGs after the Crisis. Available: http://web.worldbank.org/ WBSITE/EXTERNAL/EXTDEC/EXTGLOBALMONITOR/EXTGLOMONREP2010/0,,contentMDK:22529228~pagePK:64 168445~piPK:64168309~theSitePK:6911226,00.html [3.] Hogan MC, Foreman JK, Naghavi M, Ahn SY, Wang M, Makela SM et al. Maternal mortality for 181 countries, 19802008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010; 375:1609-1623 [4.] Potts M, Hemmerling A. The worldwide burden of postpartum haemorrhage: Policy development where inaction is lethal. Int J of Gyn and Obst. 2006; 94(2):S116-S121 [5.] Ronsmans C, Graham WJ. Maternal mortality: who when, where and why. Lancet. 2006; 368: 1189-1200 [6. World Health Organisation statistical information system. World Health Statistics 2008. Available: http://www. who.int/whosis/whostat/2008/en/index.html [7.] Save the Children. Women on the front lines of health care: state of the world’s mothers 2010. 2010 IS BN 1-88839322-X [8.] Campbell OR, Graham WJ. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006; 368:1284-1299

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[9.] Singh S, Wulf D, Hussaid R, Bankole A, Sedgh G. Abortion worldwide: a decade of uneven progress. New York: Guttmacher Institute. 2009 [10.] Haddad LB, Nour NM. Unsafe abortion: unnecessary maternal mortality. Rev Obst and Gyn. 2009; 2(2): 122-126 [11.] United Nations. The Millennium Development Goals Report 2010. Available: http://www.un.org/millenniumgoals/ pdf/MDG%20Report%202010%20En%20r15%20-low%20res%2020100615%20-.pdf [12.] United Nations Population Fund. State of the World Population on Climate Change, Population, and Women. 2009.

Cited in Save the Children. State of the World’s Mothers Report 2010.

[13.] The Alan Guttmacher Institute. Sharing responsibility women, society and abortion worldwide. New York. 1999.

Cited in Campbell and Graham 2006 [14.] Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India’s Janani Suraksha Yojana, a conditional cash transfer programme to increase births in health facilities: an impact evaluation. Lancet. 2010; 375:2009-23 [15.] UNESCO. Reaching the Marginalised: EFA Global Monitoring Report. 2010 [16.] UN Secretary General Ban Ki Moon. Global Strategy for Women’s and Children’s Health. 2010. Available: http:// www.who.int/pmnch/topics/maternal/20100914_gswch_en.pdf

aWindowintoGlobalHealth

Goal 3: Empowering women and promoting gender equality photo by

sophie white

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Empowering women means ensuring they have the same opportunities in education, employment and politics as do their male counterparts. It means giving them a voice.

In Bangladesh, the Female Secondary School Stipend programme has provided money directly to girls and their families to cover tuition and other costs, ensuring many more girls bear the radiant smile of this lady.

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Goal 6: Combat HIV/AIDS, malaria, and other diseases The sheer number of people in this picture is a powerful reminder of the difficulties of controlling communicable diseases.

In India, tuberculosis kills an estimated 330,000 people per year, but there is hope! Since 1997, the Revised National Tuberculosis Control Programme has provided treatment to more than 11 million patients and saved more than two million lives.

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6

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MDG combat HIV/AIDS, malaria and other diseases

p to 2 million people die from AIDS related illnesses every year, many of whom are in southern Africa (38%). Increased access to antiretroviral drugs in poorer countries means this is decreasing; however over 5,000 people still die each day from AIDS. Running a close second in global mortality is tuberculosis, responsible for 1.8 million deaths in 2008, about 500,000 of whom were HIVpositive. 90 per cent of malaria deaths also occur in Africa, where it accounts for a fifth of childhood mortality (equivalent to the death of one child in the world every 45 seconds)1-3. []

Challenges to achieving the targets

1

Education and knowledge of HIV is unacceptably low Knowledge about HIV and its modes of transmission is the first step to preventing its spread. However, less than a third of young men and one fifth of young women in developing countries have received education about the illness. Condom use also remains low globally, especially among developing countries.

With many young people in Africa unaware of the risks and modes of transmission for HIV, the UN’s goal on comprehensive HIV knowledge of 95 per cent of people in developing countries is still far from being achieved1,2,4. []

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Antiretroviral treatment has expanded but HIV prevalence rates continue to rise When antiretroviral therapy was launched in 2003, only 400,000 people were able to access it. By the end of 2009, more than five million people were receiving treatment. However, for every two people starting HIV treatment each year, five new people are infected. Access to antiretroviral therapy needs to be expanded for pregnant women, as most of the 2 million children younger than 15 living with HIV were infected by vertical transmission (in the womb, at birth or via breastfeeding). In 2008 alone, over 60,000 HIV infections among at-risk babies were prevented because their HIV-positive mothers received treatment. However, less than 50 per cent of HIV-positive expectant mothers currently receive treatment 1,2,5,6. []

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HIV/AIDS is becoming a chronic disease in many countries The survival rate of HIV/AIDS is growing in many countries due to the increasing availability of antiretroviral drugs in the developing world. As a result, HIV/AIDS is being transformed into a chronic disease, with a model of care that also needs to transform to focus on multidisciplinary models, continuity of care, long-term adherence support, and social support 1,4,7. []

HIV/AIDS may not just affect poorer populations Contrary to evidence for other infectious diseases, HIV may be more prevalent amongst higher-income demographic populations than previously thought.

In a large study looking at eight African countries, wealthier men and women had a higher prevalence of HIV than poorer ones and were at least as likely as poorer adults to be infected. If this is in fact a common pattern, a broader approach needs to be taken in the prevention of HIV/AIDS in developing countries 8. []

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What is being done worldwide?

The UN is coordinating global efforts to achieve these targets in reducing communicable and largely preventable deaths. Several UN programs aim to prevent these diseases and enhance access of treatments according to the following strategies:

•Increase technical support for HIV/AIDS • The Joint United Nations Programme on HIV/ AIDS (UNAIDS) coordinates the resources of ten organisations assisting developing countries with technical support in the implementation of their national AIDS plans[1.]

•Prevent mother-to-child transmission of HIV/AIDS • The UN Children’s Fund (UNICEF), the World Health Organisation (WHO), the UN Population Fund (UNFPA) and UNAIDS have assisted countries to develop and implement programmes aimed at preventing vertical transmission of HIV, including training, funding and technical expertise[1,2.]

SNAPSHOT

33 million people are currently living with HIV worldwide. Two thirds of these are in Africa (mostly women) and this number continues to grow, despite a decrease in new infections (as those infected with HIV are now surviving longer).

There are also 11 million people currently suffering from tuberculosis, and a staggering 240 million cases of reported malaria in 20081,2.

nets condoms & drugs minh nguyen flinders university

Widespread HIV/AIDS prevention and care programs • The UN Development Programme (UNDP) has engaged over three million people in prevention activities over the last five years. In Burkina Faso, an African country in West Africa, this programme provided regular support to nearly 36,000 people living with HIV, including home visits, meals and assistance to set up small-scale enterprises1,2,5-7.[ Increasing access of mosquito nets to prevent malaria • Global production of mosquito nets has increased 500% since 2004 to 150 million nets in 2009. Nearly 200 million nets were delivered to African countries between 2007 and 2009. However, nearly 350 million are needed to achieve universal coverage and this effort needs to be intensified1,2,9.]

• The first scoping study, on HIV prevention initiatives targeting men who have sex with men in Asia and the Pacific (with a focus on Vietnam Cambodia Burma Philippines and PNG), was completed in 2009. A second study on greater involvement of people living with HIV was completed in November 2009 and the final study on HIV legal and policy frameworks was completed in March 2010. Initial responses to the recommendations include 3 million dollars of funding over three years (2009-12) to support programs for men who have sex with men in Indonesia, PNG and Burma, and 1.5 million dollars over three years (2009-12) to PNG and the Solomon Islands for legal and policy development activities. Further work on incorporating recommendations from these studies into longer-term HIV programming is underway10.]

Australia’s role in achieving MDG 6

AusAID, Australia’s aid program, has focussed its global research efforts into three areas: • HIV prevention for men who have sex with Men; • greater involvement of people living with HIV; • and legal and policy enabling environments for effective HIV responses.

1.United Nations. 2010. The millennium development goals report 2010. New York: United Nations.

2.UN Development Programme (UNDP). 2010. What Will It Take to Achieve the Millennium Development Goals? An International Assessment 2010. New York: United Nations.

3.WHO. 2009. Global Tuberculosis Control: A Short Update to the 2009 Report. Available from http://whqlibdoc.who. int/publications/2009/9789241598866_eng.pdf (accessed 13 November 2010).

4.Center for Global Development. 2004. Millions Saved: Proven Successes in Global Health. CGD Brief. October 2004, 3:3.

5.MARCO. 2009. Five-Year Evaluation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, Synthesis of Study Areas 1, 2 and 3, Marco International Incorporation.

6.Nunn, A. S., da Fonseca, E. M., Bastos, F. I. and S. Gruskin. 2009. AIDS Treatment in Brazil: Impacts and Challenges.

Health Affairs, vol. 28, no. 4, pp. 1103-1113.

7.Janssens, B., et al. 2007. Offering integrated care for HIV/AIDS, diabetes, and hypertension within chronic disease clinics in Cambodia. Bull WHO, Vol. 85, pp. 880-885.

8.Mishra, V. et al. 2007. A study of the association of HIV infection with wealth in sub-Saharan Africa. DHS Working Papers.

9.WHO. 2007. WHO Releases New Guidance on Insecticide-treated Mosquito Nets: Recent Data from Kenya “Ends the Debate” About How to Deliver the Nets. Available from http://www.who.int/mediacentre/news/releases/2007/pr43/ en/index.html (accessed 20 November 2010) 10.AUSAID [homepage]. 2010. HIV/AIDS: Australia's response. Available from http://www.ausaid.gov.au/keyaid/ hivaids/default.cfm (accessed 22 November 2010)

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The Australian Government has a focussed strategy aimed at helping partner countries address MDG6.

The main focus for Australia’s support to the global HIV/AIDS effort is based in the Asia Pacific region.

In Africa, Australian support is channelled through the Global Fund and UNAIDS. Currently,

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MDG ensure environmental sustainability

M

illennium development goal (MDG) seven is to ensure environmental sustainability1.

To help us understand how this is defined, the goal is broken down into several ‘targets’.

The targets pertain to things like optimising the percentage of land area covered by forest, protecting biodiversity, improving the efficiency of energy use, reducing per capita CO2 emissions and consumption of ozone depleting chlorofluorocarbons, improving population access to clean water and sanitation, and access to adequate housing for the most impoverished. The achievement of these targets would not only improve the health of our ecosystem but also directly improve human health and assist in the mitigation of climate change. We can assist in making MDG reality by applying these global targets to the local communities in which we participate. Perhaps most appropriately, as future health professionals, we should consider the ways in which we can assist the health sector to acknowledge the ecological footprint of its business, and duly take steps to rectify this blight.

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our nation has made minimal progress in lifting its ecological game

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In the ten years since then Australian-PM John Howard was signatory to the United Nations Millennium Declaration in the year 2000, our nation has made minimal progress in lifting its ecological game. This is despite knowing that there is scientific consensus that, as a consequence of human activities, the earth’s climate is warming. During the twentieth century Australia’s average surface air temperature has increased by 0.70C and rainfall has substantially reduced2. The rise has been attributed to our reliance on the combustion of fossil fuels for energy generation and transport and the concomitant rise in atmospheric concentrations of carbon dioxide and other greenhouse gases3. Disheartingly, we are locked in to a further warming of at least 0.2-1.00C by the year 21002, however much larger rises are likely to be in store if we are unable to dramatically

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reduce greenhouse gas emissions in the next decade2.

In addition to this, extreme weather events such as tropical cyclones, heat waves, and floods will become more frequent. In this way climate change will have detrimental impacts on the environment, economy, and public health.

Rich countries such as Australia are better placed than many other nations to be able to fund climate mitigation and adaptation strategies. Mitigation is essentially primary prevention to contain a rise in surface air temperature through cuts to greenhouse gas emissions, whilst adaptation is a form of secondary prevention to allow us to live with the inevitable changes in weather patterns; tertiary prevention is tantamount to disaster response to the predicted increase in extreme climate events. As in medicine primary prevention, although unpopular, is a much more cost-effective approach than having to deal with a series of emergencies.

It is in this context that the Australian healthcare system is gradually adopting a triple-bottom line approach to evaluation, thereby moving away from an arcane system that treated environmental impacts as an ‘externality’ with little mandate or incentive for hospitals, universities and other large institutions to reduce their carbon footprint . By targeting waste, staff and patient transport and utility (water, energy) consumption some such facilities are starting to make moves. Actions are starting to pop up - ride to work days, waste reduction programs - all contributing to the broader tapestry of sustainabilitypromotion.

With the knowledge that there is no health, or economy, without the environment many current and future health professionals such as ourselves realise that to concern for population health necessitates taking action to ensure environmental sustainability.

Thus to take care of the the environment is not merely a case of “doing the right thing, it is also an opportunity to make cost savings, experience health co-benefits and mitigate some effects of climate change.

GOING

Environ

liz o’brein university of notre dame

PLAY A PART AND MAKE A DIFFERENCE

1

4

Help to build networks of like-minded people within your university, hospital or community by joining the your local green group, student division of Doctors for the Environment Australia (www.dea. org.au) and/or the climate code green project for Australian medical students (www.codegreensite.com). Consider participating in the national gathering for medical students on climate change and other environmental health issues called ‘iDEA’ which will be held in Sydney over the weekend of April 29-May1, 2011.

2

Advocate local and national policies to improve health both now and for future generations.

Educate those in positions of power (e.g. local politicians, hospital administrators, academics) about the health risks of climate change through meetings, articles in public forums such as your medical school paper and suggest ways they can incentivise sustainable practice.

3

1. United Nations. 2007. Millennium development goal seven: ensure environmental sustainability. United Nations Development programme. Accessed online October 18, 2010 at http://www.un.org/millenniumgoals/environ.shtml 2. Preston BL, Jones RN. 2006. Climate Change Impacts on Australia and the Benefits of Early Action to Reduce Global Greenhouse Gas Emissions. A consultancy report for the Australian Business Roundtable on Climate Change. CSIRO. Canberra, Australian Capital Territory. Accessed online on October 18, 2010 at http://www.csiro.au/resources/pfbg. html 3. Intergovernmental Panel on Climate Change. Climate change 2007: the physical science basis—summary for policy makers. Accessed online October 18, 2010 at: http://www.ipcc.ch/publications_and_data/ar4/wg1/en/contents.html

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Understand the threats by educating yourself and your colleagues about the links between ill health, environmental degradation, and climate change and mitigation strategies such as promotion of active transport and increasing teleconferencing to reduce unnecessary car and plane travel.

Campaign for the integration of education on climate change into the medical curriculum at your university.

west australian student member for doctors for the environment australia (DEA)

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MDG develop a global partnership for development

w h y

can’t

What’s it all about? What’s it supposed to do? And can’t we all just get along!?

Perhaps the most varied, and least understood of the UN MDGs, this MDG is designed to tie the other seven together, by taking steps towards strengthening trade, political and health systems.

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WE just All get along 30

nick watts university of western austraila

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key goals 1. Raise the commitment of Official Development Assistance (ODA) to 0.7% of the Gross National Income (GNI) of donor countries.

2. Develop an equitable finance system, by allowing the Least Developed Countries (LDC) access to markets of developed countries, and through tariff reductions benefiting these countries.

3. Ensure that in an increasingly globalised world, we address the needs of the LDCs and Small Island Developing States (SIDS) 4. Manage the heavy debts of low income countries (think Live-Aid… kind of).

5. Provide access to essential medicines, life saving drugs through a variety of patent and trade-related mechanisms.

6. Set in place structures which allow the spread of new Information and Communication Technologies (ICTs) – internet & mobile phones – to the global South.

T

en years in, where do we stand? Well, only 1 billion of the world’s 6.88 billion have access to the internet, debt levels (whilst still high) are falling rapidly, and ODA stands at roughly 0.34% of GNI of developed countries, a little under half way towards the 0.7% we’re aiming for.

Australia (one of the lucky few who has kept a budget surplus throughout the recession) has recently committed to increase our ODA to 0.5% of our GNI by 2015, falling significantly short of our 1970 promise (renewed in 2002 Monterrey Consensus). Meanwhile,

the UK - a country which is literally hemorrhaging from the results of the global financial crisis - is well on track to achieve their commitments.

Achieving these targets will require partnership… in fact… it requires “global partnerships for development. We’ll need all countries (of high and low incomes) to work with behemoths such as the Bretton Woods trio (the International Monetary Fund, the World Bank and the World Trade Organisation), three bodies charged with managing the trade and finances of the world. We’ll need unprecedented Public Private Partnerships (PPP) between governments and privatised pharmaceutical companies and ICT companies to ensure global access to essential communication technologies and medicines. We’ll need donor countries to work together to coordinate their aid, ensuring that evidence based assistance is delivered to the parts of the world where it is needed most. We’ll need non-governmental and organisations (NGO) such as Médecins Sans Frontiéres (MSF) and Oxfam to assist with aid coordination and distribution. But most of all, we’ll need a partnership between civil society, a roar from the public, telling the governments of the world that there is support for action on poverty, ‘allowing’ them to act.

Each and every partnership takes us one step closer not only to achieving MDG 8, but to the eradication of extreme poverty. After all: “It is not in the United Nations that the Millennium Development Goals will be achieved. They have to be achieved in each of its Member States, by the joint efforts of their governments and people” - Kofi Annan, Former UN Secretary General

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1. United Nations Development Programme. MDG Monitor. Geneva2010 [26 Oct 2010]; Available from: http://www. mdgmonitor.org/.

2. Australian Agency for International Development (AusAID). Australian Partners. Canberra2010 [26 Oct 2010]; Available from: http://www.ausaid.gov.au/.

3. UK Department for International Development (UKDFID). Governance and Social Development Resource Centre.

London2010 [26 Oct 2010]; Available from: http://www.dfid.gov.uk.

4. UN MDG. Millennium Development Goals - 2015. New York2010 [26 Oct 2010]; Available from: http://www.un.org/ millenniumgoals/global.shtml.

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Introduction

T

he world’s first major conference on the global environment was held in Stockholm, in 1972.

At that time few doctors seemed aware or concerned about the global environmental dimension to inequality1, though the medical profession had by then a long history of working to promote health in low income settings [2, exemplified by Albert Schweitzer, who divided his time between Europe and the hospital he had established in French Equatorial Africa.

In 2009, as the world anticipated the biggest climate change summit since Kyoto in 1997, the issue of climate change appeared to almost head the international agenda. The health literature also published many papers on this issue [3-5]. Yet, since then, developed nations including France, the U.S. and Australia have retreated from the rhetoric which briefly raised hopes of leadership from the rich world. This is not because of any weakening in the evidence or scientific consensus, but a possibly fatal weakening in the political support. The current year has been the hottest on record, and the drought in Russia and the Ukraine (during July to August 2010) has triggered the sharpest rise in grain prices seen in 30 years [6. Speculation is undoubtedly a major cause of this rise, but the market is likely sensing and reflecting increasing global concern and volatility.

This heat wave is consistent with climate change.

Health effects of climate change: primary, secondary and tertiary The list of health conditions associated with climate change can seem bewildering; from the fairly obvious to the obscure, such as gastroenteritis caused by Vibrio Parahaemolyticus[7]. One way to categorise these diverse manifestations is by grouping the most obvious effects as ‘primary’ and less obvious effects as ‘secondary’. Primary effects include heat waves, heat stress, and the physical impacts from extreme weather effects such as storms and fires. The latter group includes ecologically mediated vector borne diseases, such as malaria, and other communicable diseases whose epidemiology will be altered by climatic and associated ecological variation, from plague [8] to hantaviruses 9] .Many more details of these effects are available elsewhere [10].

There is one more level of effect that must be considered, here called ‘tertiary’ 10, 11.Ultimately, these effects should cause the greatest anxiety, to society and therefore to health. Yet, among the vast literature concerning climate change very little discusses the likely impact upon global health from the bleak social and physical conditions to which much of the world appears to now be heading. It perhaps takes courage rather than imagination to contemplate a nuclear-armed world in which sea level has risen by a metre, and where the grain yield in South Asia has declined by 18 to 22%12, ven though

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global health, 32

sustainability and

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colin

david

butler

national centre for epidemiology and population health, australian national university

several hundred million additional South Asians are then predicted to be alive. Yet such conditions, interwoven with many other difficulties, are likely to occur within 70 years.

not only for many concerns expressed by youth about the future16, but also for the level of concern about climate change in both the health and wider literature.

THE FUTURE

Linking the global climate and global health inequality crises

Beyond the health literature, frank discussion of the likely conditions in which humanity will live in 2100 is also rare, and where it exists, it is generally biased towards the optimistic [13. Official socio-economic forecasts and scenarios are excessively hopeful, perhaps because humans cannot bear too much pain, or perhaps because authorities are concerned that bleak forecasts will become self-fulfilling. However, in addition, a good deal of woolly thinking, ‘group think’ and frank denial is occurring, evidenced, for example, by the way the global financial crisis caught governments and their elite economic advisers by surprise. This disconnect between prediction and reality likely extends to the size of oil supplies[14 and to other critical limits to growth [15.

Irrespective of the reasons for this optimism [13 the health consequences of future global climate change are likely to be severely underestimated, without consideration of tertiary effects. Such effects are likely to exceed the other impacts, even if combined, perhaps by one or even two orders of magnitude.

Apprehension of these tertiary effects, though poorly articulated, appears to be a rational explanation

Although there it is legitimate to be troubled by the future, hope should not be lost. Humanity has faced great stress before. Seventy years ago the Allies fought a bitter war against the Japanese and Nazi Germany. A quarter century after that, many fears were expressed concerning impending famine in the 1970s21. [In both the early 1960s and again in the 1980s, great fear was held about a nuclear war. So far, we have escaped these fates. If humanity is to traverse this future it will do so in part because of the contribution of doctors, together with many other actors and new ways of social organisation22 .

2000–2080. Technological Forecasting & Social Change. 2007;74:1030–56.

13. Butler CD. Peering into the fog: ecologic change, human affairs and the future (commentary). EcoHealth. 2005;2:1721.

14. Kerr R. Splitting the Difference Between Oil Pessimists and Optimists. Science. 2009;326:1048.

15. Hall CAS, John W. Day J. Revisiting the limits to growth after peak oil. American Scientist. 2009;97:230-7.

16. Eckersley R. What's wrong with the official future? In: Hassan G, editor. After Blair: Politics After the New Labour Decade. London: Wishart; 2006. p. 172-84.

17. Butler CD. Inequality, global change and the sustainability of civilisation. Global Change and Human Health.

2000;1(2):156-72.

18. Diamond J. Collapse: How Societies Choose to Fail or Succeed. London: Allen Lane; 2005.

19. Tainter JA. The Collapse of Complex Societies. Cambridge: Cambridge University Press; 1988.

20. Bowles S. Did Warfare Among Ancestral Hunter-Gatherers Affect the Evolution of Human Social Behaviors?

Science. 2009;324:1293-8.

21. Ehrlich PR. The Population Bomb. London: Ballantyne; 1968.

22. Walker B, Barrett S, Polasky S, Galaz V, Folke C, Engström G, et al. Looming global-scale failures and missing institutions. Science. 2009;325:1345-6.

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1. Boyden S. The environment and human health. The Medical Journal of Australia. 1972;116:1229-34.

2. King M, editor. Medical Care in Developing Countries. A Primer on the Medicine of Poverty and a Symposium from Makerere. Nairobi: Oxford University Press; 1966.

3. McMichael AJ, Neira M, Heymann DL. World Health Assembly 2008: climate change and health. The Lancet.

2008;371:1895-6.

4. Lim V, Stubbs JW, Nahar N, Amarasena N, Chaudry ZU, Weng SCK, et al. Politicians must heed health effects of climate change. The Lancet. 2009;374:973.

5. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the health effects of climate change. The Lancet. 2009;373:1693–733.

6. Williams S. Parched Russia warns on harvest, wheat prices surge. Sydney Morning Herald. 2010.

7. McLaughlin JB, DePaola A, Bopp CA, Martinek KA, Napolilli NP, Allison CG, et al. Outbreak of Vibrio parahaemolyticus Gastroenteritis Associated with Alaskan Oysters. New England Journal of Medicine. 2005;353:1463-9.

8. Stenseth NC, Stenseth NC, Samia NI, Viljugrein H, Kausrud KL, Begon M, et al. Plague dynamics are driven by climate variation. Proceedings of the National Academy of Science (USA). 2006;103:13110-5.

9. Klempa B. Hantaviruses and climate change. Clinical Microbiology and Infection. 2009;15(6):518-23.

10. Butler CD, Harley D. Primary, secondary and tertiary effects of the eco-climate crisis: the medical response. Post Graduate Medical Journal. 2010;86:230-4.

11. Butler CD, Corvalán CF, Koren HS. Human health, well-being and global ecological scenarios. Ecosystems.

2005;8(2):153-62.

12. Tubiello FN, Fischer G. Reducing climate change impacts on agriculture: Global and regional effects of mitigation,

That humanity appears to be nearing an abyss might surprise some readers. However, another immense problem has co-existed with our increasing prosperity, since at least World War II17. This is the problem of apparently intractable Third World poverty, and of the resultant health gap between privileged and poor populations. In fact, the parallel problems of global health inequality and of our trajectory towards dangerous climate change can each be considered as manifestations of an intelligent species, a clothes-wearing primate, who is not quite as smart as s/he thinks. History is replete with civilisations that have collapsed18, 19. Even before humans had developed cities violent conflict among humans has been documented, from the end of the Pleistocene20.

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Student Electives a world of experience

whitney d o w n e s monash university

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welcome to

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I

recently undertook my medical elective at Tupua Tamasese Meole Hospital in Apia, Samoa, in the Obstetrics and Gynaecology Department. I was involved in providing ante- and post-natal care, as well as assisting in deliveries.

My first day on the labour ward, I was confronted by a thoroughfare occupied by at least 15 pregnant bellies, each attached to a woman either uncomfortably waddling up and down the corridor or leaning against a vacant doorway, labour pains acknowledged only through the cessation of movement. I entered a delivery room (a 4 x 2m space with room for a bed and a bench for equipment) to find a woman lying prone with legs apart in the timehonoured position of birthing, husband pushing the crown of her head as if he could somehow increase the force of his wife’s straining uterus, midwife shouting encouragement in the usually dulcet tones of the Samoan language, and two Austrian doctors watching the perineum in anticipation, chatting in German as the baby calmly crowned. In minutes, a boy was delivered (their 5th, the husband informed us), syntocinon administered and 3rd stage of labour apparently in progress. Fundal massage to assist placental delivery raised an interesting question, was there perhaps a second baby, explaining the prolonged 3rd stage?

Calm turned to chaos as I was ordered to get the consultant, the parents worryingly understanding the frantic tones but not the English or the German, as the midwife performed a completely unsterile vaginal examination in order to determine presentation of the latest surprise. The consultant calmly entered the room, delivered the second baby breech, and left after satisfying himself that both babies would survive, with just a cursory nod to the bewildered parents. The Austrian doctors turned to me and said,

My experience of Samoa continued in a similar fashion. Questions posed on ward rounds highlighted the dichotomy of ideal management versus that in developing countries, ‘How would you manage this

However, despite the apparent lack of equipment, the hospital has surprisingly few maternal or neonatal deaths. The staff, used to not having equipment available, work incredibly well within the imposed limits, and the women accept the basic conditions in which they are required to labour. Delivery is perhaps returned to its natural state, with the parents not focused on ‘pethidine versus nitrous oxide’, ‘Coldplay versus Mozart’, but on having a healthy child. Having said this, I definitely missed the comfort of a reassuring CTG or maternal blood pressure, and learnt the hard way when I delivered a floppy baby and was chastised by the doctors for letting the delivery carry on too long, that if I was in the room with a midwife, I was assumed to be in control.

My experience of Samoa was a welcome insight into the world of medicine in developing countries, of a beautifully strong culture and of people who are rich in ways we in the ‘developed’ world do not place enough value on. I look forward to my return, perhaps in a more senior medical role.

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‘Welcome to Samoa!’

condition, but how can we best manage it here?’

Antenatal clinics were conducted in an old ward room, curtains dividing the ‘cubicles’ and providing the illusion of privacy. The corridors are full of women waiting to see either midwives or doctors, most heavily pregnant but often on their first visit, with only unsure dates or late obstetrics scans to provide a rough estimate of due dates. Five doctors attempt to sift through the patients, assessing fundal height and blood pressure with one tape measure and one sphygmomanometer shared between them. The pitter-patter of foetal hearts is barely heard amongst the electronic whine of a Doppler probe struggling to operate on failing batteries. Any procedures are done with the supposed protection of XL gloves, which are probably a greater risk than help. Women in labour rooms who have been pushing past the limit of normal labour wait anxiously for one of the two cardiotocograph machines to be available for foetal monitoring. In these labour rooms, meconium liquor is often the first and only sign of foetal distress.

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alexandra f r a i n & l u k e hamilton co-convenors global health conference executives

T

he enthusiasm and inspiration of over 430 medical students from Australia and the Asia-Pacific region intersected in Hobart from July 1 to 4th, for the 6th Annual Australian Medical Students’ Association Global Health Conference.

The theme was ‘Small Steps, Big Picture’, with a focus on empowering students with knowledge about issues that impact on health around the world, whilst equipping them with practical skills to get involved in advocacy and activism at a grassroots level.

Delegates were addressed by Dr Helen Caldicott on the medical implications of nuclear power, by Reverend Tim Costello on child and maternal health, and by Professors Tony McMichael and Colin Butler on Climate Change and Health, just to name a few.

The stream program provided delegates with an overview on issues such as water quality and access, refugee health, sexual health, Indigenous health and resource allocation. With over 66 speakers and tutors, it is impossible to convey the amount of information that was packed in to four days at the University of Tasmania, and even more impossible to describe the intangible benefits of having 430 motivated students in one place, with one growing global conscience.

The conference was also very lucky, with the support of the University of Tasmania, SecondBite, Scolorest and the Salvation Army, to be able to contribute to the local community through a food rescue after lunch each day. Delegates were so inspired by this that many of them returned breakfast foods for distribution after the conference as well.

We certainly learned that the issues facing the health of the world are undoubtedly huge, and require action of a similar magnitude. We were powerfully urged

by Nick Bearlin-Allardice in the closing address of the AMSA GHC to remember that it is not enough to simply attend a conference. There is so much work to be done in the realm of global health, as evidenced by the array of topics covered over the four days of the conference. If you are interested in putting the passion and excitement generated at the AMSA GHC to good use, please consider joining the Global Health Group at your university, or joining an advocacy group like World Vision, Oaktree, RESULTS, the Global Poverty Project or the Doctors for the Environment Australia. We hope that the AMSA Global Health Conference will be the springboard for many people, including you, into making a real, tangible difference in global health.

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As well as being addressed by some of the most well respected figures in global health in Australia, some of the most profound learning came from our peers.

Ten students from developing nations joined us through the AusAID International Seminar Support Scheme, and we were enlightened by what they could share about health in their countries. Workshops were also run by students, for students, through the AMSA Training New Trainers and Think Global initiatives. These programs allowed delegates to develop skills in leadership, advocacy and project management.

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