Vector Issue 18: The Right to Write

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Editor’s Note

Contents

A few weeks ago during SWOTVAC I attended a gathering on campus for “an hour of peace” – an event held in light of the omnipresent unrest in the world in recent months. As I enjoyed a welcomed break from study with John Lennon playing in the background, I reflected on these recent events and the lows that humanity can reach. I must say, as I’m sure is the case with those of you reading this, it isn’t the first time I’ve felt disheartened by the way humans can treat each other and the planet with such malice. At these times I find, more than ever, comfort in the people around me – the everyday medical students that think, speak up, act, inspire and most importantly, are kind and open-minded.

Feature Article The Right to Write; A Look at Female Education through the Universal Declaration of Human Rights....................................................................4 Review Healthcare in the Wake of Cyclone Pam....................................................................9 Health in Low-Resource Settings: A Case for Public Health Measures in Nairobi’s Informal Settlements...............................................................................13 When Health is the Last Priority...............................................................................21 Case Study A case of oesophageal candidiasis with underlying HIV infection.....................28 Opinion How Greed Can be Good...............................................................................................33 Voluntourism Voluntourism and the TeamMed Experience...........................................................40 Namaste Didi.................................................................................................................45 News ARTICLE Australia’s Medical Community condemns The Border Force AcT.......................50 post-conference Reports Stories of the General Assembly...............................................................................52 Post-Conference Report: Asian Medical Students’ Conference, Singapore......54 Global health spotlight Deakin Dash 2015: We Did It In A Dress......................................................................59

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I believe the medical students who have created articles for Issue 18 take this one step further. It takes energy and passion to be change makers but it takes something more to painstakingly study, research, analyse, write and re-write something that you care about. I see the undertaking of these authors as a true reflection of their character and a predictor of their futures as successful agents of change.

With this I introduce to you Issue 18! I know the author of the feature article, Sophie Glass, personally, and her work has consolidated my views of her as a robust, intelligent and diligent woman. Sophie also has a personal blog on evidence-based feminism, which I encourage you all to read (www.evidencebasedfeminism.blogspot.com).

Next, Emma Davey has written a review article titled “Healthcare in the Wake of Cyclone Pam”. I congratulate Emma on writing on this arguably neglected event and bringing it to the fore. Similarly, Cecilia Xu’s article on homelessness in Australia has been a great reminder of the issues in our own backyard. Furthermore, Phoebe Shiu’s article on “Health in Low-resource Settings: A Case for Public Health Measures in Nairobi’s Informal Settlements” takes us beyond our backyard to provide a detailed analysis of the issues that face public health and health policy in these areas.

candidiasis with underlying HIV infection.” Next, Nikhil Autar has created a thought provoking opinion piece on “How Greed Can Be Good”. The catchy and contentious title is an accurate reflection of the body of the text!

In the ensuing pages have been brought together as a section on voluntourism, which includes a review article on “Voluntourism and the TeamMed Experience” by Chloe Higgins and Masad Alfayadh, followed by a reflective piece, “Namaste Didi”, written by Holly Richter. The authors have created articles that will no doubt leave you thinking about the ethical considerations of overseas electives and I encourage you to consider taking part in AMSA Academy’s pre-departure training course to consolidate your views on the topic and prepare you for your placements.

We end our latest issue on a high with a news article

by Durga Chandran on “Australia’s Medical Community Condemns the Border Force Act”; post-conference reports from the IFMSA General Assembly and Asian Medical Students’ Conference; and a Global Health Group Spotlight written by Lena Handrinos, the AMSA Global Health Representative for Deakin University.

No doubt these articles will leave you proud to be a medical student in Australia and inspire you to be involved in the many opportunities that our global community of future doctors has to offer.

This is the final issue of 2015 and it’s with great sadness that the Vector 2015 team will be parting ways.

I’d like to take this opportunity to thank the team who has made Vector 2015 possible. In saying this, I am excited to be handing over to Olivier Anderson who will be the incoming Editor-in-Chief. I’ve no doubt she will do a phenomenal job and look forward to reading Vector in the New Year.

Jackie Hara-Crockford Editor-in-Chief, Vector Journal

For the first time this year Vector is proud to publish a beautifully crafted case study written by Andrew Samaan and Min Zaw on “A case of oesophageal

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Associate Editors

Infographic Designer

Designer & IT Officer

Aurora Killey Faye Liu Freya Berenyi Nicolas Soputro Rose Brazilek Ross Penninkilampi Rukaiya Malik

Rebecca Kelly

Aryan Firouzbakht

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Feature Article

progress has been made. The last 15 years has seen progress in increasing enrollment and literacy rates globally, for both men and women.

Primary school enrollment in Oceania increased from 69% in 2000 to 89% in 2012.[3] Worldwide, the greatest improvement was seen in Sub Saharan Africa, where despite rapid population growth, primary school enrollment rates increased from 60% in 2000 to 90% in 2012.

[3] These are remarkable achievements. The recognition that education is not only beneficial to individuals and societies, but in fact necessary to achieve development, has led to these impressive advances.[2]

The Right to Write; a look at female education through the Universal Declaration of Human Rights Sophie Glass

About the Author Sophie Glass is a 3rd year medical student at James Cook University who will be starting a Masters of Public Health and Tropical Medicine in 2016. She started writing in early 2015 to further her exploration of how women live throughout the world. She has a keen interest in global health and hopes to continue writing within this area.

To view more work by Sophie Glass please refer to her blog on evidence-based feminism at www.evidencebasedfeminism.blogspot.com

“1. Everyone has the right to education.

Education shall be free, at least in the elementary and fundamental stages. Elementary education shall be compulsory. Technical and professional education shall be made generally available and higher education shall be equally accessible to all on the basis of merit.”

- Universal Declaration of Human Rights, Article 26, point 1.[1] In 1929, one year after women in England were granted the right to vote, Virginia Woolf published her extended essay ‘A Room of Ones Own’. In this, Woolf weaves a tale of the everyday struggles of an aspiring female writer, with the main tenet being that a “woman must have money and a room of her own” to succeed. How does Woolf suggest this is to happen? Education. She believes that, like her fictional character “Judith Shakespeare” (William Shakespeare’s sister), women were deliberately held in relative poverty without the liberation education can provide. Education allows women the ability to enter society with having attained the skills necessary to succeed.

Declaration of Human Rights and mandated by the United Nations (UN) Convention on the Rights of the Child, there are still millions of children who do not receive education.[2] This is not a standalone problem and indeed it is not as simple as striving for education for all. Whilst this is a noble goal and the ultimate one to strive for, there are complexities and inequalities beyond the absolute number of those not enrolled in schools. Large gender disparities exist, with girls and women being unduly affected. Denying the right to education does not violate one human right, it denies many more that are unattainable without the skills and empowerment education allows girls.

Currently there are 31 million school-aged girls not enrolled in school. In Africa and South Asia, boys remain 1.55 times more likely to complete secondary education than girls.[2] Additionally, according to the 2014 report on the UN Millennium Development Goals (MDGs), more than 60% of the 781 adults and 126 million children lacking basic literacy skills are female.[3]

Almost exactly 20 years later, the Universal Declaration of Human Rights was adopted by the United Nations General Assembly. The Declaration outlines in 30 articles the basic rights to which all humans are fundamentally entitled.

These are to be respected globally as the basic standard by which governments must provide and by which people must abide. Unfortunately, this is not always the case.

This is disappointing, given that the UN MDGs goal 2 is to “achieve universal primary education”, directly followed by goal 3 to “promote gender equality and empower women”. The target for goal 3 was to “eliminate gender disparities in primary and secondary education, preferable by 2005, and in all levels of education no later than 2015”.[3] Unfortunately, more than 20% of low- and middle-income countries will not have achieved this goal by the end of 2015.[2]

Despite education being declared as a fundamental human right in the Universal

The MDGs may not have been met in their allotted time, but this does not mean that no

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Following these MDGs are the proposed Sustainable Development Goals, to be released this September. Similarly, their proposed goal 4 is to “ensure inclusive and equitable quality of education and promote life long learning opportunities for all.” This encompasses their target 4.5 to “by 2030 eliminate gender disparities in education and ensure equal access to all levels of education for the vulnerable, including persons with disabilities, Indigenous peoples and children in vulnerable situations”.

[4] Goals towards gender equality and female empowerment, and increasing educational access for woman are inseparable, one does not exist without the other. As such, this is followed by the proposed goal 5 of “achieve gender equality and empower all women and girls.”

Gender equality, and equal, universal access to education for males and females are seen as a global priority, what remains to be seen is how these goals will be achieved.

Why Education?

“Education shall be directed to the full development of the human personality and to the strengthening of respect for human rights and fundamental freedoms. It shall promote understanding, tolerance and friendship among all nations, racial or religious groups, and shall further the activities of the United Nations for the maintenance of peace.”

- Universal Declaration of Human Rights, Article 26, point 2.[1]

argued that “there may be no better investment for the health and development of poor countries around the world than investments to educate girls”.[5] The Goldman Sachs Global Economics Paper entitled “Women Hold up Half the Sky”, released in 2008, concluded that education is the single most influential factor in decreasing gender inequality.[6] Increasing education for women can provide the circumstances and the tools to facilitate a demographic transition and to improve the health of those in the developing world. It is correlated with decreased fertility, maternal mortality and child marriage, and has positive effects on children’s health, education and wellbeing.[6] There is an undeniable trend that geographic areas with higher literacy rates for women have better measureable outcomes.[2] These measureable outcomes translate into women leading happier, healthier lives. The value of education is intrinsically linked with the ability to empower women; it is an enabling factor for women’s empowerment. This concept of empowerment can be broad and confusing, but it essentially has two aspects; autonomy and agency (the ability to make decisions and assert what is in their own best interests), and attaining resources financially, with opportunities, skills and social networks.[3] Dr Catherine Hamlin established the Addis Ababa Fistula Hospital to attend to those people who are one of the most underrepresented globally.

She helps women with obstetric fistulas, a disability that makes them outcasts from their own community. Hamlin believes that “women are marginalized in the developing world, they are an expendable commodity”.[7] It is for this reason, and many others, that girls do not receive education. Boys are seen as having more value, being more able to bring in an income and therefore more worthy of receiving education.

Widespread sexism and cultural perceptions of female worth are preventing the inevitable development that occurs when women are educated.

Fertility and Maternal Death

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“Motherhood and childhood are entitled to special care and assistance. All children whether volume 10, issue 18

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born in or out of wedlock, shall enjoy the same social protection.”

- Universal Declaration of Human Rights, Article 25, point 2.[1] Fertility rate, the average amount of children a woman will birth over her lifetime, can indicate the degree to which a woman has control over her own reproductive choices. Many women are not able to advocate for themselves to prevent conception and so give birth many times in their life. It has been found that for every two to three years a woman spends in education, she is likely to have one less child. This effect is not seen when males are educated, as male schooling seems to have an insignificant or positive effect on fertility rates.[6]

age.[11] Child Marriage “1. Men and women of full age, without any limitation due to race, nationality or religion, have the right to marry and to found a family. They are entitled to equal rights as to marriage, during marriage and at its dissolution.

2. Marriage shall be entered into only with the free and full consent of the intending spouses.”

- Universal Declaration of Human Rights, Article 16, points 1 and 2.[1] Child marriage is a widespread, abusive practice that denies girls the ability to achieve their potential and become empowered women. Girls are taken out of school, or more often, prevented from attending school to begin with, as they are due to be wed at a young age. In 2013, almost half of girls in South Asia, and more than one third of girls in Sub Saharan Africa were married before their 18th birthday.[12] Child marriage comes with a plethora of risks and consequences perpetuated by a society that condones marrying children, often to men decades older than themselves. Girls who are married before 18 are at significantly higher risk for domestic abuse than those who married later. Namely, being twice as likely to report being threatened, beaten or slapped, and three times as likely to report being forced into non-consensual intercourse.

[13] The detrimental effects of child marriage on the individual girls, and the culture surrounding women are undeniable.

A decreased fertility rate does not exist without influencing other global challenges faced by women, such as maternal death. As women have fewer children, they are less likely to experience the complications that cause maternal death. Currently, Sierra Leone has a maternal mortality ratio of 1100, meaning that for every 100,000 live births, 1,100 women die due to obstetric complications. This is a sharp contrast to the maternal mortality ratio of 6 in Australia.

[8] Education has a direct effect on maternal mortality, with the World Bank estimating that for every additional year of school for 1,000 women, 2 maternal deaths are prevented.[6] Moreover women who are educated are more likely to deliver in a health facility and are more likely to give birth at a later age, both of which significantly reduce the risk of maternal death.[9] Indeed declining fertility in the developing world prevented Just as child marriage prevents girls from 1.7 million maternal deaths between 1990 and continuing their education, continuing education 2008.[10] can prevent child marriage. A strategy recommended to the UN to prevent child Decreasing maternal mortality and fertility rates marriage is to provide equal access to primary can be consequence of, and reflect, an increase and secondary education for boys and girls. in the average age women are married. Female [12] Girls with secondary school education are education is an important determinant for the up to 6 times less likely to be married under the age of marriage, with positive implications for the age of 18 than those with little or no education. individual as well as the wider society. As girls stay [14] Correlation and causation have to be taken in school for longer periods of time, particularly into account here. Is it simply that the kinds of during senior schooling, they are less likely to communities that would send girls to secondary be married during adolescence. Given the age school are also the ones that would not endorse of marriage is closely associated with the age of child marriage? This is possible, however it first childbirth, the duration women are in school seems to be that girls who are in school are not becomes of particular importance in order to getting married, rather than girls being taken out prevent complications from childbirth at a young of school to be married. To put it in other terms, vector journal

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girls who are already not in school are at high risk of being married. Thus, it seems to follow, and the evidence does suggest, that enabling girls to attend school should decrease the number of girls who are being married before turning 18.[14]

has received more education will have daughters who experience better livelihoods and receive more education than would otherwise be the case.

Malala

Women and their Children “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.”

- Universal Declaration of Human Rights, Article 25, point 2.[1]

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

- Universal Declaration of Human Rights, Article 3.[1] “Everyone has the right to freedom of opinion and expression; this right includes freedom to hold opinions without interference and to seek, receive and impart information and ideas through any media and regardless of frontiers.”

- Universal Declaration of Human Rights, Article 19.[1]

By receiving education, women are able to do more than just improve their own lives; they are able to improve the lives of those around them, such as those of their children. Educating women leads to a multitude of effects external to the individual woman. In particular, mothers who are more educated are more likely to have a positive effect on their children’s health and wellbeing.[11] For example, children of more educated mothers are more likely to utilize oral rehydration solution (ORS) as treatment for diarrhoea and understand where these diseases originate.[15] Education allows women to develop cognitive abilities, causing women to question, reflect on and understand their circumstances. They are able to become health literate and gain access to information that can better their own, and their children’s lives.[15] Moreover education enables women more agency over their lives, they are able to exert the control over their own circumstances that was otherwise not possible. There are effects suggesting that women who have received education have informally learnt abilities to negotiate and alter power relationships to successfully exercise more control over their circumstances.[15] Women become less vulnerable to domestic abuse and make more household decisions than they otherwise would, such as whether to send their daughters to school.[11] Consequently, there is an intergenerational effect whereby a woman who vector journal

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Malala Yousafzai was born in Pakistan on July 12, 1997. In 2014 she became the youngest ever recipient of the Nobel Peace Prize. Malala was born into a country ranked second last for gender equality where only 42% of women are literate.[16] Malala, seeing the injustices resulting from widespread conflict and the lack of priority given to education, became an advocate for the right for girls to be educated by the age of 11. As a result, she become a target of the Taliban, and survived an assassination attempt in 2012 where she was shot in the head.[17] Malala strongly believed that education is a basic human right that should be accessible for all. By denying children, particularly girls, the right to education, a multitude of other human rights are being violated.

It is clear that educating women has the potential to create a virtuous cycle. Through both direct and indirect effects, education has the potential to give women the opportunity to thrive. The volume 10, issue 18

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age of marriage, decreasing fertility rate and maternal death are so intertwined, with such dire consequences, that prevention relieves an unimaginable burden of suffering from millions of women. Additionally, women are better equipped to lead healthier lives for not only themselves, but for their children as well.

Just as Virginia Woolf fought for women to be educated in 1929, Malala fights for girls to be educated in 2015. However Malala has the added burden of facing extreme violence and hatred for speaking out against institutionalized injustice. It is inconceivable that the notion of educating girls could be so repulsive that a child would be wanted dead for daring to suggest it.

Many, including Malala, see education as the global panacea, with particular benefits for the developing world. As a human right, education should be given priority, however beyond that is the intrinsic value education holds. Education has transformative powers not only for women, but also for the global community as a whole. The effects of female education go beyond the effects of male education. Globally health and economic standards increase when women are educated.

By attaining knowledge and more autonomy, they are able to make informed decisions for themselves and those around them. To educate is to empower. To empower is to progress as a society.

Conflict of interest declaration The author has no conflict of interest.

References 1. United Nations. Universal Declaration of Human Rights. New York: United Nations General Assembly; 1948 December 10.

2. The World Bank. Girl’s Education [Internet]. The World Bank; 2014 December 3 [updated 2014 December 8]. Available from: http://www.worldbank. org/en/topic/education/brief/girls-education.

3. United Nations. The Millennium Development Goals Report. New York: United Nations; 2014.

4. Sustainable Development Knowledge Platform.

Open Working Group proposal for Sustainable Development Goals [Internet]. United Nations Department of Economic and Social Affairs; 2015.

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Review Article

Available from: https://sustainabledevelopment. un.org/sdgsproposal.

Healthcare in the Wake of Cyclone Pam

5. Herz B, Sperling GB. What Works in Girls’ Education: Evidence and Policies From the Developing World. New York: Council on Foreign Relations; 2004

Emma Davey

About the Author Emma is a final year medical student at Monash University. She has a keen interest in global health and has been lucky enough to travel to Vanuatu several different times, including a medical elective in her 3rd year in the Vila Central Hospital. Emma was prompted to write this after Tropical Cyclone Pam devastated Vanuatu in March this year to raise awareness of the healthcare situation of one of Australia’s closest nations.

6. Lawson S. Women Hold Up Half the Sky. New York: Goldman Sachs Economic Research; 2008 March 4. Report No.: 164 7. Kristof N.D, WuDunn S. Half the Sky. London: Hachette Digital; 2010.

8. Maternal mortality ratio (modeled estimate, per 100 000 live births) [Internet]. Geneva: World Health Organisation; 2014. Available from: http://data.worldbank.org/indicator/SH.STA. MMRT?order=wbapi_data_value_2013+wbapi_data_ value+wbapi_data_value-last&sort=asc.

9. Holme A, Breen M, MacArthur C. Obstetric fistulae: a study of women managed at the Monze Mission Hospital, Zambia. BJOG 2007 August;114(8):1010-1017 10. Stoebenau K et al. How Have Fertility Declines Benefitted Women’s Lives in Low- and Middle-Income Countries? Washington DC: International Centre for Research on Women; 2014.

11. Bates LM, Maselko J, Schuler SR. Women’s Education and the Timing of Marriage and Childbearing in the Next Generation: Evidence from Rural Bangladesh. Studies in Family Planning 2007 June;38(2):101-112 12. Child marriages: 39 000 every day [Internet].

World Health Organisation; 2013 March 7. Available from: http://www.who.int/mediacentre/news/ releases/2013/child_marriage_20130307/en/.

13. Child Marriage and Domestic Violence Fact Sheet.

Washington DC: International Centre for Research on Women; 2007 14. Malhotra A, Warner A, McGonagle A, Lee-Rife S. Solutions to End Child Marriage What the Evidence Shows. Washington DC: International Centre for Research on Women; 2011 15. Kabeer. N. Gender equality and women’s empowerment: A critical analysis of the third millennium development goal 1. Gender & Development 2010 June 10; 13(1):13-24

Abstract This article discusses healthcare needs and provision in the third world nation of Vanuatu. The major focus of the article is on how healthcare needs have been affected in the aftermath of Tropical Cyclone Pam, a category 5 storm that devastated the country this year on March 13th. The article discusses developments in healthcare in Vanuatu leading up to this natural disaster as well as the immediate response to it and expected healthcare requirements

Australia – the lucky country. Few of us genuinely appreciate just how true this well-known saying is. We have political stability, an effective welfare program, a trustworthy judicial system and education available to all. We can also lay claim to one of best healthcare systems in the world.

Our life expectancy is the 8th highest worldwide and we have 1 doctor per 312 people.[1] Even in our most remote areas there is the option of transfer to a tertiary facility, with care that is equal to the best provided anywhere in the world. While there are obviously aspects to work on, we are, on the whole, incredibly privileged.

Prior to the devastation caused by Cyclone Pam, healthcare in Vanuatu was able to support the rudimentary needs of the country. Vanuatu’s 270,000 citizens were serviced by 4 regional hospitals and 2 main referral hospitals.[3] There were only 49 doctors in the country, equaling less than 1 doctor per 5,000 people and fewer than 350 nurses practicing in the whole country in 2012.[4] Life expectancy was ranked 101st globally[4] and healthcare expenditures were just $167 (international dollars) per person per year[5] (compared to $4068 per person per year in Australia).[6]

Our geographic location, however, includes many less privileged countries where healthcare is, at best, rudimentary. One of these countries recently gained significant, if fleeting, publicity in the aftermath of Tropical Cyclone Pam. An archipelago nation of more than 80 islands 2000km from Australia’s eastern coast, Vanuatu is home to around 270,000 people.[2] I was fortunate enough to call Vanuatu home for 6 months as a volunteer on one of the outer islands and also spent several weeks as a medical student in the capital’s Port Vila Hospital.

Vanuatu and Australia were different in many ways, but as a medical student, the differences in healthcare funding and provisions were the most striking. While Vanuatu is one of our closest neighbours, its healthcare system could scarcely be more distant.

Healthcare services in Vanuatu are centred almost exclusively in the two largest cities; Port Vila and Luganville. Almost all of the country’s health professionals are located in one of these two centres. Smaller health centres and dispensaries are scattered throughout the country, with most staffed by one or two nurses or volunteers with limited training who cater to around 1,000 people.[4] Tertiary services are non-existent, and patients must be referred to Australia or New Zealand for any advanced treatment.[4] Another significant complicating factor in Vanuatu’s healthcare system is the country’s ‘double burden of disease’. The incidence of non-communicable diseases has increased significantly as diets and lifestyles have changed throughout the country (particularly in urban areas) but communicable diseases still contribute significantly to morbidity and mortality

16. The Global Gender Gap Report. Geneva: World

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in both urban and rural areas. The main causes of death in 2010 were closely divided between non-communicable (ischaemic heart disease, diabetes and stroke), and communicable and nutritional causes (including diarrhoeal diseases, tuberculosis, pneumonias and malnutrition).[7] All statistics aside, the reality of practicing medicine in such a resource-poor environment cannot be understood until it has been experienced. Vanuatu’s most advanced imaging modalities are X-ray and ultrasound which are available only in the two major hospitals, and many blood tests have to be sent to Australia for analysis. Once a diagnosis has been made it is not uncommon for crucial medications to be unavailable. Patients who require complex surgeries must be flown to Australia or New Zealand to receive care. As very few locals can afford such arrangements, funding often comes from the Vanuatu government and/ or private donors. Unfortunately, the available funds are insufficient and only a small proportion of those in need can access such treatments.

[4] In the few short weeks that I spent in the Vila Central Hospital, I saw several patients die from diseases that are preventable and/or treatable in Australia. I also saw diseases that have been all but eradicated from Australia and other western countries, including rheumatic fever, malaria, and tuberculosis. While this may sound like a difficult environment in which to practice medicine, the smaller hospitals and dispensaries have even fewer resources.

In spite of these difficulties, health outcomes in Vanuatu have steadily improved over the last 25 years.[7] A government driven program for improving health and increasing numbers of medical professionals in the country has been the main force behind these changes.[4,8] Morbidity and mortality from communicable diseases have decreased yearly since the 1980’s as vaccinations and clean water have become more widely available.[7] Immunisation rates have increased, resulting in a significant decrease in childhood mortality rates and improvements in antenatal and perinatal care have caused similar decreases in maternal and infant mortality.[4] Unfortunately, these tentative advances are now in grave danger of being lost.

On the 13th of March 2015 Tropical Cyclone vector journal

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Pam, a category 5 storm, tore through Vanuatu, wreaking havoc as it went and leaving devastation in its wake. It is estimated that 90% of the population of Vanuatu’s capital, Port Vila, became homeless overnight. Some reports stated that around 70% of outer island inhabitants were left in a similar situation.[9] Electricity was lost in those few urban places that had it, clean water sources were contaminated and vital crops were flattened.[9] The country’s main hospital, Vila Central Hospital, was evacuated and some of its wards are still closed today. A large proportion of medical supplies including medications, vaccinations, and basic equipment were also damaged or lost in the storm.[9] These losses in conjunction with structural damages to healthcare facilities add up to over US $7 million.[10] This has left Vanuatu’s medical professionals almost entirely reliant on international aid to provide even the rudimentary level of care that they had achieved prior to Cyclone Pam, let alone meet the additional demands which have emerged in its aftermath.

As Vanuatu rebuilds after Cyclone Pam, the burden of disease is expected to shift dramatically. The significant advances in the fight against nutritional and communicable diseases in recent years will be largely lost.[10] The contamination of water supplies, when combined with overcrowding in emergency shelters, will create an ideal environment for the spread of many infectious diseases that Vanuatu has only recently started to control.[10,11] The destruction of crucial water tanks has drastically limited access to safe water supplies, with damage to an estimated 90% of tanks and sanitation facilities in affected areas.[10] This has already led to an increase in the prevalence of diarrhoeal diseases, which is expected to continue for the foreseeable future.[10] The widespread destruction of Vanuatu’s crops will have both immediate and long-term effects on public health.

[10] Malnutrition and vitamin deficiencies are conditions that were only recently controlled and the sudden loss of almost all agriculture in the affected areas is likely to result in a mass resurgence of such diseases as are commonly seen in post-disaster settings.[7,10] In addition, Vanuatu’s immunisation rates for diseases such as diphtheria, typhoid, and hepatitis A are much lower than those enjoyed in Australia,[4] meaning that healthcare workers will have an even greater volume 10, issue 18

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task than otherwise anticipated.

In the years leading up to Cyclone Pam, the Vanuatu Ministry of Health had worked with significant success to eradicate mosquito breeding sites, drastically reducing the number of malaria cases.[11] The utter destruction wrought by the cyclone will undo most, if not all, of the hard work on this project by creating an ideal environment for mosquitos to multiply. This, in turn, will likely result in a significant increase in the incidence of malaria and dengue fever, as was recorded after a similarly devastating earthquake and tsunami struck Vanuatu in the early 2000’s.

[11] All of these challenges come at a time when the government of Vanuatu is least able to manage them. Damage estimates alone, based on similar disasters in other Pacific nations, run between US $248 million to $316 million.[10,12] This is money that Vanuatu simply does not have, and while significant international aid has been forthcoming, with Australia, as the biggest donor, pledging $50 million,[13] current totals and ongoing projections indicate that the total aid provided to Vanuatu will likely fall short of that which is required.[12] The population’s immediate concerns are focused on food and shelter, and even within the health sector the focus is on rebuilding what was damaged by the cyclone.

This means that no real provision or funding has been allocated to long-term disease prevention at this time.[10] Economic concerns are compounded by the fact that Vanuatu’s two main industries, agriculture and tourism, have been the most severely affected by the cyclone.[12] In some cases, the damage caused to Vanuatu’s agriculture can be rectified quickly but some crops, including kava – one of Vanuatu’s biggest export crops, take several years to grow to maturity.[12] Many resorts and tourist attractions are still closed in Port Vila and the island of Tanna (one of Vanuatu’s biggest tourism areas and also one of the worst affected by Cyclone Pam), and it will be many years before the income provided by tourism matches pre-cyclone levels.[10] The Ni-Vanuatu are a resilient people who have made significant advances economically, medically, and politically over the last few decades, but they are still reliant on international aid.[14] Their healthcare, while greatly improved, vector journal

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remains at a much lower standard than that of developed countries like Australia.[5,6] Cyclone Pam has destroyed much of the infrastructure of this beautiful country and, in the space of a few hours, managed to undo years of work achieved by the people of Vanuatu. In the coming years, healthcare needs will change dramatically, and Vanuatu’s reliance on international aid has suddenly and drastically increased.[10,11] Unfortunately, as is often the case in international disasters, the extensive news coverage of the crisis lasted only a couple of weeks. While that period brought with it an inspiring influx of aid from many countries, decreased news coverage has led to a waning in international awareness and foreign aid.

The plight of many of Vanuatu’s 270,000 citizens remains dire. It will take the country years, if not decades, to completely recover from Cyclone Pam.[10] Infrastructure, tourism, agriculture and healthcare have all been set back significantly, and international support in the form of economic aid is vital to the rebuilding effort.[10,11] This will involve thousands of people, millions of dollars and many years to complete. Because of the financial situation in Vanuatu it will need to be an international effort involving governments, volunteer organisations and, perhaps most importantly, the support of tourists returning to this still beautiful country to support the economy. Vanuatu still has much to offer, with its stunning beaches, tropical rainforests, and beautiful oceans but most importantly, its unique and rich culture and the unfaltering positivity and generosity of its people.

Acknowledgements NAD Conflict of interest declaration I declare that I have no conflict of interest regarding the contents of this article.

References 1. Australian Bureau of Statistics [internet].

Canberra: ABS; April 2013. Australian Social Trends – Doctors and Nurses [cited 2015 March 20]. Available from: http:// www.abs.gov.au/AUSSTATS/abs@.nsf/ volume 10, issue 18

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aspx

2. World Vision [internet]. Australia: World Vision; July 2008. Country Profile – Vanuatu [cited 2015 March 20]. Available from: http://www. worldvision.com.au/Libraries/3_1_2_Country_ Profiles_-_Asia_Pacific/Vanuatu.pdf

10. Government of Vanuatu. Vanuatu Postdisaster needs assessment: Tropical cyclone Pam, March 2015. Port Vila, Vanuatu; Government of Vanuatu; 2015 March [cited 2015 Sep 10]. 172 p. Available from: https://www. gfdrr.org/sites/default/files/publication/Vanuatu_ PDNA_Web.pdf

3. Commonwealth Health Online [internet].

Cambridge: Commonwealth Health Online; 2015. Health Systems in Vanuatu [cited 2015 March 19]. Available from: http://www. commonwealthhealth.org/pacific/vanuatu/health_ systems_in_vanuatu/ 4. World Health Organisation [internet]. Geneva: collaboration between WHO and Ministry of Health, Vanuatu; 2012. Health Service Delivery Profile Vanuatu 2012 [cited 2015 March 21].

Available from: http://www.wpro.who.int/health_ services/service_delivery_profile_vanuatu.pdf

11. Global Health Group [internet]. Eliminating malaria in Vanuatu. San Francisco: Global Health Group; August 2013 [cited 2015 June 25].

Available from: http://static1.1.sqspcdn.com/ static/f/471029/23665701/1381362226433/ Vanuatu.

6. World Health Organisation [internet]. Geneva: WHO; 2012. Countries – Australia [cited 2015 March 21]. Available from: http://www.who.int/ countries/aus/en/

About the Author

Phoebe Shiu is a 6th year medical student studying at James Cook University, Queensland. She has a special interest in Global Health and is looking forward to working with underserved populations. Phoebe travelled to United Nations Environments Assembly in Kenya as part of a Global Voices delegation, which further sparked her interest in sustainability in healthcare and policy making. In the future, she hopes to combine both travel and medicine by volunteering and working overseas.

Abstract

INTRODUCTION A UN-Habitat (United Nations Human Settlements Programme) report projects that one in three of the world’s population will live in urban informal settlements by 2030. [1] In Nairobi, there is significant rural to urban migration with a significant proportion of population growth being directed into the slums. More than 60 percent of the city’s population of more than 3 million resides in slum communities, which occupy only 5 percent of the total residential land area. This rapid rate of population growth in urban areas is concerning as it exceeds the rate of possible economic development [2] and is not accompanied by equivalent socio-economic and environmental development. [3]

7. GBD Profile: Vanuatu [internet]. Seattle: Institute for health Metrics and Evaluation; 2010 [cited 2015 March 20]. Available from: http:// www.healthdata.org/sites/default/files/files/ country_profiles/GBD/ihme_gbd_country_report_ vanuatu.pdf 8. World Health Organisation: Western pacific region. Tenth pacific health ministers meeting; Health workforce development in the pacific.

Apia, Samoa; WHO; 2013 July 4 [cited 2015 Sep 14]. 23 p. PIC 10/10. Available from: http://www. wpro.who.int/southpacific/pic_meeting/2013/ documents/PHMM_PIC10_10_HRH.pdf 9. UNICEF Australia [internet]. UNICEF; 2015.

Cyclone Pam: UNICEF Australia emergency update for Monday, March 16 [cited 2015 March 22]. Available from: http://www.unicef.org.au/ Media/Media-Releases/3--2015-March/CyclonePam----Emergency-update-Monday,-March-16. amsa global health

Phoebe Shiu

Child mortality remains a significant concern globally with 6 million deaths in children under 5 years of age in 2012. In relation to Millennium Development Goal (MDG) 4 to reduce vaccine-preventable disease mortality and morbidity by two-thirds by the end of 2015 compared to 2004, Sub-Saharan Africa is unlikely to reach this target with the current projection. In Kenya, childhood mortality remains highly elevated and this can be correlated to a number of risk factors including poor physical environments, limited access to resources and medical facilities, lack of maternal welfare and antenatal care, and outbreaks of infectious disease. This is especially evident in low resource settings such as informal settlements, or slums as they are colloquially referred to, in Kenya’s capital, Nairobi. Despite there has been some effort to address the health and living conditions of slum dwellers, more actions are required to improve the health and quality of life in this population. Some fundamental examples include interventions relating to immunisation programmes, water sanitation, and safe waste removal. Diversity in racial and ethnic origins, cultural taboos and sensitivities must be considered when formulating policies and interventions. This article will explore and discuss barriers and focus on strategies and changes that can be implemented to raise the health status. In particular, immunisation strategies will be examined and discussed as a major intervention in the minimisation of childhood mortality rates.

5. World Health Organisation [internet]. Geneva: WHO; 2012. Countries – Vanuatu [cited 2015 March 21]. Available from: http://www.who.int/ countries/vut/en/

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Review Article Health in Low-Resource Settings: A Case for Public Health Measures in Nairobi’s Informal Settlements

The UN-Habitat defines slum as a community characterised by insecure residential status, poor structural quality of housing, overcrowding, inadequate access to safe water, sanitations and other infrastructure. [4] It is associated with a high volume 10, issue 18

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concentration of poverty and substandard living.

There is also insecurity of tenure and marginalisation from the formal sector, including basic health services. It is an area of concentrated disadvantage.

Slums are characterised by population density and diversity where the population is often transient, thus erecting unique barriers which stand in the way of achieving health, especially in the context of continuing care. [5] In the context of Nairobi, the city is comprised of seven divisions which contain over 78 informal settlements with Kibera, Korokocho and Kasarani making up the top three slums in terms of population. [2] Disaggregated urban data shows health outcomes in slums are often worse than similar groups in rural communities, especially with regards to infant and under-five mortality rates. [6] A number of factors attributed to poor health outcomes include limited access to healthcare services, lack of finances, and poor health seeking behaviours. [1] The rapid increase in population density further exacerbates volume 10, issue 18

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the social and medical problems in these resource poor settings. [2] In particular, vaccine-preventable infectious diseases, which often progress to end-stage diseases, are a major burden for the communities as they may require high-level care and treatment. [4] Child immunisation has been identified as a key factor in the prevention of many communicable diseases, as it is considered and has been proven to be the most cost-effective and efficient method of preventative health. [7] The increased rural to urban migration is associated with a decline in health due to negative trends in immunisation and lack of access to resources such as clean water. [7] Due to the complex nature of slums, factors such as cultural appropriateness cost, and accessibility must be considered for successful health interventions.

THE NATURE OF INFORMAL SETTLEMENTS IN NAIROBI Physical Environment Nairobi, the capital of Kenya, is situated in the South West of the country. It is Kenya’s largest city with a population of over three million people. [8] The annual rate of population growth in Nairobi is 4.3 percent, which is primarily due to the ruralurban migration, also known as the ‘urbanisation of poverty’ with 75 percent of the population growth occurring in informal settlements.

Over 70 percent of the population in Nairobi resides in informal settlements where the physical environment is hazardous to health and is characterised by: a lack of basic services such as roads or waste disposal; [2] substandard housing; illegal or inadequate building structures; overcrowding; and a high population density. [5,8] The dwellings are generally poorly constructed with temporary materials that have been carried away by the floods during wet season. [2] Despite the Kenyan government owning all land upon which these informal settlements stand, it continues to not officially acknowledge these settlements. [5] This translates to a near absence of any formal or official basic government services or facilities including schools, clinics, running water, electricity, or proper lavatories. [3] In the rare instances that these facilities do exist, they tend to vector journal

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be privatised services in which cost erects a barrier for access. [3] Waste disposal and water sanitation facilities are absent, along with any formal services providers such as basic healthcare. These poor living conditions leave a negative impact on the health of the residents as there is limited access to safe drinking water, sanitation, garbage and sewage treatment. All of these factors add to the increased prevalence and spread of pathogens, thus perpetuating constant infection and risk of an epidemic in slum dwellers. [2, 5] Health and Social Services Private clinics and private pharmacies are the most popular destinations for health-seeking individuals. However, these private institutions are generally managed by unlicensed or poorly trained professionals, sometimes non-professionals, and are often associated with poorer health outcomes.

[6,9] The health and disease pattern of the slum dwellers is congruent with the physical environment of the informal settlement. Water, in particular, is concern with difficulty with access, cost, and quality. The access points for water collection is only located far from their houses, and water collection may even only be available on certain days and times.

These barriers result in resident using sewage for bathing and washing, or using other sources, such as borewater and rainwater. All of these sources are highly contaminated and perpetuates the spread of waterborne diseases. [3] Legal Issues and Crime According to Mutisya and Yarime, the Kenyan government policies have yet to focus on making low-cost housing available, or providing populations within these informal settlements with viable longterm alternative which have further exacerbated the growth of slums. [3] In particular, informal settlements have been excluded from city authority planning and budgeting processes. Furthermore, the people who undergo the rural to urban migration in search of employment often have no realistic alternative to life as slum dwellers.

This results in a state of hopelessness which volume 10, issue 18

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leads to an environment and a population who are vulnerable to maladaptive coping mechanisms such as self-medicating with alcohol, addictive substances and drugs. In addition, difficulty accessing education, employment, or recreational facilities translates to unlimited free time, which further increases their risk to alcohol, drugs, and crime, which is prevalent in informal settlements.

[10]

vicious cycle of low education and poverty.

Often school are initiated as business ventures and do not meet their requirements as learning institutions. The class size ranges from 50 to 60 students, and are often lead by unqualified teachers. [2] MILLENIUM DEVELOPMENT GOAL 4 AND SUSTAINABLE DEVELOPMENT GOAL NOTE #1

Adding to the list of social issues within slums is the increase in commercial sex workers, and easy access of a list of drugs and substances including bhang (marijuana, cocaine, glue, petrol, and chang’aa (an illicit local brew believed to be responsible for both morbidity and mortality in users). [10]

The target of Millennium Development Goal (MDG) 4 is to reduce the under-five mortality rate by twothirds between 1990 and 2015. There is overall progress with MDG 4, but Sub-Saharan Africa is amongst the regions showing the least progress in reducing the child mortality rate. Statistics show an increasing trend of child death within Employment the first month of live in these regions due to many factors including: [12] high communicable Due to the complex nature of the illegal status of the disease prevalence and transmission (constant slums and the residents, health and social services risk of epidemic); [2] overcrowding; poor hygiene; are virtually non-existent within these settlements. contaminated water sources. [4,13] With the [10] For the same reasons, slum dwellers are expiration of the MDGs imminent, it is unlikely often excluded from the usual benefits provided that the target will be reached in Kenya. Neonatal to or required for formal sectors. In essence, slum mortality rates are especially grim in the slums of dwellers are often employed and exploited on a Nairobi. The under-five mortality rate in Nairobi day-to-day basis on low wages. [3,11] slums is 156 per 1000, which is greater than any other urban site within Kenya. [1] In a study published by La Ferrara, the main source of income for slum dwellers takes the It is equally important to consider the sustainability form of hawking, short term day employment, of any health interventions that are implemented and the operation of small businesses without to improve the status of public health in urban licenses. Something positive within these informal informal settlements in Nairobi. In accordance settlements are these ‘self-help groups’ that with sustainable development goals (SDG) Note are comprised of sub-populations, in particular 1 titled “Leave no one behind and provide a life of women, who support each other and pool together dignity for all”, improving the health of vulnerable their resources to build social capital for start-up and at-risk populations can help improve their projects. [11] standard of living and quality of life by reducing any disabilities or limitations stemming from chronic Education end-stage diseases that are easily preventable.

[13] For example, at risk populations are vulnerable The education level in populations in informal musculoskeletal injury and their chronic sequelae, settlements is low. Only 14 percent of the [13] mental illnesses, complications of substance population have completed high school, and abuse, and chronic infections, all of which can 33 percent have not attained education beyond negatively impact their psychological and physical primary school. [2] A mere 2 percent have achieved ability to find and retain employment, or the ability post secondary school education. Within the to care for their self and family. [13] It is imperative slums, schooling facilities are inadequate and that effort and energy is diverted into prevention often inappropriate. Most schools are initiated strategies to stop precipitating events leading to as business ventures and do not meet the poor health from occurring. Strategies such as requirements for a learning institution. Moreover, vaccination and maternal education beginning attendance remains low hence perpetuating the from the antenatal period have been shown to be vector journal

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effective in improving neonatal mortality rates, and improve the health status of children.

At present, informal settlements comprise 43 percent of combined urban populations in all developing countries. [6] The urban regions are home to 78 percent of the population in the least developed countries. Current trends show a significant continuing shift towards urbanisation of population in one-third of the world’s population projected to live in urban informal settlements by 2030. [6] Hence, it has become increasingly important to address the issues leading to concentrated disadvantage in slum dwelling populations including: physical environments hazardous to health; lack of health and social services due to the illegal nature of slums; increasing crime rates; and poverty of opportunity in education and employment. [2,10] Recognising informal settlements into government planning and budgeting will assist in building the necessary basic infrastructure (roads, water sanitation, sewage treatment, and waste disposal), and fund primary healthcare centres which is expected to have a positive impact on the health status of the slum population.

THE EVIDENCE FOR IMMUNISATION AS A HEALTH INTERVENTION According to WHO, immunisation remains one of the most successful and cost effective health interventions to date, [14] with an estimated six million deaths prevented worldwide annually.

[15] WHO also estimates that 2.5 million deaths amongst children under 5 years of age worldwide are prevented annually through immunisation against diphtheria, tetanus, pertussis, and measles.

[12] The expanded programme on immunisation (EPI) in Kenya is primarily funded by the Kenyan Government and the GAVI Alliance (International organisation funded by public and private sectors for the increase of vaccination coverage. [16] Immunisation programmes have a positive effect on public health and disease control through eradication and elimination of communicable diseases with potentially fatal outcomes. [17] For example, smallpox has been successfully eradicated globally through population immunisation and surveillance for health and outbreaks. Elimination involves high levels of immunity in the population whereby transmission vector journal

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no longer occurs indigenously, and imported cases no longer result in sustained transmission leading to epidemics. Furthermore, immunisation also have a positive health impact, not only on the population being vaccinated, but also in reducing disease incidence amongst non-vaccinated individuals.

This indirect effect, known as ‘herd immunity’, [9,18] occurs when transmission of the disease is decreased in a population with high levels of immunity, thus essentially breaking the chain of infection. Herd immunity have been demonstrated in Gambia with Hib vaccine (for the prevention of influenza caused by the pathogen Haemophilus influenze type b) coverage of approximately 70 percent of the population, there were similar findings in a West African Community vaccinated against Pertussis, commonly known as Whooping Cough. [19] There is compelling evidence in favour of vaccinations for the reduction of death and disease, as well as minimising the associated burden to the health care system. There is also mitigation of disease severity with multiple studies showing evidence of decreased severity with shorter duration of illness in vaccinated populations in comparison to unvaccinated populations. [15, 1921] On an individual basis, there is a reduction in the burden on health and better prevention of chronic sequelae from vaccine-preventable infectious disease.

CURRENT NATIONAL IMMUNISATION PROGRAMME IN KENYA The Global Immunisation Visions and Strategy (GIVS) was approved and endorsed in the World Health Assembly in 2005. The primary objective of GIVS aligns with MDG 4 and SDG Note 1 in terms of reductions in morbidity, mortality and disability due to life threatening infection from vaccine-preventable diseases by two-thirds. The Division of Vaccines and Immunisation (DVI) under the Ministry of Public Health and Sanitation of Kenya have formulated a multi-year plan running from 2011 to 2015. To minimise and prevent children from succumbing to infectious diseases that are prevalent in the community, especially low resource settings, a specific programme for infants has been formulated to reduce childhood mortality rates. Immunisations included in this programme include vaccines against tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, hepatitis volume 10, issue 18

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B, Haemophilus influenza type b, measles, and pneumococcus51. All of these diseases are highly infectious and are significant contributors to child mortality rates. The immunisation schedule for Kenya also has additional vaccinations, such as yellow fever, for children in high-risk populations and districts. The vaccines are provided free of charge to the recipients.

The African Population and Health Research Centre (APHRC) facilitates the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) which runs research projects and data collection on longitudinal Maternal and Child Health within the Korogocho and Viwandani slums of Nairobi. [6,9] The NUHDDS project enrolled women in these areas which have given birth since September 2006, and administered a questionnaire about the vaccination history of their children. Data was collected from 1848 children aged 12-23 months who were expected to receive all the WHOreccommended vaccinations. [9] Compared to the estimated global DTP3 (diphtheria-tetanuspertussis3) immunisation coverage of 83%, [22] there are regions in Sub-Saharan Africa where communities are significantly undervaccinated.

[23] Within Kenya, the number of children who are reported to have received complete vaccination range from 48.5 percent in the North Eastern regions, and 85.8 percent in the Central regions.

[24] Focussing on Nairobi, 74 percent of 12-23 month old are reported to have completed the WHO recommended vaccination programme, [24] but the percentage drops to 44 percent for children living in informal settlements. [6] In this particular study, Mutua et al, found that protective factors for complete vaccination according to the WHO recommended guidelines include older maternal age, maternal education (primary school), low parity with previous vaccination nation with older siblings, birth taking place in a health facility, and attendance of antenatal and postnatal care follow-up. Maternal age under 20, high parity, and education levels lower than primary school were identified as risk factors. [9] The study concludes that children living in slums are underserved with vaccinations with the limited and lack of access to public health facilities flagged as a major barrier. [9] This is an important consideration to take into account when formulating new public health policy.

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In addition to the routine vaccination schedule, the Kenyan Ministry of Health also conducts supplemental immunisation activities (SIA) to identify and minimise gaps in health and increase the vaccination rate. Essentially, the aim of SIAs is to address inequities in the vaccination coverage, especially in sub-populations, who were not targeted or were missed with regards to the routine vaccination programmes. This may be achieved by delivering the standard vaccination schedule and catch-up immunisations. Other goals of the SIAs include documenting the coverage and epidemiology of health within the targeted populations in addition to micronutrient supplementation (Vitamin A, zinc and electrolytes) to boost the general health and immune status. [25] Vulnerable populations living in the slums benefit the most from SIAs due to their poor vaccine coverage with routine programmes. The SIAs were also able to reach the small percentage of the previously unreached population in high-coverage districts.

[25] Vaccinations are primarily given in fixed temporary sites, most often in venues such as schools, churches and mosques. [25] Due to the informal and often illegal nature of the slums, there is very little infrastructure and few facilities contained within the complex. As a result, there is the implication of decreased rates of health seeking behaviour and vaccination due to the physical barrier of distance. This argument is supported by a study which demonstrated a general trend of mothers with unimmunized children living the furthest from vaccination sites, as well as comprising the lower end of the wealth and social status. [26] Furthermore, as shown in Bangladesh there is evidence to show increased vaccination coverage amongst children who are within close proximity to vaccination venues and clinics. [27,28] Funding of the GIVS Expanded Programme on Immunisation The targes of the EPI of the Kenyan DVI are to increase vaccination rates through routine immunisation of children with outreach strategies with particular attention diverted at sub-populations with elevated risk factors, such as children in the lowest socioeconomic brackets and slum residents.

The particular EPI has secured over $46 million of funding in 2011, and the amount will increased volume 10, issue 18

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to $91 million by the end of 2015. In addition, the Kenyan Government, and the GAVI Alliance, other significant financial donors include WHO, UNICEF, and foreign aid. [6, 23, 29] According to WHO Global Health Observatory Data, the expenditure for public health in Kenya is 4.49 percent of their Gross Domestic Product (GDP) or USD 14.35 per capita which remains low on the global scale despite increasing from previous years. [30] The low funding is a key factor leading to and perpetuating poor health status and outcomes. overflow effects of poor health conditions include loss of productivity and decreased socioeconomic growth in communities. Vulnerable populations include slum dwellers, especially due to an increased risk factors associated with absolute poverty, high susceptibility to famine, overcrowding and disease outbreak.

The Australian Government has made some contributions to projects and programmes that assist in achieving the MDGs on a global scale.

The fundamental objective of the former AUSAID programme is to help people overcome poverty through multi-lateral pathways: microscopic and macroscopic finance and economics strategies: health and community engagement; and funding of basic supplies and health provisions. [31] Australia’s Official Development Assistance (ODA) target of 0.37 percent of the gross national income totalling USD 5251 million in the financial year of 2013 – 2014 was met. [31] This translated to USD 429 million donated to Africa and the Middle East, with USD 93 million being allocated to Kenya.

However, with recent changes to AUSAID being amalgamated under the Department of Foreign Affairs and Trade (DFAT), funding to the SubSaharan programme has been cut. The anticipated budget for 2013-2014 of $249.9 million has been slashed to $133 million resulting in the many programmes under this particular portfolio to be completed earlier or have reduced funding[31]. The funding is projected to decrease, and will fall well below the internationally recommended target (ODA target of 0.7 percent of the gross national income) set by the United Nations as a strategy towards meeting the MDGs. Despite the funding cuts to the Sub-Saharan African programme, the Federal Australian Government has pledged $250 million over the five year period of 2011-2015 towards the GAVI alliance, with further ongoing support of another $250 million contribution over 2016-2020. [31] vector journal

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GAVI estimates over 7 million lives have been saved since the implementation of GAVI programmes for children in developing nations.

RECOMMENDATIONS The limited and lack of public health infrastructure in the informal settlements within Nairobi are a major barrier to poor health seeking behaviours and health outcomes in particular in relation to vulnerable population such as women and children.

It is estimated that 21 percent of children under five in Sub-Saharan Africa are moderately or severely underweight. This proportion is increased in children living in slums. [31] Despite the establishment of the EPI and the national immunisation schedule for infants and children, barriers to accessing health services and vaccinations still exist. Common themes include limited maternal education, young maternal age, physical distance, and monetary constraints. With regards to physical barriers, the delivery of antenatal care and immunisation are quite centralised with fixed facilities and posts within Nairobi city.

Strategies to address this issue to implement public health facilities within the informal settlements or outreach services which does increase the cost of delivery. Many studies have shown compelling evidence in favour of publically funded health facilities and with associated positive outcomes in health, [31] thus comprehensive policy making and significant efforts towards building a public health system in slums must be undertaken to help in closing the gap in health disparities.

Furthermore, the establishment of public health facilities within the informal settlements bring along other benefits to the community. There is creation of opportunities for education, training, empowerment, and employment. The opportunity for up-skilling and employment can assist in reducing some of the financial and societal burdens associated with living on or below the poverty line and reduce the unemployment rate within informal dwellings. 48 percent of Sub-Saharan Africans live on less than $1.25 each day, and residents within slums are overrepresented in this statistic. [31] Another major advantage of training local people is the flow-on effect of education and awareness trickling out into the wider community. The intended effects are the dissemination of information volume 10, issue 18

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relating to health and disease implications, raising awareness of risk factors, and more important, the preventative measures involving hygiene and nutrition that can be implemented without specialised equipment. In a population that has been displaced with very little social or community networks and support, community ownership and access to information will lay the foundations in re-establishing connections and reduce gaps in knowledge for health.

CONCLUSION A multitude of factors impact the state of health and wellbeing in low resource settings, such as in the context of informal dwellings in Nairobi. At present, the projection of progress of MDG 4 is not on track for the targets to be reached by 2015, thus child mortality prevention strategies and implementation requires further discussion and efforts at the post2015 agenda meetings.

Many long-standing issues exist including malnutrition, overcrowding, high disease prevalence, and poor access to resources. These issues have a detrimental influence on the health status of the residents of the Nairobi slums, and require long term solutions requiring extensive planning. Immunisation is one of the most cost effective and efficient strategies that can be implemented rapidly and can vastly minimize many of the harmful factors skewing towards infectious diseases and poor health outcomes. In addition, the EPI also supports SDG target of providing a life of dignity for all, especially through improved health of at-risk populations. An emphasis on the DVI having establishments in and working together with the local community should be highlighted as evidences indicate the positive effect of community integrated approaches to healthcare, especially in low resource settings, and to negate cultural barriers which may otherwise impede the delivery of essential immunisations.

References: [1] Taffa N, Chepngeno G. Determinants of health care seeking for childhood illnesses in Nairobi slums. Tropical Medicine & International Health.

2005;10(3):240-5.

[2] Gulis G, Mulumba JAA, Juma O, Kakosova B. Health status of people of slums in Nairobi, Kenya.

Environmental research. 2004;96(2):219-27. vector journal

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[3] Mutisya E, Yarime M. Understanding the grassroots dynamics of slums in Nairobi: The dilemma of Kibera informal settlements.

[4] Riley LW, Ko AI, Unger A, Reis MG. Slum health: diseases of neglected populations. BMC international health and human rights. 2007;7(1):2.

[5] Vlahov D, Freudenberg N, Proietti F, Ompad D, Quinn A, Nandi V, et al. Urban as a determinant of health. Journal of Urban Health. 2007;84(1):16-26.

[6] Population A, Center HR. Population and health dynamics in Nairobi’s informal settlements: report of the Nairobi cross-sectional slums survey (NCSS) 2000: African Population and Health Research Center; 2002.

[7] Fotso J-C, Ezeh AC, Madise NJ, Ciera J. Progress towards the child mortality millennium development goal in urban sub-Saharan Africa: the dynamics of population growth, immunization, and access to clean water. BMC Public Health.

2007;7(1):218.

[8] Oteng-Ababio M. When necessity begets ingenuity: e-waste scavenging as a livelihood strategy in Accra, Ghana. African Studies Quarterly.

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[9] Mutua MK, Kimani-Murage E, Ettarh RR. Childhood vaccination in informal urban settlements in Nairobi, Kenya: who gets vaccinated? BMC public health. 2011;11(1):6.

[10] Mugisha F, Arinaitwe-Mugisha J, Hagembe BO. Alcohol, substance and drug use among urban slum adolescents in Nairobi, Kenya. Cities.

2003;20(4):231-40.

[11] Fafchamps M, La Ferrara E. Self-help groups and mutual assistance: Evidence from urban Kenya. Economic Development and Cultural Change. 2012;60(4):707-33.

[12] Economic UNDo. The Millennium Development Goals Report 2008: United Nations Publications; 2013.

[13] Un-Habitat. The challenge of slums: global report on human settlements 2003. Management of Environmental Quality: An International Journal.

2004;15(3):337-8.

[14] World Health Organisation 2005. WHO Global Immunisation Vision and Strategy 2006-2015.

Geneva: World Health Organisation.

[15] Ehreth J. The global value of vaccination.

Vaccine. 2003;21(7):596-600.

[16] Division of Vaccines and Immunization (DVI) Multi Year Plan 2011-2015, in Ministry of Public Health and Sanitation (ed.), (1st edn.; Republic of Kenya ).

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John T, et al. Vaccination greatly reduces disease, 2013-14: Sub-Saharan Africa Program. disability, death and inequity worldwide. Bulletin of the World Health Organization. 2008;86(2):140-6.

[18] Anderson RM, May R. Immunisation and herd immunity. The Lancet. 1990;335(8690):641-5.

[19] Préziosi M-P, Yam A, Wassilak SG, Chabirand L, Simaga A, Ndiaye M, et al. Epidemiology of pertussis in a West African community before and after introduction of a widespread vaccination program. American journal of epidemiology.

2002;155(10):891-6.

[20] TAYLOR WR, MA-DISU M, WEINMAN JM. Measles control efforts in urban Africa complicated by high incidence of measles in the first year of life.

American journal of epidemiology. 1988;127(4):78894.

[21] Ruiz-Palacios GM, Pérez-Schael I, Velázquez FR, Abate H, Breuer T, Clemens SC, et al. Safety and efficacy of an attenuated vaccine against severe rotavirus gastroenteritis. New England Journal of Medicine. 2006;354(1):11-22.

[22] WHO U. Global immunization data. 2008.

[23] Organization WH. WHO vaccine-preventable diseases: monitoring system: 2009 global summary.

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[24] KNBoS. Kenya Demographic and Health Survey 2008-09: Kenya National Bureau of Statistics; 2010.

[25] Vijayaraghavan M, Martin RM, Sangrujee N, Kimani GN, Oyombe S, Kalu A, et al. Measles supplemental immunization activities improve measles vaccine coverage and equity: Evidence from Kenya, 2002. Health Policy. 2007;83(1):27-36.

[26] Streefland P, Chowdhury AMR, RamosJimenez P. Quality of vaccination services and social demand for vaccinations in Africa and Asia. Bulletin of the World Health Organization.

1999;77(9):722-30.

[27] Jamil K, Bhuiya A, Streatfield K, Chakrabarty N. The immunization programme in Bangladesh: impressive gains in coverage, but gaps remain.

Health Policy and Planning. 1999;14(1):49-58.

[28] Bhuiya A, BHUIY I, Chowdhury M. Factors affecting acceptance of immunization among children in rural Bangladesh. Health policy and planning. 1995;10(3):304-11.

[29] McCoy D, Chand S, Sridhar D. Global health funding: how much, where it comes from and where it goes. Health policy and planning.

2009;24(6):407-17.

[30] WHO U. Global immunization data. 2013.

[31] Australian Government. Department of Foreign Affairs and Trade. Aid Program Performance Report vector journal

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When Health is the Last Priority Cecilia Xu

About the Author Cecilia is a third year medical student at Monash University in Melbourne. Homelessness is an issue that she has felt strongly about for a long time, but felt lacked the knowledge and confidence to act on her concerns. It is her hope that this article will offer practical suggestions for improving healthcare for the homeless population and empower current and future health professionals like herself to be a part of the solution to homelessness.

Abstract On any given night, 1 in 200 Australians are homeless. Evidence shows that being homeless is associated with an increased risk of poor health, yet for many people without adequate housing, healthcare is but a luxury.

What can we as advocates for health do when for some, health is the last priority? In an attempt to address this question, this article first provides an overview of the homelessness issue in Australia and explores some of the current strategies for addressing homelessness. An evaluation of the effectiveness of these strategies reveals that while current response-based housing efforts yield positive results, an all-encompassing approach, consisting of response-based and prevention strategies, is needed for more meaningful and effective services in the prevention and management of homelessness. The knowledge gained from evaluating current strategies is useful in directing future homeless policy, specifically, an increased focus on preventative strategies that identify risk factors, prevent homelessness at its source and support families and individuals to maintain tenancy. The final section of this article provides evidence-based recommendations for medical practitioners and other health care workers in the identification, prevention and management of homelessness. These recommendations include recognising patients at risk of homelessness and taking preventative action to ensure they remain safely housed, obtaining a comprehensive social history, understanding the specific needs of homeless people and the barriers they face to healthcare, making timely and appropriate referrals, and practising compassionate care.

Introduction “Everyone has the right to a standard of living adequate for the health and well-being of themselves and their family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond their control.”

Universal Declaration of Human Rights [1] It is a rainy day in Melbourne city and I am on a street corner, pressing a few coins into the hand of a middle-aged man named George . I wonder aloud what kind of healthcare he has access to, if he ever needs to see a doctor. “Miss,” he replies, “I’m not really worried about healthcare right now. I just need to start eating properly. I’m wasting away.”

I look at the greying clothes hanging off his body and I know he is right.

On a separate afternoon in the city, I’m sitting near a busy intersection with a young woman who introduces herself as Myra. She has three copies of The Big Issue held up with one arm and a sleeping corgi with a pink collar - Bailey- cradled in the other.

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The magazines sell for $6 each, $3 of which is kept by the vendor. “Kept by Bailey,” she corrects me.

“She was kicked in the ribs a few days ago and is running out of painkillers. Once she gets those, I might look into accommodation for the night.

Then I’ll think about food.” She lists her priorities in order of importance. “Dog, accommodation, me.”

Healthcare is not even on the radar.

In the medical profession we are often concerned with the latest advancements, the newest drugs on the market or the efficacy of one procedure over another - and we should be. But when confronted with people at the very edges of society like George and Myra, all of that seems superfluous. What can we as advocates for health do when for some, health is the last priority?

In an attempt to address this question, this article will provide an overview of the homelessness issue in Australia and explore some of the current strategies for addressing homelessness and evaluate their effectiveness. This will lead to further discussion on future directions in homelessness policy. Finally, the article will discuss the role of the health system and medical practitioner and provide volume 10, issue 18

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who are disadvantaged by their circumstances to rebuild their lives, improve their health, increase their participation in the community and contribute to the Australian economy.[4] In addition, addressing homelessness is a step towards ensuring all people enjoy the fundamental human right of having a place to call home.

Current strategies

some recommendations for medical practitioners to adopt in their practice in order to help prevent and manage homelessness for patients.

The homelessness issue Homelessness is defined by the Australian Bureau of Statistics[2] as a current living arrangement that: • is in a dwelling that is inadequate; or • has no tenure, or if their initial tenure is short and not extendable; or • does not allow them to have control of, and access to space for social relations.

By this definition, homelessness cannot be considered as merely the absence of a ‘roof’.

It encompasses persons living in improvised, temporary, severely crowded or otherwise inadequate dwellings, and therefore not all who are homeless can be seen out in public spaces.

In the 2011 Census [3] just over 105,000 people in Australia were estimated to be homeless. This equates to approximately 1 in 200 Australians.

Contrary to the belief that homelessness primarily affects older men, 60% of the homeless were aged under 35 years and nearly half were women.

Homelessness is a manifestation of a myriad of social issues, including domestic violence, a shortage of affordable housing, unemployment, mental illness, family breakdown and drug and alcohol abuse.[4] The most common reason for people to seek support from homelessness vector journal

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agencies is financial difficulty, followed by domestic and family violence.[5] Homelessness is associated with poor health for a number of reasons. Health issues can be both a cause and a consequence of homelessness, and homelessness may exacerbate illnesses that are pre-existing. Being homeless is associated with increased risk of depression and suicide,[6] poor dental health, eye problems, podiatry issues, infectious diseases, sexually transmitted disease, pneumonia, lack of preventive and routine health care and inappropriate use of medication.[4] When health is the last priority, or when services are not readily accessible, many who are homeless have no choice but to allow illnesses and injuries to progress until they are severe. Consequently, people who are homeless use hospital emergency services at higher rates than the general population, and to be treated for conditions and injuries that are worsened by being homeless.[7] From an economic perspective, the Commonwealth Government spends annually $30,000 more on people experiencing homelessness for the same services than those who are stably housed. The potential savings, if homelessness and therefore its associated costs were addressed, total up to $1 million per person over an average lifetime.[8] Decreasing rates of homelessness will allow those volume 10, issue 18

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In 2008, the first White Paper on homelessness (National Affordable Housing Agreement)[4] was released. The agreement set the ambitious target of halving homelessness by 2020, with plans to increase current investment in homeless services by 55% implement additional housing for homeless people and supporting victims of domestic violence to stay in their homes safely. The paper reported that current efforts to reduce homelessness in Australia were inadequate, and if no additional action was taken, it predicted that rates of homelessness would rise.[9] As an extension of efforts in 2008, three National Partnership Agreements were made between all Australian States and Territories in 2009 in response to the National Affordable Housing Agreement.

1. The National Partnership Agreement on Homelessness[10] committed $1.1 billion of funding over 5 years for the construction of 600 new homes for homeless families and individuals as well as provision of homeless support services.

2. The National Partnership Agreement on Social Housing[11] committed $400 million of funding over 5 years for the construction of new, affordable, social housing dwellings targeted towards people who were homeless or at risk of homelessness.

3. The National Partnership Agreement on Remote Indigenous Housing[12] committed $5.5 billion of funding over 10 years for the reduction of overcrowding, homelessness and poor housing conditions in remote Indigenous communities.

It is evident from the distribution of funding above that significantly more funding is directed towards building homes and managing homelessness than on preventing homelessness in those who are at risk. Undoubtedly, both response and prevention-based strategies play crucial roles in the reduction of homelessness in Australia. However, it is important to examine the benefits delivered by each type of service in order to evaluate their costeffectiveness and direct future funding. vector journal

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Response-based strategies consistently yield significant positive outcomes for clients. In an evaluation of 14 homelessness programs in Western Australia aimed at moving clients into longterm accommodation most programs exceeded their target number of clients assisted and were able to obtain and maintain accommodation for these clients.[13] Being accommodated led to improved health, return to work or study, maintenance of sobriety for sufferers of addiction, and restoration of dignity, self-respect, confidence and independence. Similarly, the Accommodation Options for Families (AOF) initiative in Victoria was able to achieve long-term housing for 74 previously homeless families.[14] Clients reported less stress and anxiety, improvements in their children’s health and improved ability to meet their children’s needs in terms of meals, access to healthcare and educational support.

However, the positive immediate and long-term benefits of response-based housing initiatives demonstrated by programs like the AOF are not extrapolated to all programs in Australia. Evaluation of Sydney’s Way2Home service 2012[15] part of Street to Home initiative, which involved assertive street outreach, immediate access to secure housing and ongoing ‘wrap around’ support, revealed that 90% of clients sustained housing over a 12 month period. Clients reported reduced psychological distress and improvements in nearly all measures of quality of life and satisfaction.

However, there were no improvements in the low rates of employment, education, training and job-seeking behaviours among clients after the 12 month period of accommodation compared to baseline.[15] A similar limitation is seen with the Housing First approach, which is based on the concept that a homeless individual or household’s first and primary need is to obtain stable, permanent housing, after which more enduring issues can be appropriately addressed.[16] While the retention rate of this approach has been quoted in one randomised control study as 66%,[17] there is no strong evidence to suggest that the Housing First model affects rates of substance abuse, social isolation or loneliness.[18] The literature makes it clear that simply providing a homeless person with a house is not always enough to facilitate their integration into society, as the underlying social determinants of homelessness volume 10, issue 18

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such as employment and education are not addressed. In many cases, accommodated clients who receive no additional support will therefore continue to be at risk of social disadvantage or return to homelessness.

Another limitation is that as long as the causes of homelessness are not addressed through prevention strategies, people will continue to become homeless and place overwhelming burden on housing and support services. In the Queensland Government’s Responding to Homelessness strategy in 2005,[19] $235.5 million of funding was spent on building new homes and providing support services over a period of four years. Initiatives were able to increase the quantity of accommodation and support services, but the gains were overtaken by increasing demand.[19] The evidence presented here shows that current response-based housing efforts are effective, however only to an extent. Homelessness programs should focus on holistic and sustainable approaches in conjunction with response-based efforts. An all-encompassing approach, consisting of response-based and prevention strategies, is needed for more meaningful and effective services for the prevention of homelessness and the management of those who are already homeless.

Future directions at the policy level In keeping with the international trend and evidence in reducing homelessness, Australia is shifting away from crisis-based responses that manage the effects of homelessness to focus on preventative strategies that maintain people who are at risk of homelessness in sustainable housing.[20] The benefits of preventative strategies are long-term and cost-effective. In a report on the Supported Accommodation Assistance Program,[21] almost all clients at imminent risk of homelessness who received support to retain their current tenure remained housed after 12 months. Furthermore, a cost-effectiveness analysis on this program found that the cost of health and justice services is higher for clients of homelessness programs than in the general population, however, the potential cost offsets by providing assistance to these clients is substantially greater than the cost of support.[21] Women and children escaping domestic and vector journal

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family violence are particularly vulnerable to homelessness, with the majority of women seeking assistance from homelessness support services in Australia for this reason.[5] They are therefore a major target for preventative strategies and initiatives. An evaluation of the ‘Staying Home Leaving Violence’ (SHLV) initiative,[22] which involved intensive case management, an integrated system with partnership with key agencies and elements of community awareness, showed success in supporting women to maintain tenancy in situations of domestic violence. The authors concluded that Australia should implement provision of homelessness prevention schemes that are as extensive as the current provision of refuge and crisis accommodation. Furthermore, an unrestricted eligibility criteria, good social marketing and the provision of both practical and emotional support were identified as key elements of an effective preventative strategy in this cohort.

Based on this evidence on current and previous strategies for reducing homelessness, both responsive and preventative services are required.

In saying this, there is an overall scarcity of evidence regarding the structure and effectiveness of preventative strategies, as few preventative strategies have been implemented in the past.

Consequently, there is currently no clear model to aid in the design and execution of new preventative programs.[23] However, what evidence there is shows that preventative strategies hold promise for long-lasting, cost-effective reform, and as more programs of this kind are implemented, their effectiveness can be evaluated and the information used to shape future policy and practice. Housing services alone are not sufficient in addressing the issue of homelessness, and should always work in the context of a supportive framework that aims to maintain people in their homes.[23] Current best practice for the identification, prevention and management of homelessness for medical practitioners and health care workers Health practitioners can play a significant role in reducing homelessness through early interventions, preventative strategies and responsive strategies.

Their role can be divided into three key areas of action: 1. identification of those at risk of becoming volume 10, issue 18

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homeless, particularly where a health issue may result in homelessness; 2. initiation of preventative care in those at risk of becoming homeless, including referrals to non-clinical support services; 3. and provision of targeted healthcare towards those already experiencing homelessness.

The first step in the prevention of homelessness in the healthcare setting is to recognise those who are at risk of becoming homeless.[24] Key risk factors include mental illness and substance abuse; marital breakdown and a history of abusive relationships, transitions out of institutionalised care and financial difficulty.[25] In young people, the three groups most at risk of homelessness are Indigenous school students, young people from single parent and blended families, and teenagers who have been in state care and protection.[26] The Indigenous population is continually over-represented in the homeless population, especially in remote areas, where 71% of clients at specialist homelessness services were of Aboriginal and Torres Strait Islander descent.[3] Furthermore, gaining a good social history can facilitate in the identification of at-risk patients.

Patients may not always present to their general practitioner with these social issues as their chief concern, therefore routine questions around mental health, substance use, occupation status, family relationships, financial stressors and current living situation should be used in every consultation, regardless of the presenting complaint.

In some situations however, obtaining a helpful social history and assessing risk based on this history may prove challenging for medical practitioners. For this reason, tools such as the Homelessness Assets and Risk Screening Tool (HART) from Canada have been developed.[27] The HART consists of a patient questionnaire and includes questions on current housing status, income and education and social supports. The HART was evaluated in a clinical context and showed promise in identifying risk and protective factors in individuals in the community.[27] The HART and similar tools could therefore be used to identify at-risk individuals in the setting of general practice or community service.

Enquiries about social history and housing status should extend beyond general practice. The vector journal

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National Affordable Housing Agreement[4] has put forward a ‘no entry into homelessness’ policy as part of its strategy for reducing homelessness. The policy has a focus on the hospital setting as an opportunity for enquiring into a patient’s housing situation and ensuring that they are discharged with housing arrangements in place. A study conducted in the United States [28] showed that assessing the housing status of a patient at discharge was independently associated with higher rates of discussions about cost of medications, physical activity levels, diet, transportation, and mental health follow-up.

In those identified to be at high risk of homelessness, it is then important to address the health and social issues specific to that person in order to prevent their relationships, jobs and housing situations from being compromised. A large proportion of this action involves referral, for example to mental health services, addiction clinics, social workers and financial counsellors.[29] The Homelessness Australia webpage also contains a useful list of specialist services for referral of at-risk patients.[30] In addition to recognising and managing those at high risk of homelessness, clinicians should also be able to provide services to those who are already homeless. The medical care of a homeless person requires an understanding of both their specific needs and the barriers they face to healthcare. A recent report on a healthcare provision program for the homeless in the Netherlands[29] identified a need for the care of homeless patients to be holistic and multi-faceted. A narrow focus on the patient’s acute physical problems resulted in patients who are homeless feeling neither heard nor understood, which negatively affected the frequency of their service use. Treating only the presenting complaint is of little value as homelessness can impede on adherence to treatments and lead to reoccurrence of and worsening of health problems.[31] In response to the need for holistic care, practitioners in the afore mentioned Dutch program also increased cooperation with institutions such as addiction centres, mental health care institutions, case management organisation, domiciles, employee recruitment centres and welfare institutions as the program progressed. This allowed practitioners to address social problems, that were often strongly linked to the patient’s volume 10, issue 18

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current health issue, through quick and efficient referrals. In addition, liaising with homeless shelters also improved treatment adherence as shelter staff were able to supervise medications and encourage clients to attend follow-up appointments.[29] In addition to understanding the healthcare needs of a person experiencing homelessness, practitioners should also be aware of the barriers they face in accessing healthcare. Over half of people who are homeless have mental health and substance abuse issues requiring counselling or treatment, but they are less likely to access health services due to inability to afford co-payment, inadequate insurance coverage, prioritising health below housing and food and lack of information on what help is available.[32] While the three former barriers call for changes to public policy, the latter barrier is an issue that health workers can directly help to address. Acquiring and passing on knowledge of the services available is a simple yet effective way to provide practical help to those who require it.

Many of the issues faced by homeless people, including domestic violence, mental illness and substance abuse, are deeply personal and sensitive in nature. When doctors practise empathy, such as mirroring the patients’ nonverbal cues, patients feel more comfortable and give fuller histories.

[33] Furthermore, compassionate management of homeless adults in hospital has been shown to decrease repeated visits to the emergency department.[34] Indeed, the importance of empathy and a humane focus on individuals who are homeless may be underestimated. Most importantly, empathy is a component of a clinical encounter that anyone can offer, including students who might lack the knowledge and expertise to provide clinical advice. One does not have to be a policy-maker or a healthcare worker to make a positive impact on a homeless person’s life.

Towards the end of our conversation, I asked Myra if there was anything one could give to someone like her that was better than money. Her answer came without hesitation, “say a kind word. Don’t look down on them. When people walk past, read my sign, and ignore me - that hurts. But a kind word really helps.”

homelessness is occurring in Australia, with an increased focus on preventative strategies that identify risk factors, prevent homelessness at its source and support families and individuals to maintain tenancy. Increasing the funding allocated for prevention-based programs will allow reach to larger populations sustainably and exert a greater effect. However, as long as there are still people affected by homelessness, provision of affordable housing and homeless support services will continue to be an essential part in the larger homelessness reduction strategy.

In the health care setting, identifying and addressing underlying social issues, such as domestic violence or mental illness, should be a fundamental part of every clinical encounter. Healthcare practitioners are suitably positioned to recognise the risk factors for homelessness and taking appropriate preventative action to ensure that their patients stay safely housed. Furthermore, when health is the last priority, the provision of targeted, accessible, holistic and compassionate healthcare is more important than ever. It is by this combination of prevention, targeted support and collaboration between governments and service providers that the health of homeless persons may be improved and the overall prevalence of homelessness reduced.

Acknowledgements Conflict of interest declaration No conflicts of interest declared References 1. United Nations General Assembly. Universal declaration of human rights [Internet]. Paris: United Nations; 1948 Dec 10 [cited 2015 Mar 25]. Available from: http://www.un.org/en/documents/udhr 2. Australian Bureau of Statistics. Information Paper - A Statistical Definition of Homelessness, 2012. Canberra (AU): ABS; 2012. 64p. ABS Cat. No. 4922.0.

3. Australian Bureau of Statistics. Census of population and housing: estimating homelessness, 2011. Canberra (AU): ABS; 2011. 124p. ABS Cat. No. 2049.0.

4. Australian Government Department of Families, Housing, Community Services and Indigenous Affairs. The road home: a national approach to reducing homelessness [Internet]. Canberra (AU): Australian Government; 2008 [cited 2015 Mar 25]. 80 p. Available from: https://www.dss.gov.au/sites/ default/files/documents/05_2012/the_road_home.pdf 5. Australian Institute of Health and Welfare. Specialist homelessness services 2011-12 [Internet]. Canberra (AU): AIHW; 2012 [cited 2015 Mar 25]. 142p.

Cat. No.: HOU 267. Available from: http://www.aihw.gov.au/WorkArea/ DownloadAsset.aspx?id=60129542529 6. Lippert AM, Lee BA. Stress, coping and mental health differences among homeless people. Sociol Inq [Internet]. 2015 Mar. DOI:10.1111/soin.12080.

A paradigm shift in the approach to reducing

7. G Phillips. Homeless people in emergency departments. Parity. 2007;20(2).

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23. Culhane DP, Metraux S, Byrne T. A prevention-centred approach to homelessness assistance: a paradigm shift? Hous Policy Debate [Internet]. 2011 May [cited 2015 Apr 1];21(2):295-315. DOI: 10.1080/10511482.2010.536246. Available from: http://works.bepress.com/cgi/viewcontent.cgi?article=1105&context=dennis_ culhane

9. Homelessness Australia. Doing a project on homelessness? [Internet].

2012 [cited 2015 Mar 24]. Available from: http://www.homelessnessaustralia. org.au/index.php/about-homelessness/doing-a-project-on-homelessness

24. Parsell C. Beyond the ‘at risk’ individual: housing and the eradicaton of poverty to prevent homelessness. Aust J Publ Admin. 2012 Mar;71(1):33-44.

DOI:10.1111/j.1467-8500.2012.00758.x

10. Council of Australian Governments. National partnership agreement on homelessness. Canberra (AU): Australian Government; 2009. 21p.

25. Echenberg H, Jensen H. Risk factors for homelessness [Internet]. Ottawa (ON): Canadian government; 2009 Feb [cited 2015 Apr 1]. Publication No. PRB 08-51E. Available from: http://www.parl.gc.ca/content/lop/researchpublications/prb0851-e.pdf

11. Council of Australian Governments. National partnership agreement on social housing. Canberra (AU): Australian Government; 2009. 18p.

12. Council of Australian Governments. National partnership agreement on remote Indigenous housing. Canberra (AU): Australian Government; 2009.

20p.

13. Cant R, Meddin B, Penter C. National partnership agreement on homelessness evaluation of Western Australian programs - final report [Internet]. Perth (AU): Social Systems & Evaluation; 2013 Mar [cited 2015 Mar 25]. 240p. Available from: http://www.dcp.wa.gov.au/servicescommunity/Documents/WA%20 NPAH%20Evaluation%20Report.pdf 14. Homeground Services. Housing homeless families: an evaluation of the accommodation options for framilies program (AOF) [Internet]. Victoria (AU): Homeground Services; 2012 Feb [cited 2015 Apr 1]. 42p. Available from: http://www.homeground.org.au/assets/evaluation-of-accommodationoptions-for-families-aof-report.pdf 15. Parsell C, Tomaszewski W, Jones A. An evaluation of Sydney Way2Home: final report [Internet]. Brisbane (AU): University of Queensland Institute for Social Science Research; 2013 May [cited 2015 Mar 25]. 89p. Available from: http://homelessnessclearinghouse.govspace.gov.au/files/2013/09/AnEvaluation-of-Sydney-Street-to-Home-final.pdf 16. Johnson G, Parkinson S, Parsell C. Policy shift or program drift?

Implementing Housing First in Australia [Internet]. Melbourne (AU): Australian Housing and Urban Research Institute; 2012 Mar (cited 2015 Sep 15). 25p.

Available from: http://www.ahuri.edu.au/publications/download/ahuri_30655_ fr 17. Sadowski L, Kee R, Vanderweele T, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. J Am Med Assoc. 2009;301(17):1771-1778.

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8. Zaretzky K, Flatau P. The cost of homelessness and the net benefit of homelessness programs: a national study [Internet]. Perth (AU): Australian Housing and Urban Research Institute; 2013 Dec (cited 2015 Sep 15).

218p. Available from: http://www.ahuri.edu.au/downloads/publications/ EvRevReports/AHURI_Final_Report_No218_The_cost_of_homelessness_ and_the_net_benefit_of_homelessness_programs_a_national_study.pdf

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18. Johnson G. Housing first ‘down under’: revolution, realignment or rhetoric? Eur J Homelessness. 2012 Dec;6(2):183-191.

19. Rudland S, Ohlin J. Strategic impact evaluation of the Queensland government’s Responding to Homelessness strategy [Internet]. Brisbane (AU): Queensland Department of Housing; 2009 Jun [cited 2015 Mar 25]. 194p. Available from: http://rti.cabinet.qld.gov.au/documents/2009/ jul/implementation%20plan%202009-13%20for%20homelessness/ Attachments/Homelessness%20Strategic%20Impact%20Evaluation%20 Final%20Report.pdf

26. MacKenzie D, Chamberlain C. Youth homelessness in Australia 2006 [Internet]. Victoria (AU): Commonwealth of Australia; 2008 [cited 2015 Apr 1].

61p. Available from: https://www.dss.gov.au/sites/default/files/documents/05_2012/youth_ homelessness_report.pdf 27. Tutty LM. On the brink? A pilot study of homeless assets and risk tool (HART) to identify thsoe at risk of becoming homeless [Internet]. Calgary (AB): Calgary Homelessness Foundation; 2012 [cited 2015 Apr 1]. 85p. Available from: http://www.homelesshub.ca/ResourceFiles/HART%20Pilot%20 Report%20Final%202012.pdf 28. Greysen SR, Allen R, Rosenthal MS, Lucas GI, Wang EA. Improving the quality of discharge care for the homeless: a patient-centered approach.

J Health Care Poor Underserved [Internet]. 2013 May [cited 2015 Apr 1];24(2):444-55. DOI: 10.1353/hpu.2013.0070.

29. Elissen AM, Van Raak AJ, Derckx EW, Vrijhoef HJ. Improving homeless persons’ utilisation of primary care: lessons to be learned from an outreach programme in The Netherlands. Int J Soc Welfare [Internet]. 2013 Jan [cited 2015 Apr 1];22(1):80-89. DOI: 10.1111/j.1468-2397.2011.00840.x.

30. Homelessness Australia. Other homelessness organisations [Internet].

2012 [cited 2015 Apr 11]. Available from: http://www.homelessnessaustralia. org.au/index.php/about-homelessness/other-res 31. O’Connell JJ. Dying in the shadows: the challenge of providing health care for homeless people. Can Med Assoc J [Internet]. 2004 Apr [cited 2015 Apr 1];170(8):1251-1252. DOI: 10.1503/cmaj.1040008. Available from: http:// www.cmaj.ca/content/170/8/1251 32. Brubaker MD, Amatea EA, Torres-Rivera E, Miller MD, Nabors L. Barriers and supports to substance abuse service use among homeless adults. J Addict Offender Couns [Internet]. 2013 Oct [cited 2015 Mar 15];34(2):81-98.

DOI:10.1002/j.2161-1874.2013.00017.x.

32. Halpern J. What is clinical empathy? J Gen Intern Med [Internet].

2003 Aug [cited 2015 Apr 1];18(8):670-674. DOI: 10.1046/j.15251497.2003.21017.x.

33. Redelmeier DA, Molin JP, Tibshirani RJ. A randomized trial of compassionate care for the homeless in an emergency department. Lancet.

1995;345:1131-34.

20. Parsell C, Jones A, Head B. Policies and programmes to end homelessness in Australia: learning from international practice. Int J Soc Welf.

2013 May;22(2):186-94. DOI:10.1111/j.1468-2397.2012.00884.x.

21. Flatau P, Zaretzky K, Brady M, Haigh Y, Martin R. The cost-effectiveness of homelessness programs: a first assessment [Internet]. Perth (AU): Australian Housing and Urban Research Institute; 2008 Feb [cited 2015 Mar 24]. 52 p. Available from: http://www.ahuri.edu.au/publications/download/ ahuri_80306_fr 22. Spinney A. Home and safe? Policy and practice innovations to prevent women and children who have experienced domestic and family violence from becoming homeless [Internet]. Victoria (AU): Australian Housing and Urban Research Institute; 2012 Nov [cited 2015 Apr 1]. 111p. Available from: http://www.ahuri.edu.au/downloads/publications/EvRevReports/AHURI_ Final_Report_No196_Home_and_safe_policy_and_practice_innovations_to_ prevent_women_and_children_from_becoming_homeless.pdf

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Case Study

the population. Upon reflection it may have been prudent to include neoplasia in this list given the clinical signs and symptoms.

Andrew Samaan & Min Zaw

Investigations A complete blood count revealed a hemoglobin of 8.6 gm/dl, white blood cell count of 4,810/ mm3 with 79% neutrophils, 7.7% lymphocytes, 0.2% eosinophil, 0.06% basophils and 8.4% monocytes. He had a platelet count of 688,000/ mm3 and an ESR of 95 mm after the first hour.

His blood glucose and electrolytes levels were within normal limits. Rapid diagnostic test for malaria was negative. Serological tests for hepatitis B and C were negative. However, his HIV rapid diagnostic test results were positive.

The CD4 count was 66/mm3. The stools were examined for evidence of parasitic infection and were found to be negative.

A Case of Oesophageal Candidiasis with Underlying HIV Infection About the Author

Andrew Samaan obtained his Bachelor Medical Science (UNSW), ranked second in his class and graduated with First Class Honours. He then joined the department of Anatomy first working as a tutor then enjoying the lofty heights of associate lecturer. He was the youngest lecturer in department history. He moved on to study medicine, a masters in tropical medicine and has been interning in his holidays at Oxford University Tropical Medicine Department since 2013.

Min Zaw is a consultant infectious diseases physician with over 30 years of clinical experience, ten of them obtained serving as an army doctor in Myanmar active war zones. He recently retired as head of infectious diseases department to become Chief Medical Officer of a 100 bed hospital in Dawei. He is looking forward to meeting and working with more Australian medical students looking for placements.

Abstract

This is a case of a 32-year old man with HIV infection and candida oesophagitis. Systemic candidiasis is one of the common presenting features in late stage HIV infection in Myanmar and is considered pathognomonic for AIDS in resource poor settings. Candida oesophagitis causes epigastric pain and tends to occur concomitantly with oropharyngeal candidiasis, yet epigastric pain is also a leading symptom of peptic ulcers, which are common in Myanmar.

Therefore, it can easily mislead doctors to diagnose a peptic ulcer and treat accordingly. In Myanmar private health care physicians and traditional healers are initial points of contact for the majority of the population seeking health care. If private general practitioners misdiagnose, it will delay diagnosis of AIDS, resulting in further HIV transmission to others and subsequent complications for the presenting patient. This is pertinent as Myanmar has the second highest HIV prevalence in Southeast Asia, hence this case elucidates how important it is for a clinician to have a high index of suspicion for HIV infection in a patient who presents with epigastric pain, chronic fever, chronic diarrhea and weight loss.[1]

Case report A 31-year-old man presented with a five week history of fever, four week history of epigastric pain, semi-solid bowel movements, dysphagia, weight loss and a two week history of mild headache. He described the character of his epigastric pain as burning, which was not exacerbated or alleviated by meals and did not radiate to the back. The site was constant, localized and he experienced insomnia due to continuous burning pain although the pain did not improve or worsen at any time during the day or night. During this time his initial point of contact with health services was a traditional healer who administered a remedy that did not relieve his symptoms. It was unknown by the patient what the contents of the remedy were.

This patient had no history of regular medication before his current illness. He had sex with female sex workers, at times without condoms although his last contact was 5 years ago. This is because vector journal

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he developed purulent discharge with dysuria following his last contact, which was relieved by a general practitioner prescribing medication. The patient was unable to identify the medication or name his previous infection. He did not provide any previous history pertinent to peptic ulcer and gastro-oesophageal reflux disease.

Upon physical examination he appeared pale and emaciated. The body temperature was 37.8 degrees Celsius. His other vital signs such as blood pressure and respiratory rate were within normal range. His palate and pharynx showed white patches with erythema along the rims.

Examination of heart and lungs revealed no abnormalities. There were no obvious signs of dehydration.

The initial differential diagnosis list included opportunistic infection due to HIV, peptic ulcer in addition to HIV infection, malaria as he came from an endemic region and tuberculosis as this is the most common opportunistic infection in volume 10, issue 18

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He then underwent an upper gastrointestinal endoscopy which showed candidiasis at middle and lower end of the esophagus with no varicose vein or evidence of reflux. However, the stomach had mild mucosal congestion and edema at the pyloric antrum with no growth and ulceration.

The diagnosis was acquired immunodeficiency syndrome (AIDS) with oesophageal candidiasis.

Treatment Oral fluconazole was initiated at the dose of 200mg daily for 14 days. Then for fever and diarrhea, he was given ciprofloxacin 500mg twice a day for 5 days and he also received co-trimoxazole as a primary prophylaxis of Pneumocystic jiroveci pneumonia (PCP) and toxoplasmosis and ranitidine 300mg daily for mild gastritis. He was also suggested to take a nutritious diet and vitamins. He showed significant improvement of his burning pain. In addition, loose motion and fever subsided within a week.

There were strong indications for antiretroviral therapy (ART) so other laboratory and radiological investigations were done as a part of preparation for ART. Sputum microscopy for acid fast bacilli (AFB) were negative and chest radiography revealed no abnormalities. Serological testing for syphilis was non-reactive. Serum alanine transaminase (ALT) was 22 U/L. He started to take the first line regimen of ART vector journal

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after two weeks of the initial empirical antibiotic treatment with the patient’s improvement. The first line regimen includes stavudine (d4T), samivudine (3TC) and nevirapine (NVP). There was no skin rash or liver toxicity during the first two weeks of lead-in dose so the NVP dose was increased from 200mg once a day to 200mg twice a day.[2] One week after starting full dose of the ART, he complained of high fever, abdominal pain and loose motion again. However, he had no jaundice or skin rash. There was a high index of suspicion of Mycobacterium Avian Complex (MAC) immune reconstitution disease, hence some indirect indicators for MAC infection were used. Direct MAC diagnostic facilities were not available. On stool analysis, AFB and pus cells were seen.

Serum alkaline phosphatase (ALP) was 544 units per liter. Ultrasound abdomen showed enlarged para-aortic lymph nodes and mild hepatosplenomegaly. Therefore, he was treated as MAC by giving Azithromycin and Ethambutol. The patient improved over a 12 day course.

He completed the course of MAC treatment and has continued to take the first line ART until now.

His body weight increased from 50 kilogram to 65 kilograms and the CD4 count rose to 275/ mm3 over the three years. His counselor reported that he adhered to more than 95% of his ART doses. The CD4 count has not increased beyond 300/mm3 although his HIV plasma viral load became undetectable.

Discussion Odynophagia and dysphagia are common symptoms of oesophagitis. There are many conditions causing oesophagitis: oesophagitis due to gastric acid reflux, drug-induced oesophagitis and infections. If it is not treated, they may severely compromise nutritional status of the patients and may be responsible for life threatening complications.[3] Oesophageal related symptoms occur in 40-50% of patients with AIDS at some point in the course of their disease.[4] These are mainly caused by infections. There are a variety of pathogens which may cause oesophagitis, including fungi, bacteria, viruses and protozoa.[3] Among the causes, fungal agents especially Candida volume 10, issue 18

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species are the most common etiology and other oesophageal disorders such as cytomegalovirus (CMV), herpes simplex virus (HSV) may coexist.

[4] CMV infection has been reported in 10% to 28% of HIV infected patients complaining of oesophageal symptoms while HSV is diagnosed in approximately 10% of HIV infection.[3] Candida species may survive in food, air, floor, other surfaces and hospital environment and therefore be transmitted. Candida albicans is the major isolate found in individuals with candidiasis.

[5] Other Candida species that cause candidiasis include Candida glabrata and Candida krusei.

[3] These Candida species are detected in 31% to 55% of healthy individuals.[5] This is just colonization, and does not indicate active disease.

In the immunocompromised, (such as those with poor nutritional status and diabetes mellitus) taking broad spectrum antibiotics, colonization may progress to infection and produce inflammatory responses. Oropharyngeal candidiasis commonly occurs in the above mentioned conditions while oesophageal candidiasis is common in advanced immune deficiency associated with HIV infection.

Although oesophageal candidiasis may occur at any stage of HIV infection, it is usually seen in patients with CD4 count of less than 200/mm3.

[5] According to the WHO clinical staging of HIV/ AIDS, oesophageal candidiasis can be diagnosed presumptively on the basis of clinical signs or simple investigation.[6] Oesophageal related symptoms seen in candida oesophagitis are non-specific so it is difficult to diagnose candida as the definite cause. There is also the possibility of co-infection. Candida oesophagitis presents most commonly with dysphagia, odynophagia, and retrosternal pain but occasionally epigastric pain is the dominant symptom and fever occurs infrequently.[5] Dysphagia and odynophagia are common symptoms not only in oesophageal candidiasis but also in CMV and HSV oesophagitis.[4] In this case report, the HIV infected patient presented with epigastric pain and fever. The pain is not a specific marker for oesophageal candidiasis and it can be caused by various gastrointestinal diseases such as peptic ulcer, vector journal

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gastroesophageal reflux and acute gastritis.

As a result, it may be easy for physicians to overlook candida oesophagitis as a potential cause. However, the patient had oropharyngeal candidiasis, which should prompt the physician to consider oesophageal candidiaisis. It is also important to note that oesophageal candidiasis may be completely asymptomatic.[3] The treatment regimen depends on the causative organism and the drugs used for candidiasis and other viral infections are also different. If there is coexistence of CMV or HSV with candidiasis, a combination of different drug regimens is required. Therefore, detection of definite cause is important for proper management of candida oesophagitis.

For HIV/AIDS staging and management purpose, diagnostic accuracy is important. In earlier time, Barium esophagography was a main diagnostic tool. Double contrast barium esophagography has a high sensitivity (over 80%) in detecting oesophageal lesions but radiographic abnormalities are often non-specific and endoscopy with biopsy and/or brushing is necessary to make a definite diagnosis.[3] Endoscopy has its benefits of not only rapid and high sensitivity diagnosis but also reliable method of differentiating the various causes of oesophagitis.[5] In a study conducted

by Connolly, Forbes & Gleeson, endoscopy (without pathological support) had a sensitivity of 97.5% and a specificity of 100% compared with the sensitivity and specificity of 25% and 100% respectively for barium studies.[7] Therefore, endoscopy has displaced radiography.

In the resource limited situation, both esophagoradiography and endoscopy are not available. Therefore, clinicians in such a situation have to rely mainly on presumptive diagnosis.

Some studies have been conducted to analyse the reliability of clinical features for diagnosis.

Oral thrush, either alone or in combination with oesophageal symptoms was a reliable marker of candida oesophagitis only in patients with a previous AIDS-defining event.[8] The same study concluded that a presumptive diagnosis of candida oesophagitis on the basis of the Centers for Disease Control and Prevention (CDC) clinical criteria is a valid diagnostic method only in HIV1 infected patients with a previous diagnosis of volume 10, issue 18

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full-blown AIDS.[8] CDC clinical criteria for the diagnosis of oesophageal candidiasis are recent onset of retrosternal pain on swallowing and oral candidiasis diagnosed by the gross appearance of white patches or plaques on an erythematous base.[9] Therefore, oropharyngeal candidiasis and oesophageal symptoms are important markers for clinical diagnosis in a situation where there are no facilities for endoscopy. However, there might be an argument that clinical diagnosis cannot exclude infectious oesophagitis caused

by CMV and HSV. In HIV infection, candidiasis is the commonest cause of oesophagitis while CMV and HSV are generally less common and they rarely occur unless CD4 count is less than 100/mm3. This means that CMV and HSV are at risk in far advanced immune deficiency. Another point is that HSV oesophagitis is frequently associated with labial or oral cavity lesions.[10] Rationally, candidiasis should be considered as a cause of oesophagitis in HIV infected individuals with odynophagia unless it is in the state of very low immune status. Thus, Belitsos described that if the CD4 count is appropriately low and other gastrointestinal conditions appear unlikely by history, the next diagnostic step in an HIVinfected person with odynophagia is usually an empirical trial of antifungal therapy and if it is not responsive, upper endoscopic evaluation should be done.[10] Asymptomatic oesophageal candidiasis is usually seen in people with significant immune suppression. It is shown in a study conducted by Zaidi & Cervia, invasive candidiasis in esophagus can be seen in 90% of patients having CD4 count less than 100/ mm3.[4] So, severe immunocompromised HIV infected individuals are likely to get candida oesophagitis, though some will be asymptomatic.

Regarding the treatment, systemic antifungals are required for effective therapy and a 1421 day course of either fluconazole (oral or IV) or oral itraconazole is highly effective.[9] Other antifungals which are effective in treating oesophageal candidiasis include IV caspofungin, IV voriconazole, micafungin and anidulafungin.

Although these are effective, oral or IV fluconazole remains the preferred therapy.[9]

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However, it should be noted that there is high risk of recurrence in HIV infected individuals.

Fluconazole (or azole) resistance is predominantly the consequence of previous exposure to fluconazole (or azole) and it is followed by gradual emergence of non-albican Candida species, particularly Candida glabrata, as a cause of refractory mucosal candidiasis.[9] If an individual does not improve in their candidiasis related symptoms despite fluconazole therapy, initially, it is better to consider other causes rather than resistance. It may be co-existant CMV or HSV oesophagitis or other causes of oesophagitis or incompliance of the drug. In the resource limited countries, health care providers should also be careful not to use unqualified or counterfeit fluconazole drugs which do not improve the illness.

Fluconazole refractory disease frequently develops in HIV infected individuals with very low CD4 T cell count who are not treated with ART. Zingman has shown that refractory AIDSrelated mucosal candidiasis can be resolved by initiating antiretroviral therapy.[11] ART improves immune function which fights effectively against the refractory candidiasis in synergistic action with fluconazole. Thus, ART should be initiated as quickly as possible in the case of candida oesophagitis with HIV infection. In some cases, mucosal candidiasis recurs repeatedly instead of being refractory to the treatment.

Despite the frequency of oesophageal candidiasis in HIV-infected patients, primary prophylaxis is not widely administered because the disease is not life threatening, and therapy is usually very effective. There is also some concern about drug resistance if primary prophylaxis was used extensively.[4] However, secondary prophylaxis (with fluconazole 100mg/day or 150mg once weekly) is commonly given for patients with multiple recurrences of oropharyngeal and oesophageal candidiasis until effective ART can be instituted.[4] Conclusion Oesophageal candidiasis is one of the common AIDS defining diseases and it can be diagnosed clinically if the patients are symptomatic and HIV has been diagnosed. It may be the first presenting symptom of AIDS in resource poor countries. Private health care providers should volume 10, issue 18

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have a high index of suspicion and not miss the disease because it is an entry point for diagnosis of HIV infection in late stage which is necessary to initiate antiretroviral therapy as quickly as possible. Moreover, the treatment of candida oesophagitis is simple and even non-specialist medical providers can provide it at private clinics.

Another important point is that if it is not relieved by fluconazole after a week, the patient should be referred to a higher level medical facility for assessment of other cause or co-existing viral oesophagitis or drug resistance. Furthermore, fluconazole is an effective drug for systemic candidiasis, there is a high risk of refractory to the drug unless ART is initiated.

In this case report, the patient was also coinfected with MAC because he was in very severe immune deficiency state (CD4 count 66/ mm3).

Management of late stage of HIV infection is more difficult and complicated than that of early stage of infection. Therefore, early detection and management of HIV infection is desirable not only improves quality of life but also control to reduce complications.

5.

Vazquez JA, Sobel JD. Mucosal candidiasis. Infect Dis Clin North Am. 2002;16(4):793-820, v.

6.

WHO. Interim WHO clinical staging of HIV/AIDS and HIV/AIDS case definitions for surveillance. Geneva, Switzerland: WHO, 2005.

7.

Connolly GM, Forbes A, Gleeson JA, Gazzard BG. Investigation of upper gastrointestinal symptoms in patients with AIDS. AIDS. 1989;3(7):453-6.

8.

Antinori A, Antinori A, Ammassari A, Masetti R, De Luca A, Murri R, et al. Presumptive clinical criteria versus endoscopy in the diagnosis of Candida esophagitis at various HIV-1 disease stages. Endoscopy. 1995;27(5):371-6.

9.

Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-infected Adults and Adolescents, (2009).

10.

Belitsos PC. Management of HIVassociated esophageal disease. AIDS Clin Care.

1995;7(3):19-22.

11.

Zingman BS. Resolution of refractory AIDS-related mucosal candidiasis after initiation of didanosine plus saquinavir. The New England journal of medicine. 1996;334(25):1674-5.

Acknowledgements I would like to thank Dr Zaw for his time, input and guidance in the writing of this paper.

Conflict of interest declaration No known conflicts References 1. National AIDS-STD control program DoH, Ministry of Health. Guidelines for the clinical management of HIV-AIDS in adults and adolescents. Yangon, Myanmar2004.

2. AIDSinfo Drug Database 2012 [cited 2015 Jan]. Available from: http://aidsinfo.nih. gov/drugs/116/nevirapine/0/professional Section_5.4.

3. Parente F, Porro GB. Infectious Esophagitis: Etiology, Diagnosis, and Treatment. In: Bremner CG, DeMeester TR, Peracchia A, editors. Modern approach to benign esophageal disease. New York, USA: Quality Medical Publishing, Inc. ; 1995.

4. Zaidi SA, Cervia JS. Diagnosis and management of infectious esophagitis associated with human immunodeficiency virus infection.

J Int Assoc Physicians AIDS Care (Chic).

2002;1(2):53-62. vector journal

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Opinion

How Greed Can Be Good

Nikhil Autar

About the Author

Nikhil Autar is in his second year of medicine at Western Sydney University and has intense interest in all things global health, sparked by personal experiences while young and the desire to help as many people as possible. He believes that global health and inequality can be fixed by understanding the entire problem and implementing ideal solutions, and that the private sector is a huge untapped resource bank that can be turned to do good, and has started his own social enterprise, PlayWell, trying to do just that.

Abstract

Despite shifts in the distribution of charity and aid to support more effective causes, the overall numbers when it comes to giving remain unchanged. The stagnation and decline of worldwide total charity and aid, particularly during times of economic turmoil and cuts to developmental assistance by major aid giving nations, shows that giving often becomes a secondary concern. To change this we need to expand aid beyond moral responsibility, and more frequently frame it as a sound investment. A greater awareness of the value of aid and charity, further innovation in the methods of conducting it, and perhaps a paradigm shift in how we conduct business and developmental work is needed. Avenues for achieving this are discussed in this article.

Effective altruism is a movement that is revolutionising the way we give to the poor.

Peter Singer describes it as, “one that combines both the heart and the head”[1]. The heart empathising with and wanting to help those who are less well off, with the head ensuring our efforts go the furthest. That’s where the concept of effectiveness comes in; one hundred dollars given to the Guide Dogs Foundation will pay for less than 2 days of training.[2] That amount could provide a reliable source of clean water to 300 people in Sierra Leone.[3] This is not to say that guide dogs are not a worthy cause, however with this logic, it becomes apparent that individuals, businesses and governments can cause the most significant change in the world’s most deprived regions by giving to the most effective causes. It is without surprise then that a shift towards this reasoning has been adopted in all three of these sectors.[1,5,23] While it’s great that there’s a movement highlighting the importance of giving well, it is evident that there needs to be a movement that encourages people to give more. However, increasing donation amounts is a difficult task; currently 72% of income diverted to charities comes from individuals.[4] The challenge remains to increase the proportion that comes from companies, the top 500 of which alone earns more than the entire United States.[5]

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Furthermore, the significant debts amassed by many governments across the world means that foreign aid is not prioritised.[7,24] However, I argue that government spending on foreign aid can have direct and indirect benefits for all involved. In order to increase the size of the “slice of the pie” from which aid and charity is derived, we need to think differently about how we convince people to give. Although our hearts are starting to be tempered by our heads when it comes to where we send our money, relying on the heart alone to gain funds is limiting the change we can make. In a world driven by profit, we need to show how giving can also be profitable.

Altruism, the second component of the movement, underlies most of our efforts to acquire the resources needed to combat global inequity. At its core, altruism encapsulates the very essence of humanity; our ability to care for the wellbeing of others and attend to their interests above our own. However, the very words charity and aid exude connotations of personal sacrifice. The fact that only 5 out of 22 OECD countries give the agreed upon 0.7% of Gross National Income (GNI) towards Official Developmental Assistance (ODA),[23] and that a 40% drop occurred in private flows to charities from 2007 to 2008 due to the Global Financial Crisis [7] shows that sacrifice, especially in times volume 10, issue 18

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of adversity, is often deemed too much; the reward of a warm, fuzzy feeling too little to justify the expense.

Yet, what if the rationality of the mind, which so often gives us excuses not to give, could be used to justify giving, and allow us to give more? What if we viewed charity beyond the strict confines of altruism; what if we started seeing charity as a win-win?

In many ways, charity already is viewed in this light. Although it seems counterintuitive, there are already many ways governments, corporations and individuals benefit themselves fiscally and morally by helping those less fortunate than themselves. The rise of the concept of Corporate Social Responsibility (CSR) in the 1950s signalled a change in the ideals of businesses as they recognised their success was intimately entwined with a thriving community. Since then, the benefits of engaging in charitable behaviour on increased productivity and moral capital are well documented. For example, businesses both large and small that allowed employees days off to volunteer noticed dramatic increases in workforce morale and productivity,[8,9] and thus concepts such as “volunteering days” and “community leave” were born. Today, as many as 81% of corporations have adopted these concepts.[5] Furthermore, 65% now strive to be more impactful by narrowing down eligibility of employee donation-matching programs to certain charities proven to be more effective, and 84% evaluate the impact their contributions make, marking a shift to them genuinely caring about their impact.[5] Larger corporations, particularly those in disputatious industries, which engaged in strategic, high impact corporate philanthropy generated moral capital that mitigated the severity of sanctions and unfavourable press during times of controversy.[10-12] With public accountability only growing with the rise of the social media’s “trending news” sections and viral online petitions, it is already becoming evident that companies can’t afford not to engage in generous activities. However, this need not be a knife to the throat of businesses; the benefits of CSR are wide-ranging and go beyond those of improved productivity and public relations.

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beyond that of maintaining ethical practices and adherence to codes and guidelines; they have become a marketing tool. A large-scale study found that 89% of consumers are likely to switch brands similar in price or quality if the brand supports a worthy cause.[13] Strategic charitable initiatives undertaken by companies benefit both the recipients and the companies that organise them. For instance, Monsanto partners with several governments in the developing world to reduce world hunger through programs such as Project Share, which provides farmers in India with education, tools, and their genetically modified seed.[38] This firstly benefits the farmers who are able make the vital jump from sustenance to commercial farming. Second, Monsanto gains free publicity through press coverage; Monsanto’s widely denigrated image of a greedy, “GMO-producing”, “evil” corporation is somewhat lifted; and they continue to grow their potential market from farmers who become future customers.

Cause related marketing and the charity-business partnerships that are born of it have been proven to increase the effectiveness and impact of money given by corporations.[16] The Red Revolution, which has multinational, householdname companies, such as Nikon and Starbucks, on board, is an initiative where product lines with red labels donate 10% to 50% of profits to the Global AIDS Fund. This allows consumers to make an impact in their day-to-day lives and purchases whilst also helping the company sell more product. This strategy is extremely effective; it reduces the cost required to set up individual programs, benefits the brand that participates in this program by improving brand image, and creates a more distinguishable product. It has been established that positive brand image leads to increased sales and also garners businesses another highly desired commodity – brand loyalty.

Indeed, potential customers are more likely to preference products from companies that they perceive to care about social issues.[14,15] The success of microfinance in developing countries is further proof that the gratitude of charity pays-off in tangible ways as well.

Microfinance consistently achieves staggeringly low default rates of less than 1% [17,18]; a lower risk than a mortgage in the developed world.

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Over the years, consumers have become more and more willing to switch brands for companies that give more.

Cone Communications 2014 [13] program, as well as those in wider society who appreciate their values, are more likely to be loyal customers of that brand.

The alleviation from poverty of those benefiting from microfinance brings to the fore another, less widely acknowledged idea; that increasing wealth in the developing world results in increased consumerism, and the development and growth of emerging markets. Transnational corporations, particularly those from services and technology industries, are beginning to capitalise on this already with the surge of the middle class in nations like China, Taiwan and India. Sony forecasted a tripling of phone sales in China alone over one year,[19] and Cisco Systems is already providing nearly 40 million homes in India with our equivalent of cable.

[20] In 2013, General Motors sold more cars in China than it did in the United States.[41] This highlights the gains that can be made by pushing more of the world’s poorest into the middle classes. The benefits to poor countries are, of course, immense; every 10% increase in the number of people earning between $10 to $100 a day corresponds to a 0.5% rise in Gross vector journal

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Domestic Product (GDP),[21] which correlates directly to improved health and social outcomes.

[39] The number of people in this bracket is set to double to 3 billion by 2030.[40] Imagine how much companies and the world’s poorest both stand to gain by accelerating this growth and by establishing themselves and their brands early in the developing world through effective giving programs.

There is argument that the profits from human development take time and great investment to be realised. However, even now the world’s poorest are attracting interests from corporations and businesses. Microsoft researchers published a paper on how to increase the efficacy of mobile phone sales in Mumbai’s slums,[22] showing even the world’s least-well-off are beginning to access technology. Taking away their biggest obstacles – basic sanitation, employment, housing and attainment of education – is not only the cheapest, most effective way to help them, it’s also promoting economic growth as more of the population will be able to purchase goods and services. Innovative, for-profit models of conducting business, such as micro-franchising volume 10, issue 18

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allows the poor to access life-changing products and services, while also turning a profit. These aren’t pipe dreams or propositions. They’re happening now. Nestle’s microfranchise venture in the Dominican Republic employs and equips locals with proven, reputable products and business strategies and business knowledge.

In turn, Nestle is able to deliver vital minerals and nutrients to communities suffering from micronutrient deficiencies [35] whilst also creating a new market.

EcoFuelAfrica, a fast growing start-up, provides kilns that turn farm waste into electricity, drinking water and fertilizer in a bottom-of-the-pyramid up, for-profit structure.[36] This business model has been the only reason it has been able to grow as rapidly as it has whilst delivering vital services to remote and rural regions.

Increasingly, not-for-profit organisations are catching on the concept of social enterprises.

The success of firms such as Toms Shoes, ThankYou Water and Hero Condoms, is creating hundreds of millions of dollars of revenue that goes directly into combating social and health needs in developing nations. This sector is booming, with 29% of all social enterprises having been developed between 2011-2013 alone.[42] The beauty of these organisations is that they allow consumers to make a bigger difference without further sacrifice.

Governments are in a unique position of having both the political and financial power that charities and businesses lack, which is why they are responsible for 80% to 85% of developmental aid that breaks down the barriers of poverty.

[23] Developed nations’ governments and their people tend to own and dominate the technology, research and services sectors which stand to gain the most from the potential spike in consumerism that come as a result of helping the world’s poorest. Thus, despite popular opinion, it is indeed in their best interests to foster this development.

Yet the aid budgets of many countries in the Development Assistance Committee have decreased, as lower than expected economic growth during periods of austerity call for reductions in “unnecessary spending”.

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ignores that there are short-term and longterm benefits for countries that invest in other countries. Multilateral aid reduces the likelihood of international conflicts and provides a very effective, collaborative way of dealing with crisis situations. However, bilateral aid, which comprises the 70% of ODA,[23] often directly benefits the giving nation through the concept of aid-in-kind. Tied-aid programs, which attach assistance to the fulfilment of certain trade or policy concessions, are often criticised for being less effective, even predatory in nature, as they are designed to mainly generate income for the donating nation, or addressing human rights violations while ignoring the larger issue of global poverty.[25-27] Although the nature of aid is sometimes believed to be paternalistic and rooted in self-interest, this trend is gradually changing. Developed countries are increasingly utilising cheap labour and locally-sourced, cheaper goods from developing nations, while providing them with what they don’t have; technology and expertise. Australia’s contribution to the Small Hydro Power Scheme in remote Fijian villages is a perfect example of this. In this program, villagers were able to access electricity for the first time, giving them the ability to store food and crops for longer periods, and for their children to study at night.

Australia gained contracts and higher demand for their engineers and Hydro-electric companies which not only stimulated economic activity, but the nation also gained valuable expertise.[28] Indeed, the very engineers who participated in that program went on to help design the Snowy Mountain Hydroelectric Scheme, which provides Australia’s largest state with 10% of its electricity usage and invaluable irrigation to this day. When you add to this the less measurable, albeit very real, mutual economic and cultural connections that arise from aid; and the economic boom leading to increased demand, it becomes clear that development aid is both a morally and fiscally sound investment.

Given the benefits outlined above, investing in the poor seems like an obvious benefit. However, many companies and governments remain hesitant. A lack of evidence for the benefits of giving is part of the reason. Though there are numerous studies linking CSR to improved financial performance,[30,31] little evidence exists volume 10, issue 18

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that quantifies those benefits.[29] Some suggest the lack of consistent theory behind the benefits of giving are to blame,[8,33] while others believe that the methodology and sample sizes are not consistent or reliable enough.[31, 32] Overall, it is difficult to justify charity as an investment to shareholders and voters when you can’t put a dollar figure to it.

Securing data to prove the benefits will cause change, but it’s only part of the answer. The development and emergence of markets due to human development; the concept of customer and recipient loyalty leading to profits; and the improvement of brand image and international relationships are not currently being measured as benefits of giving. Thus, a paradigm shift on how we view and study aid is required to get data that truly reflects the benefits of giving.

Furthermore, acquiring this data will be a crucial step to making giving something businesses and governments can’t afford not to do.

In saying this, perhaps people simply aren’t aware that giving can be mutually beneficial.

The semantics of giving and the sacrifice it is associated with are in part to blame for this.

The Red Revolution discussed previously is backed by large corporations such as CocaCola, Starbucks and Apple, yet most reading this would not have previously been aware of its existence. Innovation and technology can help fix this issue and an idea has already been put forward by a new social enterprise, Buywell.

In short, Buywell is a platform that allows products and services associated with charity to be advertised for free and also evaluates companies on their philanthropic actions.

Created in a way that incentivises rather than punishes businesses, this venture will reward consumers and companies alike for choosing products and brands that donate proceeds to charities. In addition it will potentially force companies to compete and differentiate down a whole new avenue for marketing based on “goodness” rather than the traditional focus on price, branding and reputation to which they are currently limited. This idea has already secured seed funding and support from professionals ranging from CEOs of successful tech start-ups to Google Engineers who have deemed the idea not only viable but also potentially revolutionary.

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It can be argued that a mentality of benefiting yourself while helping others corrupts both the ideals and the structures of giving. If care is taken in the approach however, incorporating charity into the private sector will only further advance global development. Currently, charities are forced to compete and scramble over oneanother to gain a slice of the charitable dollar.

By involving the private sector and our scope on charity, we create another “pie” altogether. Care needs to be taken to ensure that a change such as this does not compromise current donorbased programs. I argue that our compassion and willingness to help others will not diminish so long as inequality exists in this world. Rather, perceiving charity as a win-win will not smother the power of humanity; it will be unleashed, as it unfetters the concept from the chains of sacrifice that currently binds it.

If people, businesses, and government could see giving as something that could go beyond this concept of sacrifice, we could expand the scope of investment into global health and development from the spare change in someone’s pocket to entire banks’ self-interests. If we could bring the $100 trillion world economy to realise that growth need not come from the subjugation of others, but rather the advancement of humanity as a whole; and if we could finally unshackle giving from the confines of just sacrifice and see it also as the win-win it can be, we could finally find the cure to poverty.

References: 1.

Singer P. The Why and How of Effective Altruism [Ted Talk]. 2013, Retrieved September 21, 2015, from https://www.ted.com/talks/peter_ singer_the_why_and_how_of_effective_altruism.

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Guide Dogs South Australia and Northern Territory. Frequently Asked Questions. 2008, Retrieved from https://www.guidedogs.org.au/ frequently-asked-questions 3.

UNICEF. Share of a Deep Well Campaign. 2015, Retrieved September 21, 2015, from http://donate.worldvision. org/OA_HTML/xxwv2ibeCCtpItmDspRte. jsp?section=10373&item=158.

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Charity Navigator. Giving USA 2015 report: Giving Statistics. 2015, Retrieved volume 10, issue 18

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September 21, 2015, from http://www. charitynavigator.org/index.cfm/bay/content.view/ cpid/42#.Vf6-dN-qqko.

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Giving in Numbers.CECP and The Conference Board. 2015, Retrieved September 21, 2015 from cecp.co/research.

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World Bank. World Development Report 2005: A Better Investment Climate for Everyone.

World Bank, Oxford University Press; 2004.

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World Bank. Global Development Finance 2009: Charting a Global Recovery. Global Development Prospects; 2009.

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Smith C. The New Corporate Philanthropy.

Harvard Business Review; 1994.

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Points of Light. Measuring Employee Volunteer Programs: The Human Resources Model. Points of Light Foundation, Center for Corporate Citizenship, Boston College; 2015.

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Godfrey P. The Relationship between Corporate Philanthropy and Shareholder Wealth: A Risk Management Perspective. Academy of Management Review. 2005; 30(4):777-798.

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Fombrun C. Reputation: Realizing Value from the Corporate Image. Harvard Business School Press;1997.

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Jackson K. Building Reputational Capital: Strategies for Integrity and Fair Play that Improve the Bottom Line. New York: Oxford University Press; 2004.

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Cone Communications. Cause Evolution Study. Cone publication. 2014, retrieved from

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http://www.conecomm.com/stuff/contentmgr/ files/0/e3d2eec1e15e858867a5c2b1a22c4cfb/ files/2013_cone_comm_social_impact_study.pdf.

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Hsieh A. and Li C. The moderating Effect of Brand Image on Public Relations, Perception and Customer Loyalty. Marketing Intelligence and Planning, 2007; 26(1), 26-42.

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Brink D, Schroder, G, Pauwels, P. The Effect of Strategic and Tactical Cause-Related Marketing on Consumers’ Brand Loyalty. Journal of Consumer Marketing. 2006; 23(1), 15-25.

16.

Porter M. and Kramer M. The Competitive Advantage of Corporate Philanthropy. Harvard Business Review. 2002; 80(12), 57-68.

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Field E. and Pande R. Repayment Frequency and Default in Micro-Finance: Evidence from India. Journal of the European Economic Association. 2008;6(2-3), 501-509.

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Osnos P. The Economist; Microlending From tiny acorns. Grameen Bank. 1998, Retrieved from http://www. grameen-info.org/index.php?option=com_

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Voluntourism

the potential ethical implications of ‘voluntourism’, and endeavoured to be careful in how we conducted ourselves during our experience.

TeamMed, the organisation which arranged our volunteer experience conducted a stringent predeparture selection process and comprehensive training and cultural education which assisted us in our preparation. The aim of this article is to use our experience to facilitate an exploration of how international volunteering trips can be made more ethical and beneficial to host communities.

Voluntourism and the TeamMed Experience Chloe Higgins & Masad Alfayadh About the Authors: Masad Alfayadh: Masad is a 4th year medical student at Monash University in Melbourne. She recently participated in an international volunteering trip with TeamMed, Help Us Grow and The Suubi Centre in rural Uganda, volunteering mainly at a primary healthcare facility. She has an interest in environmental, refugee and indigenous health issues.

Chloe Higgins: Chloe is a 3rd year medical student at Monash University in Melbourne. At the start of 2015, she partook in an international volunteering trip with TeamMed, Help Us Grow and The Suubi Centre, mainly volunteering in rural Uganda on projects to screen the population and conduct health promotion. She has a strong interest in global health and the environment.

Abstract Uganda has a ratio of 1 doctor to every 10,000 people. Conversely, Australia has a ratio of 1 doctor to every 3,000 people. This contributes to a very high death toll resulting from preventable or curable diseases. Medical volunteering can potentially help to alleviate the issues surrounding limited medical resources and workforce shortages; however, there can also be ethical issues surrounding medical volunteering. A group of seven Monash medical students volunteered in Lubanda, a small village in the Lwengo district of Uganda. This trip was organised meticulously by TeamMed, working closely with Help Us Grow and The Suubi Centre Uganda, with a thorough selection process, extensive pre-departure training, cultural awareness sessions and language training. The trip organisers endeavoured to work very closely with the Ugandan locals to avoid the shortfalls commonly associated with such volunteering trips.

This article will explore the difference between ‘voluntourism’ and medical volunteering. Our volunteering trip with TeamMed will form the basis for reflection on the current literature about the role of international volunteering in medicine and the likely impacts it may have on both the local populations and the volunteers. Furthermore, we will propose recommendations for future volunteering trips in order to avoid common ‘voluntourism’ shortfalls and maximise potential benefits.

World Bank statistics indicate that Uganda has a ratio of 1 doctor to every 10,000 people.[1] This is 25 times below the World Health Organisation’s minimum of 2.5 doctors per 1000 people required simply to maintain primary care.[2] In comparison, Australia has a ratio of 1 doctor to every 3,000 people.[3] Although the issues that act as barriers to progress in Uganda’s healthcare system are very complex, the discrepancy in doctor-patient ratios and the lack of access to healthcare in Uganda compared to Australia is an element that can explain part of the stark difference in health and, therefore, life expectancy between the two countries. Ugandans live to 59 years old on average, while Australians live to 81.[4] Despite the tireless work of healthcare workers in Uganda, 60% of the death toll is due to potentially preventable and curable communicable diseases, while this is only implicated in 4% of Australian deaths.[5] The vector journal

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top causes of death in Uganda are: HIV (17%), Malaria (12%), lower respiratory tract infections (7%), tuberculosis (5%) and meningitis (4%).[6] Medical volunteering has a role in countries such as Uganda as it can potentially help to alleviate the issues surrounding limited medical resources and workforce shortages in healthcare.[1] Conversely, international volunteering has been criticised as having several deleterious consequences such as disrupting local economies and contributing to a culture of dependency. [7] In January 2015, we, a group of seven Monash Medical Students, volunteered in a rural medical centre in Lubanda, Uganda. After researching the challenges faced by the healthcare system, we were very passionate and motivated to use our medical knowledge to assist whilst learning from the locals at the same time. We were acutely aware of volume 10, issue 18

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The Trip Our trip was organised by TeamMed, Help Us Grow and The Suubi Centre. TeamMed is a student-run public health advocacy organisation which conducts international volunteering trips for medical students. Currently TeamMed coordinates trips to Tonga, Nepal and Uganda. Help Us Grow (HUG) is a not-for-profit organisation led by a dedicated couple from rural Victoria which operates across several rural villages in Uganda.

HUG operates in very close association with The Suubi Centre, a local Ugandan organisation.

Their aim of the partnership between HUG and Suubi is to create self-sustaining, independent, entrepreneurial, healthy communities by building strong partnerships and engagement. Suubi and HUG have both worked for decades to concretely establish the foundations of their project in Lubanda. Their achievements include an environmentally sustainable vocational school, a community centre which provides jobs and financial security for local women, and a health centre which provides low-cost healthcare and health education.

In preparation for the trip, we sourced medical equipment to donate and raised over $6000 to buy more medical supplies for the Suubi Medical Centre. The medical supplies ranged from basic supplies such as syringes, gauze, and alcohol hand rub, to more sophisticated laboratory machinery such as centrifuges, a dental steriliser and airway management equipment. The items sourced were donated and our group volunteered in the medical clinic in an attempt to promote health and increase screening. All treatment at the centre was provided free of charge during our stay.

Medical Volunteering Medical volunteering, or medical ‘voluntourism’ as vector journal

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some perceive it, has the potential to be helpful to the host community, or to propagate a culture of paternalism and privilege. As McLennan [8] reflects, ‘finding positive outcomes are not a natural consequence of voluntourism, but must be nurtured’.

Voluntourism has been criticised for many reasons.

Firstly, and perhaps most alarmingly, it can detrimentally impact a host community by creating an industry which thrives on the persistence of poverty.[8, 9] There are also concerns about the lack of skilled volunteers, the lack of autonomy and consent opportunities given to locals, the fuelling of dependency of communities on external aid while also taking away jobs that could be performed more effectively by locals. Furthermore, many of the projects conducted for the purpose of voluntourism trips are unsustainable and have no concrete long term benefit to the host community.[9] However, when done responsibly, voluntourism does have the potential to help host communities.

[10] In places like Uganda, where there is an extremely low doctor-to-patient ratio, [1] medical volunteers can contribute to improving access to health care [1] and can support local healthcare providers through information sharing and the building of health infrastructure.[11, 12] The evidence from healthcare projects conducted in the North-Eastern parts of Uganda and our experiences support this notion.[12] Moreover, international volunteering can also help to create a more socially responsible globalised society.[8] McGehee and Santos [10] found that the networks formed during a voluntourism trip are likely to help an individual participate in more social movements later in life. Following on from this understanding, medical students will potentially be better equipped to ‘address the health advocate role, foster global citizenship, and develop a sense of social responsibility to tackle worldwide disparities and inequities in health and social development.’[11 p.530]. Building on this, some studies suggest that international volunteering can contribute to creating doctors with a stronger holistic and humanitarian focus.[13] A study conducted at the University of Massachusetts Medical School reported that medical students who had participated in electives overseas experienced a stronger desire to learn about the working and living situations of their patients.[13] volume 10, issue 18

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Furthermore, these medical students were better able to comprehend the cultural factors which are involved in patient care.[13] Particularly in a multicultural country like Australia, understanding cultural nuances and having experience in crosscultural communication are beneficial and useful skills to have when working in healthcare. In addition, participation in global health projects has been found to allow students to improve their understanding of the social determinants of health and learn about the importance of public health measures.[9] International medical volunteering has been recognised worldwide as having the potential to alter the landscape of medical education.

[14] A recent survey published in the Journal of the American College of Surgeons found that 98% of surgical residents supported international volunteering becoming part of their formal training.

[14] This highlights the increasing interest in such opportunities. The survey concluded that, ‘it may be time to begin discussion on how to formally incorporate international experience into US surgical training.’[14 p.168] Furthermore, the Australian Medical Students’ Association (AMSA) supports the incorporation of international experiences in medical education and a stronger presence of global health in the medical curricula. This is based on the recognition that there is now ‘unprecedented global interconnectedness and interdependence’[15 p.266] of which medicine is a part of. Although the benefits of a greater understanding of global health and overseas volunteering experiences are undeniable, it is imperative that such programs are guided by research relating to ethically appropriate volunteering programs.[14] Organising a Medical Volunteering Trip There isn’t a shortage of companies endeavouring to make a material profit from this industry through exploiting locals to give Westerners an egoboosting experience. However, there are also other organisations which endeavour to utilise the altruism of volunteers to genuinely benefit locals. Even the latter, though, may cause harm despite their benevolent intentions. Hence, it is very important to be wary and critical when embarking on an international volunteering trip.

Simpson [16] affirms that a volunteer should select an organisation which has a strong ‘pedagogy for social justice’ which explores why and how the vector journal

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local community came to face poverty and other adverse circumstances. From our experience, HUG was such an organisation. HUG worked closely with a local organisation, the Suubi Centre, and conducted very clear, comprehensive predeparture training and post-departure feedback and education. It did not reinforce the idea of ‘us and them’, but rather advocated for a full immersion of participants into the lives of the locals and seeing the common humanity which united us. This training, though, did not include a more comprehensive perspective on the systems and historical events which led to the poverty we encountered in Uganda. Furthermore, it did not address the political instability and why diseases which are so preventable are so rampant. Although such questions require a lifetime of investigation and lead to no clear conclusions, an introduction to making an enquiry into these discussions would have, in our opinion, been a useful addition to the training program, and would have given volunteers a much broader understanding of social injustice.

Another important aspect of organising a volunteering trip is to choose an organisation and a project which is sustainable and supported by the locals. One way we endeavoured to encourage sustainability of our project was to work within existing infrastructure and services.[16] In the Suubi community, the clinic where we volunteered was a pre-existing community facility which was always open and available to locals. Our project was mainly aimed at raising community awareness of the services available at the Suubi medical clinic and providing the extra manpower and resources required to perform medical screening. In our absence, the Suubi Clinic continues to provide healthcare to its community members.

Participant selection is also an important aspect of organising an international volunteering trip.

Some individuals may not be ready to be exposed to social inequity and poverty and may be hugely discouraged and demotivated by the experience.

Others may not have the correct motivations for getting involved in the trip, such as wanting to perform medical procedures outside of their training. To organise our trip, TeamMed used an application and interview processes, which were consciously and carefully designed to select participants who had an appropriate level of understanding to undertake the volunteering experience. Furthermore, there was an extensive volume 10, issue 18

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pre-departure training program held approximately once a week over a seven-month period. A TeamMed participant from the 2014 trip ran the education sessions, along with the founder of HUG who has spent an extensive amount of time in the Suubi community. The aim of the education program was to educate the team on the local culture and the objectives of the trip in order to strengthen the team’s ability to build rapport and to work in collaboration with The Suubi Centre. In addition, participants were educated on the shortfalls of international volunteering, in particular the limitations and dangers of ‘band-aid solutions’ that fail to deliver long-term benefits to a community.

During the trip, the medical student team were briefed on the expectations from them. In doing so, TeamMed ensured that our trip wasn’t used as an opportunity to experiment and practice new skills. It Is imperative that there are clear practice boundaries for medical students on international placements and allocated supervisors to ensure these boundaries are adhered to.[17] In addition, our team coordinated closely with local community members with the aim of ensuring that our efforts were in line with the needs of the community. The dental health promotion was the epitome of that. It was conducted at the community centre and took into consideration the needs, culture and language of the locals. In organising the health promotion session, we liaised very closely with community health leaders to ensure that our health promotion focused on an area of need for the community and sought assistance in making it culturally acceptable and achievable for the local people. Methods we used in order to make dental health accessible to the locals included conducting the session and designing all signs and colouringin sheets in the local language; providing cups to the attendees for teeth rinsing and for hygienic storage of their toothbrushes and toothpaste; providing toothpaste and other equipment to the health centre staff to distribute to the locals after our departure; and selecting a locally available toothpaste brand, so that villagers would be able to buy the same toothpaste if the clinic supplies run out.

Perhaps the most important aspect of any volunteering experience is to continually reflect on the goals, failures and achievements of the trip. vector journal

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Indeed, a call for a stricter review process and data collection for volunteering organisations and their work has been a recent focus of discussion.

[18] Our Uganda trip was interspersed with times where there were cross-cultural misunderstandings, for instance differences in the concepts of work ethic and time. Holding evaluation meetings and taking part in open discussions at the end of each day were crucial in addressing misunderstandings and ensuring that they were resolved. To help improve future trips, TeamMed collected data in the form of surveys from the local doctors and community leaders, as well as medical data on the prevalence and distribution of illness. We were able to assess the degree of success of the trip from this information, and this had an added benefit of encouraging us to maintain an ongoing dialogue with the community. As this review process was in its first year, it was quite rudimentary and laborious to conduct. This will be expanded on and refined for future trips.

Conclusion Our trip to Uganda with TeamMed was a truly remarkable experience. Aside from broadening our medical knowledge and learning from a different culture, we also took away many lessons about the complexities of volunteer work internationally.

In an attempt to portray these complexities, the benefits and pitfalls of volunteering were discussed.

To add to this discussion, we examined some approaches that TeamMed incorporated in their program, both in the lead-up and execution of the trip, in order to bring to the fore some practical approaches that can help shape a more informed and ethically sound experience.

Notwithstanding the shortcomings of volunteering, international trips for medical students can be of benefit to future doctors and leaders in global health. In saying this, volunteering trips must envisage to include constant reflection on the volunteer’s actions, goals and accomplishments.

With this in mind, we believe TeamMed, HUG and the Suubi centre have created a novel program through their pre-departure training, ongoing communication with local clinics and community members, and evaluation processes. Although there is some improvement to be made, mainly in the area of data evaluation to measure effectiveness and sustainability of the program, we feel that volume 10, issue 17

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the model adopted by TeamMed provides useful insights for other similar organisations and medical students wishing to complete an international placement.

Acknowledgements We would like to thank the staff at The Suubi Community Health Centre for their hospitality and teaching. We really enjoyed our trip and are grateful for the time we spent with them. We would also like to thank Help Us Grow, TeamMed and The Suubi Centre for giving us this opportunity and for facilitating the trip.

Conflict of interest declaration Both authors are currently volunteering for TeamMed. Chloe is on the Executive Committee, and Masad is the Monash 4th Year Representative.

[12] The Guardian. Healthcare a Major Challenge for Uganda [Internet]. The Guardian; 2009 [Updated 2009 April 1st ; cited 2015 April 20th]. Available from: http://www.theguardian.com/katine/2009/apr/01/healthcare-in-uganda [13] Flatau PM. International Health Electives: What is the Impact on Primary Care Recruitment? Fam Med. 2010 April; 42 (4): 238-9 [14] Powell AC, Mueller C, Kingham P, Berman R, Pachter HL, Hopkins MA. International Experience, electives, and volunteerism in Surgical Training: a survey of resident interest. J Am Coll Surg. 2007 Jul; 205(1): 162-8 [15] Australian Medical Students Association. The Orange Book [internet].

Australia: Australian Medical Students Association; 2014 [Cited 2015 April 19th]. 327 p. Available from: https://www.amsa.org.au/wp-content/ uploads/2014/10/Orange_book_4ed_3rd_Council_2014.pdf [16] Simpson, K. Doing development: the gap year, volunteer-tourists and a popular practice of development. J. Int. Dev. 2004; 16: 681–692.

[17] The Huffington Post. The Problem with Little White Girls, Boys and Voluntourism [Internet]. The Huffington Post; 2014 February 23 [Cited: 2015 April 1st]. Available from: http://www.huffingtonpost.com/pippa-biddle/littlewhite-girls-voluntourism_b_4834574.html [18] McCall D, Illtis A. Health Care Voluntourism: Addressing Ethical Concerns of Undergraduate Student Participation in Global Health Volunteer Work.

HealthCare Ethics Committee Forum: An Interprofessional Journal on Healthcare Institutions’ Ethical and Legal Issues [Internet]. 2014 July 31 [Cited 2015 May 1st]. Available from: http://link.springer.com.ezproxy.lib.monash. edu.au/article/10.1007/s10730-014-9243-7/fulltext.html

References [1] The World Bank. Uganda [Internet]. Geneva: The World Bank; 2015 [Updated 2015; Cited: 2015 April 1st]. Available from: http://data.worldbank. org/country/uganda

[3] The World Bank. Physicians (Per 1,000 People) [Internet]. The World Bank; 2015 [Updated 2015; cited 2015 April 22nd] Available from: http://data. worldbank.org/indicator/SH.MED.PHYS.ZS [4] The World Bank. Explore, Create, Share: Development Data [Internet]. The World Bank; 2015 [Updated 2015; Cited 2015 April 21st]. Available from: http://databank.worldbank.org/data/views/reports/tableview.aspx [5] The World Bank. Cause of death, by communicable diseases and maternal, prenatal and nutrition conditions (% of total) [Internet]. The World Bank; 2015 [Updated 2015; Cited 2015 April 21st]. Available from: http:// data.worldbank.org/indicator/SH.DTH.COMM.ZS [6] Centres for Disease Control and Prevention. CDC in Uganda [Internet].

Clifton Hill, Atlanra: Centres for Disease Control and Prevention; 2013 October 22 [Cited: 2015 April 2nd]. Available from: http://www.cdc.gov/globalhealth/ countries/uganda/ [7] ABC News. Voluntourism: Questions Raised about Benefits of Burgeoning Volunteer Tourism Sector [Internet]. Australia: ABC News; 2014 November 29th [Cited 23rd April 2015]. Available from: http://www.abc. net.au/news/2014-11-29/questions-raised-about-benefits-of-volunteertourism/5926344 [8] McLennan S. Medical voluntourism in Honduras: ‘Helping’ the poor? Sage Publications. 2014 pp. 163–179 [9] Hanrahan D. Pre-Medical Voluntourism in Developing Countries: Beneficient Intentions, Maleficent Consequences. Bioethics International.

2013 June 12.

[10] McGehee N & Santos C. Social Change, Discourse and Volunteer Tourism. Annals of Tourism Research. 2005 July: 32 (3): 760-79 [11] Dharamsi S, Osei-Twum JA, Whiteman M. Socially responsible approaches to international electives and global health outreach. Med Educ.

2011 May: 45 (5): 530-1

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Namaste Didi Holly Richter

About the Author Holly is a second year MD student at Flinders University in Adelaide, South Australia. She completed a Bachelor of Medical Science at Flinders, and has lived in Adelaide her whole life. She enjoys her involvement in her medical students’ society and global health group, and has more recently enjoyed new experiences within AMSA and AMSA global health. She has been writing for as long as she can remember, Holly loves playing sport and tries to travel as much as studies allow. In 2016 she’ll begin full time rural placement where she’ll spend the entire year undertaking the Flinders University Parallel Rural Community Curriculum.

Abstract Medical electives in developing countries can be, in equal parts, a blessing and a curse for the communities they intend to serve. Too often students fall into the trap of voluntourism, which is at its heart unethical and truly damning to the broader aims of global health. It is only through pre departure training, a broader understanding of the social determinants of health and grassroots collaboration that we can begin to make a positive impact in the communities we visit. This article uses several anecdotes from personal experiences in Cambodia and Nepal to comment on voluntourism, medical electives and the things we must do as medical students in order to have a meaningful impact when we travel overseas to participate in electives.

Each year Flinders University’s Health and Human Rights Group (HHRG) sends up to sixty medical students on overseas electives as part of one of the largest student run volunteer programs in the country, Flinders Global Action Project (FGAP). As for any electives program it is important to reflect on the voluntourism discussion permeating medical schools and universities alike. I am wary that those of us quick to criticize overseas electives may forget the fundamental reasons these electives exist. One of those reasons is to learn and observe medicine in the developing world, in a setting unlike your own.

To experience something that you can’t at home, because you’re curious and you’re passionate and you want to maybe try to make a difference. And on the path to finding out how you could make a difference you will inevitably learn about any number of disparities. Disparities between your life, your medical teaching and the lives of the patients you will treat here in Australia compared to those lives, those medical schools and those patients in the country you are visiting. The differences are of course cultural, logistical, political and fiscal and there is so much to be learnt from them. I think the opportunities for advocacy, a shared curiosity breeding community involvement and a greater selfawareness are extremely important to embrace.

[2] Australian Doctors International. PNG Health Statistics [internet]. Australia: Australian Doctors Internation; 2015 [Cited: 2015 April 1st]. Available from: http://www.adi.org.au/health-in-png-2/png-health-statistic/

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From my perspective, as a return volunteer for the volume 10, issue 18

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Ponheary Ly Foundation in Cambodia and as a previous FGAP student, and a current student of AMSA Academy’s Global Academy, I believe these electives should continue. But that cannot happen without serious consideration of the implications of such work; establishing firm goals including fostering long term relationships with communities; formalized pre departure trainings and a wider discussion about the impacts of the socioeconomic determinants of health on local communities. At the AMSA Global Health Conference in Perth this year, Damien Brown reminded us to constantly question our reason for going on these electives.

He emphasized the importance of grassroots work in communities, and he stressed that we must be fully aware of our reasons for undertaking these electives. His comments echoed those from a wider community of global health experts who are taking part in this discussion about voluntourism.

The following excerpt is from the halfway mark of my placement at Kathmandu Model Hospital in Nepal late last year. In the journal entry below you will read my thoughts at the time of the elective.

Some of them still hold true today, but of course in the eight months since then I have learnt even more about the ethics of medical electives in developing countries, and I look forward to being able to return one day with a new skill set and a volume 10, issue 18

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better understanding of public health and medical infrastructure and how to truly affect change.

A Journal Entry from a first year students’ FGAP in Nepal: December 2014.

I wonder if I’ll ever get used to the adrenaline rush I experience when a patient’s vitals change. The beeping of the monitors, the ECG pattern just slightly different from before, the hum of the blood pressure cuff expanding.

There’s a strange heat First day of placement at Kathmandu Model Hospital that radiates through my body, a slight frown enveloping my forehead, and I become acutely aware of how far away the most senior physician is. I quickly run through the physics, do a mental check and some quick calculations to make sure I’m justified in my heightened awareness. Then I instantly wonder if anyone else is noticing what I am noticing. My heart rate speeds up and I begin the torturous process of waiting for someone else to see. Sometimes, they do. Other times they don’t. More often than not, they don’t need to- a minor change, a slight deviation from baseline is nothing of consequence and I’m simply too green to realize.

Most difficult of all is that I can’t just ask the patient how they’re feeling. Firstly, of course, because they are likely under a general anaesthetic plus physically incapacitated by the endotracheal tube keeping them alive. Secondly, however, is the unfortunate fact that I don’t speak Nepali. Although I’ve made at least some effort in these early days to learn a simple ‘how are you’ or ‘any complaints?’ I still fear their response may be lost amidst my ignorance.

It is, after all, quite a difficult language and many of our patients speak completely different dialects to the medical team themselves, so communication is often challenging even for the Nepali locals.

I’ve spent almost a week here in the anaesthetic department of Kathmandu Model Hospital, a nongovernment hospital which is part of a not-for-profit trust here in Nepal. In my time I’ve seen babies, young men, mothers, eighty year olds and everyone vector journal

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else in between undergo a myriad of different surgeries. Usually there are no complications, and the patients wake up somewhat disoriented but alive and ‘well’ nonetheless. Sometimes, things go wrong. Thus far I’ve been fortunate that none of these things have been fatal. There are many differences from the way operating theatres are run in Australia; however, there are also many similarities. I could not help but notice that needle stick practices could be improved. I almost had a stress-induced heart attack when I saw a nurse plunge her hands into a pile of rubbish that was collecting on top of the unconscious patient, which I knew contained an open needle. Similarly, my friends and I went to great lengths to respectfully talk about hand hygiene with our colleagues and gently broach the idea of promoting regularly washing hands after each physical exam performed at this hospital. However, it’s becoming clear as the week progresses that it is the stark contrasts in resource availability, which is the greatest difference between the two settings. Here, a paediatric procedure must wait until a specific piece of equipment currently in use for an O&G surgery is available. The lights under which surgeons operate are 20 years old and require manual adjustments throughout the operation. Beds are recycled constantly between operating theatres and post op and fluid lines are kept warm in jars of hot water.

The sharps container is an old coke bottle. Gauze is washed and reused several times per surgery, the rubbish bins are plastic bags hanging from the bed and patients are woken up from general anaesthetic in theatre, as there is no recovery room.

Comments about resources like these are typical of an idealistic young Westerner, travelling to far away lands to experience the ‘true culture’ and ‘real poverty’ of another region. Next up the brilliantly philanthropic ingénue would comment on how the locals’ spirit is unaffected despite their hardships, and how their resilience and joy is inspiring when considering just how little they have. Then I might muse upon the ungrateful nature of my own countrymen, lament at the lack of humility and grace in my counterparts in comparison to these volume 10, issue 17

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poor, happy Nepali. This clichéd voluntourism is the last thing in which I wish to participate, and I have taken great lengths to ensure I don’t unwittingly succumb to its trap.

It is fair enough to want to see other communities, and it is human nature to want to help. It is admirable to actively seek knowledge in an environment unlike your own and it is brave to travel to a developing country and immerse yourself in the local lifestyle.

Still, it is both arrogant and naïve to think that as a medical student, with no official qualifications and no intent in staying here after my two week placement finishes, that I can make any real difference during this placement.

At least, not to the patients. I may be able to make some small difference through human interaction with the staff.

They may remember me.

Not because of any skill I would have shown, nor any intelligence or generosity on my part, but because I was respectful, funny and open minded. I listened patiently. I did not ask to perform procedures above my skill level and I did not intend to boast about my achievements to my mates back home. I accepted lunch when they offered it, sharing forks and tea with six other doctors crouching on the floor in a small cubby outside the theatre.

I did menial tasks and spent 95% of my time observing the Nepalese medical students and junior doctors complete jobs I would love to have the opportunity to attempt. And this is how it should be. In my country, there is an abundance of wealth, opportunity and resource for young medical students. Here in Nepal there are no plastic arms for cannulation practice, or model airways to perfect intubation. They must learn on their patients and if I were to inject myself into the scene to further my own knowledge I would be taking away an opportunity for a local and far more deserving student.

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program. Flinders University’s Nepal FGAP is now in its fourth year of implementation and I can see the way there is a true partnership between Flinders University’s HHRG and Kathmandu Model Hospital. What does this partnership involve?

Firstly- fundraising. HHRG runs a quiz night to raise money for each of the countries students go to, and in addition the Nepal students engaged in a partnership with a local Lions club branch.

Due to such fundraisers, we were able to come to Nepal with $2000 ready to offer Kathmandu Model Hospital. But how best to spend that money was entirely decreed upon through communication with the locals. We met the heads of department and members of the hospital’s board of directors in their small office. We all laughed together when my friend, who is six foot eight, crouched awkwardly into a tiny chair with his knees almost touching his chin. In what was a very polite, engaging and open discussion we asked the heads of department what we could bring to their hospital- what do they really need? Money? Equipment? Teaching? More volunteers?

As we were in that meeting suddenly a story I heard the first time I was in Cambodia came to the forefront of my mind because it resonates so strongly with my beliefs about sustainable project development. An American who had moved there and started a not-for-profit organization was lamenting the fact that so many NGOs come in to Cambodia, find an empty lot, build a school and then leave. She pointed one out to me as we walked past; a dilapidated three story establishment with no one inside. Nobody had thought to provide staff for this school. Or books. Or pencil cases for the students. Or money to fund a lunch program.

So the building sat there, thousands of wasted dollars sitting right before our eyes. I will always remember this story any time I envision change or embark on planning any sustainable project in a developing country.

Hence, the discussion at Kathmandu Model Hospital was productive, and the replies to how our fundraising money would be spent were interesting and varied. Some of the board felt their resources were clearly lacking, and that they needed us to buy paediatric pulse oximeters and ECG machines.

Others thought a fund should be set up to offer surgeries to patients who can’t afford them. One of the heads of department explained that we cannot well provide an ECG machine unless we’re able to fund the ongoing costs of the paper also. We didn’t volume 10, issue 17

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From L to R: Srijanna (junior doctor), with Jagat and Kumar (two very charismatic anaesthetic assistants) at the Kathmandu Model Hospital

reach a decision at the meeting, but I’m sure that through ongoing discussion this partnership will grow and we’ll see some fantastic and sustainable results.* I feel incredibly lucky to be given the chance to participate in this elective. The colleagues I have met humble me and I enjoy their friendship. We share jokes and they teach me and occasionally even I can teach them. There is a mutual respect, which serves our purpose well. Whilst all medical students would die for hands on experience and the opportunity to ‘learn by doing’, right now I am more than happy to observe, lend a helping hand and wait in the wings knowing that if I am needed I will be called upon. This may not be my country but sitting, writing, in this small room with its blue walls and a cup of chiya tea, I feel almost at home.

* Whilst no decision was made during my time in Nepal, the subsequent groups who completed their FGAPs in the following month were able to further the discussion. I found out just last month that finally the money, plus additional funds raised early this year, has gone towards 20 new ECG machines, paper to fill it and some fifteen more pulse oximeters.

Note: If you have any questions about my work in Cambodia, the experiences I had in Nepal or down here at Flinders as the current Vice President External of the Medical Students’ Society, please contact me on vpe@fmss.org.au.

Acknowledgements: These experiences wouldn’t have been made possible without the Ponheary Ly

Vision… …to provide high quality, engaging preparatory material for medical students embarking on overseas elective placements

For many of us, overseas medical electives are informative, horizon-broadening experiences which can teach us as much about the world as ourselves. PreDeparture Training is your essential guide to approaching your elective placement with confidence and sensitivity to enable you to get the most out of your experience. Suitable for students from all year levels (it’s never too early to start thinking about your dream elective!), the course features case studies and talks from an exceptional line-up: Dr Jenny Jamieson, Professor Paul Komesaroff, Dr Rosemary Wyber, Dr Julian Sheather and Dr Peter Burke.

Pre-Departure Training covers a range of topics from travel medicine to practical ethics to sustainable electives, and asks YOU the hard questions around WHY you do WHAT you do!

For more information, take a look at the course brochure http://bit.ly/1Ej1Iyt or visit the website to enroll today https://academy.amsa.org.au/courses/predeparture-training/

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News

Australia’s Medical Community Condemns The Border Force Act Durga Chandran

About the Author Durga is a 4th year Medical Student at the University of New South Wales. He is passionate about global health and finding strategies for reducing health inequities. He is the secretary of the global health group at his university, Medical Students Aid Project, and has been involved in Model United Nations conferences in the World Health Organisation committee.

The Border Force Act (2015), which came into effect on July 1st 2015 following bipartisan support, was met with universal outrage from the medical community. Doctors and health care workers participated in rallies across Australia, protesting the legislation which can incriminate people working in asylum seeker detention centres for speaking out about what they see. More than 40 former detention centres workers have denunciated the new laws through an open letter, accusing the Abbott government’s Department of Immigration and Border Protection (DIMP) of “strengthen[ing] the wall of secrecy… which prevents proper public scrutiny”.[1] The act could see any person working directly or indirectly for the DIMP facing up to 2 years in jail if they disclose “protected information” – widely defined to include anything learned in their capacity as an employee.[2] The act stipulates exemptions; those working in detention centres can disclose information if they believe doing so was necessary to prevent serious harm or threat to life, but the onus of proving there was “reasonable belief” rests on the individual. Whistle-blower protection laws offered by the Public Interest Disclosure Act 2013 only apply if concerns of the employees are reported internally. Furthermore, whistleblowing is not protected if the subject matter is government policy or anything the Immigration Minister is taking, or plans to take, action on.[3]

patients begging for treatment, doctors’ requests for medications not being met and long delays in transferring patients to mainland hospitals.[4] Deplorable rates of child abuse were revealed in the Australian Human Rights Commission’s (AHRC) report “The Forgotten Children”, which showed that between January 2013 and March 2014, there were 233 instances of child assault and 128 children engaging in self-harm.[5] The AHRC reported that it was the combination of prisonlike environments, lack of meaningful activity and erosion of family that was contributing to high rates of mental health problems.[6] Consequently, in May 2015, the Royal Australian College of Physicians (RACP) released a position statement calling for the “end of mandatory detention”.[7] RACP President, Laureate Professor Nicholas Talley, stated “As physicians we are duty bound to speak on behalf of our patients – especially since their humans rights are increasingly seen as optional.” [8]

Besides bordering on censorship, the act poses vast ethical challenges for medical professionals.

“Standing by and watching sub-standard and harmful care, child abuse is not justifiable”, the open letter to the government stated.[1] There have been a number of reports on gross health care insufficiencies and human rights violations since the establishment of off-shore detention facilities on Manus Island and Nauru in 2012. In December 2013, a forensic report of the medical care at Christmas Island revealed “numerous unsafe [health care] practices” through case studies of

The Australian Medical Students’ Association (AMSA) also responded through their student run advocacy group AMSA for Refugee and Asylum Seeker Mental Health (AFRAM). AFRAM set up call centres across the country and contacted 226 central parliamentarians to express their condemnation of the obstructions to reporting the health and welfare of asylum seekers in detention centres. Co-coordinator of AFRAM and AMSA Global Health Policy Officer Timothy Martin said, “It’s really important that medical students continue to talk about this issue.” “Can any doctor work

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In light of these realities, hundreds of doctors in Sydney, Melbourne, Darwin and other cities rallied in protests on July 11th and 12th, organised by the Medical Association for the Prevention of War and Doctors Against the Border Force Act.[1] Dr John-Paul Sanggaran, who previously worked on Christmas Island responded “The things that we’ve seen are too terrible… we’re not going to respond to these threats from the Government.” [9]

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in an environment so toxic to the welfare of their patients?” he queried. “Can they be complicit in what is going on?”

AMSA Global Health also coordinates the national project “Crossing Borders for Health” which employs three tiers of action – direct assistance for refugees and asylum seekers, education of medical students and the wider public, and advocacy at a local and national level.

“The Australian public has very little clue as to what being in the detention centre is actually like. There’s no wake up call…we really need public leadership,” he urged. “Anyone who has direct experience with refugee and asylum seeker health or expert knowledge should be advocating for changes to health care policy.”

For more information on Crossing Borders for Health and involvement in AFRAM, visit their website http://afram.amsa.org.au/ and Facebook page. vector journal

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Acknowledgements Tim Martin for his comments on the issue and summary of Australian Medical Student Association’s response.

Conflict of interest declaration This is an original piece with no conflicts of interest.

References

1. Kembrey, M. (2015, July 11). Retrieved from: http://www.smh.com.au/ comment/human-rights-commission-keeping-asylum-seeker-children-indetention-doesnt-stop-people-smugglers--so-why-do-it-20141007-10rcz3. html 2. Sedghi, S. (2015, July 1). Retrieved from: http://www.abc.net.au/ news/2015-06-30/detention-centre-workers-face-imprisonment-forwhistleblowing/6584392 3. Roberts, P. (2015, July 13). Retrieved from: https://theconversation.com/ factcheck-could-a-whistleblower-go-public-without-fear-of-prosecutionunder-the-border-force-act-44467 4. Marr, D. (2013, December 20). Retrieved from: http://www.theguardian. com/world/2013/dec/19/revealed-doctors-outrage-over-unsafe-refugeepatients 5. Triggs, G. (2015). The Forgotten Children: National Inquiry into Children in Immigration Detention 2014. The Medical journal of Australia, 202(11), 553.

6. Ireland, H. (2015, July 7). Retrieved from: http://www.theage.com.au/ comment/global-reputation-for-child-protection-has-crumbled-with-theborder-force-act-20150707-gi6xvh.html 7. Zwi, K., Paxton, G., Cherian, S., Francis, J., Smith, M., Napthali, K & Talley,

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Post-Conference Report

Stories from the IFMSA General Assembly

Jazmin Daniells (The university of Newcastle) & Mingxue Fan (Monash University) Attending the IFMSA General Assembly as an Australian delegate was a truly humbling experience. Amidst the passionate discussion of international issues, frenzied policy making and fatiguing debate of by-laws, the most valuable experiences we gained were from the conversations we had with medical students from around the world. In the precious time we had during these seven days, we were able to gain just a glimpse into the healthcare systems, health issues and lives of medical students in environments so different from our own.

Attending workshops and standing committees with students from around the world, we quickly understood that Australia is a privileged country in which to practice medicine, undergo training and receive health care; this could not be demonstrated more clearly than in the area of maternal health.

Obstetric violence, where labour is dehumanised, is a major issue in Latin America, where routine episiotomies are still seen as standard practice; women unnecessarily receive cold, punishing treatment by midwives and doctors during labour; and childbirth is not seen as an empowering experience, but as a procedure in which women mechanically produce children. The medicalisation of labour contributes to the lack of autonomy of the woman in this process and severely erodes the rights of the woman to have what should be an important and positive milestone in their lives. Health-wise, this leads to increased rates of postpartum depression and complications as a result of malpractice.

My first experience of obstetrics in medical school was in a public hospital in the Bolivian city of Cochabamba. Cochabamba is nestled in a valley within the Andes mountains, it is the home to nearly two million people. Bolivia has the second highest maternal and highest infant mortality rates within South America. Governments, being aware of the poorer health outcomes in Bolivia, have tried to address the situation by implementing policies and schemes aimed at improving antenatal and maternal care.

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Materno Infantil German Urquidi. On my first day I arrived at the hospital along with two of my peers, also from The University of Newcastle. We made our way to the delivery room, changed into our white scrubs and entered the sterile environment of the labour suite.

We entered what could be described as a waiting room for those in labour. Ten beds lined the walls of the room, pushed into two neat rows. Most of the women delivering at this hospital were of Quechua descent, Indigenous people of Bolivia.

There were no curtains separating the beds and if a woman wanted, she would be able to reach out across the bed to touch the woman next to her.

Family members, friends, partners, husbands were not allowed into the Waiting Room of labouring women. The Waiting Room, wasn’t only for women in labour. It was often shared with those whose pregnancies had suffered complications. Laying next to a labouring expectant mother, it was not uncommon to see a young girl suffering “wounds from sexual abuse”, or a woman lying with a kidney tray catching the remains of her miscarriage - we were invited to inspect the fetus that now lay lifeless in the cold metal dish. At times the Waiting Room wasn’t busy and there were free beds available.

Medical students would lounge on the vacant beds and listen to music whilst cheerily gossiping or snacking on takeaway empanadas. Music was constantly playing in the Waiting Room, except for when a consultant would be coming around to check on problem pregnancies. The blasting of “Turn down for what” or Pitbull would quickly stop with the warning of the consultant’s arrival.

Prior to their admission into the Waiting Room, all women were given an enema, regardless of their wishes. They were not offered the options of pain relief such as epidural. Once a woman was ready to deliver she was moved into one of three birthing bays. Women of all ages were alone throughout the process and delivered without the kind words of encouragement we expect and see as normal.

The most typical encouragement a woman would receive was “peude” - “you can”, “empujar” “push” and “continuar” - “continue or keep going”.

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hold the hand of a young woman going through a difficult labour. During labour most women received an episiotomy, this helped to speed up the process and was regularly carried out. Local anaesthetic would be administered merely seconds before the cut was made, even when there had been plenty of time to administer the anaesthetic and allow for the appropriate effect before continuing. Often a medical student would try and initiate anaesthesia earlier, but was stopped the consultant.

Once the woman delivered, her new baby lay on her chest. Finally! We were relieved that after all of the trauma, it was worth it, but sadly she had minutes to share with her child before they were taken away for their newborn baby check. The newborns would then remain in a room until it was time for them to be fed.

I knew this cold, loveless waiting room and birthing bay wasn’t like anything in Australia and were far from what we would accept, but it also didn’t feel like our place to say anything. This is a country trying, what seemed to be, its hardest to improve women’s health. One of the problems thought to contribute to the increased maternal and infant mortality was delivery at home without a healthcare professional. The most recent intervention in place during my time in Bolivia was a financial incentive to attend antenatal appointments and deliver in a hospital. Seeing the way women were treated at hospital it was more than understandably why women would want to deliver at home. The financial incentive was up to one third of the average yearly income, a price too alluring to resist despite the conditions a woman would find herself in.

At the time, I didn’t realise the obstetric violences that were occurring; the denial of pain relief, the lack of communication and support, not allowing a partner to accompany the woman through the labour process, unnecessary episiotomy and a general lack of respect for the women. Even now I reflect upon this and think to myself “Am I harshly judging a health system that is struggling?”

I don’t think so. I think by speaking up and creating awareness about these issues we can begin to make a difference.

Taking a step back, the story of obstetric violence raises three major concerns for us as medical students: Firstly, and most obviously, lack of autonomy is a violation of human rights; secondly, it vector journal

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does not follow high levels of scientific evidence in the field, of which access, or disregard, could both be contributing factors; thirdly, and perhaps the most sinister issue, is the impact this practice will have on medical training in this part of the world.

We learn from students that, in Latin America, clinical expertise is still often the default pinnacle of evidence, despite availability of evidence-based national guidelines and textbooks. Anecdotally, we are told that students fear challenging the teachings of specialist consultants and professors, seen as a sign of utmost disrespect. With analytical thought discouraged and lack of adoption of evidencebased practice, this begs the question: “What does the future face of clinical practice look like?”

Fortunately, student voices are strong – the empowerment of women is a major advocacy issue for DENEM, the national medical student body of Brazil, meaning that it is still identifiable in spite of lack of access of best practice guidance.

With obstetric violence brought to the forefront this General Assembly, developing a position statement at the IFMSA is not far behind.

Having heard these stories, we could not help but ask, “What can we do to help?” Yes, this General Assembly was an enlightening experience; but, as an Australian medical student, one could not help but feel at times frustrated and helpless in the face of these local issues faced by our global neighbours. However, with these issues being brought to a public, international forum such as the IFMSA, perhaps we can slowly, as a stronger, unified body, advocate for and educate others about them, and head steadily towards the goal of global health equity.

Sally Gordon At this General Assembly we were fortunate to spend some time with Jaer, the National Exchange Officer for FEVESOCEM, Venezuela’s Medical Student Association, and hear first hand about the current political and economic situation occurring in Venezuela. Due to falling international oil prices, a failing economy, and governmental restrictions, Venezuelan citizens are unable to access foreign currency, such as American dollars or euros, through legal means. In the last few months, this has had a significant effect on the country’s ability to purchase essential medicines, such as volume 10, issue 17

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contraceptives and antibiotics, and has worrying implications on the future health of the Venezuelan people.

During the meeting we had the unique opportunity to advocate on behalf of Venezuela, and other low and middle income countries, to increase opportunities for participation in the IFMSA. Jaer was present at the General Assembly to explain why his organization was unable to pay a euro 1280 annual membership fee to the IFMSA, with the threat of possible eviction from the organization if payment could not be achieved. This exorbitant fee was calculated by looking at a country’s annual per capita gross national income (GNI). However, whilst Venezuela’s GNI is USD$12800, classifying it as a high-income country according to the World Bank, the monthly minimum wage is a meagre USD$33.

This indicates, likely due to the gross inequalities experienced in this country, that GNI alone is not an accurate measure of the country’s true economic state. Many other countries from the Americas and other regions shared similar experiences with us during the meeting, with inequality being a central theme. For example, 57.9% of Colombia’s wealth is owned by the top 20% of the country’s citizens. We decided that it was important to have a fairer and more transparent method of calculating membership fees within the IFMSA, and sought support from many of the medical student societies from other countries present at the General Assembly. This process culminated in us being able to successfully pass a motion mandating the executive board to investigate fairer mechanisms to calculate membership fees, and encourage greater participation within the IFMSA.

Post-Conference Report

Asian Medical Students’ Association Conference, Singapore 2015

Nicholas HIM1, Joey (Chau) LAM1, Victor YANG2, Cecilia XU2, Caroline McBRIDE3, Andrew WANG3, Seong Jun PARK4, Charis KHO3, Anisha HASEEB1, Felanita HUTANI3, Nicholas BETTS5, Yasmean KALAM1, James TSAKISIRIS6, Charles McCAFFERTY5, Marra AGHAJANIAN5, Zhan Yi LIM7, Shuwanugha SUBRAMANIAM1, Yen Yi LIM1, Anita PRATT3, Bryan LEE8, Nadia PERERA9, Michael KEEM3 The 36th annual Asian Medical Students’ Conference (AMSC 2015) was held in sunny Singapore from July 5-12, and was well-attended by hundreds of medical students from over 20 countries spanning the Asia- Pacific region and beyond. Over a jam-packed 7 days, the 35-strong Australian delegation representing both AMSA and the Asian Medical Students’ Association International – Australian chapter (AIA) took part in both academic and community service activities based upon the conference theme ‘Geriatric Medicine - Embracing The Silver Tsunami’, as well as a wide-variety of cultural and social activities.

The following is a day-by-day summary of our experiences at the AMSC Singapore 2015.

Day 1 – Arrival, Ice-breakers and Welcome Dinner After arriving at the accommodation at the National University of Singapore (NUS), delegates met with their group members and group moderators (GMs) to engage in introductions and ice-breaking activities. Each group consisted of approximately 22 delegates and 5 Singaporean GMs. Any initial awkwardness between group members quickly melted away as delegates embarrassed themselves repeatedly in front of one another playing icebreaking games. The evening concluded with an abundant buffet dinner of Singaporean delights and entertainment provided by local live-looping artist, Kai, as well as an all-delegate-involving game of ‘Beach-Ball Hot-Potato’, a dancing competition and ‘Chubby Bunny’ in which participants attempted to stuff their mouths with as many marshmallows as possible.

Day 2 – Opening Ceremony and Sightseeing AMSC 2015 officially opened on Day Two with a spectacular Chinese lion dance performance and an address from the Singaporean Minister of State for Health, Dr Lam Pin Min. The keynote session followed, with delegates having the privilege of attending presentations on ageing, end-of-life care and decision-making, and community services for the elderly from three highly respected professors,

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all specialists and international experts in the field of geriatric medicine. Issues were explored, preconceptions challenged, questions answered and many more engendered in what was a comprehensive and enlightening introduction to geriatric care.

Following the opening ceremony, the first sightseeing event of the conference was a group visit to one or more of Singapore’s cultural heartlands. Since colonial times, these areas have been the traditional centres of activity for

Singapore’s three major ethnic groups: Little India, Chinatown, and Kampong Glam for those of Malay heritage. Each of the heartlands retains many elements of the people and cultures that were and still are located there, allowing delegates to experience the traditions, food and culture of the many different people who make up Singapore.

Day 3 – Site Visits, Cultural Workshops and AMSC Olympics Site visits allowed delegates to gain an insight into Singapore’s health care and medical education systems. Some delegates visited Khoo Teck Puat Hospital where they learned about its commitment to instilling a strong healthy and sustainable volume 10, issue 18

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living philosophy in its staff and patients, through mediums such as food, lifestyle and biophilic architecture. Other delegates visited local agedcare community centres to provide patrons with company and entertainment, whilst some reviewed their clinical and procedural skills in simulation labs at NUS.

Delegates spent the rest of the day participating in cultural workshops and the ‘AMSC Olympics’.

The workshops immersed delegates in local Singaporean culture, with activities including an introduction to Singlish (Singapore’s unique brand of English), Silat (a traditional Malay martial art form), Indian dancing, silk painting and playing with traditional childhood toys. The AMSC Olympics were filled with fun group-bonding activities including charades, physical challenges and trivia.

Day 4 – Scientific Paper Competition, Academic Workshops and Night Safari Facing tough competition, the Scientific Paper team highlighted the issue of polypharmacy in the Australian geriatric population. The team presented their systematic review’s findings that clinicianlevel educational interventions show promise in promoting appropriate prescribing in geriatric patients, thereby reducing the risk of adverse drug events in the elderly. Chief Delegate Nathan Jamieson and presenting team Victor Yang, Cecilia Xu and Yen Yi Lim gave a visually and academically enthralling seven-minute presentation, expertly answering questions from the panel of consultantphysician judges.

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of the Singaporean healthcare system through conversations with elderly patients and doctors.

Patients and their carers shared their frustrations in dealing with ill-health due to advancing age, while doctors spoke of issues such as language barriers in multicultural Singapore, in addition to sharing clinical pearls of wisdom for treating senior citizens.

After a full day of academic activities, delegates relaxed with their groups in the evening at the Singapore Zoo’s ‘Night Safari’, first watching the spectacular ‘Creatures of the Night’ show before embarking on a tram safari through various replicated habitats to observe nocturnal animals from around the world when most active.

Day 5 – Scientific Poster, White Paper and Photography Competitions, Group Discussion and Cultural Fair Day 5 saw the resumption of academic competition presentations from shortlisted chapters. In line with the conference theme, the Australian scientific poster team focussed on heart failure in elderly Australians. Led by Chief Delegate Joey Lam, the

twelve-person team conducted a retrospective cohort study in the lead-up to AMSC 2015, finding that older patients or those with a longer length of hospital stay had the greatest odds of all-cause readmission within 30 days. Shelton Leung, Andrew Wang, Felanita Hutani and Esther Park presented the team’s findings and adeptly answered all questions asked by the panel of expert judges.

The White Paper category made its debut as an academic competition at AMSC 2015. It required entrants to create a document detailing an area of health policy in their country relevant to geriatric medicine, and to provide recommendations for the improvement of that policy area. Entrants were also required to create a short film clip to introduce their paper. The Australian team addressed the low awareness of Advance Care Planning in Australia.

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highlighted potential causes including inconsistent legislation and poor access, and recommended several changes to policies, law, and education for healthcare professionals. The presentation began with a short film made by Laura Cashman, and continued with a discussion by Chief Delegate Caroline McBride and presenters Yen Yi Lim and Anisha Haseeb.

The Photography Competition allowed another creative opportunity to engage with the conference theme. Australia submitted two inspiring entries for this competition by Irene Chua and Dexter Sim. Their entries challenged the notion that growing old is inexorably accompanied by dread and gloom, instead underscoring the positive aspects of ageing.

The academic activities that followed included a professorial lecture and discussion of various subthemes of geriatric medicine. Associate Professor Goh Lee Gan spoke of the challenges currently faced by Singapore’s aged care system, which served as an impetus for delegates to subsequently create short presentations addressing ageism, models of geriatric care and aged care in the community setting. Friendly competition was encouraged between groups in the spirit of mutual learning, with the winning group performing a skit that contrasted the challenges faced in geriatric medicine in various countries across the AsiaPacific.

The Cultural Fair brought a fantastic end to Day Five. It enabled chapters to showcase their unique cultures in the form of a booth, comprising of traditional foods, costumes, and gifts, with delegates free to mingle, share a laugh and learn about the customs and cultures of their new friends. The Australian booth quickly became a crowd favourite, hosting a photo-booth with lots of fun props, face painting and a table piled high with classic Australian snacks, including Tim Tams, Fairy vector journal

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bread, Australian cheeses, and Vegemite.

Day 6 – Community Engagement, Sightseeing and Cultural Night

The Community Engagement activity saw over 400 elderly Singaporean residents share an early lunch with delegates at NUS before strolling together over the university grounds to engage in both traditional and childhood games. Some delegates were able to sit and chat with the elderly visitors who were unable to take part in physical activities.

In the afternoon, delegates explored the beautiful outdoor ‘Gardens By the Bay’ and the Flower Dome with their groups. There was also the opportunity to visit the Marina Bay Sands complex and the surrounding riverside area, and to relax and enjoy the sights with group members before preparing for Cultural Night.

Cultural Night was an eagerly anticipated social highlight of AMSC 2015. Delegates shared a lavish final dinner together and enjoyed the

stage performances showcasing the cultures of each chapter. Australia collaborated with New Zealand, providing a rousing performance filled with singing and dancing, much to the delight of audience. Other activities on the night included on-stage dance competitions and the GMs’ dance performance. The night ended with an emotional farewell video, which pieced together the AMSC 2015 journey over the preceding week.

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Day 7 – Closing Ceremony and Free Sightseeing Conclusion AMSA International conferences provide an abundant source of research, professional and social opportunities for all medical students. The academic, community service, social and cultural activities provide delegates with opportunities to both expand and explore their knowledge horizons, whilst concurrently learning about other cultures and establishing international networks and lifelong friendships. The next AMSA International The Closing Ceremony marked the conclusion conference is the EAMSC 2016, hosted in Taiwan of the academic and official business of the from January 24-29, with the theme ‘Medical Care conference. The Organising Committee of AMSC in the Future’. The AIA and AMSA Global Health 2015 presented a heart-warming closing speech encourage all Australian medical students to apply before the introduction of the incoming 2015-16 for EAMSC 2016 and future AMSA International Asian Medical Students’ Association International conferences, and warmly welcome all enquiries Executive Committee. Academic competition about its programmes. results were then announced, with Australia successfully placing first for Best Video for White Paper, second overall for White Paper and third overall for both Scientific Paper and Scientific Poster entries.

Thereafter, brief introductory presentations were given about the upcoming AMSA International Conferences, the East Asian Medical Students’ Conference (EAMSC) 2016 and AMSC 2016, which will be held in Taipei and Manila respectively.

This was followed by a presentation from Nathan Kuk who introduced AMSC 2017, to be held in Melbourne, Australia; just the second time Australia has hosted a conference in AMSA International’s 30-year history. The Closing Ceremony concluded with musical performances from talented local medical students and group photos of all present delegates.

Global Health Group Spotlight

Deakin Dash 2015: We Did It In A Dress

Lena Handrinos (AMSA Global Health Representative, Universal Health At Deakin) “The impact of sending just one girl to school is undeniable: she will marry later, have a smaller and healthier family and for every year a girl stays in school she’ll increase her income by at least 10%, investing 90% of it back into her family,” says Chantelle Baxter, Chief Executive Officer of One Girl.

At our 2015 Global Health Unzipped Conference, Universal Health At Deakin (UHAD) members and medical students heard from Chantelle firsthand that there are over 60 million girls in the world who are not in school, and in Sierra Leone, only one in six girls get the opportunity to attend high school. In addition to attendance at school comes increased access to healthcare, safety from sexual exploitation, and ultimately, an opportunity to break out of the poverty cycle. At UHAD, we think this is a fantastic cause.

The Deakin Dash was far from a one-person job.

The idea adapted and changed in numerous ways, and stemmed largely from the inaugural event in October 2014. It took a supportive network of dedicated people with a range of skills and passions to put the event together. This year, we had a team of ten people devising crazy obstacles, dreaming up the course and sourcing materials and funds. Come event day, we had 38 volunteers without whom the joy and excitement of the event would not have been possible.

With pride, I can report that Deakin Dash 2015 raised over $8,600 for One Girl! With these funds, One Girl will provide 28 girls with year-long high school scholarships. On the day, 106 participants slid down the slip-and-slide and clambered through the mud crawl, splashed through the jelly pit and In consideration of these values, UHAD came got bombarded with colour bombs. The Deakin together in unanimous support of One Girl to Dash was proof that ideas need not remain in organise our biggest event of the year, the Deakin the imagination. It was a humbling example of Dash. The Deakin Dash is a 5km obstacle course putting thoughts into action with collaboration, held at our Waurn Ponds campus, with all proceeds perseverance and some very rewarding hard work. from tickets and food sales going to One Girl.

Better still, many of our participants this year signed up for One Girl’s ‘Do It In A Dress’ campaign in a substantial show of sponsorship, where runners and volunteers procured donations to sport school dresses on the day.

With the conference brought to an official end by the morning of Day Seven, delegates had the rest of the day to spend with their group mates.

Groups ventured to locations such as Orchard Road and Sentosa Island, opting for activities such as shopping, playing beach games and indulging in local dishes such as Singaporean Chilli Crab. By evening, some groups continued their festivities in Clarke Quay’s bars and clubs while others decided to have a night-in of chatting and games. Most groups continued on to the wee hours of the next morning; each delegate wanting to spend every last moment of their time in Singapore with their newest friends before bidding final farewells.

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