AJGH Volume 14 Issue 1 by The Australian Medical Students' Association

THE LENS

13 VOL 14 ISSUE 1 JUNE 2020 EST 2006

VACCINE HYSTERIA

CROSS BORDER SURROGACY

CAN INTERNET SEARCHES PREDICT AN OUTBREAK? 80

Volume 14

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AJGH 2020 Volume 14 Issue 1

ADVISORY BOARD Consists of academic mentors who provide guidance for the

THE LENS

present and future direction of Vector Journal

Dr Claudia Turner

With borders closed,

Consultant paediatrician and clinician scientist with the

social distancing in place,

University of Oxford and chief executive officer of Angkor Hospital for Children

our access to the world

Professor David Hilmers

is facilitated by

Professor in the Departments of Internal Medicine and Pediatrics, the Center for Global Initiatives, and the Center for

The Lens.

Space Medicine at the Baylor College of Medicine.

Associate Professor Nicodemus Tedla Associate Professor in the School of Medical Sciences at the

Through The Lens

University of New South Wales.

held firmly in our hands

Dr Nick Walsh

our global perspective is guided.

Medical doctor and regional advisor for viral hepatitis at the Pan American Health Organization / World Health Organization Regional Office for the Americas.

PEER REVIEWERS Professor Richard Kanaan Dr Paolo Fornaro Dr Irmgard Bauer Dr Mariana Galrao Dr Kim Dunphy Ella Dumaresq

EDITOR-IN-CHIEF

With a simple twist our world is rearranged new angles of global health come into view. At a glance, a flick of a page,

Terra Sudarmana

we embark on landscapes once foreign;

SENIOR EDITORS

his experience, her research, their knowledge.

Stephanie Kirkby Marisse Sonido

ASSOCIATE EDITORS

As a team (authors included)

Masrur Joarder Anandita Soundappan John Koh Sophia Moshegov Rosemary Kirk Joy Drieberg Thompson

we’ve taken the time to:

PUBLICATIONS DESIGNERS

enhance the quality (edit),

Kit Lindgren Hyun Jae Nam

peer through the lens (research), take a snapshot (write), adjust our scope (select), and present the pertinent (publish).

PROMOTIONS DIRECTORS Pabasha Nanayakkara Christine Manuel Design and layout © 2020, AJGH Australian Medical Students’ Association Ltd, 42 Macquarie Street, Barton ACT 2600 ajgh@amsa.org,au ajgh.amsa.org.au Content © 2020, The Authors Cover design by Kit Lindgren AJGH is the official student-run, peer-reviewed journal of AMSA Global Health. Responsibility for article content rests with the respective authors. Any views contained within articles are those of the authors and do not necessarily reflect the views of AJGH or the Australian Medical Students’ Association.

So widen your scope, look through The Lens, AMSA’s Journal of Global Health will take you through a kaleidoscope of articles.

THE AJGH TEAM

CONTENTS 5 10

15 16

June 2020 Issue 1

Exploring the Impact of Local Knowledge and Attitudes Anita Niu, Elizabeth Zhang

THE WEIGHT OF THE WORLD

Unpacking the Global Health Workforce Shortage and Supporting Migrant Healthcare Workers Dayna Duncan

Tara Kannan

VACCINE HYSTERIA

The Role of Gender in the Anti-Vaccination Movement Katharine Robertson

CROSS BORDER SURROGACY

ELECTIVE OR ESSENTIAL?

“IT’S ALL IN YOUR HEAD”

RESHAPING THE ROLE OF MEDICAL STUDENTS IN GLOBAL HEALTH

UNIVERSAL BASIC INCOME

‘SITTING DUCKS’ FOR COVID-19: DETENTION OR DEATH TRAP?

CAN INTERNET SEARCHES PREDICT AN OUTBREAK?

A Literature Review on Nowcasting with Google Trends Daniel Bil

A Public Health Perspective Kajanan Parameshwaran

The Implications of COVID-19 on Refugees and People Seeking Asylum from a Global and Australian Perspective Raelene Emmanuel, Che Hooper

A Comprehensive Policy Response to Somatisation in Victoria Travis Lines

Exploring Decolonised Humanitarianism in the Context of Rural Eswatini Ishka de Silva

THE RUBEN CENTRE

Fighting Malnutrition in Kenyan Slums Che Hooper

THE HEALTH BENEFITS OF KUCHIPUDI DANCE

An Indian Classical Dance-Based Intervention to Manage Musculoskeletal Injury and Psychological Distress in Young and Otherwise Healthy Individuals Laalithya Konduru

The Necessity for a National and International Convention Jordan Kirby

The Case for Reproductive Autonomy During COVID-19 Afreen Akbany

A FIRSTHAND LOOK AT AUSTRALIAN ICUS IN THE TIME OF CORONA An Interview of Dr Ken Hillman Marisse Sonido

CAPTIVES OF COVID-19

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TYPE 2 DIABETES IN VANUATU

HEALTH, HUMAN RIGHTS, AND OFFSHORE PROCESSING The Health Implications of Australia’s Mandatory Offshore Processing Practices Jackie Maher

EATING PLANTS FOR THE PLANET

The EAT-Lancet Planetary Health Diet Explained Wynona Chin, Jacqueline Bredhauer

graphic by Kit Lindgren

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TYPE 2 DIABETES IN VANUATU Exploring the Impact of Local Knowledge and Attitudes Anita Niu, Elizabeth Zhang This article was influenced by our experiences during a four week elective at Vila Central Hospital in Vanuatu, during which we were able to observe the impact of diabetes on both patients and healthcare workers. Jean* lies in the operating theatre of Vila Central Hospital in Vanuatu, about to receive a below elbow amputation of her left arm. The surgeon asks if she’s ready while holding her right hand, from which two fingers have been previously amputated. She is not ready, but does she have a choice? She is 49 years old and has been struggling to control her type 2 diabetes mellitus (T2DM) for the past 10 years, in between the responsibilities of looking after her family. The sepsis from the wound on her finger is rapidly ascending up her arm, and this is the best option to avoid losing the entire limb, as had happened to her leg two years earlier.

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This is only one of the numerous amputations on diabetic patients conducted at the hospital each year. Background The global prevalence of non-communicable diseases (NCDs) is on the rise, especially in developing nations, and Vanuatu is no exception. [1,2] Diabetes, mainly T2DM, affects approximately 13% of the population of 265,000 on this island nation and is a significant cause of premature death in adults.[3,4] One of the major factors contributing to this increase is globalisation, which has caused a shift away from traditional lifestyles and local food to a more sedentary lifestyle and Western diets.[2,5] Although the rates of diabetic complications have declined in developed nations over the past two decades [6], the opposite trend is observed in developing nations where there has been an increase in diabetic complications, such as peripheral neuropathy and peripheral vascular disease, frequently leading to complicated ulcers that result in amputation.[7,8] Amputation has significant impacts on the patient’s quality of life, especially when living in areas of low socioeconomic status where physical labour makes up a major part of everyday life. Furthermore, it complicates access to healthcare due to the difficulties of moving around with an amputation. Some factors 6

contributing to this health issue come from an organisational level due to the lack of health infrastructure and resources.[9] However, additional individual factors such as knowledge and attitudes towards healthcare also significantly impact health outcomes and need to be addressed in the development of interventional strategies. [10] Importance of traditional medicine The majority of the population of Vanuatu are Melanesian, with a few islands that have Polynesian populations. In Melanesian culture, there is a strong belief that spirits affect all aspects of daily life.[11] Many local people have a spiritual view of health, accepting disease as a part of fate rather than seeing it as something that can be prevented.[12] They will also frequently use complementary medicine, locally termed ‘kastom medicine’, to treat illness. A study conducted at Vila Central Hospital reported that 86% of the staff and patients had used kastom medicine and 28% of the staff interviewed had sought kastom medicine within the past year.[13] Many traditional healers in Vanuatu also reported that diabetes was one of the illnesses routinely treated.[12] A number of factors contribute to the strong presence of kastom medicine. The strong sense of community and maintenance of tradition within Pacific island cultures may influence treatment decisions, with patients preferring to seek support from their local community or family, whom they are more familiar with.[11,12] Traditional healers are well-respected members of the community, and they often combine ‘botanical expertise’ with spiritual knowledge to give culturally acceptable explanations for and treatment of illness.[12] Other factors may include practical considerations such as the accessibility and affordability of services.[12] As a result, presentation to hospital is often

delayed. Many patients like Jean only present when late complications of diabetes develop, most commonly a severely infected wound for which the only available treatment is amputation. This generates a vicious cycle in which people in the community start to make negative associations of hospitals as a place for amputations, rather than for improving their health. This further contributes to a reluctance to present to hospital in a timely manner for routine check ups or when complications first arise.

Opportunistic education is common in Vanuatu, where there are limited healthcare resources and low nurse and doctor to patient ratios.[17,18] Nurses provide patients with practical, timely, and culturally relevant advice when they come in for other services such as medication dispensing and glucose monitoring. This may be the only chance to catch patients living in more remote areas who are only able to visit clinics a few times a year. However, without a national program, the quality of diabetic education is highly variable and some patients fall through the cracks. This is often the case for those living in rural areas who tend to be poorer and have lower levels of education.[19]

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Despite these negative associations, people in Vanuatu do not reject the idea of using Western medicine. Studies on health interventional strategies have revealed that individuals in Vanuatu are open to new ideas from overseas, are inclined to agree with researchersâ&#x20AC;&#x2122; efforts, and see health screening as a positive and encouraging act.[12,14] This may be partly due to the respect for authority and strong sense of hierarchy that makes up an important aspect of their culture.[11] Therefore, perhaps community-based education about the role of hospitals as a place for monitoring and preventing complications could break this vicious cycle and encourage earlier and more frequent presentations to seek appropriate healthcare.

One such patient experiencing limited healthcare due to geographic isolation is Simon*, a 55-yearold farmer living in a rural area of Efate, who was recovering from a forefoot amputation for a gangrenous toe one year after being diagnosed with T2DM. He was unaware that hyperglycaemia was asymptomatic or that it could lead to complications. As a result, he stopped taking medications while feeling well and had not thought to seek healthcare until he noticed an ulcer on his right toe. With little chance of a prosthetic device being available, this is a devastating outcome for someone who was previously independent and performed very active work. Diabetes education at diagnosis and a regular follow up schedule may have delayed complications for Simon and may benefit other patients in similar situations. In addition, some diabetic patients have noted a lack of motivation to maintain good physical health but that more regular health checks would encourage them to make and maintain more positive lifestyle changes.[5]

Local knowledge about diabetes There is currently no formal diabetes education given to newly diagnosed diabetic patients in Vanuatu, a vital service usually provided by the diabetes educator as part of multidisciplinary management in developed countries. As is the case for many patients, most of what Jean and her family know about managing her condition comes from nurses at the local clinic where she collects her medications every few months. This includes basic dietary advice such as cutting back on refined sugars, salt, and deep-fried foods, as well as an emphasis on the importance of taking metformin and insulin daily. These are two of seven vital self-care behaviours identified by the American Association of Diabetes Educators to reduce complication rates and improve long term outcomes.[15,16] The others are exercise, selfmonitoring of blood glucose levels, problem solving, risk reduction, and healthy coping skills, which Jean could not recall discussing at the clinic. Given that most day-to-day management falls on patients and their families, education on self-care behaviours is important to give them the skills to make better lifestyle and treatment choices.

Culturally appropriate strategies Although diabetes education and regular health monitoring have obvious benefits, it is uncertain how to best implement a culturally appropriate intervention in a country with limited resources and a small population spread over dozens of islands. Creative solutions to these challenges have been trialled locally and in other disadvantaged communities worldwide. As a way of addressing the shortage of healthcare workers, local volunteers with T2DM and medical, nursing, and allied health students could be trained to lead group education sessions.[20,21] There is also scope for involving traditional healers in the long term management of diabetic patients, especially in remote areas where access to health clinics is difficult and limited. When 7

asked in a survey, many traditional healers in Vanuatu reported having worked with health clinics and were willing to collaborate with hospitals providing Western medicine.[12] Involvement of local communities to develop more relevant resources, as well as educating family members, also increases patient engagement. [22] This was useful in other cultures with similarly strong family and community ties as they often live under one roof and are closely involved in caring for the patients.[23]

diseases and the growing impact of environmental issues. In their spare time, they enjoy travelling and exploring different cultural perspectives. Conflicts of Interest N/A Correspondence yutong.niu@student.unsw.edu.au Acknowledgements We would like to acknowledge the help of the staff and patients in Vila Central Hospital.

Although most of these studies are small, the outcomes for both patients and educators are promising. There is the potential to use strategies like these to develop larger scale, evidence-based diabetes education programs that can achieve lasting reductions in HbA1c levels through long term reinforcement, involving patient input, and clear goal-setting.[24,25]

Images N/A References

1. Zhou B, Lu Y, Hajifathalian K, Bentham J, Di Cesare M, Danaei G, Bixby H, Cowan MJ, Ali MK, Taddei C, Lo WC. Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4Âˇ 4 million participants. Lancet. 2016 Apr 9;387(10027):1513-30. 2. Naqshbandi M, Harris SB, Esler JG, Antwi-Nsiah F. Global complication rates of type 2 diabetes in Indigenous peoples: A comprehensive review. Diabetes Res Clin Pract. 2008 Oct 1;82(1):1-7. 3. World Health Organization. Noncommunicable diseases country profiles [Internet]. World Health Organization. 2018 [cited 22 March 2020]. Available from: https://www.who.int/diabetes/country-profiles/vut_ en.pdf?ua=1 4. Carter K, Tovu V, Langati JT, Buttsworth M, Dingley L, Calo A, Harrison G, Rao C, Lopez AD, Taylor R. Causes of death in Vanuatu. Popul Health Metr. 2016 Dec;14(1):7. 5. Siefken K, Schofield G, Schulenkorf N. Laefstael jenses: An investigation of barriers and facilitators for healthy lifestyles of women in an urban pacific island context. J Phys Act Health. 2014 Jan 1;11(1):30-7. 6. Gregg EW, Sattar N, Ali MK. The changing face of diabetes complications. Lancet Diabetes Endocrinol. 2016 Jun 1;4(6):537-47. 7. Simmons D, Clover G, Hope C. Ethnic differences in diabetic retinopathy. Diabet Med. 2007 Oct;24(10):1093-8. 8. Simmons D, Scott D, Kenealy T, Scragg R. Foot care among diabetic patients in south Auckland. N Z Med J. 1995 Mar;108(996):106-8. 9. Anderson I. The economic costs of noncommunicable diseases in the Pacific Islands: a rapid stocktake of the situation in Samoa, Tonga, and Vanuatu. 10. Tin ST, Gadabu E, Iro G, Tasserei J, Colagiuri R. Diabetes related amputations in Pacific Islands countries: a root cause analysis of precipitating events. Diabetes Res Clin Pract. 2013 May 1;100(2):230-4. 11. Reynaud D. South Pacific Cultures and the Concept and Practice of History. This article was originally published as: Reynaud, D.(2006). South pacific cultures and the concept and practice of history. Journal of Pacific Adventist History, 6 (1), 5-10. Retrieved from http://documents. adventistarchives. org/ScholarlyJournals/JPAH/Vol6_N1_ June% 202006. pdf ISSN: 1445-3096. 2006.

About the Authors Elizabeth and Anita are final year medical students from UNSW. They are interested in global health disparities, in particular the rise in non-communicable

June 2020 Issue 1

Another major part of the plan is to address poor health literacy and unhelpful attitudes towards diabetes through public health campaigns and further training in diabetes education for nurses. [26] As traditional medicine is already a culturally important part of health care for many, there is also a push to establish a more formal role for traditional healing to complement standard care. However, despite progress in the right direction, more research is still needed to determine the types of interventions that would be most effective in Vanuatuâ&#x20AC;&#x2122;s cultural context. *names have been changed

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What needs to be done T2DM and NCDs have been recognised as a growing problem by the Republic of Vanuatu Ministry of Health for over a decade and most recently in the National Sustainable Development Plan 2016 to 2030.[26] This plan acknowledges that T2DM is a complex issue and must involve collaborative and comprehensive solutions. This includes the implementation of high-priority interventions, identified by the World Health Organization as having a low cost to disability-adjusted life year reduction ratio. The key ones include the provision of antihyperglycemic medications, foot care, screening and treatment for retinopathy, and access to home blood glucose monitoring.[27]

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12. Viney K, Johnson P, Tagaro M, Fanai S, Linh NN, Kelly P, Harley D, Sleigh A. Traditional healers and the potential for collaboration with the national tuberculosis programme in Vanuatu: results from a mixed methods study. BMC Public Health. 2014 Dec;14(1):393. 13. Maden C, McKendrick S, Grace R. Alternative medicine use at Vila Central Hospital Vanuatu: a survey of the use of ‘custom medicine’ in patients and staff. Trop Doct. 2003 Jan;33(1):22-4. 14. Siefken K, Schofield G, Schulenkorf N. Inspiring Pacific Women for Lifestyle Change: An Attempt to Halt the Spread of Chronic Diseases. In Global Sport-for-Development 2013 (pp. 216-242). Palgrave Macmillan, London. 15. American Association of Diabetes Educators. AADE7 self-care behaviors. Diabetes Educ. 2008;34(3):4459. 16. Shrivastava SR, Shrivastava PS, Ramasamy J. Role of self-care in management of diabetes mellitus. J Diabetes Metab Disord. 2013 Dec 1;12(1):14. 17. World Health Organization. Density of physicians (total number per 1000 population, latest available year) [Internet]. World Health Organization. 2019 [cited 22 March 2020]. Available from: https://www.who.int/gho/health_ workforce/physicians_density/en/ 18. World Health Organization. Density of nursing and midwifery personnel (total number per 1000 population, latest available year) [Internet]. World Health Organization. 2019 [cited 22 March 2020]. Available from: https://www. who.int/gho/health_workforce/nursing_midwifery_ density/en/ 19. Petrou K, Connell J. Food, morality and identity: Mobility, remittances and the translocal community in Paama, Vanuatu. Aust Geogr. 2017 Apr 3;48(2):219-34. 20. Lorig K, Ritter PL, Villa FJ, Armas J. Communitybased peer-led diabetes self-management. Diabetes Educ. 2009 Jul;35(4):641-51. 21. Shiyanbola OO, Randall B, Lammers C, Hegge KA, Anderson M. Impact of an Interprofessional Diabetes Education Model on Patient Health Outcomes: A Longitudinal Study. J Res Interprof Pract Educ. 2014 Sep 1;4(2). 22. Krebs JD, Parry-Strong A, Gamble E, McBain L, Bingham LJ, Dutton ES, Tapu-Ta’ala S, Howells J, Metekingi H, Smith RB, Coppell KJ. A structured, group-based diabetes self-management education (DSME) programme for people, families and whanau with type 2 diabetes (T2DM) in New Zealand: an observational study. Prim Care Diabetes. 2013 Jul 1;7(2):151-8. 23. McElfish PA, Bridges MD, Hudson JS, Purvis RS, Bursac Z, Kohler PO, Goulden PA. Family model of diabetes education with a Pacific Islander community. Diabetes Educ. 2015 Dec;41(6):706-15. 24. Steinsbekk A, Rygg L, Lisulo M, Rise MB, Fretheim A. Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis. BMC Health Serv Res. 2012 Dec 1;12(1):213. 25. Loveman E, Frampton GK, Clegg AJ. The clinical effectiveness of diabetes education models for Type 2 diabetes: a systematic review. Health Technol Assess. 2008;12(9):1-36. 26. Republic of Vanuatu, Ministry of Health. Vanuatu 2030 The People’s Plan [Internet]. Republic of Vanuatu, Ministry of Health. 2016 [cited 22 March 2020]. Available from https://www.gov.vu/attachments/article/26/

Vanuatu2030-EN-FINAL-sf.pdf 27. World Health Organization. Tackling NCDs:&#39;best buys&#39; and other recommended interventions for the prevention and control of noncommunicable diseases [Internet]. World Health Organization. 2017. [cited 22 March 2020]. Available from https://apps.who.int/iris/bitstream/handle/10665/259232/ WHO-NMH-NVI-17.9-eng.pdf

THE WEIGHT OF THE WORLD Unpacking the Global Health Workforce Shortage and Supporting Migrant Healthcare Workers Dayna Duncan Introduction In 2015 the World Health Organisation (WHO) estimated that only half of the world’s population had access to appropriate health services.[1] An essential element of achieving the Sustainable Development Goal (SDG) of ‘Universal Health Coverage’ is having appropriate health workforce. This is outlined in SDG 3c which requires financing for ‘the recruitment, development, training and retention of the health workforce’.[2] In Australia the domestically trained health workforce is not sufficient for the growing population, and as such internationally trained graduates are recruited.[3] This movement of health workforce toward higher income countries exacerbates global maldistribution, however policies prohibiting international recruitment pose an ethical dilemma.[4] Additionally, recruitment of migrant health workers from lower income countries may not be effective if not paired with effective professional support, such as that provided in skilled migrant mentoring programs. Supporting healthcare workers to prevent workforce attenuation due those leaving the field is crucial to addressing health workforce shortages, alongside increased local training for reduced international migration and maldistribution. Global workforce shortage and maldistribution The world is currently facing both a shortage and a maldistribution of healthcare workers.[5] This maldistribution has resulted in a disproportionate shortage in developing countries, which is in part due to migration of healthcare workers to more affluent countries.[4] It is estimated that 1 billion people don’t have access to a health worker.[6] Worldwide, 40% of countries had fewer than ten doctors per 10,000 people.[1] This deficiency is more common in developing countries, 90% of which have fewer than ten doctors per 10,000, as

opposed to developed countries, only 5% of which are affected (figure 1). A significant contributor to this disparity is the migration of doctors, often from developing to developed countries.[7] A proposed solution to this phenomenon is to reduce acceptance of healthcare workers from developing countries. However, this presents an ethical dilemma; the rights of the individual contrasting with the needs of the community.[8] It is unethical to prohibit the movement of healthcare workers, particularly those from disadvantaged areas who may be facing

Figure 1: Proportion of countries by income status with insufficient health worker coverage, demonstrating that low income countries are more affected by an insufficient global health workforce.[1] persecution or poor living conditions.[4] In these situations, overly stringent guidelines may result in skilled healthcare workers taking jobs outside of their profession in order to seek opportunities in other countries.[9] This can exacerbate the deficiency of health professionals and waste the resources utilised in training each doctor. WHO Code of Practice In response to the global health workforce shortage, the WHO created the WHO Global Code of Practice on the International Recruitment of Health Personnel. The objective is to â&#x20AC;&#x2DC;mitigate the negative effects of health personnel migration on the health systems of developing countries and to safeguard the rights of health personnelâ&#x20AC;&#x2122;.[8] It states that; (1), developed countries should provide technical and financial support to strengthen health systems through development of health personnel; (2), in

recruitment, countries should consider the source countries citizenâ&#x20AC;&#x2122;s rights to the highest attainable standard of health; (3), the code should not limit the freedom of individual personnel; and (4), international recruitment should be transparent, fair, and promote sustainable health systems in developing countries.[6] The impact of this code of practice was evaluated 11 months and 4 years after its adoption, and no difference was found in the recruiting practices of the four largest destination countries; Australia, the UK, the US and Canada.[4] Australian health workforce At present, Australia does not have a selfsufficient health workforce; if current training and recruitment trends were to continue, by 2025 there would be an estimated shortfall of 2,500 doctors, rising to 5,000 by 2030.[10] It is considered more economically sustainable to recruit internationally

graphic by Hyun Jae Nam

Can you tell me a bit about what it involves and why you started it? The City East Mentor Program is based on the former NSW Government funded ‘Skilled Migrant Mentor Program (SMMP). In 2016, City East Community College saw a need amongst people, professionally skilled migrants, refugees and asylum seekers with functional English and full work rights, who have spent at least 6 months looking for work. There is a ‘brain waste’ of skilled and qualified people washing dishes, driving Ubers and painting houses. The program aims to support people to work to their full potential and contribute to Australian society.

trained doctors than to train locally.[3] Australia is therefore an active recruiter of health workers, with 32.2% of Australian health professionals trained overseas.[11] A possible solution to this problem is to increase the number of positions for medical training, but while there may be space to expand the number of medical students in Australian universities, there remains limited positions in postgraduate training programs. The current bottleneck in prevocational, and to a lesser degree vocational, training positions results in disruption to the training pipeline.[10] To address this, clinical placements in medical school and postgraduate training require capacity in terms of infrastructure as well as educators.

So how does the City East Mentor Program actually work? I’ll walk you through one of our success stories. Ali was a statistician in Pakistan with over 10 years work experience, and his last job was with the state bank. He came to Australia under the skilled migrant visa program, which is how the majority of our clients arrive. This needs to be applied for from the home country and prior to application he had to upskill in English language and have his qualifications assessed, a long and costly process. Once successful, Ali was able to move to Australia with his family with permanent residency and full work rights. Ali had been in Australia over 12 months and submitted well over 100 job applications with little or no response. He ended up getting night work as a security guard and was told by everyone in his community ‘forget about finding professional work, you’ll only ever be a security guard’. Ali undertook a ‘Skillsmax’ 5-week course for migrant professionals focussing on Australian workplace skills and culture. I do presentations at these courses and personally interview everyone who applies. Then I match them with appropriate mentors.

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The globalisation of healthcare and health workforce is increasing in response to external factors such as economic globalisation and environmental degradation are blurring the lines of borders. To both minimise the impacts of workforce shortage and the inequity of healthcare in developing countries, Australia must both bolster its own training capacity and support lower income countries to do the same. Supporting migrant healthcare workers in Australia The experience of doctors migrating to Australia has been reported on in the ABC’s article ‘‘Doctors and engineers end up driving taxis’: The uphill battle facing migrants to Australia’.[9] It suggests that one of the most significant barriers faced by migrant workers seeking employment in the Australian healthcare system is the requirement to have local experience in order to gain employment. Without local referees or experience, hospitals are unwilling to hire overseas-trained doctors, even after applicants having jumped through a multitude of hoops to gain Australian registration. This raises the questions of how to integrate skilled workers into local employment positions. A model has been implemented in the business sphere by City East Community College, which utilises mentoring to provide support and foster networks between established professionals and newly arrived skilled migrant workers.[12] The program’s founder and coordinator, Margaret Teed, explains how this project works and how it might be applied to the health system.

I matched Ali with Janet, a HR and finance professional who has worked at the big four [accounting firms] but is now semi-retired. They worked hard together over 7 months. The program process is for mentors and mentees to have contact at least once every two weeks, by skype, email or in-person, to support people in their job strategies. They work on resumes, cover letters, LinkedIn profiles, interview skills, and how to ‘sell yourself’ to prospective employers. The interview process in other countries can be very different to Australia, for example, we have more behavioural style questions. Mentors also assist in broadening the professional network. Ali’s success story is that he is now working as an analyst for a

Thank you so much Margaret for taking the time to meet with me today and discuss your program. 12

a hospital in Sydney. She had to seek people she could shadow for Australian experience. We’ve also had a pharmacist who was able to get a pharmacy internship position here, and a dentist from Iraq who was very highly qualified and matched with a dentist here, he was able to undertake dental assistant work while going through the process. We’ve also got a healthcare worker from Myanmar who’s currently trying to get JMO work and going through that long, involved process.

bank and has had his short-term contract extended. What components did you need to set up the program? The first thing was creating processes, how it would all come together, and criteria for both the mentees and mentors. Then it was a matter of sourcing both. Job seekers were fairly easy to find, through TAFE and other organisations, we created partnerships with the Asylum Seekers Centre and multicultural centres. The mentor base was more difficult, I sent emails to 100 mentors in the database from the previous SMMP program, we got 20 back and 10 of them converted to mentors. Beyond that I advertised on seek, but it was very much word of mouth. We’ve since established links with companies through personal connections who now support us by encouraging staff to volunteer.

Support of migrant healthcare professionals who enter Australia continues to be an issue, leading to trained doctors and other healthcare workers seeking employment in roles outside of their field. The ‘City East Mentor Program’ is a model which may be useful in the healthcare industry to match doctors going through the process of AMC and MBA accreditation with established professionals to organise opportunities for shadowing and growing professional networks. Greater support for migrant healthcare workers will reduce ‘brain waste’ in the professional space and prevent exacerbation of global health workforce shortages.

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What barriers are experienced by your program? Funding is the biggest problem. For the first two years of the program we had no funding and I was working alone one day a week, which then had to increase to two days. We did get NSW Government funding for 12 months, but despite exceeding all of the goals for the program, the funding ceased June 2019. Currently we’re operating on one grant from a philanthropic organisation, a little support from our partner companies, and small grants from councils to run networking events. We’re operating at a funding shortfall, and City East Community College accounts for this.

About the Author Dayna is a fifth year UNSW medical student in the BMed/MD program at the Albury/Wodonga campus. She holds volunteer committee positions with AMSA and UNSWMS where she explores her passions for medical education, rural health and student advocacy.

What are the main outcomes of this professional mentoring program? Mainly employment outcomes, 58% of our jobseekers get work within 5 months of being matched with a mentor, and we’ve paired over 320 job seekers with mentors. In addition, there are social impact outcomes of connecting community and supporting migrants in their transition into life and work in Australia.

Conflicts of Interest N/A Correspondence dayna.duncan@student.unsw.edu.au Acknowledgements Thank you to Margie from the City East Mentor program for taking the time to meet and be interviewed as well as sharing information and stories about the program.

Do you think this could be successful in the healthcare sector? What are some barriers you could foresee to implementation? We’ve had very few healthcare workers through the program. It’s mainly because I don’t actively seek jobseekers; they find me. Most of our applicants participate in Skillsmax courses and the majority of applicants have engineering, IT and finance backgrounds. The few we’ve had – one was a doctor from Iran who we matched with a mentor in

Images N/A References

1. World Health Organization, World health statistics 2019: monitoring health for the SDGs, sustainable development goals. 2019. 2. United Nations, Transforming our world: The 2030 agenda for sustainable development. 2016.

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3. Buchan, J.M., L. Naccarella, and P.M. Brooks, Is health workforce sustainability in Australia and New Zealand a realistic policy goal? Australian Health Review, 2011. 35(2): p. 152-155. 4. Tam, V., J.S. Edge, and S.J. Hoffman, Emperically evaluating the WHO global code of practice on the international recruitment of health professional’s impact on four high-income countries four years after adoption. Globalization and health, 2016. 12(1). 5. World Health Organization, World health statistics 2010. 2010: World Health Organization. 6. Crisp, N. and L. Chen, Global supply of health professionals. New England Journal of Medicine, 2014. 370(10): p. 950-957. 7. World Health Organisation, Global strategy on human resources for health: Workforce 2030. 2010. 8. World Health Organisation, Code of Practice on the International Recruitment of Health Personnel, W.H. Organisation, Editor. 2010. 9. Edraki, F. and C. Pryor, ‘Doctors and engineers end up driving taxis’: The uphill battle facing migrants to Australia, in Radio National. 2019, Australian Broadcasting Corporation. 10. Health Workforce Australia, Australia’s future health workforce: doctors. 2014. 11. Department of Health. Medical Workforce 2016 Factsheet. 2017; Available from: https://hwd.health.gov. au/webapi/customer/documents/factsheets/2016/Medical workforce factsheet 2016.pdf. 12. City East Community College. Mentor Program. 2019; Available from: https://www.cec.edu.au/mentorprogram?fbclid=IwAR2dd3zgdSWaA7bqoes9ERd4g5bjLSBE6cWbqzBmR5dov1vD1vgSSJOHCk.

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CAPTIVES OF

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graphic by Tara Kannan

VACCINE HYSTERIA The Role of Gender in the Anti-Vaccination Movement

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Katharine Robertson

graphic by Hyun Jae Nam

“Overwhelmingly, vaccine choices are mothers’ choices”

- Calling the Shots [1]

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accine hesitancy—the conscious refusal of all or some vaccines, delaying vaccination, or continuing on the schedule with doubts or misgivings—has been identified by the World Health Organisation as one of this century’s top ten threats to public health.[2] The phenomenon has been discussed at length by sociologists, public health workers, medical practitioners, and laypeople alike. However, despite it being well known that mothers make most healthcare decisions for their children [1,3,4] and that their experience of healthcare is different to that of men,[5] few have attempted to tackle its highlygendered nature.[6] In light of this, vaccine hesitancy will be briefly examined here using feminist theory, beginning with a brief outline of the history of the anti-vaccination movement and further explanation on why feminism is specifically relevant to this topic. Next, second-wave feminism’s criticism of the medical establishment will be explored, before finishing with a look at how the patriarchal tool of mother-blame has contributed to the continued rejection of such a cheap and safe public health intervention. What is vaccine hesitancy? For as long as vaccines have existed, there have been those who reject vaccination.[1] Their concerns about vaccine safety, violation of bodily integrity, and mistrust of institutions and industry have changed little over time. Vaccine hesitancy, rather than outright rejection of all vaccinations, will be discussed here, as vaccine hesitant parents represent the vast majority of those who delay or refuse some or all vaccines for their children.[1] In recent years, increased knowledge-sharing via the Internet, a lack of first-hand experience of vaccine preventable illnesses, and changes to parenting expectation (detailed below) have contributed to an expansion and organisation of vaccine hesitancy into a widespread movement. It is estimated that vaccination rates greater than 90% for children under 5 [7] are needed to provide adequate herd immunity for those who are unable to be vaccinated for medical reasons. Unfortunately, according to the most recent data released by the Australian government,[8] many areas are not meeting this target. Some of the lowest 17

rates can be found in affluent inner-city suburbs,[9] whose residents are a key demographic for vaccine rejection.[1,10] Clearly this issue will continue to be a public health concern for Australia, and its causes are therefore worthy of further investigation. Vaccine hesitancy and gender There are many reasons why vaccine hesitancy can be considered a gendered issue. Picture your typical ‘anti-vaxxer’ –most likely you pictured an affluent, white woman, perhaps doing yoga or drinking a kale smoothie. In this case, your stereotyping would be correct: affluent white women are overrepresented in the antivaccination movement [1] and are most active on online anti-vaccination forums where over 70% of user activity is female.[11] They are also the public faces of the movement – think Jenny McCarthy and Dr Sherri Tenpenny in the USA or Australian Taylor Winterstein, the wife of an NRL player, who made headlines in March this year for hosting a $200-per-head anti-vaccination workshop.[12] Throughout the world, women are responsible for most of the caregiving and healthcare-related decisions about their children, including whether to vaccinate.[1,3,4] Even though many men also reject vaccinations, women are most often the primary healthcare decision makers for their children and are therefore the focus of most studies on vaccine hesitancy. Where both women and men are included, there is significant (60-70%) gender bias in responders to vaccine surveys.[13,14] These facts suggest that the anti-vaccination movement is indeed gendered and would benefit from a feminist perspective. It is important to note that there are also race, socioeconomic, cultural, and many other dimensions to vaccine hesitancy that are outside the scope of this piece and deserve their own consideration and analysis. Women, trust, and the medical establishment Another way in which vaccine hesitancy is gendered is by its association with the medical establishment. Women’s historical mistreatment by the medical

health of their children, rather than trying to reclaim it.

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establishment may well contribute to their mistrust of vaccination, and an understanding of the gendered history behind vaccine hesitancy is crucial for doctors to be able to sensitively approach this topic with their patients. Throughout history, the institution of medicine has abused women; some examples include the diagnosis of ‘hysteria’ for Victorian women who defied gender roles [15] and medical experimentation on women of colour.[16] Even today, women endure painful sex following the administration of a ‘husband stich’ after labour [17] and, when presenting to emergency departments with pain equal to that of men, they are more likely to be prescribed antidepressants than painkillers. [18] Is it any wonder, then, that so many women doubt that the institution of medicine has their best interests at heart? These concerns, while still valid today, coalesced at the beginning of the secondwave feminist movement.

Mother-blame, vaccines, and risk When second-wave feminism’s expectation of questioning medical science interacts with modern Western society’s culture of mother-blame, it creates an environment that further encourages vaccine hesitancy. Mother-blaming first entered the biomedical discourse when behaviourist Ivar Lovaas attributed the development of autism in children to ‘refrigerator mothers’, implying that autism was caused by mothers who were emotionally ‘cold’ towards their children.[20] Mothers have since been held responsible for communism, crime, and schizophrenia—just to name a few things. [21] Various feminist theorists have discussed the phenomenon,[21,22] with the overarching theory being that a culture of mother-blame acts as an enforcer of patriarchal gender roles. A ‘good’ mother spends an inordinate amount of energy questioning the food her child eats, the school they attend, the clothes they wear, and the medical interventions they receive, including vaccination.[22] It is ironic that such a burdensome task had its origins in female liberation. Should a child fail to thrive or have an adverse reaction to a vaccination, the mother will likely bear much of the blame. There have even been reports of the anti-vaccination movement approaching grieving mothers and attempting to convince them that vaccines were to blame for their child’s death.[23] It is somewhat understandable, then, that mothers might be hesitant to expose their child to even a tiny risk of harm, for fear of losing the social capital which is accompanied by playing the ‘good mother’ role. An approach to a vaccinehesitant mother which acknowledges the pressure of society’s expectations and her fears of failure might lead to a deeper understanding of her concerns and therefore be more effective at addressing them.

Vaccine hesitancy and the women’s health movement Second-wave feminism is based on the theory that women’s oppression is created and perpetuated by sexist power structures. Second-wave feminists fought against biomedical powers to reclaim autonomy over their bodies and to access safe and acceptable medical treatment, which culminated in the publication of ‘Our Bodies Ourselves’ in 1973 and has continued ever since. The Our Bodies Ourselves website [19] encourages women to re-think the doctor–patient power dynamic in order to become effective advocates for their own health. According to this theory, women should become ‘informed health consumers’ and ‘their own health experts’.[19] These phrases are repeated verbatim in anti-vaccination discourse, as is the broader idea of women fighting against the institution of medicine and government.[1] While there is no doubt that these ideas have contributed positively to the women’s health movement, this questioning mindset and re-situation of power in the woman/mother as an expert health consumer can unfortunately lead to the rejection of a safe and effective public health intervention. Antivaccination may therefore be seen, in part, as a misguided individual application of ideas put forward by second-wave feminism. Doctors should be aware of this power dynamic when approaching a conversation about vaccination and be careful to use language which allows vaccine hesitant mothers to hold on to their power as experts in the

In conclusion, vaccine rejection represents a real threat to public health in the 21st century. Previous discussions of the topic have largely ignored its gendered nature. Women make the majority of healthcare decisions for their children and have an experience of healthcare that is closely tied to their gender. Women are rightly disillusioned with the biomedical establishment. Second-wave feminism encouraged women to question medical institutions and reposition themselves as experts in their own 18

(and, by extension, their children’s) health, including whether or not to participate in vaccination. Modern western society’s culture of mother-blame leads to an expectation that affluent white mothers control every detail of their children’s lives in order to be labelled a ‘good mother’. This interacts with the previously mentioned points to create an environment where questioning vaccinations is encouraged to some degree, and taking on the small but real risk that vaccines pose seems unreasonable to many mothers. Only by continuing to unpack and better understand the phenomenon of vaccine hesitancy can we effectively combat this public health issue. About the Author Kitty Robertson is currently undertaking a MD/MPH at the University of Melbourne. Her masters studies led to an interest in the application of social theory to better understand medical and public health issues. She is also AMSA Global Health's 2020 Vice Chair International. In her spare time, she enjoys cooking and caring for her many houseplants. Conflicts of Interest N/A Correspondence karo@student.unimelb.edu.au Acknowledgements N/A Images N/A

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References

1. Reich JA. Calling the shots : why parents reject vaccines [Internet]. New York University Press; 2016 [cited 2019 Oct 22]. (Books at JSTOR All Purchased). Available from: https://search.ebscohost.com/login. aspx?direct=true&AuthType=sso&db=cat00006a&AN=melb. b6225872&site=eds-live&scope=site 2. World Health Organisation [Internet]. WHO; 2019 [cited 2019 Oct 22]. Ten threats to global health in 2019; 2019. Available from https://www.who.int/emergencies/ten-threats-to-globalhealth-in-2019 3. Dube E, Gagnon D, MacDonald N, Bocquier A, PerettiWatel P, Verger P. Underlying factors impacting vaccine hesitancy in high income countries: a review of qualitative studies. Expert Review of Vaccines [Internet]. [cited 2019 Oct 22];17(11):989– 1004. Available from: https://search.ebscohost.com/login.aspx? direct=true&AuthType=sso&db=edswsc&AN=000450627400005 &site=eds-live&scope=site 4. Matoff-Stepp S, Applebaum B, Pooler J, Kavanagh E. Women as Health Care Decision-Makers: Implications for Health Care Coverage in the United States. 2014 [cited 2019 Oct 22];25(4):1507– 13. Available from: https://search.ebscohost.com/login.

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Origins of American Gynecology [Internet]. Athens: University of Georgia Press; 2017 [cited 2019 Oct 24]. Available from: https://search-ebscohost-com.ezp.lib.unimelb.edu.au/login. aspx?direct=true&AuthType=sso&db=edsjbk&AN=edsjbk.j.ct t1pwt69x&site=eds-live&scope=site 17. Murphy C. The Husband Stitch Isn't Just a Horrifying Childbirth Myth [Internet]. Healthline; 2018 Jan 24 [cited 2019 Oct 24]. Available from https://www.healthline.com/ health-news/husband-stitch-is-not-just-myth#1 18. Kiesel L. Women and pain: Disparities in experience and treatment [Internet]. Harvard Health Publishing; 2017 Oct 7 [cited 2019 Oct 23]. Available from: https://www. health.harvard.edu/blog/women-and-pain-disparities-inexperience-and-treatment-2017100912562 19. Issues & Impact [Internet]. [cited 2019 Oct 22]. Available from: https://www.ourbodiesourselves.org/issuesimpact/ 20. Waltz MM. Mothers and Autism: The Evolution of a Discourse of Blame. American Medical Association Journal of Ethics [Internet]. 2015 Apr [cited 2019 Oct 22]; 17(4):353– 8. Available from: https://search-ebscohost-com.ezp.lib. unimelb.edu.au/login.aspx?direct=true&AuthType=sso&db= phl&AN=PHL2338665&site=eds-live&scope=site 21. Ladd-Taylor M, Umansky L. “Bad” mothers : the politics of blame in twentieth-century America [Internet]. New York University Press; 1998 [cited 2019 Oct 22]. Available from: https://search-ebscohost-com.ezp.lib.unimelb.edu.au/login. aspx?direct=true&AuthType=sso&db=cat00006a&AN=melb. b2323376&site=eds-live&scope=site 22. Jiao M. Mothering and Motherhood: Experience, Ideology, and Agency. 2019 [cited 2019 Oct 22];56(3):541–56. Available from: https:// search-ebscohost-com.ezp.lib.unimelb.edu.au/login. aspx?direct=true&AuthType=sso&db=edspmu&AN=edspmu. S1528421219300060&site=eds-live&scope=site 23. Zadronzy B, Nadi A. How anti-vaxxers target grieving moms and turn them into crusaders against vaccines [Internet]. National Broadcasting Corporation News; 2019 Sep 24 [cited 2019 Oct 22]. Available from: https://www. nbcnews.com/tech/social-media/how-anti-vaxxers-targetgrieving-moms-turn-them-crusaders-n1057566

aspx?direct=true&AuthType=sso&db=edspmu&AN=edspmu. S1548686914400044&site=eds-live&scope=site 5. Watts JH. Gender, health and healthcare : women’s and men’s experience of health and working in healthcare roles [Internet]. Ashgate Publishing Limited; 2015 [cited 2019 Oct 22]. Available from: https://search.ebscohost.com/login. aspx?direct=true&AuthType=sso&db=cat00006a&AN=melb. b5976540&site=eds-live&scope=site 6. Valenti J. The Measles Moms: Why Women Lead the Anti-Vaxx Movement [Internet]. Medium; 2019 Jun 14 [cited 2019 Oct 22]. Available from: https://gen.medium.com/whywomen-lead-the-anti-vaxx-movement-13bb6ff6ae5c. 7. Australian Government Department of Health. Childhood immunisation coverage [Internet]. Australian Government Department of Health; 2019 Aug 31 [cited 2019 Oct 23]. Available from: https://www.health.gov.au/healthtopics/immunisation/childhood-immunisation-coverage. 8. Australian Government Department of Health. Immunisation coverage data, surveys and reports [Internet]. Australian Government Department of Health; 2019 May 7 [cited 2019 Oct 22]. Available from: https://www.health.gov. au/health-topics/immunisation/childhood-immunisationcoverage/immunisation-coverage-data-surveys-and-reports. 9. Gregory K. Immunisation rate as low as 70pc in inner-city suburbs: AIHW [Internet]. Australian Broadcasting Corporation; 2017 June 8 [cited 2019 Oct 22] Available from: https://www.abc.net.au/news/2017-06-08/immunisationrates-among-children-still-below-national-target/8600680. 10. Understanding the Anti-Vaxxer movement [Internet]. University of South Australia; 2018 Nov 1 [cited 2019 Oct 22]. Available from: https://www.unisa.edu.au/research/ institute-for-choice/Our-Research/Understanding-the-AntiVaxxer-Movement/ 11. Smith N, Graham T. Mapping the anti-vaccination movement on Facebook. Information, Communication & Society [Internet]. 2019 Aug [cited 2019 Oct 22];22(9):1310– 27. Available from: https://search.ebscohost.com/login.aspx ?direct=true&AuthType=sso&db=bth&AN=137589947&site= eds-live&scope=site 12. Black N. Taylor Winterstein defends $200 'anti-vax' workshops: "I'm not a glamorous WAG that has all this money to splash around." [Internet]. Practical Parenting; 2019 Mar 15 [cited 2019 Oct 24]. Available from: https://www. practicalparenting.com.au/wag-taylor-winterstein-defendsdecision-to-charge-200-for-antivax-workshops 13. Bianco A, Mascaro V, Pavia M, Zucco R. Parent perspectives on childhood vaccination: How to deal with vaccine hesitancy and refusal? Vaccine [Internet]. 2019 Feb 8 [cited 2020 Apr 26];37(7):984–90. Available from: https:// search.ebscohost.com/login.aspx?direct=true&AuthType=ss o&db=agr&AN=IND606295429&site=eds-live&scope=site 14. Ren J, Wagner AL, Zheng A, Sun X, Boulton ML, Huang Z, et al. The demographics of vaccine hesitancy in Shanghai, China. PLoS ONE [Internet]. 2018 Dec 13 [cited 2020 Apr 26];13(12):1–11. Available from: https://search.ebscohost. com/login.aspx?direct=true&AuthType=sso&db=a9h&AN=13 3533512&site=eds-live&scope=site 15. Astbury J. Crazy for you : the making of women’s madness [Internet]. Oxford University Press; 1996 [cited 2019 Oct 24]. Available from: https:// search-ebscohost-com.ezp.lib.unimelb.edu.au/login. aspx?direct=true&AuthType=sso&db=cat00006a&AN=melb. b2156803&site=eds-live&scope=site 16. Owens DC. Medical Bondage : Race, Gender, and the

Iâ&#x20AC;&#x2122;ve wanted to see beyond the Western, mechanical view of the world and see what else might appear when the lens was changed.

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- Margaret J. Wheatley

graphic by Kit Lindgren

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CROSS-BORDER SURROGACY The Necessity for a National and International Convention Jordan Kirby For parents Lesley and John Brown, Assisted Reproductive Technology (ART) transformed their lives and provided them a means of conceiving the family they had long dreamt of. In 1978, Louise Brown, the child of Lesley and John, was born as the first baby conceived with the use of in vitro fertilization (IVF).[1] This ground-breaking event heralded a new era of reproductive medicine, enabling greater reproductive autonomy for both men and women. By 1980, the first successful Australian IVF baby was widely celebrated at Melbourne’s Royal Women’s Hospital, followed closely by the first baby from an egg donor and a frozenthawed embryo.[2] With 1 in 6 couples and approximately 186 million individuals suffering from infertility worldwide, ARTs have begun to unmask the unprecedented possibilities of conceiving a family for many. [4, 3] Initially faced with polarising ethical debate, ART has increasingly become more accepted within society, coinciding with evolving modern family dynamics, more accessible IVF subsidies and improved IVF success rates.[5] Currently, over 230,000 Australian babies have been born with the support of ART since the 1980s.[2] Accordingly, 5% of all babies born in Australia today are conceived with the support of reproductive technologies, such as IVF and gamete donation.[6] However, one of the more legally, socially and economically complex forms of ART is surrogacy, with the demand for cross-border surrogacy becoming progressively more prevalent. Cross-Border Surrogacy Surrogacy, where a woman bears a child for another person or couple, can take the form of traditional surrogacy or gestational surrogacy. Traditional surrogacy, the earliest form of surrogacy, involves using the surrogate’s own egg (ovum) and a donor’s sperm, resulting in the surrogate being the genetic mother.[7] Gestational surrogacy, the more common form today, involves a surrogate bearing a child for another person or couple where the surrogate is not genetically related to the child. Therefore, the sperm and the ovum from the intended parents are retrieved, fertilised and implanted into the surrogate’s uterus.[7] From an economic perspective, surrogacy can be altruistic, where there is no financial gain for the surrogate, or commercial, where the surrogate

profits. In Australia, altruistic surrogacy is the only legal form of surrogacy. [8] Due to legal variations between Australian states and difficulties finding a surrogate, Australians have begun to look overseas, creating the phenomenon known as ‘cross-border surrogacy’.[9] The acceleration in ART developments during an era of globalization in a multi-cultural world prompted the beginnings of cross-border reproductive care (CBRC). Amongst other forms of ART, cross-border surrogacy has become one of the most pursued overseas reproductive services for both couples and singles looking to achieve their reproductive goals.[9] For women with congenital anomalies of the uterus, cancer patients receiving chemotherapy or radiotherapy, or women who have had a

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not married nor in a de facto relationship, from accessing ART in a variety of states in Australia. However, a number of legal challenges argued that this contravened the Sex Discrimination Act 1984 (Cth), discriminating on the basis of marital status or sexuality.[17] Consequently, the Victorian Assisted Reproductive Treatment Act 2008 permitted both single women and same-sex couples to access ARTs, such as IVF.[18] However, as ART legislation is under the jurisdiction of the state government, no nationwide legal consensus exists. Western Australia (WA) still prohibits surrogacy for same-sex couples and single men.[19, 20] Whilst Queensland (QLD) currently allows same-sex couples and singles access to surrogacy,[21] changes in political leadership led to attempts to re-criminalise surrogacy for these marginalised groups in 2012.[22] An ongoing lack of bipartisanship and the tribulations with navigating enigmatic legislation has fuelled the demand for CBRC, particularly for single women and same-sex couples.

previous hysterectomy, surrogacy offers a means of preserving reproductive autonomy.[9, 10] Typically, the parties involved include an individual (or couple) intending to become the legal parent(s), a traditional or gestational surrogate in a foreign country, a team of health professionals, a broker who organises the financial and legal contracts necessary, and a prospective party, the child.[9] The extensive process of cross-border surrogacy entails a multitude of financial, legal, socio-cultural and medical complexities as it transcends political borders and legal frameworks.

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Why are Australians looking for cross-border surrogacy? Globally, an estimated 25,000 couples travel overseas annually to initiate CBRC including IVF and surrogacy.[11] Approximately, 160 million people in Europe do not have access to donor eggs or sperm, further amplifying demand for transnational reproductive care.[12] Those seeking CBRC do so for a number of reasons, including substantially lower costs and more flexible laws overseas.[13] A recent survey of Australian and New Zealand couples found that one of the key motives for seeking CBRC were difficulties with eligibility in their home countries, pushing them to seek a less restrictive legal system for fertility services.[14]

Financial adversities The current expense of IVF and surrogacy in Australia has considerably contributed to the growing popularity of CBRC. A typical cycle of IVF can cost up to $9,828 with out of pocket costs estimated at $4,990 for the first cycle, with couples commonly requiring multiple cycles.[18, 23] For rural and remote individuals, there may be additional costs associated with travel, accommodation and time away from work. Whilst most countries place limits on the number of subsidised IVF cycles, Australia does not, providing Medicare rebates for all subsequent IVF cycles should one require them.[18] However, to be eligible for subsidy, a single woman or a couple must be deemed ‘medically infertile’ by a fertility specialist.[24] Infertility is defined as the inability to conceive and have a baby after 12 months of regular unprotected sexual intercourse if under 35 years, or 6 months of regular unprotected sexual intercourse if 35 years or over.[24] However, many IVF clinics state that an individual (male or female) with no pre-existing fertility ailment and same-sex couples, who are defined in the literature as ‘socially infertile’, do not meet this strict criteria.[24, 25]

Single women and same-sex couples With recent changes in social beliefs and the political sphere, the denotation of a modern nuclear family and the consequential rights to reproductive autonomy for single women and same-sex couples have come under the limelight. Whilst 44% of families in the 2016 Australian census were traditional nuclear families consisting of a male and female partner with two children, a substantial 15% of families were one-parent families.[15] Additionally, the data demonstrated a significant 39% increase in the amount of samesex couples living together since 2011, which has quadrupled over the past 2 decades.[16] The statistics undoubtedly illustrate a growing pluralism in modern family architecture, congruent with shifting societal values and legislative alterations, with same-sex couples legally permitted to marry as of late 2017. However, access to ART, such as IVF and surrogacy, continues to be problematic for single women and same-sex couples.

In comparison, an IVF cycle overseas can range from $12,400 AUD in the United States to $1,272 AUD in Iran, with extensive variations in medical expertise, insurance coverage and ART success rates. [11] Although commercial surrogacy is illegal in Australia, altruistic surrogacy is not entirely cost free as intended

Prior laws had restricted single women, who were 24

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parents are expected to cover the costs of medical tests, ultrasound scans, doctor’s consultations, counselling and legal fees.[26] The total cost of a surrogacy is pre-determined and agreed upon prior to entering a legal contract.[26, 27] However, it can cost anywhere from AUD$15,000 to $100,000. [26, 27] In contrast, commercial surrogacy in India ranged from US$10,000 to US$20,000, inclusive of the IVF, antenatal care and financial compensation for the surrogate.[9] Ultimately, large discrepancies in financial expectations and overall costs have driven singles and couples to seek more affordable CBRC in overseas countries, which can potentiate financial vulnerability and exploitation in an unregulated transnational economy.

ART success rates disconcerting when attempting to make informed decisions regarding their fertility choices.[30] The complexities of transnational surrogacy agreements The international nature of cross-border surrogacy lends itself to further downstream complications, legally, medically and economically. Inconsistencies in legislation between the intending parents’ resident country and the surrogate’s country can lead to lasting legal difficulties, even after the birth. Currently, NSW, QLD and the Australian Capital Territory (ACT) criminalise any individual from engaging in overseas surrogacy, subjecting individuals to extensive fines and imprisonment. [33] Due to legislative restrictions, there are inherent difficulties with determining the citizenship status of the child in the intending parents’ country, generating legal obstacles for parentage rights.[33] In addition, birth certificates under one international jurisdiction are not binding under Australian laws.[33]

Defining ART success As pregnancy encompasses an ever-changing biological journey with constant embryonic development and maternal physiological adaptations, the question of when the process is deemed ‘successful’ can be challenging. A successful IVF procedure, external to the intricacies of the human body, has not yet endured the uncertainties of intra-uterine implantation and months of gestation with the hope of a live birth. A study on Australian and Canadian parents seeking CBRC found that the ambiguity surrounding ART success rates and an inadequacy of available information on surrogacy in their resident country significantly motivated their decision to pursue care overseas.[28] Furthermore, a recent study found 53 fertility clinic websites used 51 various outcome measures to define ART success.[29] Another study, conducted in New Zealand, found various fertility clinics defining success in 32 diverse ways, further blurring the lines on ART outcomes.[30] The study found inconsistencies between clinics, incorrectly using the overall pregnancy rate and live birth rate as measures of ART success interchangeably.[30] Additionally, multiple embryo transfers still commonly occurs overseas despite concerns regarding maternal and neonatal safety.[31] This skews pregnancy success rate data and, subsequently, paints an equivocal image of prosperity for patients, encouraging them to seek CBRC.[32] Fertility clinics may be selectively reporting biased data, leading to poor quality healthcare communication for prospective patients.[30] Whilst the appropriate measure of success will depend on the procedure itself and will vary from patient to patient, couples are finding the reported disparities in international

Recently, a German court recommended the biological mother of a child who was born from a gestational surrogate in Ukraine, would have to adopt her child in order to gain parental rights back in Germany.[34, 35] The dissonance in surrogacy legislation between Germany and Ukraine, and the fact that neither court’s decision is transferrable to the other country, leaves all parties involved in constant insecurity. Furthermore, disparities in healthcare quality, availability and costs between each party’s country can lead to unfavourable and distressing outcomes when unexpected medical problems ensue. In 2014, the story of ‘Baby Gammy’ fuelled polarising debate on the ethics of cross-border surrogacy, pushing Thailand to ban foreigners from pursuing surrogacy in Thailand altogether.[36] A young couple had found a willing commercial surrogate in Thailand and during the pregnancy, one of the two foetuses was diagnosed with Down Syndrome. Subsequently, the discussion of abortion, ongoing medical care and the desires of both the intending parents and surrogate led to conflict between the parties involved.[36] The intending parents decided to return to their home country, Australia, with the non-Down Syndrome child only.[36] The surrogate decided against a termination of pregnancy due to an inherent conflict with her Buddhist beliefs. 25

whether same-sex couples should be eligible for ART subsidy is ethically and economically difficult, requiring further liaison with clinicians and LGBTIQA+ representatives.[43] The Reproductive Technology Accreditation Committee (RTAC), an independent Australian regulatory board formed in 1987, has since aimed to standardise ART success rate communication in Australia. However, the current RTAC guidelines for fertility clinics are not effectively translating into improved patient understanding. [30] To improve ART data transparency and the patients’ understanding, stricter standards on data communication and consistency amongst clinics requires further review from the RTAC.

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[36] This dilemma raises the ethical conundrum of how a surrogate determines the continuation of a pregnancy with unexpected outcomes, dire or not, if conflict arises between each party. From an ethical and legal standpoint, who has the authority to determine the continuation of the pregnancy, particularly if it is commercial in nature? How does one access these services in each country and what are the laws surrounding termination of pregnancy in the surrogate’s country should this be required? Prior to the ban of commercial surrogacy for nonIndian citizens and non-Indian residents in India during 2017, the surrogacy economy had become a US$445 million-a-year industry in India alone.[9, 37, 38] The outsourcing of surrogacy overseas and the unregulated nature of the market poses threats to those who are financially vulnerable, causing crossborder surrogacy to walk a fine line between nonmaleficence and beneficence from an economic perspective. The inconsistencies in the pricing of surrogacies, associated medical costs and legal fees between clinics and countries can expose intending parents to financial manipulation. Whereas, surrogates can fall victim to economic exploitation, human trafficking and coercion.[39] A survey of commercial surrogates in India found that the key motivation for accepting surrogacy was financial in nature.[40] The interviewed women stated that the stigma from family members often resulted in the surrogates having to relocate away from family after childbirth.[40] Moreover, Schurr and Militz argue that no matter the form of surrogacy, commercial or altruistic, the attachment and detachment of the gestational mother and the emotional and social implications of gestation carry heavy costs for the surrogate.[41] Hochschild, a sociologist, reiterates that modern commercialization of intimate life “reach[es] into the heart of our emotional lives, a realm previously more shielded from the market”, and perhaps, establishing a new, yet potentially dangerous, form of ‘emotional capitalism’.[42, pg.11]

From an international perspective, despite the ease of outright prohibition, forbidding surrogacy and the ability to pursue CBRC altogether restricts intending parents’ and a surrogate’s reproductive autonomy. As cultural, religious and ethical beliefs markedly differ between countries, instituting transnational unison on surrogacy legislation would be unrealistic. However, an internationally recognised convention, outlined by Trimmings and Beaumont, that establishes minimum medical standards for surrogacy agreements would see improved support and safety for all parties involved.[44] Nonetheless, the level of minimum healthcare enforced is difficult to determine with large discrepancies in healthcare availability, public subsidy and quality between countries. In addressing economic exploitation, a number of countries have prohibited commercial surrogacy and only allow altruistic forms to occur. In countries that allow commercial surrogacy, enforcing one nationally standardised price may prevent parents from being financially manipulated, offering a level of national economic control. However, an internationally set price would be impractical with large variations in currency, economic performance and inflation within dynamic economies.[45] Conclusion With the unrelenting rise of a multi-billion dollar international industry, CBRC is multifaceted and calls for urgent stricter regulation. Since the birth of ART during the 1970s, the demand for international reproductive care has substantially increased, yet transnational regulations have failed to keep up, leaving surrogates and intending parents in danger of adverse outcomes. Undeniably, CBRC enables the world to access greater reproductive autonomy and healthcare services. However, the transnational nature precipitates a multitude of inherent medical,

Building multi-national solutions from a top down approach The phenomenon of CBRC is rapidly growing and inadequacies and inconsistencies in national and international regulations pose risks for all parties involved. From a national perspective, legislating to allow single men, women and same-sex couples to access ART, including surrogacy, will help to address the demand for fertility services. The debate on 26

legal and financial risks, engendering a tight-rope balancing act between beneficence and nonmaleficence. Arguably, meticulous international regulation is certainly arduous. However, given the intricate ripple effects of cross-border surrogacy, a harm minimisation approach, set by an internationally agreed upon convention, is unquestionably indispensable.

6. Rawlings L, Ding P, Robson SJ. Regional Variation in Rates of IVF Treatment across Australia: A Population-based Study. Journal of Health Economics and Outcomes Research. 2017 Mar 23;5(1):16-26. 7. Everingham SG, Stafford‐Bell MA, Hammarberg K. Australians' use of surrogacy. Medical Journal of Australia. 2014 Sep;201(5):270-3. 8. Everingham SG, Stafford‐Bell MA, Hammarberg K. Australians' use of surrogacy. Medical Journal of Australia. 2014 Sep;201(5):270-3. 9. Salama M, Isachenko V, Isachenko E, Rahimi G, Mallmann P, Westphal LM, Inhorn MC, Patrizio P. Cross border reproductive care (CBRC): a growing global phenomenon with multidimensional implications (a systematic and critical review). Journal of assisted reproduction and genetics. 2018 Jul 1;35(7):1277-88. 10. Sreenivas K, Campo-Engelstein L. Domestic and international surrogacy laws: implications for cancer survivors. InOncofertility 2010 (pp. 135-152). Springer, Boston, MA. 11. Simopoulou M, Sfakianoudis K, Giannelou P, Pierouli A, Rapani A, Maziotis E, Galatis D, Bakas P, Vlahos N, Pantos K, Koutsilieris M. Treating infertility: current affairs of cross-border reproductive care. Open Medicine. 2019 Jan 1;14(1):292-9. 12. Ferraretti AP, Pennings G, Gianaroli L, Natali F, Magli MC. Cross-border reproductive care: a phenomenon expressing the controversial aspects of reproductive technologies. Reproductive biomedicine online. 2010 Feb 1;20(2):261-6. 13. Salama M. Cross border reproductive care (CBRC): a global perspective. Obstet Gynecol Int J. 2014;1(2):00008. 14. Rodino IS, Goedeke S, Nowoweiski S. Motivations and experiences of patients seeking cross-border reproductive care: the Australian and New Zealand context. Fertility and sterility. 2014 Nov 1;102(5):1422-31. 15. ABS shows changes on International Families Day [Internet]. Australia: Australian Bureau of Statistics; 2016 [updated 2017 May 15; cited 2020 Mar 20]. Available from: https://www.abs.gov.au/ausstats/abs%40.nsf/ easesbyCatalogue/5E4BABA5BD22D73DCA2581210009D3D8 16. Same-sex couples in Australia, 2016 [Internet]. Australia: Australian Bureau of Statistics; 2018 [updated 2018 Jul 11; cited 2020 Mar 20] Available from: https:// www.abs. gov.au/ausstats/abs@.nsf/Lookup/by%20 Subject/2071.0~2016~Main%20Features~Same-Sex%20 Couples~85 17. Access to Assisted Reproduction [Internet]. Australia: Health Law Central; 2019 [cited 2020 Mar 21]. Available from: http://www.healthlawcentral.com/assistedreproduction/ access/ 18. Gordon M. Independent Review of Assisted Reproductive Technologies [Internet]. Sydney, Australia: University of Sydney; 2006 [cited 2020 Mar 21]. Available from: https://www1.health.gov.au/internet/main/publishing. nsf/Content/79D96DD80F01073ECA257BF0001C1ABB/$File/ artrc_appendices.pdf 19. Australia now has adoption equality [Internet]. Australia: Human Rights Law Centre; 2018 [cited 2020 Mar 21]. Available from: https://www.hrlc.org.au/news/2018/4/20/ australia-now-has-adoption-equality 20. Shine R. Surrogacy, assisted reproductive technology laws outdated after 25 years, WA review finds [Internet]. Australia: ABC News; 2019 [updated 2019 Mar 21; cited 2020 Mar 21]. Available from: https://www.abc.net.au/

About the Author Jordan Kirby is a final year medical student completing his clinical years at South West Healthcare, Warrnambool through Deakin University. He is the current president of Deakin University Obstetrics & Gynaecology Society and is enthusiastic about women's health on a national and global scale. Prior to studying medicine, Jordan completed research in malarial infections in the placenta, appreciating the significance of public health and women's rights advocacy in achieving positive health outcomes. Conflicts of Interest N/A Correspondence jkirby@deakin.edu.au Acknowledgements N/A Images N/A

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References

1. Leeton J. The early history of IVF in Australia and its contribution to the world (1970–1990). Australian and New Zealand journal of obstetrics and gynaecology. 2004 Dec;44(6):495-501. 2. Chambers GM, Lancaster P, Illingworth P. ART Surveillance in Australia and New. Assisted Reproductive Technology Surveillance. 2019 Jul 4:142. 3. Vander Borght M, Wyns C. Fertility and infertility: Definition and epidemiology. Clinical biochemistry. 2018 Dec 1;62:2-10. 4. Fertility and Infertility [Internet]. Australia: Department of Health; 2011 [updated 2011 Feb 07; cited 2020 Mar 22]. Available from: https://www1.health.gov.au/internet/ publications/publishing.nsf/Content/womens-health-policytoc~womens-health-policy-experiences~womens-healthpolicy-experiences-reproductive~womens-health-policyexperiences-reproductive-maternal~womens-health-policyexperiences-reproductive-maternal-fert 5. Fortin C, Abele S. Increased length of awareness of assisted reproductive technologies fosters positive attitudes and acceptance among women. International journal of fertility & sterility. 2016 Jan;9(4):452.

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news/2019-03-21/surrogacy-laws-discriminate-against-samesex-couples-report-says/10925562 21. Regulating Surrogacy in Australia [Internet]. Australia: Human Rights Law Centre; 2015 [cited 2020 Mar 22] Available from: https://www.hrlc.org.au/bulletin-content/regulatingsurrogacy-in-australia 22. Hurst D. Gays face surrogacy ban as LNP pushes civil union changes [Internet]. Australia: Brisbane Times; 2012 [cited 2020 Mar 22]. Available from: https://www. brisbanetimes.com.au/national/queensland/gays-facesurrogacy-ban-as-lnp-pushes-civil-union-changes-2012062120q9j.html 23. IVF Costs and Fees [Internet]. Australia: IVF Australia; 2019 [cited 2020 Mar 22]. Available from: https://www.ivf. com.au/ivf-cost/ivf-costs 24. Medicare Eligibility [Internet]. Australia: Rainbow Fertility; 2016 [cited 2020 Mar 22]. Available from: https:// www.rainbowfertility.com.au/costs/medicare-rebate/ 25. Medicare Rebate [Internet]. Australia: Hunter IVF; 2015 [cited 2020 Mar 22]. Available from: https://www. hunterivf.com.au/ivf-fees/ivf-and-medicare 26. Altruistic Surrogacy: How much does it cost? [Internet]. Australia: Sarah Jefford; 2019 [cited 2020 Mar 22]. Available from: https://sarahjefford.com/altruistic-surrogacyhow-much-will-it-cost/ 27. The financial costs of surrogacy [Internet]. Australia: VARTA; 2019 [cited 2020 Mar 22]. Available from: https://www. varta.org.au/information-support/surrogacy/commissioningparents/surrogacy-australia/financial-costs-surrogacy 28. Blyth E. Fertility patients' experiences of cross-border reproductive care. Fertility and Sterility. 2010 Jun 1;94(1):e115. 29. Wilkinson J, Vail A, Roberts SA. Direct-toconsumer advertising of success rates for medically assisted reproduction: a review of national clinic websites. BMJ open. 2017 Jan 1;7(1):e012218. 30. Goodman LK, Prentice LR, Chanati R, Farquhar C. Reporting assisted reproductive technology success rates on Australian and New Zealand fertility clinic websites. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2020 Feb;60(1):135-40. 31. Jaspal R, Prior T, Denton J, Salim R, Banerjee J, Lees C. The impact of cross-border IVF on maternal and neonatal outcomes in multiple pregnancies: Experience from a UK fetal medicine service. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2019 Jul 1;238:63-7. 32. Waller KA, Dickinson JE, Hart RJ. The contribution of multiple pregnancies from overseas fertility treatment to obstetric services in a Western Australian tertiary obstetric hospital. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2017 Aug;57(4):400-4. 33. Fact file: How easy is it to bring overseas-born surrogate babies back to Australia and what are their parents’ rights? [Internet]. Australia: ABC News; 2014 [updated 2014 Aug 21; cited 2020 Mar 22]. Available from: https://www.abc. net.au/news/2014-08-19/rights-of-surrogate-children-bornoverseas/5654602 34. German woman to adopt own child after using surrogate mother [Internet]. Germany: Deutsche Welle; 2019 [cited 2020 Mar 22]. Available from: https://www. dw.com/en/german-woman-to-adopt-own-child-after-usingsurrogate-mother/a-48445783 35. Gesley J. Germany: Federal Court of Justice Rules on Legal Motherhood of Surrogates [Internet]. United States:

Library of Congress; 2019 [cited 2020 Mar 22]. Available from: https://www.loc.gov/law/foreign-news/article/germanyfederal-court-of-justice-rules-on-legal-motherhood-ofsurrogate/ 36. Whittaker A. From ‘Mung Ming’to ‘Baby Gammy’: a local history of assisted reproduction in Thailand. Reproductive biomedicine & society online. 2016 Jun 1;2:71-8. 37. Chang M. Womb for rent: India's commercial surrogacy. Harvard International Review. 2009 Apr 1;31(1):11. 38. Palattiyil G, Blyth E, Sidhva D, Balakrishnan G. Globalization and cross-border reproductive services: Ethical implications of surrogacy in India for social work. International social work. 2010 Sep;53(5):686-700. 39. Spar D. For love and money: the political economy of commercial surrogacy. Review of International Political Economy. 2005 May 1;12(2):287-309. 40. Karandikar S, Gezinski LB, Carter JR, Kaloga M. Economic necessity or noble cause? A qualitative study exploring motivations for gestational surrogacy in Gujarat, India. Affilia. 2014 May;29(2):224-36. 41. Schurr C, Militz E. The affective economy of transnational surrogacy. Environment and Planning A: Economy and Space. 2018 Nov;50(8):1626-45. 42. Hochschild AR. The outsourced self: Intimate life in market times. Metropolitan Books; 2012 43. Allan S. The Review of the Western Australian Human Reproductive Technology Act 1991 and the Surrogacy Act 2008 (Part 1). Independent Review of the HRT and Surrogacy Acts (WA)(Report: Part 1). 2019. 44. Trimmings K, Beaumont P. International surrogacy arrangements: an urgent need for legal regulation at the international level. Journal of Private International Law. 2011 Dec 1;7(3):627-47. 45. Ramskold LA, Posner MP. Commercial surrogacy: how provisions of monetary remuneration and powers of international law can prevent exploitation of gestational surrogates. Journal of medical ethics. 2013 Jun 1;39(6):397402.

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graphic by Hyun Jae Nam

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ELECTIVE OR ESSENTIAL? The Case for Reproductive Autonomy During COVID-19 Afreen Akbany Introduction Each year, 56 million women around the world choose to end a pregnancy.[1] This corresponds to over 150,000 abortions a day. Access to safe and legal abortions is important for many reasons. It allows a woman an option for recourse if she falls pregnant as a result of being raped. It means doctors cannot deny treatment to women who might otherwise die from life-threatening pregnancy complications, such as ectopic pregnancies or amniotic fluid embolisms. Unrestricted access to abortion means women can choose not to have their life plans derailed by unwanted pregnancies. Women with unwanted pregnancies resort to unsafe self-managed termination practices when their access to safe abortion is curtailed, resulting in high levels of deaths and disabilities.[1]

that this right to privacy should be balanced by ‘compelling state interests’, which might include the state’s interests to protect the future life of the foetus.[4] As well, the ruling allows states to regulate abortions once the foetus is deemed to be viable ex utero.[4] Consequently, women would be required to carry pregnancies to term when states deem it necessary.[4] Beyond Roe, access to abortion is curtailed in many ways, such as funding, access to information, mandatory (but misleading) counselling, the requirement of consent from third parties and parents, waiting periods, and targeting providers and their ability to practice.[5] Three years after Roe, Congress passed the Hyde Amendment, which banned federal Medicaid funding for abortion unless a woman’s life was in danger.[5,6] This provision has been upheld by the Supreme Court in subsequent cases.[6]

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Despite these arguments, access to abortion remains difficult in many parts of the world. The COVID-19 pandemic has led to an oversaturation of healthcare systems globally, to which some jurisdictions have responded by delaying or canceling abortions. In the United States, eleven states have taken steps to defer abortions indefinitely, deeming them ‘non-essential’. [2] While these are being challenged in court, a growing number of conservative states are questioning whether abortions should be allowed to continue.[2,3]

In 1988, the antiabortion movement targeted Title X, the federal program funding comprehensive family planning and related preventive health services for underinsured and low-income women. [6] The Reagan administration proposed a rule that would (a) ban doctors in Title X-funded clinics from counselling patients about abortion and referring them to abortion providers, and (b) require that abortion provision be physically and financially separate from other healthcare services.[6] While this rule never came into effect, the Trump administration has recently devised and enacted a similar policy to take full effect in March 2020, reinforcing the idea that abortions are not part of comprehensive healthcare.[6] Planned Parenthood has since withdrawn from the Title X programme, with other clinics following suit.[6] Without Title X funding, however, many of these clinics risk shutting down, further limiting access to safe abortions.[6]

The crackdown on abortion is not new In 1973, the United States Supreme Court ruled on landmark case Roe v Wade, allowing unrestricted abortions within the first trimester of pregnancy. [4] Perhaps no other court case has done so much good for public health.[5] Despite this, attempts to overturn the Supreme Court decision are ongoing. [3,4,5] The Roe ruling itself leaves much to interpretation and state legislation.[4] While it protects a woman’s right to have an abortion under the ‘right to privacy’—a right derived to exist from the Due Process Clause of the Fourteenth Amendment to the United States Constitution—it also decided

Last year, ‘heartbeat’ bills proposed by many conservative states dominated news cycles.[7] Signed into law by some states, these effectively prohibit abortions as early as 6 weeks, as soon as a foetal heartbeat can be detected.[7] 31

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Figure 1: Changes to abortion access in Republican-led states during the COVID-19 pandemic, as of 22 Apr 2020. [11,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27] These ‘heartbeat’ bills are among laws that are incompatible with Roe, deliberately passed in the hope that the current conservative-majority Supreme Court judiciary revisits that precedent. [8] Currently, the Supreme Court is hearing June Medical Services v Russo, which will decide whether abortion providers need to have the credentials to admit their patients to hospitals.[8] While such a requirement might appear to be a step in the right direction towards making abortions and post-abortion care safer, the need for additional credentials will likely force many abortion clinics to close.[8]

abortion is a time-sensitive procedure, and delays may increase risks or even make the procedure inaccessible.[9] As well, obstacles to obtaining an abortion can have profound impacts on a woman’s health and wellbeing.[9] What is it like to try to get an abortion during this pandemic? Several news outlets have chronicled the difficulties faced by women looking to have abortions in the United States during the COVID-19 pandemic. Following social distancing guidelines, women now wait in their cars for appointments, during which time some are yelled at by antiabortion activists. [10] Getting to appointments and paying for them has become difficult for women who now find themselves out of work.[10]

Given the attempts to undermine women’s reproductive autonomy since Roe, it should come as no surprise that some states are trying to use this pandemic as an excuse to limit access to abortions. The American College of Obstetricians and Gynecologists, along with seven other medical societies, released a statement against the categorisation of abortion as a procedure that can be delayed.[9] Their statement highlights that

Fifteen weeks pregnant, a 31-year-old mother of three in Houston, Texas shows up for her abortion appointment at a local clinic to find a sign taped inside the glass door: the clinic was closed.[10] At the time, in Texas, abortions (excluding those 32

Table 1: Arguments for and against anti-abortion bans during the COVID-19 pandemic.[28]

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that were necessary to save women’s lives) were included on a list of elective and nonessential procedures to be cancelled during the pandemic. [10] She immediately Googles her options and lists six clinics in four different states.[10] Three weeks later, she considers driving nine hours to a clinic in Wichita, Kansas, with her infant son in the backseat. [10]

when abortion clinics have been forced to close or women are unable to travel to them, 18 states currently ban the use of telemedicine to provide abortion care.[28] Another obstacle to medication abortions at this time is a Food and Drug Administration (FDA) restriction, which requires that mifepristone—a drug used to induce abortions—be dispensed at a clinic or hospital.[29] It cannot be mailed to women who require it, and they cannot fill prescriptions for it at a pharmacy.[28,29]

Women who are indigenous, young, or poor, or live in rural areas already face systemic barriers to abortion access.[11] In ordinary times, women in the rural reaches of Alaska have to take a snowmobile, two flights, and a bus to reach one of four abortion clinics in the state.[11] Restrictions imposed by state governments during this time compound existing barriers.[11] With abortion clinics ordered to close and social distancing measures in place, women are unable to obtain surgical abortions, or attend necessary follow-up appointments after medication abortions.[11]

What happens when women try to self-manage abortions? While the pandemic increases barriers to abortion, it is likely that women will look outside formal medical care to end their pregnancies, as they have when abortion was legally or otherwise inaccessible.[30] The World Health Organization recommends the use of mifepristone and misoprostol, or misoprostol alone, to end pregnancy.[30] These regimens have been extensively studied and have acceptable safety profiles for cliniciansupervised and self-managed abortions.[30] Despite the availability of these medications, not all self-managed abortions can be carried out safely, owing to lack of access or information. [30] In the United States, women have reported using herbs, such as rue, sage, and St John’s wort, none of which have been shown to be effective.

Abortion access in Republican-led states has swung wildly during the pandemic, creating uncertainty and causing appointment cancellations and rescheduling.[10] While temporary restraining orders (TROs) have blocked most state abortion bans, a federal judge ruled on April 22 to restore Arkansas’ ban on surgical abortions.[12,13] The pandemic also threatens access to medication abortions.[28] While telemedicine would be useful 33

as such, should be accessible in order to minimise preventable complications and deaths. The way forward in the COVID-19 response should be dictated by inclusion and consideration of the needs of already marginalised populations.

[30] The use of some of these substances has been associated with toxic reactions and even death, especially so for rue.[30] Women have also resorted to means such as vaginal insertion of implements or objects and attempts to inflict abdominal trauma. [30]

About the Author Afreen Akbany is a medical student at the University of New South Wales. Currently, she is intermitting her medical studies to pursue a certificate in Data Science. She is also a research assistant at the University of Sydney School of Public Health, analysing data from past and present Sydney Women and Sexual Health (SWASH) surveys. Afreen is passionate about improving the health outcomes of socially disadvantaged communities.

Globally, in countries where abortion is illegal, effective post-abortion care includes outpatient uterine evacuation and management of complications.[30] If pandemic restrictions expectedly cause a surge in self-managed (and unsafe) abortions, healthcare providers should be equipped with the skills and infrastructure required to manage abortion complications. This will prove challenging given the current widespread strain on hospital resources.

Conflicts of Interest N/A

Weighing the premise behind anti-abortion orders American obstetrician and gynaecologist Daniel Grossman, MD made a case against anti-abortion orders imposed by several state governments in the Boston Review.[28] His arguments are summarised in the table above.

Correspondence a.akbany@student.unsw.edu.au Acknowledgements N/A

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Challenges to abortion access in Australia In Australia, abortions are classified as essential and urgent.[31] However, measures introduced to curb the spread of the coronavirus present logistical challenges for both providers and patients.[31] Doctors who fly interstate to provide abortions are now required to quarantine for two weeks, delaying time-sensitive consultations and procedures.[31] In rural and regional Australia, abortion providers are few and far between, making travel essential to obtain abortions.[31] While efforts are being made to expand telemedicine services, this is not an option for those seeking to have medication abortions in South Australia, as the first dose of mifepristone is required to be administered in a clinical setting.[31]

Images N/A References

1. World Health Organization. Preventing unsafe abortions [Internet]. 2019 [cited 6 April 2020]. Available from: https:// www.who.int/news-room/fact-sheets/detail/preventingunsafe-abortion 2. Keating D, Tierney L, Meko T. In these states, pandemic crisis response includes attempts to stop abortion [Internet]. 2020 [cited 25 April 2020]. Available from: https://www. washingtonpost.com/nation/2020/04/21/these-statespandemic-crisis-response-includes-attempts-stop-abortion/ 3. Abrams A. COVID-19 could permanently make abortions harder to access nationwide [Internet]. 2020 [cited 8 April 2020]. Available from: https://time.com/5816530/coronavirusabortion-clinics-access/ 4. Studnicki J. Late-term abortion and medical necessity: a failure of science. Health Serv Res Manag Epidemiol. 2019;6:2333392819841781. 5. Gruskin S. Safeguarding abortion: a matter of reproductive rights. Am J Public Health. 2013 Jan;103(1):4. 6. Day E. The coronavirus is a flimsy excuse to ban abortion [Internet]. 2020 [cited 8 April 2020]. Available from: https:// www.washingtonpost.com/outlook/2020/04/08/covid-19-isflimsy-excuse-ban-abortion/ 7. Caron C. What does it really mean to be 6 weeks pregnant? [Internet]. 2019 [cited 8 April 2020]. Available from: https:// www.nytimes.com/2019/05/18/parenting/abortion-sixweeks-pregnant.html 8. Dyer O. US Supreme Court hears pivotal abortion case as prolifers seek to undermine Roe v Wade. BMJ. 2020;368:m917.

Conclusion While healthcare facilities are adjusting to the bleak realities of the COVID-19 pandemic, conservative jurisdictions make efforts to halt abortion provision, citing reasons such as abortion being non-essential and the need to conserve PPE. However, these arguments are unfounded. Diversion of resources away from abortion care is expected to cause a surge in poor health outcomes, adding to the strain on resources posed by the pandemic. Sexual and reproductive health services are not a luxury and, 34

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9. The American College of Obstetricians and Gynecologists. Joint statement on abortion access during the COVID-19 outbreak [Internet]. The American College of Obstetricians and Gynecologists. 2020 [cited 8 April 2020]. Available from: https://www.acog.org/news/news-releases/2020/03/jointstatement-on-abortion-access-during-the-covid-19-outbreak 10. Tavernese S. ‘Overwhelmed and frustrated’: what it’s like to get an abortion in Texas [Internet]. 2020 [cited 17 April 2020]. Available from: https://www.nytimes.com/2020/04/14/us/ abortion-texas-coronavirus.html 11. Reid S. Alaska issues COVID-19 abortion ban [Internet]. 2020 [cited 18 April 2020]. Available from: https://www.hrw. org/news/2020/04/16/alaska-issues-covid-19-abortion-ban 12. Bayefsky MJ, Bartz D, Watson KL. Abortion during the Covid-19 Pandemic - Ensuring Access to an Essential Health Service. N Engl J Med. 2020;382(19):e47. 13. Desanctis A. Eighth Circuit allows Arkansas COVID-19 abortion restriction to stand [Internet]. 2020 [cited 25 April 2020]. Available from: https://www.nationalreview.com/ corner/eighth-circuit-allows-arkansas-covid-19-abortionrestriction-to-stand/ 14. Order of the state health officer suspending certain public gatherings due to risk of COVID-19 [Internet]. The Office of the Alabama Governor. 2020 [cited 25 May 2020]. Available from: https://governor.alabama.gov/assets/2020/03/AmendedStatewide-Social-Distancing-SHO-Order-3.27.2020-FINAL.pdf 15. Robinson et al. v. Marshall (2020) 2:19cv00365-MHT-JTA 137 (United States District Court for the Middle District of Alabama). 16. Burkhalter E. Alabama appeals federal judge’s injunction against temporary abortion ban amid COVID-19 [Internet]. 2020 [cited 24 May 2020]. Available from: https://www. alreporter.com/2020/04/16/alabama-appeals-federal-judgesinjunction-against-temporary-abortion-ban-amid-covid-19/ 17. Arkansas Department of Health. RE: Healthcare facility complaint survey conducted April 7, 2020. Letter to Little Rock Family Planning 2020 April 10 [cited 24 May 2020]. Available from: https://media.arkansasonline.com/news/ documents/2020/04/10/doc04063020200410111819.pdf 18. Knowles H. Ohio clinics ordered to halt abortions deemed ‘nonessential’ amid coronavirus response [Internet]. 2020 [cited 24 May 2020]. Available from: https://www.washingtonpost. com/health/2020/03/21/ohio-abortion-clinics-coronavirus/ 19. Preterm-Cleveland et al. v. Attorney General of Ohio et al. (2020) 1:19-cv-00360 (United States District Court for the Southern District of Ohio). 20. Fourth amended executive order 2020-07 [Internet]. Office of the Governor, State of Oklahoma. 2020 [cited 24 May 2020]. Available from: https://www.sos.ok.gov/documents/ executive/1919.pdf 21. South Wind Women’s LLC v. Stitt (2020) 5:20-cv-00277-G 70 (United States District Court for the Western District of Oklahoma). 22. An order to reduce the spread of COVID-19 by limiting non-emergency healthcare procedures [Internet]. State of Tennessee Executive Order by the Government. 2020 [cited 24 May 2020]. Available from: https://publications.tnsosfiles. com/pub/execorders/exec-orders-lee18.pdf 23. Adams & Boyle, P.C. et al. v. Slatery et al. (2020) 3:15cv-00705 6136 (United States District court for District of Tennessee). 24. Governor of the State of Texas Greg Abbott. Executive Order No. GA-09 relating to hospital capacity during the COVID-19 disaster [Internet]. 2020 [cited 24 May 2020].

Available from: https://lrl.texas.gov/scanned/govdocs/ Greg%20Abbott/2020/GA-09.pdf 25. Health care professionals and facilities, including abor tion providers, must immediately stop all medically unnec essary surgeries and procedures to preserve resources to fight COVID-19 pandemic [Internet]. Ken Paxton: Attorney General of Texas. 2020 [cited 24 May 2020]. Available from: https://www.texasattorneygeneral.gov/news/releases/ health-care-professionals-and-facilities-includingabortion-providers-must-immediately-stop-all 26. Planned Parenthood Center for Choice et al. v. Abbott et al. (2020) 20-50296 00515388718 (United States Court of Appeals for the Fifth Circuit). 27. Tavernese S. Texas allows abortions to resume during coronavirus pandemic [Internet]. 2020 [cited 24 May 2020]. Available from: https://www.nytimes.com/2020/04/22/ us/coronavirus-abortion-texas.html 28. Grossman D. Abortions don’t drain hospital resources [Internet]. 2020 [cited 26 April 2020]. Available from: https://bostonreview.net/science-nature-politics-lawjustice/daniel-grossman-abortions-dont-drain-hospitalresources 29. Mifeprex REMS Study Group. Sixteen years of overregulation: time to unburden mifeprex. N Engl J Med. 2017;376(8):790-4. 30. Harris LH, Grossman D. Complications of unsafe and self-managed abortion. N Engl J Med. 2020;382(11):102940. 31. Davey M. Later gestation abortions hit by Australia’s coronavirus restrictions [Internet]. 2020 [cited 23 April 2020]. Available from: https://www.theguardian.com/ world/2020/mar/31/later-gestation-abortions-hit-byaustralias-coronavirus-travel-restrictions

THE RUBEN CENTRE Fighting Malnutrition in Kenyan Slums Che Hooper

unventilated rooms is bad enough to make their eyes water. Most of these houses do not have electricity. Those that do are connected through live wires that insert directly into the metal walls, meaning that in the rain, touching the sides of these shacks is an electrocution risk.

The Context: Life in Mukuru slums Dozens of mothers line up outside the Ruben Centre, holding their little babies. They file into the Nutrition Clinic, four at a time, where their babies are undressed, weighed, measured, and redressed in the span of less than a minute. It is a welloiled conveyor-belt like process, and it has to be - thereâ&#x20AC;&#x2122;s no time to waste as more mothers and babies wait outside. The Ruben Centre sees hundreds of babies a day.

Babies slung across their bodies, the mothers navigate unsteady terrain. Careful where they walk lest they step in garbage or faeces (hopefully animal), or trip on a decaying carcass of one of the many deceased animals. When it rains and the water turns the place to mud, itâ&#x20AC;&#x2122;s like wading through a sewer.

Many of these mothers have walked kilometres through the haphazard streets of the Mukuru slums. They walk past compact corrugated iron houses, where families are cooking meals inside on wooden stoves. The smoke filling up the

The 600,000 people living in the Mukuru slums, located on the outskirts of Nairobi, live below the poverty line. Many have come from far off rural areas of Kenya in search of work in the capital. Unfortunately most of them are uneducated and

unskilled, and despite their best efforts, remain jobless. Health literacy is poor and access to healthcare is even poorer. The Problem: Childhood malnutrition Childhood malnutrition is a significant issue in Mukuru. Malnutrition can be measured in three main ways: stunting, which refers to a measure of height-for-age; wasting, a measure of weight-for-height; and underweight, a measure of weight-for-age. The stunting, wasting and underweight percentages of children under five in Mukuru are 40.6%, 13.3%, and 30.5% respectively.[2] These percentages are more than double those for the whole of Nairobi, and higher than the national average for Kenya. Based on the World Health Organisationâ&#x20AC;&#x2122;s descriptors, the prevalence of stunting and wasting of children under 5 in the Mukuru community is very high and high, respectively,[3] indicating a huge need for an organisation like the Ruben Centre to find a solution in this area.

Image 1: (L-R) Che Hooper, Megan Baxter and Grace Borchert on the most recent visit to the Ruben Centre in 2019.

The solutions to malnutrition in children are multifactorial, diverse, and complex. UNICEFâ&#x20AC;&#x2122;s Conceptual Framework of the Determinants of Maternal and Childhood Nutrition [5] explores the requirements of good nutrition in children as an interplay of adequate food, adequate feeding, and a

healthy environment. This includes not only nutrientrich, age appropriate foods prepared in a sanitary manner, but also a healthy living environment and access to health and nutrition services. These factors will contribute to a sufficient diet and reduction in morbidity, ultimately resulting in improved nutrition.

Image 2: The high protein corn/soy blend that Ubuntu Through Health’s funding allows the Ruben Centre to purchase.

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Image 3: A baby getting weighed in the nutrition clinic at the Ruben Centre.

Image 4: the staff in the nutrition clinic. There are often the three staff, four mums and four babies in this tiny room - all lining up to be weighed and measured.

Looking firstly at the contributing factor of adequate food in the Mukuru slums, it is apparent that food security is an issue. Weekly food expenditure by households in Mukuru equates to around 42% of total household expenditure; [7] compared to 17% of total household expenditure in Australia [8]. In response to this food insecurity, 69% of households interviewed by Amendah D et al. [7] described eating fewer meals per day due to lack of money to purchase food, 27% of households had to take out a loan to purchase food, 16% reported spending a full day without eating, and 7% resorted to begging for money or food.[7] Another study of 150 households in the Mukuru slums found that 80% had reported a lack of food in the past month [9] and “although a large proportion of the households have an average dietary diversity score, the diet consists mainly of carbohydrates and minimally of protein”, [9] which may further contribute to malnutrition. A healthy environment is also vital for proper nutrition as poor sanitation and food preparation practices increases the spread of communicable and food-borne illnesses, leading to increased morbidity. The Mukuru slum has no system of waste disposal and upon walking the ‘streets’ surrounding the Ruben Centre, it is obvious that household waste is dumped in the nearby river or on the street where people walk and children play. Muoki M et al. [10] found that 55% of households they interviewed in Mukuru used ‘flying toilets’, where human waste is “disposed into polythene bags and thrown [into] garbage dumps, nearby rivers or near the houses”,[10 p. 391] 42.5% of households disposed of garbage very close to their homes and 47.5% did not wash their hands when preparing food. Muoki also suggests that within the children in the Mukuru slums, there is strong correlation between their morbidity and nutrition status.[2] Those children with illnesses such as malaria, diarrhoeal, or febrile diseases were more likely to be malnourished. Hence, food security and proper sanitation may be factors contributing to the high numbers of malnourished children in Mukuru. The Potential Solution: The Ruben Centre The Ruben Centre was first established in 1986,[1] 38

when it started as a school for a few dozen children in the slums. Since then, it has grown to include a hospital, secondary school, community garden, and radio station. The Ruben Hospital has a maternity wing, antenatal clinic, pharmacy, a TB and HIV clinic, pathology lab, a small emergency department, and a physiotherapist. They provide education and healthcare at low-cost or free to the hundreds of thousands of people living in the Mukuru slums. In order to tackle the huge numbers of malnourished children in Mukuru, one of the projects run by the Ruben Centre addresses some of the factors that may be contributing to malnutrition. The Ruben Centre runs a supplemental feeding program which provides additional food to those struggling with food security and includes a strong educational component which aims to increase the community’s health literacy when it comes to nutrition. Babies are screened for malnutrition using their length, weight, and arm circumference. If a child is found to be moderately or severely malnourished, the child and their family are provided with a calorie dense ‘peanut paste’ and corn/soy flour blend which is high in protein and calories. The child is

reviewed regularly to ensure they are progressing and these follow-ups at the clinic allow for further supplemental food, education, and healthcare to be provided to the child and their carer. Education is provided on nutrition, sanitation, and appropriate food preparation, with the aim to educate the carers on how to increase nutritional intake and reduce the spread of communicable diseases. Immunisations, multivitamins, and vitamin A supplements are also given to the children. The Ruben Centre treats between 30 and 80 malnourished children per month and their work is vital to the strength of the local community.

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A similar program run by another organisation in Mukuru, which combines provision of the corn/ soy flour blend with nutritional education for the caregivers, showed positive increases in stunting, wasting, and weight-for-age Z-scores for the children involved in the program.[10] Looking at global randomised controlled trials of supplemental feeding programs with or without education, Bhutta Z et al. [11] reports that education alone is sufficient to decrease malnutrition in food secure populations, but that in non-food secure populations (such as Mukuru), food supplementation is of most benefit when combined with education, providing hope that the Ruben Centre’s program will show positive outcomes.

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Image 6: The Ruben Centre provides other aspects of healthcare. Here a prospective mother receives one of her vaccinations.

Image 5: the ‘streets’ of Mukuru. Grace Borchert walks through the Mukuru slums. She is surrounded by corrugated metal sheets that are connected to live electrical wires. The ground is covered in rubbish and waste water.

Whilst the effects of the supplemental feeding program at the Ruben Centre have not been quantified, the combination of increasing food security, providing nutritional education, and educating carers on appropriate sanitation and preparation of food aligns with what we know about successful supplemental feeding programs. These initiatives show promise in addressing the factors that affect the malnutrition of 39

children within the Mukuru population. The Ruben Centre provides valuable health care to a very disadvantaged community in Kenya. The work they do is significant and life-saving for the thousands of children who, without the work of the Ruben Centre, would be left without healthcare and support. Ubuntu Through Health, a not-for-profit charity founded and run entirely by Griffith University medical students, funds the nutrition clinic at the Ruben Centre, and has done so since 2013.[12] They enable the Ruben Centre to purchase the corn/ soy flour blend. A 2 kg bag costs around AUD $15 and is provided free to families at the clinic. One bag provides supplementary food to a family for a week. Every year, Ubuntu Through Health raises money through their Annual Fundraising Dinner. In 2019, they raised over AUD $6000 for the centre, which equates to supporting around 40 families for 10 weeks.

Image 7: The Ruben Centre provides other aspects of healthcare. Here a prospective mother is receiving an antenatal scan.

just like it has worldwide, it will spread and affect the lives of hundreds of thousands of people. The Ruben Centre has reported that in response to the threat of COVID-19, as of Monday 27th April 2020, the gates to the centre will remain closed and there will be no general medical services for the people of Mukuru.[15] The Ruben Centre has made such incredible inroads into fighting malnutrition in the Mukuru slums, but if mothers cannot attend the clinic with their babies, children at risk of malnutrition will not be identified and they will not be able to access supplementary food or education. The Ruben Centre reports that hundreds of people are already lining up outside the closed gates, forced to ask for help to feed their families as most have lost their income with the closure of non-essential businesses.[15] It is too early to say how badly this is going to impact on the nutrition status of the Mukuru community, but it seems fair to assume that it is going to be disastrous.

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The Twist: Navigating COVID-19 Ubuntu Through Health is particularly worried about the Ruben Centre, given the unfolding situation of COVID-19. Fundraising activities have been severely affected, meaning that financial support will be lacking this year. More importantly, the Mukuru community will undoubtedly be incredibly affected by the impact of coronavirus. Given the population density of the community, social distancing is an impossibility. Poor health, health literacy, and access to health care will mean that this community will struggle in the coming months as COVID-19 continues to unravel and seep through borders.

The Ruben Centre does significant work, but they are no match for COVID-19. Hundreds of thousands of people in Mukuru will dive deeper into poverty, go hungry, and potentially die. We can only hope that once the immediate threat of this pandemic has passed, places like the Ruben Centre are not forgotten and are supported to return to the lifesaving work they were doing so that communities like Mukuru can repair, rebuild and recover.

COVID-19 has already reached and affected the Kenyan population with 1192 reported cases of COVID-19 as of 24th May 2020.[13] Although this number may seem small, it may be an underestimation due to a combination of: the lack of resources to test, and general fear of being tested. Currently, Kenya has tested less than 50,000 people - far less than 1% of their population.[14] There are also reports of people refusing to be tested out of fear that they will then be forced to quarantine at their own expense, an expense which many cannot afford.[14] The World Health Organisation is concerned that Africa will suffer a prolonged outbreak over a number of years, with up to 190,000 Africans dying in the first year of the pandemic.[14] It may be a long time before we know the full impact this pandemic has had on the African continent, and Kenya specifically. What we do know is that COVID-19 is already present in Kenya and,

Authorâ&#x20AC;&#x2122;s Note Ubuntu Through Health is a not-for-profit charity run by a group of Griffith University Medical Students. Ubuntu Through Health was founded in 2010 and their vision is to promote positive health outcomes in developing regions and assist in the realisation of health equality. In late 2019, Ubuntu Through Health sent three students to The Ruben Centre in Nairobi, Kenya. The Ruben Centre was established in 1986 40

as a school for children living in the surrounding Mukuru slums, which is home to around 600,000 people. Since then, the Ruben Centre has grown to include providing basic healthcare to this incredibly disadvantaged population. Since 2013, Ubuntu Through Health has been funding the nutrition clinic at the Ruben Centre.The funds that Ubuntu Through Health provides to the nutrition clinic each year equates to providing 40 families with supplemental food for 10 weeks. This allows the Ruben Centre to carry out their life-saving programs.

slums; p. 70. 5. UNICEF. The State of the World’s Children 2019. Children, Food and Nutrition: Growing well in a changing world. UNICEF, New York; 2019. 6. UNICEF. The State of the World’s Children 2019. Children, Food and Nutrition: Growing well in a changing world. UNICEF, New York; 2019. Graphic, Conceptual Framework of the Determinants of Maternal and Child Nutrition; p. 97. 7. Amendah D, Buigut S, Mohamed S. Coping strategies among urban poor: evidence from Nairobi, Kenya. PLoS One. 2014;9(1). 8. Australian Bureau of Statistics. Household Expenditure Survey, Australia: Summary of Results, 2015-16. Canberra, Australia: ABS; 2017. Report No.: 6530.0 9. Onyuma Omolo J. Factors Associated with Nutritional Rehabilitative Effectiveness of Children Aged 6-36 Months at Corn Soy Blend in Mukuru, Nairobi [master’s thesis]. Nairobi, Kenya: University of Kenya, 2012. 10. Muoki M, Tumuti D, Rombo G. Nutrition and public hygiene among children under five years of age in Mukuru slums of Makadara division, Nairobi. East African Medical Journal. 2008;85(8):386-97. 11. Bhutta Z, Ahmed T, Black R, et al. What Works? Interventions for Maternal and Child Undernutrition and Survival. Lancet. 2008;371(9610):417-440. 12. Ubuntu Through Health. The Ruben Centre — Ubuntu Through Health [Internet]. Gold Coast, Australia: Ubuntu Through Health; 2020 [cited 17 April 2020]. Available from: https://www.ubuntuthroughhealth.org/ruben-centre 13. Olawale Malomo. Coronavirus in Africa tracker [Internet]. United Kingdom: BBC; 2020 [updated 2020 May 24; cited 2020 May 24]. Available from: https://www.bbc.co.uk/news/ resources/idt-4a11d568-2716-41cf-a15e-7d15079548bc 14. BBC. Coronavirus in Africa: Contained or unrecorded? [Internet]. United Kingdom: BBC; 2020 May 20 [cited 2020 May 24]. Available from: https://www.bbc.com/news/worldafrica-52702838 15. Ruben Centre. Covid-19 lands in Mukuru Slums [Internet]. Nairobi, Kenya: Ruben Centre; 2020 Apr 27 [cited - 2020 May 1]. Available from: https://www.rubencentre.org/ directors-corner/2020/4/27/covid-19-lands-in-mukuru-slums

About the Author Che Hooper is a third year medical student at Griffith University. With a long passion for global health, she is part of Ubuntu Through Health, a not-for-profit that aims to promote positive health outcomes in developing regions and assist in the realisation of health equality. In 2019, alongside two fellow Griffith University students, she visited the Ruben Centre in Kenya, which provides healthcare to the Mukuru slums of Nairobi Kenya. Ubuntu Through Health has been funding the nutrition clinic at the centre since 2013. Acknowledgements Ubuntu through Health would like to acknowledge past and current members of Ubuntu Through Health for their incredible work in supporting past and present projects, including the Ruben Centre. Conflicts of Interest N/A Correspondence ubuntuth@hope4health.org.au Images All photographs used with permission.

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References

1. Ruben Centre. Ruben Centre [Internet]. Nairobi, Kenya: Ruben Centre; 2020 [cited 17 April 2020]. Available from: https://www.rubencentre.org/ 2. Muoki M. Effects of Dietary Intake and Hygienic Practices of Nutritional Status of Children Under Five Years in Mukuru Nyayo Slums, Nairobi [master’s thesis]. Nairobi, Kenya: Kenyatta University. 69-71. 3. de Onis M, Borghi E, Arimond M, et al. Prevalence thresholds for wasting, overweight and stunting in children under 5 years. Public Health Nutrition. 2018;22(1):175-179. 4. Ahembe Muok M. Effects of Dietary Intake and Hygienic Practices of Nutritional Status of Children Under Five Years in Mukuru Nyayo Slums, Nairobi [master’s thesis]. Nairobi, Kenya: Kenyatta University. Figure 4.3, A comparison between the study findings, the provincial and national figures for malnutrition in children under five years in Mukuru Nyayo

UNIVERSAL BASIC INCOME A Public Health Perspective

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Kajanan Parameshwaran

graphic by Hyun Jae Nam

Free money for all – no strings attached? t’s an idea that transcends centuries and political divides. From Thomas More to Elon Musk, Milton Friedman to Martin Luther King Jr., the idea of a universal basic income (UBI) has been promoted by some of humanity’s leading figures and now finds itself thrust back into mainstream political and economic discussions.[1] Its reemergence is driven by concerns regarding the relentless march of automation, growing income inequality, increasingly precarious employment arrangements, and an inherent sense that there must be better way to secure one’s basic needs with our modern prosperity.[2] Given income is a fundamental determinant of health, affecting almost all health outcomes from infant mortality to overall life expectancy, a policy that would provide payments to all is a tantalising public health intervention. [3,4] So, does UBI work and what’s stopping us from introducing it? This article explores what we know about the effect of UBI on health outcomes and the key arguments for and against its implementation (Table 1).

Universal basic income 101 UBI has been defined as a periodic, unconditional payment to all individuals, without work criteria or means testing.[5] UBI aims to provide all individuals with the means to access basic needs such as food and housing, thereby significantly reducing or eliminating material poverty.[2]

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Proponents argue that UBI removes the stigma, employment disincentives, and bureaucratic complexity associated with existing meanstested or work-defined social security programs. Furthermore, UBI would allow more time for education, caring, community, and voluntary work—activities which are invaluable to the health and wellbeing of society but do not have any direct monetary or economic value.[6] In addition, the security provided by basic income could spur greater entrepreneurship, so-called ‘venture capital for people’.[7] On the other hand, critics argue that UBI would disincentivise work, promote dependency, is unaffordable, and lead to dismantling of existing welfare infrastructure that would leave the most vulnerable individuals of society worse off.[4,8] Clearly these are complex arguments rooted in political ideology, economics, and behavioural theory, but let us consider the relationship between UBI and health. In March 2020, the first scoping review of the public health effects of basic income interventions was published by Gibson, Hearty, and Craig in The Lancet Public Health.[9] They were unable to identify any examples of a full basic income, that is, universal, unconditional, and regular payments to individuals over a specific time period. Nonetheless, several similar interventions involving lump-sum or regular, unconditional payments to certain individuals or households have been

conducted. During the 1960s and ‘70s, negative income tax (i.e., unconditional cash payments below a certain income threshold) was trialled in several North American towns, most notably in Dauphin, Canada. More recently, the Alaskan Permanent Fund has delivered annual lump sum payments to residents using the state’s oil revenues, and Native American nations have distributed revenue from casinos to all tribal members in the form of dividend payments. Numerous studies have analysed the health, educational and social outcomes from these interventions, providing invaluable insight into the potential benefits and drawbacks of a universal basic income.[9] What have we learned? Studies into basic income interventions have identified modest to strong positive effects on birth weight; infant obesity; child and adult mental health; and overall hospital admissions and service use.[9] For instance, in the town of Gary (Indiana, USA), there was a significant increase in birth weight (136-544 g) amongst high-risk groups. Meanwhile in Alaska, birth weight increased by 17.7 g for every additional $1000 in annual payments.[10,11] Furthermore, results from the Great Smokey Mountains Study (GSMS) into Native American nations with universal payment systems identified large reductions in psychiatric disorders amongst children and adolescents (OR 0.66; 95% CI 0.48-0.90, p = 0.008), as well as modest reductions in body-mass index (0.6 lower at age 21) and obesity rates (2-4% decrease at age 21).[12,13] Perhaps most notably, total hospital admissions in Dauphin decreased by 8.5%, largely driven by reductions in admissions for accidents and mental health diagnoses.[14] The mechanisms underlying these improvements are multifactorial, but qualitative evidence suggests that reduced financial stress, improved parental supervision of children, and increased food security are implicit factors.[15,16] 43

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Table 1. Arguments for and against a universal basic income. Furthermore, basic income interventions have had positive effects on other social determinants of health, such as school absenteeism and familial relationships. For example, the basic income trials in North America showed that there were significant reductions in truancy, higher rates of school completion, and higher scores in standardised tests (e.g., the SAT).[17-19] In addition, GSMS identified several positive effects on families, including increased time supervising children, improved quality of parent-child relationships, and better relationships between parents.[9,16,19] Meanwhile, no effect on marital dissolution was identified.[9] This is important as early analysis of the UBI trials in Seattle and Denver erroneously identified a 50% increase in divorce rates. This finding was later attributed to statistical error but, at the time, it generated enough controversy to overshadow all other outcomes and derail President Nixon’s attempts to introduce UBI in the 1970s. [20] In lieu of long-term studies assessing basic income interventions, it is reasonable to suggest that these positive effects on education and familial relationships would lead to downstream health and economic benefits.

Permanent Fund pays annually, whilst childhood payments from Native American nations accrue and are paid as a lump sum once an individual reaches age 18. Similar rises in mortality have been identified following the receipt of other types of income, including social security payments, wages and tax rebates.[22] Qualitative evidence indicates that Native American youth often spend their substantial first payment on vehicle purchases and illicit substances.[21] Reassuringly, these effects were temporary. In Alaska, there was no change in annual crime rates, and mortality rates returned to baseline 4 weeks later.[23] In Native American nations, overall adolescent and adult rates of offending actually decreased significantly: individuals were 22% less likely to have been arrested at 16-17 years of age and there was an 11% reduction in the probability of paternal arrest.[9,19] The ‘Laziness’ myth One of the key criticisms labelled against universal basic income, and many other social security initiatives, is that it would lead to large reductions in employment and encourage idleness. Certainly, from a health perspective, the ‘laziness’ contention would be disastrous if proven true. However, as summarised by Gibson et al. in their scoping review, ‘A common argument against basic income, that it will lead to large reductions in employment, is not supported by the evidence reported here’.[9]

However, these interventions have not been without adverse effects. In Alaska, substance abuserelated crime and overall mortality increased in the 4 weeks following receipt of their annual lump sum, whilst Native American nations saw a doubling of mortality risk following dividend receipt, largely driven by motor vehicle accidents and substance use.[21,22,23] Significantly, both interventions involved large lump sum payments; the Alaska

That is not to say there was no effect on employment. In North American towns with basic income interventions, total annual worked hours decreased 1-9% for married men, 3-33% for married women, 44

and 7-30% for single parents, but few of these effects were statistically significant.[9] On average, the reduction in paid work in these North American towns was 9% per family, with a significant portion due to adolescents delaying employment to seek higher education and women staying at home to look after young children.[20] The concluding report in the Seattle experiment notes that ‘[the] declines in hours of paid work were undoubtedly compensated in part by other useful activities, such as search for better jobs or work in the home.’[20] Unfortunately, our current political and economic systems, which are seemingly geared towards maximising gross domestic product, may deem any short-term reductions in working hours as undesirable without giving due consideration to the positive effects of these non-employment activities on individual, family, and societal wellbeing. Nevertheless, the time to dispel the ‘laziness’ myth is long overdue, at least until substantial evidence emerges to contradict these findings.

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It’s unaffordable Ultimately, the affordability of large-scale basic income interventions may be the most important factor in determining its implementation. Costbenefit analyses are imperative to understanding the utility of any public health intervention, but there are currently no studies assessing the economic benefits of basic income interventions, which include reduced health service use, improved education, decreased crime, and better early childhood development, among others.[9] In addition there is no data on the effect of UBI on macroeconomic variables such as inflation, productivity, wage growth, and consumption. However, several studies have attempted some cost-benefit estimates. A simulation model of the Alaska Permanent Fund estimated that every dollar paid in dividends led to a 20-92 cent decrease in healthcare expenditure, whilst the large reduction in hospital admissions and mental health service use in Dauphin was projected to result in substantial cost savings.[14,23] Furthermore, indirect economic benefits that have been identified include increased wages in Alaska and Dauphin, as well as increased average incomes in Native American nations.[9,24] Gibson et al. also note that the effects of basic income interventions on health and education outcomes exceed those usually obtained by targeted interventions, such as the provision of

micronutrients for low birthweight or expenses for higher education.[9] Additionally, proponents argue that there are significant cost savings to be made by dismantling the complex bureaucracy that underpins current social security programs and by discontinuing programs that would be made redundant by a universal basic income (e.g., Australia’s Newstart and Youth Allowance programs). 21st century UBI Over the last 5-10 years, UBI trials have been proposed or implemented by various aid groups and governments. In 2013, an Indian non-governmental organisation (NGO), SEWA, partnered with UNICEF to trial unconditional cash transfers in several rural villages. Peer-reviewed studies into this pilot project have not been published, but a summary report identified numerous benefits including improved housing and sanitation, increased children weight for age, lower incidence of common illnesses, and improved school enrolments.[25] Currently, a USA-based NGO, GiveDirectly, is conducting a controlled UBI trial in Kenya.[1] It involves 21,000 adults receiving 2250 Kenyan shillings (roughly US$22.50) per month and is planned to run for the next 12 years, making it the largest and longest UBI trial. The idea of direct cash transfers has been gathering steam in the aid industry, and this trial may be the ‘proof-of-concept’ required for governments and foreign aid institutions to jump on board.[26] Meanwhile, a two-year partial basic income trial was recently conducted in Finland. [27] Preliminary results were mixed: recipients of the partial basic income had significantly improved wellbeing (e.g., fewer problems related to health, stress, and concentration ability) and increased confidence in their employment prospects, but there was no difference in employment rates between trial and control groups.[27] Unfortunately, a threeyear UBI trial in Canada, the Ontario Basic Income Pilot, was abandoned in 2018 due to a change in provincial government, despite early qualitative data highlighting positive sentiments from recipients.[28] Show me the money Universal basic income has arrived onto the political and economic mainstage, with 2020 US Presidential nominee, Andrew Yang, using UBI as a central platform in his campaign.[29] In fact, politicians and media outlets around the world have proposed 45

universal basic income schemes to cushion the economic crisis dealt by the COVID-19 pandemic. [30,31] However, if universal basic income is to be a credible public health intervention once this crisis subsides, reliable data will be key. Large scale trials with community randomisation and appropriate comparison groups need to be conducted and evaluated over many years to appreciate the full effects of such an immense intervention. These trials are expensive and notoriously challenging to plan, but not unworkable. The Ontario experience alone highlights the enormous financial and political barriers to investigating universal basic income and unconditional cashless payments, but the seismic shifts that have occurred in global politics over the last few years suggest that now may be the time to try these ‘radical’ ideas. And, if so, a cheque for free money may just be on its way to you soon. About the Author Kajanan Parameshwaran is a final year medical student at the University of New South Wales who is interested in health economics. Kajanan is passionate about using economic policies to broaden access to healthcare, improve community wellbeing and tackle emerging public health challenges. Conflicts of interest N/A Correspondence kajananp@gmail.com Acknowledgements N/A

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Images N/A References 1. Arnold C. Money for nothing: the truth about

universal basic income. Nature. 2018;557(7707):626-8. 2. Gerard N. Universal healthcare and universal basic income. J Health Organ Manag. 2018;32(3):394-401. 3. Painter A. A universal basic income: the answer to poverty, insecurity, and health inequality? BMJ (Clin Res Ed). 2016;355:i6473. 4. Ruckert A, Huynh C, Labonte R. Reducing health inequities: is universal basic income the way forward? J Public Health (Oxf). 2018;40(1):3-7. 5. Basic Income Earth Network. About basic income [Internet]. Available from: https://basicincome.org/basicincome/. 6. Painter A, Thoung C. Creative citizen, creative state: the principled and pragmatic case for a Universal Basic

Income. London: The RSA; 2015. 7. Groth A. Andrew Yang’s basic income plan permits Americans to fail. And that’s a good thing: Quartz; 2019 [Internet]. Available from: https://qz.com/1687957/the-casefor-andrew-yangs-ubi-plan/. 8. The Centre for Social Justice. Universal Basic Income: An Effective Policy for Poverty Reduction? 2018. [Internet] Available from: https://www.centreforsocialjustice.org.uk/ core/wp-content/uploads/2018/08/CSJ_UBI_August-2018.pdf. 9. Gibson M, Hearty W, Craig P. The public health effects of interventions similar to basic income: a scoping review. Lancet Public Health. 2020;5(3):e165-e76. 10. Kehrer BH, Wolin CM. Impact of income maintenance on low birth weight: evidence from the Gary Experiment. J Hum Resour. 1979;14(4):434-62. 11. Chung W, Ha H, Kim B. Money transfer and birth weight: evidence from the Alaska permanent fund dividend. Econ Inq. 2016;54(1):576-90. 12. Costello EJ, Erkanli A, Copeland W, Angold A. Association of family income supplements in adolescence with development of psychiatric and substance use disorders in adulthood among an American Indian population. JAMA. 2010;303(19):1954-60. 13. Akee R, Simeonova E, Copeland W, Angold A, Costello EJ. Young adult obesity and household income: Effects of unconditional cash transfers. Am Econ J Appl Econ. 2013;5(2):128. 14. Forget EL. New questions, new data, old interventions: the health effects of a guaranteed annual income. Prev Med. 2013;57(6):925-8. 15. Kodish SR, Gittelsohn J, Oddo VM, Jones-Smith JC. Impacts of casinos on key pathways to health: qualitative findings from American Indian gaming communities in California. BMC Public Health. 2016;16:621. 16. Akee R, Copeland W, Costello EJ, Simeonova E. How Does Household Income Affect Child Personality Traits and Behaviors? Am Econ Rev. 2018;108(3):775-827. 17. Palmer JL, Pechman JA. Welfare in rural areas: the North Carolina-Iowa income maintenance experiment. Soc Work.1978;24(4):342-3 18. Maynard RA, Murnane RJ. The effects of a negative income tax on school performance: Results of an experiment. J Hum Resour. 1979:463-76. 19. Akee RK, Copeland WE, Keeler G, Angold A, Costello EJ. Parents’ Incomes and Children’s Outcomes: A QuasiExperiment. Am Econ J Appl Econ. 2010;2(1):86-115. 20. Bregman R. Utopia for realists: And how we can get there: Bloomsbury Publishing; 2017. 21. Bruckner TA, Brown RA, Margerison-Zilko C. Positive income shocks and accidental deaths among Cherokee Indians: a natural experiment. Int J Epidemiol. 2011;40(4):1083-90. 22. Evans WN, Moore TJ. The short-term mortality consequences of income receipt. J Public Econ. 2011;95(1112):1410-24. 23. Watson B, Guettabi M, Reimer M. Universal cash and crime. Rev Econ Stat. 2019:1-45. 24. Conner TW, Taggart WA. Assessing the impact of Indian gaming on American Indian nations: Is the house winning? Soc Sci Q. 2013;94(4):1016-44. 25. SEWA Bharat. A Little More, How Much It Is ... Piloting Basic Income Transfers in Madhya Pradesh, India [Internet]; 2014. Available from: https://sewabharat.org/wp-content/ uploads/2015/07/Report-on-Unconditional-Cash-TransferPilot-Project-in-Madhya-Pradesh.pdf

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26. Lowrey A. The Future of Not Working. The New York Times Magazine. 2017. [Internet]. Available from: https:// www.nytimes.com/2017/02/23/magazine/universal-incomeglobal-inequality.html?_r=0 27. Kangas O, Jauhiainen S, Simanainen M, Ylikännö M. The basic income experiment 2017–2018 in Finland: Preliminary results [Internet]. 2019. Available from: https:// julkaisut.valtioneuvosto.fi/bitstream/handle/10024/161361/ Report_The%20Basic%20Income%20Experiment%20 20172018%20in%20Finland.pdf?sequence=1&isAllowed=y 28. Hamilton L, Mulvale JP. “Human Again”: The (Unrealized) Promise of Basic Income in Ontario. J Poverty. 2019;23(7):576-99. 29. Yang2020. The Freedom Dividend [Internet]. Available from: https://www.yang2020.com/policies/the-freedomdividend/. 30. Baskin J. “Whatever it takes” should now include a universal basic income Melbourne: The Conversation; 2020 [Internet]. Available from: https://theconversation.com/ whatever-it-takes-should-now-include-a-universal-basicincome-134405. 31. Widerquist K. America is in crisis. We need universal basic income now [Internet]: The Guardian; 2020 Available from: https://www.theguardian.com/commentisfree/2020/ mar/20/america-coronavirus-recession-universal-basicincome.

‘SITTING DUCKS’ FOR COVID-19: DETENTION OR DEATH-TRAP? The Implications of COVID-19 on Refugees and People Seeking Asylum from a Global and Australian Perspective Raelene Emmanuel, Che Hooper

OVID-19 has already overwhelmed many of the best equipped healthcare systems in the world. The United States and United Kingdom, despite ranking high on the list of pandemic preparedness by the Global Health Security Index, have both seen massive numbers of deaths. They have faced widespread concern about the lack of ventilators and PPE.[1] If these healthcare systems have fared poorly, this does not bode well for the majority of the world’s population who do not have access to such a high standard of healthcare. Over-crowded communities rife with malnutrition and communicable diseases. Without access to healthcare and basic sanitation, these communities will have devastatingly poor health outcomes in the face of this pandemic. One of these populations is that of refugees and people seeking asylum, both globally and in Australia. It is imperative that we do what we can to protect these vulnerable people from the devastation of COVID-19. In Australia, this means moving people from overcrowded onshore immigration detention centres, into community detention where they can appropriately and safely socially distance.

“We are preparing for the worst” - Avril Benoit, executive director of Doctors Without Borders in the United States.[2]

facilities.[6] Inside the Villawood detention centre, there are concerns from refugees and people seeking asylum that no one, including the staff, is wearing PPE.[5] To express their extreme anxiety, detainees across Australian immigration detention centres have written a letter to Prime Minister Scott Morrison, detailing their fears that they are currently in “a potential death trap in which we have no option or means to protect ourselves”.[6] As well as being prime candidates for contracting the virus, a high proportion of people currently held in immigration detention centres have comorbidities such as diabetes or upper respiratory tract infections, which places them at a higher risk of complications from COVID-19.[7] Hence, It is imperative that actions are taken to prevent an outbreak in these facilities.

The Global Refugee Crisis Assessing the global refugee perspective sheds light on the full scale of this issue. For example, in the largest refugee camp in Kenya, there are eight doctors for 200,000 people.[2] A refugee camp in Bangladesh houses a population density four times the size of New York City.[2] Is it reasonable to expect true social-distancing in such circumstances? When people do get sick, where will they go to be treated? Equally distressing, is the situation unfolding in the Moria refugee camp. The 42,000 refugees trapped in these camps on the Greek Islands, have only one water tap for every 1,300 people, and no available soap.[3] They cannot socially distance, nor are they afforded appropriate sanitation. Tangible action to assist these people has been evidenced in the recent evacuation of twelve children to Luxembourg, and the European Union’s agreement to accept 1600 more.[4] While this is a step in the right direction,

The Australian government’s advisory recognises that individuals in detention facilities are especially susceptible to COVID-19;[8] it acknowledges

“We are sitting ducks for COVID-19 and extremely exposed to becoming severely ill, with the possibility of death.” - Asylum seekers detained in Australian immigration detention centres write in a letter to prime minister Scott Morrison, pleading to be released into the community.[5]

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the sheer number of those remaining in squalid, overcrowded camps, fraught with fear, and at risk of infection and death, remains outstanding and unacceptable.

the increased risk this pandemic poses to the vulnerable people detained on our shores. Urgent action by the Australian government is especially warranted as a guard has already tested positive at an Alternative Place of Detention in Brisbane, where over 100 refugees are currently being kept, after being transferred to Australia from offshore detention for medical treatment.[9] Two refugees at the same detention centre are now showing symptoms of the virus.[9]

The Refugee Crisis: On Australian Shores This issue is not limited to refugee camps in faraway areas of the world. One of the glaring health inequalities in Australia is our treatment of refugees and people seeking asylum. There is a stark double standard within the Australian government’s call for ‘social distancing’. While they aim to slow the spread of COVID-19, they continue to turn a blind eye to the refugees and people seeking asylum who continue to be detained in Australia.

An outbreak of COVID-19 would not only place those who are detained at an unfair risk of contracting the virus, but also of spreading it to the wider Australian community. As stated by Professor David Isaacs, an infectious diseases physician and prominent refugee advocate, "failure to take action to release people seeking asylum and refugees from detention will not only put them at greater risk of infection and possibly death, it also risks

The people living in Australian detention centres are often confined in bunks of up to four per room, are expected to stand in close proximity whilst waiting for meals and have very limited access to handwashing 49

placing a greater burden on wider Australian society and the health care system."[10]

is it idealistic to ask that people in immigration detention have access to the medical care and treatment they need at a standard consistent with the Australian community?

In response to the disregard for the health of refugees and people seeking asylum, more than 1,100 doctors signed an open letter calling for the release of people in Australia's immigration detention centres into community-supported accommodation, where they can safely self-isolate.[10] Crossing Borders has also long advocated for fairer treatment of refugees and people seeking asylum under the premise that ‘detention harms health’. On April 5th of this year, hundreds of medical students marched virtually in the Palm Sunday Rally, to support refugees all around the world and to call for community-based accommodation for people currently trapped in detention centres.

As medical students, we learn about health and the social determinants of health. Can we really be complacent with the Australian government’s current treatment of refugees and people seeking asylum when it so blatantly impacts their wellbeing? As Australians, we are a country that prides itself on equality. Should we be asking ourselves if this is really how we want to express these values? Authors’ Note If you want to learn more about how you can be involved in advocating for refugees and people seeking asylum during and after this current pandemic, follow us on Facebook and Instagram at AMSA Crossing Borders to stay up to date with these opportunities.

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A Call for Community Detention Community detention allows a person to live in designated housing, with ample room for self-isolation, whilst also ensuring immigration authorities can maintain surveillance on those in community detention. Implementing community detention is not an idealistic and unreasonable scenario. Australia has had community detention for 15 years and 846 people were already living in community detention before COVID-19.[11] The Minister for Immigration has the power to move those in onshore detention into community detention and should do so, in order to protect the most vulnerable in our society.

About the Authors Raelene Emmanuel is a fourth year medical student at the University of Adelaide. Coming from a Sri Lankan Tamil background, she has also been driven by her experiences volunteering with refugees in her community. Raelene has taken the opportunity to advocate for refugee and asylum seeker health on a local and national scale, with a focus on raising awareness of the health inequities they face. As AMSA Crossing Borders National Project Co-Coordinator in 2020, she and Che aim to create opportunities for medical students to engage with and learn about the health of refugees and people seeking asylum.

Let us take up our Australian Values Australians pride themselves on equality, compassion and lending a helping hand where it is needed. Australia is a signatory of the United Nations Refugee Convention,[12] stating our intention that we have promised not to discriminate against people on the basis of their refugee status or route to reach Australia. We have promised to allow these vulnerable people access to healthcare and ensure their safety in the face of the hardships they have endured. The continued detention of refugees and people seeking asylum, despite the obvious risk to their health in the face of this pandemic is incompatible with these values and promises. We should be protecting those in our society who are most vulnerable, allowing them to rebuild their lives in safety.

Che Hooper is a third year medical student at Griffith University. With a long passion for global health, she is one of the Crossing Borders National Project Co-Coordinators, alongside Rae. Che has been involved in Crossing Borders for a number of years and in 2020 has moved from advocating in her local community for the health of refugees and people seeking asylum, to advocating on a national scale. Conflicts of Interest N/A

Conclusion As young people, we may be prone to idealism. But 50

Correspondence raelene.emmanuel@amsa.org.au che.hooper@amsa.org.au

amid coronavirus fears [Internet]. Australia: SBS News; 2020 Apr 2 [cited - 2020 May 3]. Available from: https://www.sbs. com.au/news/australian-doctors-call-for-refugees-to-bereleased-amid-coronavirus-fears 11. Foster M, Robertson K. DETENTION INCREASES COVID-19 HEALTH RISK [Internet]. Melbourne, Australia: University of Melbourne; 2020 Apr 17 [cited - 2020 May 3]. Available from: https://pursuit.unimelb.edu.au/articles/ detention-increases-covid-19-health-risk 12. The Refugee Convention 1951 (United Nations).

Acknowledgements N/A Images N/A

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References

1. Maizland L, Felter C. Comparing Six Health-Care Systems in a Pandemic [Internet]. New York, USA: Council on Foreign Relations;2020 Apr 15 [cited - 2020 May 3]. Available from: https://www.cfr.org/backgrounder/comparing-sixhealth-care-systems-pandemic 2. Beech H, Hubbard B. Unprepared for the Worst: Worldâ&#x20AC;&#x2122;s Most Vulnerable Brace for Virus [Internet]. New York, USA: The New York Times; 2020 Mar 26 [cited - 2020 May 3]. Available from https://www.nytimes.com/2020/03/26/world/ asia/coronavirus-refugees-camps-bangladesh.html 3. Medecins Sans Frontieres Australia. AS COVID-19 SPREADS, EVACUATING GREECEâ&#x20AC;&#x2122;S SQUALID REFUGEE CAMPS IS MORE URGENT THAN EVER [Internet]. Sydney, Australia: Medecins Sans Frontieres Australia; 2020 Mar 13 [cited - 2020 May 3]. Available from: https://msf.org.au/article/statementsopinion/covid-19-spreads-evacuating-greece%E2%80%99ssqualid-refugee-camps-more-urgent 4. Deutsche Welle. Greece refugee crisis: First 12 children evacuated from camps [Internet]. DW.COM; 2020 Apr 15 [cited 2020 Ma y4]. Available from: https://www.dw.com/ en/greece-refugee-crisis-first-12-children-evacuated-fromcamps/a-53129449 5. Knowles L, Carter J. Asylum seekers plead to be released from detention centres amid coronavirus fears [Internet]. Australia:ABC News; 2020 Mar 25 [cited 2020 May 4]. Available from: https://www.abc.net.au/news/202003-25/coronavirus-fears-asylum-seekers-plead-for-releasedetention/12084604 6. Holt R and Vasefi S. 'We are sitting ducks for Covid 19': asylum seekers write to PM after detainee tested in immigration detention [Internet]. The Guardian; 2020 Mar 25 [cited - 2020 May 3]. Available from: https://www.theguardian. com/australia-news/2020/mar/24/we-are-sitting-ducks-forcovid-19-asylum-seekers-write-to-pm-after-detainee-testedin-immigration-detention 7. Public Interest Advocacy Centre. In Poor Health: Health care in Australian immigration detention. Sydney, Australia: Public Interest Advocacy Centre; 2018. 8. Australian Government Department of Health. What you need to know about coronavirus (COVID-19) [Internet]. Canberra, Australia; Australian Government Department of Health; 2020 Apr 30 [cited - 2020 May 3]. Available from: https://www.health.gov.au/news/health-alerts/novelcoronavirus-2019-ncov-health-alert/what-you-need-to-knowabout-coronavirus-covid-19 9. Refugee Action Coalition Sydney. Over 1100 doctors and health professionals call for release of refugees and asylum seekers from detention [Internet]. Sydney, Australia: Refugee Action Coalition Sydney; 2020 Apr 2 [cited - 2020 May 3]. Available from: http://www.refugeeaction.org.au/?p=8237 10. Australian doctors call for refugees to be released

graphic by Hyun Jae Nam

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HEALTH, HUMAN RIGHTS, AND OFFSHORE PROCESSING The Health Implications of Australia’s Mandatory Offshore Processing Practices Jackie Maher

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Introduction Australia’s mandatory offshore processing practices are directly harmful to health and breach international treaties on human rights.[1] Article 12 of the International Covenant on Economics, Social and Cultural Rights (ICESCR) states that everyone is entitled to the ‘enjoyment of the highest possible standard of physical and mental health’ and has been ratified and in force in Australia since 1976.[2] Underlying these practices, the policy in question is the 2013 Regional Resettlement Arrangement (The PNG Solution), in the context of Section 189 of the 1958 Migration Act which, when amended in 1992, established mandatory detention of unauthorised maritime arrivals in Australia.[3] The PNG Solution ascertains that any person arriving in Australia by boat to seek asylum, will not ever be eligible to enter or apply for asylum in Australia and will be removed and held in mandatory offshore detention centres for processing.[3] This practice is well out of step with the policies of other comparable countries.[3]

remains open. Approximately 359 people remain on Nauru, with fewer than ten held in the processing centre and notably all children have been resettled, primarily to the U.S.[4] Those remaining in Nauru live in the community. Of the 3,127 people denied the opportunity to apply for asylum in Australia more than 80% are recognised as refugees and have this important legal status.[6,8] Thus, for the remainder of this review the group of people discussed are these adults remaining on Nauru or Manus Island requiring of refugee status, not other groups of people who remain in legal ‘limbo’ after not being recognised as refugees for local settlement, but the UN not deeming it safe and therefore allowable for them to go home.[9] Despite the current reduction in numbers, it remains that refugees arriving in Australia by boat will be subject to mandatory detention. Mandatory offshore processing is illegal under Australia’s party to Article 9 of the International Covenant on Civil and Political Rights (ICCPR), despite this it persists at extreme financial cost to Australian taxpayers and does not fulfil the claimed political agenda of stopping boat arrivals. [1,10] As of May 2019, 14 people have died while being detained under this policy.[11] Of paramount importance are the direct harms to health, the lack of appropriate services and inability of refugees to achieve basic health, and the prevention of flourishing in good health that directly results from detaining refugees in detention.

Since offshore processing in Australia resumed in 2012, 4,177 people have been held on Nauru and Manus Island (Papua New Guinea), after attempting to seek asylum in Australia.[4] In July 2013, The PNG Solution was announced and since then 3,127 people, with no pathway for settlement in Australia, have been detained.[4] The numbers of detainees peaked in 2014 and have since dwindled.[4] This is as more than 800 people have been returned to their country of origin with others transferred to The United States (U.S.) in a deal struck under the Obama Administration, or settled in the local community in Papua New Guinea (PNG) or Nauru. [4,5] Manus Island Regional Processing Centre was forcibly closed in 2017 after the PNG government ruled it to be unconstitutional.[6] This left 690 men on Manus Island to fend for themselves in highly hostile conditions.[7] They now live in the community or in transit centres and await transfer to Nauru, The U.S. or removal to their country of origin.[4,7] Nauru Regional Processing centre

Direct harms to health Mandatory offshore detention and resettlement within itself is damaging to health, particularly mental health.[3] This kind of detention is not only arbitrary but it breaches the human right to seek asylum as per the Universal Declaration of Human Rights (UDHR), no matter the mode of transport, and is directly prohibited in the 1951 United Nations (UN) Convention and 1967 UN Protocol Relating the Status of Refugees.[8,12] Human rights are further breached through the extended time-period of this 53

detention, which is up to six years for this cohort. As per Tobin [13] this demonstrates that Australia is unreasonable in meeting their obligations as this measure is far from proportionate to meeting their aim.[4] These breaches directly lead for poor mental health and establish clearly the interlinking nature of health and human rights.

This combination of the detention process, environment and lack of meaningful activity culminates in the high rates of mental health problems, self-harm and attempted suicide in this group. According to a submission by the Royal Australian College of Physicians (RACP) the harms of detention are specifically amplified in offshore detention facilities, due to environmental and infrastructure challenges, limited access to specialist health services, and uncertainty around the future and settlement options.[16] Dr Nick Martin, a general practitioner who has worked on Nauru, states that the mental health of people there could not be helped by improved services and instead require removal from the situation itself, which is directly harming their health.[19] This sense of hopelessness and fear is particularly exacerbated in those separated from their families. Under the PNG Solution there is no formal structure or process for family reunification.[20] Family separation is one of the most significant contributors to poor mental health for refugee communities.[21] Many refugees still have family members in their country of origin, where persecution, war, poverty and violence are ongoing and being able to reunite with their family is often the only way people are able to ensure they are safe.[21] MSF's report also found that people whose families have been split because of medical evacuations were 40 per cent more likely to be suicidal.[14]

The physical environment of offshore processing centres also directly harms health. Beyond migration trauma, people are further re-traumatized by this environment, which has been described by visiting RACP physicians as ‘like a prison’.[16] They report a heavy security presence, restriction of liberty, de-personalising use of identification numbers, institutional living conditions and inadequate feminine hygiene.[16] Forcing people to live in this environment is a breach of their right to an appropriate standard of living, a fundamental determinant of health as per the UDHR and ICESCR. [2,12] Further, within this environment sexual and physical assault and violence is frequent, perpetrated by co-inmates and security staff hired by the Australian Government.[16,17] In 2014 a riot in Manus Island Processing Centre resulted in the murder of 23-year-old asylum seeker Reza Barati, with those who witnessed and spoke out about the attack left to fear for their own safety.[18]

The locations Australia has chosen under the PNG Solution as a ‘final-destination’ are not safe for permanent resettlement, particularly PNG. [18,22] Human Rights Watch has deemed the process of settling refugees on PNG a failure and the Australian Journal of Human Rights ruled in a report that ‘the human rights situation in PNG makes it an unsuitable country for the resettling of refugees’.[22,23] The 1951 Refugees Convention, amongst other treaties, states that Australia must not return people to any country where they face a real chance of being persecuted or subjected to other serious harm.[8] This fundamental obligation is known as non-refoulement.[8] While Australia states that selecting this final destination ‘frees them’ from their obligations to non-refoulement,

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In an independent report on the mental health situation on Nauru in 2018, titled ‘Indefinite Despair’, Medecins Sans Frontieres (MSF) describe that more than 30% of asylum seekers had attempted suicide and that over time the situation had become worse than many other disaster zones worldwide, with multiple people diagnosed with resignation syndrome, unable to eat or drink in a semi-comatose state.[14] MSF Executive Director Paul McPhun states that this situation is a direct result of offshore processing - ‘It's people's inability to cope, their absolute abject despair, their loss of will, their loss of control over their own lives that's a direct result of more than five years of detention, that's creating these really acute symptoms of selfharm and suicide’.[15] Any person in immigration detention faces profound uncertainty, hopelessness and fear for their future. They are unable to exert agency and control or participate in society in a meaningful way.

Charter of Healthcare Rights does not apply, and the existing PNG and Nauruan health-systems are unable to cope.[27] There is no statute on the ‘responsibility for refugees’ and Australia has long argued they do not have a duty of care for the people on Manus and Nauru.[28] Lawyer George Newhouse argues however that under common law Australia is responsible, by using its constitution to place these people in harm’s way on these remote islands, like soldiers and diplomats abroad.[28] Nevertheless, the lives of these people provide a torturous example of how international law fails to bind states when it is not implemented into a domestic system. This allows shirked responsibility to the Australian Charter of Healthcare Rights and international conventions on refugees and torture. This group of people are particularly vulnerable to this political-healthcare-human-rights grey-zone. People seeking asylum usually have highly complex physical and mental health needs.[16] This may include infectious diseases not common to Australia, poor nutrition and undiagnosed or untreated health conditions and injuries.[16] Pre-existing poor mental health is also common because of prearrival experiences such as torture and trauma.[16] Regarding physical health, The Australian Human Rights Commission has condemned Australia’s offshore processing arrangements for the lack of maternity care and specialist reviews for chronic conditions, and for keeping people in cramped, overcrowded, hot and poorly maintained facilities that are intended only for short term use and encourage the spread of infectious disease.[29]

Lacking health service provision Beyond direct damage, the health services organised on Manus Island and Nauru under the PNG Solution are not sufficient to meet basic health needs.[3] This failure directly stems from Australia, as the 5th most prosperous OECD country, not taking responsibility for people who are genuine refugees and originally sought asylum in Australia. [3] The UN’s Special Rapporteurs on migrant rights, torture, and mental health, have told the Morrison Government that the lack of care on Manus and Nauru ‘amounts to cruel, inhuman and degrading treatment’[24] The PNG Solution stipulates that ‘Australia will bear the full cost of implementing the arrangement’ but this does not appear to be the case.[20] The Australian government has a $21.5 million contract with Pacific International Hospital in Port Moresby to provide care, however many people are being referred to the locally funded East Lorengau hospital, which has been described as ‘no more than a GP clinic’.[25] This lack of appropriate healthcare includes mental health, with the Australian government cutting counselling and trauma services last year.[26]

Information gathered by the UN suggests that several deaths have occurred due to lack of access to medical care in the offshore facilities.[24,27] Case examples range in severity to include a man with a broken arm that was not treated for more than four years, to Hamid Khazaei a 24-year-old man who died from sepsis after his transfer to Australia was postponed by political discourse.[30] His death was ruled by the coroner as preventable.[27] A key issue displayed in this health and human rights tragedy of the PNG Solution is the way Australia’s Political discussion has manipulated this relationship. Politicians have used their position of power to deny other human beings appropriate medical care, and

The PNG Solution places these refugees in a health and human rights ‘grey-zone’ where Australia’s

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evidence suggests there are serious dangers of remaining in PNG for this group.[20] There have been multiple cases in which of groups of local PNG young men, often intoxicated and sometimes armed with sticks, rocks, knives, or screwdrivers, have targeted, assaulted and robbed refugees and asylum seekers on Manus Island and in the PNG capital Port Moresby, with victims requiring emergency medical attention.[18,22] Homosexual men who have fled their countries of origin due to persecution for their sexuality face settlement in a country where homosexuality remains not only highly stigmatised but illegal.[23] On Nauru women have often said they felt safer in detention than in the community, where they are subject to racist abuse and sexual harassment.[16] With numerous cases of rape resulting in pregnancy on the island, abortion remains a crime in Nauru.[16] The breach of human rights in direct exposure to violence undeniably directly damages physical and mental health.

People held in immigration detention do not have the right to work, earn income or to attend educational institutions. According to a report co-written by The Refugee Council of Australia and Amnesty International Australia, the men who are left on Manus Island are unable to leave the island to seek employment or educational opportunities without approval from PNG officials and those settled in PNG and Nauru struggle to find sustainable income with fair wages.[18] These direct and indirect obstructions are not in line with Australia’s obligations under multiple articles of The ICESCR including: (1), Article 1 - The right to self-determination; (2), Article 6 - The right to work; (3), Article 13 - The right to education; and (4), Article 12 - The right to the highest attainable standard of health.[10] The 1951 Refugee Convention also clearly stipulates the rights to work and freedom of movement for migrants.[8] It is important to note while the ‘social profiles’ of these refugees ranges from ‘young and troublesome’ to highly skilled and educated, all are being denied a vast earning capacity and the ability to support their own health, the health of their families and communities.[18]

Inability to flourish Underlying direct health damage and lack of health service provision, the people detained on Manus Island and Nauru have had their right to enjoy good health violated. While the ‘highest’ attainable standard of health is carefully worded to be location and situation specific, refugees have sought protection from the Australian Government and thus the health status of refugees living in Australia should be used as a comparator standard. Migrant health is complex even within a comprehensive system such as Australia’s, however refugees that have been settled in Australia, have access to many services and health opportunities, which those in offshore processing do not.[16] The importance of these opportunities can be understood by considering the determinants of health. In addition to the previously addressed determinants of physical environment and adequate health service provision, further relevant determinants are employment and education, social support networks and preventative health opportunities. [35]

These refugees are also being denied the right to flourish in a socially supported network, a key determinant of health and right under Article 1 of The ICESCR.[10] The PNG Solution places these refugees from a variety of distinct religious and cultural backgrounds in isolating, arbitrary detention and then forces them to settle in remote countries that are not culturally diverse or welcoming in the case of PNG, particularly in comparison to the multicultural community of Australia.[23] The extent of social connectedness or degree to which people have close bonds with family, friends and acquaintances is associated with lower morbidity and increased life expectancy.[36] ‘Social capital’ provides sources of resilience against poor health, through social support which is critical to physical and mental wellbeing.[36] Breaching this right to connection, breaches the rights to its health cobenefits. This further extends to the rights to have a planned family and reproductive health. A planned family is a key part of human rights and human nature as per Article 10 of ICESCR.[10] Failures of access to this right include no reunification with martial partners, access to reproductive services for family

These refugees have no ability to exert control over their employment status, income or to further educate themselves. It is widely accepted that people from poorer social or economic positions are at greater risk of poor health and have much higher rates of disease, disability and early mortality.[36]

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overshadow medical opinion of doctors who are bound to do no harm.[30, 31] Mr Khazaei’s death was specifically ruled to be in part due to a failure of Australian immigration officials to grant a doctor’s request for his timely transfer to Australia.[30] MSF, which prides itself on neutrality and functions to provide objective healthcare, was denied access to Manus Island in 2017 and was forced to leave Nauru in 2018.[32] New legislation that came into effect in 2019 allowed asylum seekers to be medically evacuated to Australia, only for medical care, if two doctors say that it was necessary.[33] This legislation was designed to protect health and was defended by multiple key groups such as RACP as ‘life-saving’, but has since been repealed.[33,34] The human rights and thus health of these people has been used as a political soccer ball under the PNG Solution.

rights, it’s time to properly protect them in our laws. We need an Australian Charter of Human Rights to ensure practices like indefinite detention are prohibited.’[24,27]

planning or contraception, quality maternity care and for those who do settle to have their newly born children registered.[12,37]

To end this situation which has destroyed and taken human lives, there must be more transparency about the Australian Government’s current actions towards asylum seekers and a human rights-based approach to health and justice must be applied to legally overturn the PNG Solution and amend the 1958 Migration Act. About the Author Jackie Maher is a Doctor of Medicine at the University of Melbourne currently completing the integrated Masters of Public Health program. She is the AMSA Global Health 2020 Vice Chair External. She is passionate about many areas of global health, particularly paediatric and refugee and asylum seeker health. Conflicts of interest N/A Correspondence jackie.maher@amsa.org.au Acknowledgements N/A

Conclusion Australia’s 2013 PNG Solution, has led to the human rights travesty that is the forgotten people of Manus Island and Nauru, who were requiring of Australia’s refuge. Australia has failed to meet many of its obligations under the ICESCR. Article 12, related to the highest attainable standard of health, has been violated due to the entwined nature of health and all human rights. People legally requiring refugee status under the 1951 Refugee Convention have been arbitrarily detained and physically and mentally abused. There has been inadequate health service provision, and key determinants of health have not been addressed. Ms Robertson, Legal Director at The Human Rights Law Centre states:

Images N/A References

1. Truu M. Australia’s refugee policy out of step with global standards and breaks international law: report. SBS News. 2019. 2. Australian Human Rights Commission. Right to health 2019 [Available from: https://www.humanrights.gov. au/our-work/rights-and-freedoms/right-health. 3. Phillips JS, Harriet Immigration Detention in Australia. Parliamentary Library: Parliament of Australia; 2013. 4. Refugee Council of Australia. Offshore processing statistics 2019 [updated 8.04.2019. Available from: https:// www.refugeecouncil.org.au/operation-sovereign-bordersoffshore-detention-statistics/2/. 5. Refugee resettlement from Regional Process Centres [press release]. Home Affairs Index of Media Releases. 2016. 6. Karlsen E. Australia’s offshore processing of asylum seekers in Nauru and PNG: a quick guide to statistics and

‘Australian governments make various promises on the world stage by signing UN treaties, but they fail or refuse to actually incorporate them into domestic law. If Australians believe in human

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The final denied determinant for good health is preventative health. Despite a lack of acknowledgement in the literature on this issue, without appropriate services, self-employment, freedom of movement and self-determination it is unlikely that these refugees have adequate capacity to prevent chronic disease such as type II diabetes mellitus or cardiovascular disease (CVD). Risk factors relevant to these diseases (amongst others) include limited opportunities for exercise in detention, no support for smoking cessation and poor nutrition.[16,38] Further lacking is protection from infectious diseases in the tropical environments of Manus Island and Nauru with access to full vaccination schedules.[39] The possibility of access to the progressive screening programs equivalent to Australia’s cervical screening, CVD risk assessment and breast, bowel and prostate cancer screening is restricted, unlike migrants settled in Australia who are offered these services.[16] Through lack of acknowledgement of these determinants, the highest attainable standard of health cannot be reached.

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Island ‘inexplicable’, Amnesty Says. The Guardian. 2018. 27. UN calls for refugee transfers to Australia [press release]. Human Rights Law Centre2019. 28. National Justice Project. Why Australia has a duty of care to asylum seekers on Manus and Nauru. 2019. 29. Triggs G. The forgotten children: national inquiry into children in immigration detention 2014. Australian Human Rights Commission Sydney. 2015. 30. Robertson J. Asylum seeker Hamid Khazaei’s death from leg infection was preventable, Queensland coroner finds. The ABC News. 2018. 31. Borys S. Peter Dutton says court ruling on medevac laws could ‘start the boats’. The ABC News. 2019 20 June 2019. 32. Davidson H. Manus Island: MSF denied access to refugees as thousands rally in Australia. The Guardian. 2017. 33. Gothe-Snape J. What now for asylum seekers on Nauru and Manus Island in need of medical evacuation? The ABC News. 2019. 34. Boochani B. Medivac missteps rack sick refugees. The Saturday Paper. 2019. 35. Marmot M, Allen J, Bell R, Bloomer E, Goldblatt P. WHO European review of social determinants of health and the health divide. The lancet. 2012;380(9846):1011-29. 36.Australian Institute of Health & Welfare. Australia’s Health 2016. 2016. 37. Togiba LC, Michelle. Life in limbo: the Manus babaes who face a stateless future. The Guardian. 2018. 38. Crosland P, Ananthapavan J, Davison J, Lambert M, Carter R. The health burden of preventable disease in Australia: a systematic review. Australian and New Zealand Journal of Public Health. 2019;43(2):163-70. 39. Procter NSSSGP, G; Block, A. Nauru Site Visit Report. 2014.

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resources. Parliamentary Library: Parliament of Australia; 2016. 7. Ben Doherty. 600 men refuse to leave Manus Island detention centre as closure imminent. The Guardian. 2017. 8. The United Nations. The 1951 Convention relating to the Status of Refugees and its 1967 Protocol: A Commentary. International Journal of Refugee Law. 2011;23(4):884-8. 9. Eric Tlozek. 'Negative status' asylum seekers on Manus Island left hanging in legal limbo, unable to leave or stay. The ABC News. 2018. 10. International Covenant on Civil and Political Rights, Article 49 (1966). 11. Asylum Insight. Asylum Insight Facts & Analysis 2019 [Available from: https://www.asyluminsight.com/subscribe .XQh1gntS8Wo. 12. Nations U. Universal Declaration of Human Rights. 1948. 13. Tobin J. Judging the judges: Are they adopting the rights approach in matters involving children. Melb UL Rev. 2009;33:579. 14. Medecins Sans Frontieres. Indefinite despair - The tragic mental health consequences of offshore processing on Nauru. 2018. 15. Metherell L. Nauru mental health situation equivalent to 'victims of torture', Medecins Sans Frontieres says. The ABC News. 2018. 16. Royal Australian College of Physicians. RACP Submission: Conditions and treatment of asylum seekers and refugees at the regional processing centres in the Republic of Nauru and Papua New Guinea. 2016 April 2016. 17. Evershed NL, Ri; Farrell, Paul; Davidson, Helen. The lives of asylum seekers in detention detailed in a unique database. 2015. 18. Amnesty International Australia TRAC. Until When: The Forgotten Men on Manus Island. 2018. 19. Lyons A. Current standards of Care on Nauru are unacceptable: RACGP. RACGP “NEWSGP”. 2018. 20. Regional Resettlement Arrangement Between Australia and Papua New Guinea, (2013). 21. Refugee Council of Australia. Australia’s offshore processing regime 2016 [Available from: https://www. refugeecouncil.org.au/offshore-processing-facts/. 22. Human Rights Watch. Australia/PNG: Refugees Face Unchecked Violence 2017 [Available from: https://www. hrw.org/news/2017/10/25/australia/png-refugees-faceunchecked-violence. 23. Gerber P, Wilkinson C, Langlois AJ, Offord B. Human rights in Papua New Guinea: is this where we should be settling refugees? Australian Journal of Human Rights. 2016;22(1):27-65. 24. Australia: UN experts urge immediate medical attention to migrants in its offshore facilities [press release]. Geneva, 18 June 2019 2019. 25. Truu MB, Rosemary. Manus asylum seekers treated at local hospital despite million dollar health contract. SBS News. 2019. 26. Davidson H. Australia’s cut to healthcare on Manus

A FIRSTHAND LOOK AT AUSTRALIAN ICUs IN THE TIME OF CORONA An Interview of Dr Ken Hillman Marisse Sonido These days, our media, our emails, and our thoughts are saturated with news of the COVID-19 pandemic. A lot of this news is filtered down from one source, to the next. As medical students, while we understand more about it than the general population, we still find ourselves on the outskirts of this pandemic. Dr Ken Hillman is an ICU specialist at Liverpool Hospital NSW and a Professor of Intensive Care at UNSW. In this capacity, he has helped manage many severe cases of COVID-19 in Southwest Sydney. We were fortunate enough to interview him in April about his firsthand experiences and insight on the pandemic. Based on your personal experiences, how are you and other ‘frontliners’ coping with the emotional stressors of dealing with this pandemic? Relative to other seriously ill patients, the COVID-19 patients are no different in terms of the level of their illness and support required. The major difference has been the anxiety of staff and the fear that they themselves may contract the illness and pass it onto their families. The workload is also increased, related to the number of seriously ill patients and

the lengthy procedures that have to be undertaken with PPE. Having said that, I stand back in awe at how committed the ‘frontliners’ are; the way they organize themselves with all sorts of innovations and how team work becomes genuine interaction around a common challenge. Memorable. How do you feel about how Australia (as a whole) is handling the COVID crisis? What was handled well and what could be improved on?

We have done well in Australia with early and appropriate interventions. However, with this question I can’t help but reflect on the serious situation in the USA. According to WHO, it is the 36th worst health system in the world. It is a system based on individuals and their ability to pay. In other words, there may be some centres of excellence, but the public health system is poor, and serious inequalities still persist across the country. The number of people infected may not even be a reflection of the real number as people may not have testing available or the ability to pay for it. Twenty percent of Americans become bankrupt as a result of management in ICUs. I’m not too sure who is paying for those costs in the current pandemic. For the advocates of a private health system, the way America is handling the situation will cause some reflection.

Although I work in an intensive care unit (ICU), surrounded by technology and a complex mix of drugs, I’m more a believer that the secret of good care in ICU is doing the simple things well. We have a history in ICU of searching for the magic bullet and despite millions of dollars from international pharmaceutical companies, it has yet to be found. We use drugs such as morphine to relieve pain (when did you last see the morphine drug representative trying to sell their product?); intravenous fluids and noradrenaline to maintain blood pressure (when did you last see the noradrenaline drug representative?); and antibiotics to treat infections. There are several trials currently being undertaken both in the community and in intensive care. So far, no magic bullet.

How is our health system coping, given the added burden by COVID-19? Are we equipped with the resources necessary to cope with potentially increasing demands?

The key to caring for severe cases of COVID-19 being managed in ICU is early intervention, teamwork, and using interventions such as tried and true ventilator strategies that we have been using for many years. Early intervention is particularly important for the common presentations that we manage in ICUs, such as severe trauma and septicaemia. Australian intensive care clinicians are responsible for a hospital wide system for the early detection of deteriorating patients in the general wards of hospitals: doing simple things early and well.

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Intensive care is an international specialty that believes in communication. Intensivists have been in contact with each other since the pandemic first started; firstly with our Chinese colleagues, then from Italy, Spain, the UK, and the USA. We were able to quickly figure out that the strategies we have been using for many years work in COVID-19 patients and that the key to managing the pandemic was control in the community. If those measures were late in coming, the number of detected cases would rise and of those, a certain percentage would deteriorate and require ICU.

Do you feel that Australian medical students, preclinical and clinical, have a role in this crisis? If so, what might those role/s be? When I was working at St. Bartholomew’s hospital in London, I used listen to the stories from the senior consultants about how they were conscripted into an allied army that was sweeping across Europe towards the end of the Second World War. They were at the end of their fourth year of training and said that, under the supervision of more senior physicians, they felt they could cope and that in the bigger picture they were better doctors as a result. In other words, I think it is great idea. As we have little idea of where this crisis will take us, their role shouldn’t have too many boundaries. At the same time, they need to be genuinely supported at all times.

Modelling and projections would give us some idea of the resources required in ICU. Some countries such as the UK have had shortages of personal protective equipment (PPE) and others with ventilators and ICU and hospital beds. The Australian health system has been well organized and well prepared to cope with the pandemic. So far, there have been no shortages of supplies for the seriously ill. The death rate has been low compared to many countries. I suspect this is related to the early and strict community measures. We keep hearing about interventions that supposedly work against COVID-19 (e.g. hydroxychloroquine). What actually works in the management of moderate to severe cases of COVID-19?

How do you think COVID-19 will change the global picture of health in the long term? 60

There will be more emphasis on not just

measuring public health problems from centralized academic departments and offices in major Australian cities, but a move to more interventions that work—developing, implementing, and evaluating them at the coalface. For example, it remains a disgrace that Aboriginal Australians have the same health outcomes as developing countries. But, how often do we hear those statistics from well-meaning public health people and other advocates. Change is necessary. The COVID-19 crisis has demonstrated that health care can address and solve health issues at the coalface. The funding models need to change; emphasizing the need to get one’s hands dirty, getting out there, and doing something that genuinely changes the appalling figures. Is there anything else you want our readers to know as a healthcare professional seeing this crisis firsthand? Most of the deaths that occurred because of the pandemic were in the elderly and frail. As one ages, you become more vulnerable to incidents such as falls and infections. The pandemic has focused our attention on the need to revise the way we teach medicine. Currently, we teach a single disease model with single disease specialists diagnosing and treating that single disease. There is still a need for that. However, the population of patients needing health care is changing as the population ages. Increasingly, patients will have multiple comorbidities as they age which may be modified but rarely cured. Ageing and frailty are inevitable, progressive, and largely irreversible. This is occurring in an age and death denying society. Our health system is not being honest with what we can do and, equally important, what we can’t do. I would like to see a universal system where we could determine the attitudes and beliefs of people and how that can be translated into their genuine wishes and choices around health care. In other words, who this person is. Then, this would be available to the health system every time someone encounters it. Over 70% of Australians want to die at home; over 70% die in acute hospitals. While appreciating the efforts of well-meaning health professionals, most older frail people do not want to be in hospitals. Empowering people to make genuine choices

based on who they are and what their priorities in life are will happen in the lifetime of current medical students. A bit like how birthing was reclaimed by society in the 1960’s, dying and death will become demedicalised. Author’s Note For more firsthand reflections on intensive care, Dr Hillman’s book ‘Vital Signs’ sheds light on the experiences of patients, families, and staff in the ICU. To explore regarding the de-medicalisation of dying and death, his other work ‘A Good Life to the End’ is another good resource. If you want to learn more about COVID-19 from a firsthand Australian perspective, tune into the episode of our podcast The Global Health Chat entitled ‘Things May Never Be the Same Again: COVID-19 and the Australian Frontline’ where we discuss the pandemic with respiratory physician, Dr Jonathan Williamson. Acknowledgements N/A Conflicts of Interest N/A Correspondence marisse.sonido@amsa.org.au

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THE HEALTH BENEFITS OF KUCHIPUDI DANCE An Indian classical dance-based intervention to manage musculoskeletal injury and psychological distress in young and otherwise healthy individuals

Dr Laalithya Konduru

ABSTRACT Aims: Dance therapy is a recognised form of complementary medicine, primarily used with therapeutic intent. Additionally, recreational dance has been shown to be beneficial in individuals with certain physical and psychological disabilities. Indian classical dances are believed to alleviate anxiety and depression, prevent musculoskeletal problems by improving posture, body-awareness, and neuromuscular coordination. This study was conducted to investigate if recreational Kuchipudi dance, an Indian traditional dance form, can be used as a public health intervention to manage psychological distress and musculoskeletal injury. Methods: A repeated measures design was used. Twenty-one healthy young individuals filled out a questionnaire assessing their level of psychological distress, problems with neuromuscular coordination, and level of disability from lower back pain. They then underwent structured training in Kuchipudi dance for 6 months. At the end of 6 months, the same questionnaire was administered again, and the preand post-intervention scores were compared.

Conclusions: Recreational Kuchipudi dance is shown to have beneficial effects on physical and psychological disability.

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Results: There was a statistically significant reduction in the scores of all domains tested.

Introduction Dance is recognised as an effective exercise conferring both physical and mental health benefits. [1] All traditional Indian dances must adhere to the Natyashastra, which is not only a treatise on music, dance, and drama but also a compendium of knowledge of anatomy [2] and psychology.[3] It describes various poses and hand movements which are not only used in Indian classical dances but also in Hatha Yoga, or the yoga postures commonly identified with the practice of Yoga all over the world. Natyashastra regards Indian traditional dance as Yoga in motion, set to music designed to elicit specific emotions and moods in both the dancer and the spectator.[4]

recreational use of Kuchipudi, a form of Indian classical dance, in the improvement of psychological distress, neuromuscular coordination, and back pain. Methods Participants To be included in the study, participants must not have any pre-existing physical, mental, or developmental health conditions, apart from diabetes and/or hypertension, or have a current acute health condition. They must also not have visited a doctor regarding back pain. After meeting the principles outlined in the Declaration of Helsinki regarding human experimentation and obtaining informed consent, a total of 23 Chennai residents who were 17 years of age and above and were newly enrolled in the Kuchipudi dance training program of the Narthanasala School of Kuchipudi Dance, Chennai were recruited to participate in the study in September 2018.

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The benefits of dance include (a) the prevention and management of depression [5]; (b) prevention of dementia [6]; (c) increasing flexibility [1]; (d) increasing muscle strength [7]; and (e) promoting a general feeling of well-being.[1] Research has also demonstrated the benefit of dance in improving neuromuscular coordination in individuals on the autism spectrum.[8] Given the mental health benefits of dance, pioneers of dance therapy began to harness the potential of dance as a form of psychotherapy.[9] In the context of stigmatization of mental illness which occurs across cultures [10] and the universality of dance and movement [11], dance therapy becomes particularly useful as it can help overcome the stigma and the fear of being judged by others.[12]

Facilitators The training program was facilitated by experienced Kuchipudi dance teachers who taught Kuchipudi as a form of recreational dance. They were not dance therapists or health professionals. Survey instrument and scoring A 12-item survey divided into 4 sections was developed for the purposes of this study. The survey instrument and the scoring criteria have been included in the online supplementary material (www.ajgh.amsa.org.au). Briefly, the first section measured psychological distress of the participants. It had 4 items that were taken from the Kessler Psychological Distress Scale (K10). The second section measured disability due to problems with neuromuscular coordination. It had 6 questions that were taken from the Adult Developmental Disorder Checklist (ADC). The Rowland-Morris Low Back Pain and Disability Questionnaire (RMQ) was included as one of the items on the survey, which formed the third section, measuring current disability from back pain. Section 4 consisted of a single unvalidated 5-point Likert scale question, â&#x20AC;&#x2DC;How often do you find yourself slouching?â&#x20AC;&#x2122; This question was asked because slouching is a risk factor for developing back pain.[14, 15]

Natyashastra describes multiple non-psychological benefits of Indian classical dance, including prevention and management of musculoskeletal problems, as well as improvement in body awareness and neuromuscular coordination.[4] Though other health benefits have been studied, whether Indian classical dance can directly aid in the prevention and management of musculoskeletal problems, neuromuscular coordination, and mental health status remains relatively uninvestigated. An earlier study reported a high prevalence of lower back pain among practitioners of Bharatanatyam, an Indian classical dance form.[13] Though Bharatanatyam and Kuchipudi may look similar to the untrained eye, there are many differences which affect the mechanics of movement among practitioners of both art forms.

Each section of the survey was scored separately. The first 3 sections were scored according to the scoring instructions of the appurtenant questionnaire. For the last section, the item was scored from 0 â&#x20AC;&#x2DC;None of

This study was conducted to investigate the 64

were lost to follow-up and did not complete the post-intervention survey. Twenty of the 23 initially enrolled participants were females. One male and 1 female participant dropped out of training before the end of the study. All the participants either took up dance as a new hobby or were returning to dance as a hobby after a long hiatus of 10 years minimum.

the timeâ&#x20AC;&#x2122; to 4 â&#x20AC;&#x2DC;All the timeâ&#x20AC;&#x2122;. Higher scores on each section indicated a higher disability pertaining to that section. Procedures The survey was administered at the start of the study to measure the baseline self-reported psychological distress, problems with neuromuscular coordination, lower back pain, and frequency of slouching. The participants then commenced their traditional Kuchipudi training. One-hour classes were held 3 times per week in a group setting. After completion of 6 months of training, the same survey was administered again. When surveys were conducted, laptops open to the survey page hosted on Google Forms were kept in a private room at Narthanasala School of Kuchipudi Dance, where the participants were asked to fill in the survey before entering the class. The pre- and post-intervention scores were calculated and compared.

Descriptive statistics The results of the Shapiro-Wilk test for normality are shown in Table 1. As it can be seen from Table 1, only pre-intervention psychological distress score was normally distributed (p > 0.05). The descriptive statistics for the data used to compute the z-scores of the Wilcoxon Signed-Ranks Test are shown in Table 2. The effect of Kuchipudi dance training on selfreported disability The Wilcoxon Signed-Rank Test revealed a statistically significant reduction, with a large effect size, in the self-reported psychological distress scores (z = -3.229, p = 0.001, r = 0.5), self-reported problems with neuromuscular coordination (z = -2.658, p = 0.008, r = 0.4), and self-reported disability due to lower back pain (z = -2.974, p = 0.003, r = 0.46).

Statistical analysis The results were analysed using SPSS v25. The Shapiro-Wilk test indicated that not all scores were normally distributed, hence the Wilcoxon signedrank test was run, and the effect size was calculated on the scores for the pre- and post-intervention surveys.

The effect of Kuchipudi dance training on selfreported frequency of slouching The Wilcoxon Signed-Rank Test revealed a statistically significant reduction in the self-reported frequency of slouching after 6 months of training in Kuchipudi (z = -3.680, p < 0.001), with a large effect size (r = 0.57).

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Results Participant characteristics Twenty-three participants aged between 17 and 32 years consented to participate in the study and filled in the baseline survey. The median age of the participants was 26 years. Two participants

Table 1: Normality test of the section and global scores. 65

Table 2: Descriptive statistics used for the Wilcoxon Signed-Ranks test.

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Discussion There was a statistically significant improvement in the level of disability due to psychological distress, problems with neuromuscular coordination, and lower back pain after an intervention consisting of structured training in Kuchipudi dance for a period of 6 months. These findings reinforce the findings of previous studies which showed that the regular practice of dance has a positive effect on various physical and mental health conditions. [1,5,16] However, these studies looked at dance as an intervention in the elderly or individuals on the autism spectrum, while the present study looks at younger adults with no pre-existing conditions other than hypertension and diabetes.

nature of Kuchipudi movements and the difference in the Aramandi postures are likely to result in significantly different ground reaction forces as compared to Bharatanatyam. This could explain why Kuchipudi may be reducing existing lower back pain rather than causing lower back pain as the study on Bharatanatyam showed. However, the ground reaction forces generated by Kuchipudi movements have not been studied. It is a novel area which merits research, especially given the results of this study. The results of a study on the ground reaction forces generated during Kuchipudi, when compared to the studies on ground reaction forces generated during Bharatanatyam, could provide evidence towards the mechanism by which Kuchipudi is reducing lower back pain, rather than causing it.

Both Bharatanatyam and Kuchipudi place the utmost importance on maintaining the Saushtavam and Aramandi postures. In Saushtavam, the back is held erect, the shoulders are pinched backward, and the neck is held perpendicularly above the shoulders. However, the Aramandi posture of Bharatanatyam and Kuchipudi are different from each other. The Bharatanatyam Aramandi requires the feet to form a straight line, pointing away from each other while bending the knees such that the dancer is standing at half their height, while the Kuchipudi Aramandi requires the dancer to similarly stand at half their height but with their feet forming a V-shape. Kuchipudi also includes upper-body and torso movements which are precluded in Bharatanatyam. This makes Kuchipudi a much more free-flowing style. The free-flowing

Students of Kuchipudi are constantly reminded to maintain Saushtavam even while resting between choreographies, slouching is highly discouraged within the class premises. The present study showed participants slouched less often at the end of 6 months of Kuchipudi training compared to when they began their training. From the pre-intervention surveys, it was seen that the mean self-reported frequency of slouching was 2.62 on a scale of 0 to 4, indicating that the participants were at risk of developing back pain. They were already reporting some disability due to back pain though they did not yet seek medical attention for the same. The emphasis on the Saushtavam posture and the persistent maintenance of an erect back could be one of the reasons for the improvement in the disability 66

due to back pain and the self-reported frequency of slouching seen in this study. Recreational Kuchipudi dancing after undergoing structured training may therefore prevent back pain, but further research is needed to assert the same.

called ethnochoreology.[11] Almost every culture has its own style of dance, making dance a wellaccepted part of life. A dance-based intervention could therefore be more easily accepted by these communities.

Tsimaras, et. al. (2013) postulate that since dancing requires planning and execution of a pre-determined sequence of movements requiring whole-body coordination, people with movement disorders benefit from the regular practice of dance.[8] While the previous study demonstrated that regular traditional Greek dancing improved neuromuscular coordination of individuals on the autism spectrum, the results of the present study show this is true even in non-autistic adults, Kuchipudi dancing can improve neuromuscular coordination. This is important because impairments in neuromuscular control can predispose to musculoskeletal injury. [17]

Dance as a hobby is well-accepted in Indian culture as well. Since there is already community support for recreational dance, a recreational Indian traditional dance like Kuchipudi could be accepted as a physical and psychological health intervention in this community more easily and has a good chance of success in India. Considering the cost of treating psychological and physical conditions, and the low cost and high acceptability of a dancebased intervention to prevent health problems, trialling such interventions globally is also worth consideration. Conclusion While this study is limited by a small sample size, these results support Kuchipudi as a potential low-cost intervention to be further investigated in future studies. It can be posited that practicing Kuchipudi after learning the correct technique can be an effective intervention to improve mental health, prevent musculoskeletal injury by improving neuromuscular coordination, and improve or prevent disability from back pain in the general population.

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Psychological distress has a detrimental effect on health.[18] Due to various factors like cost, and the stigma attached to mental health in India, most people do not seek professional help even if they experience psychological distress. Dance therapy is a recognised form of complementary medicine for treating neuro-psychological ailments.[19-22] However, due to the prevailing stigma associated with seeking therapy for psychological problems, the uptake of dance therapy also remains poor in India (N. Mittal, personal communication, July 28, 2018). There is limited literature on the use of recreational rather than therapeutic dancing as a strategy to prevent or treat psychological illness. This study provides some evidence that recreational Kuchipudi dancing may have beneficial effects on psychological illness.

About the Author Laalithya Konduru is a public health specialist and a molecular immunologist, currently pursuing Doctor of Medicine at Flinders University. She is passionate about preventive medicine and ensuring access to healthcare for all. Conflicts of Interest and Funding N/A

Traditional dance can easily be marketed to groups that report barriers to traditional exercise programs, with dance sometimes being the preferred form of exercise in these groups.[23] For example, dance has been reported as the preferred form of physical activity among girls belonging to African American, Hispanic, and Caucasian ethnicities.[24] Studies in the Hispanic [25], Asian [26-28], African [29], and Native American [30] populations have reported that participation in traditional dancebased interventions has several physical and mental health benefits. The universality of dance and its biological and evolutionary significance has led to the emergence of a specialization of anthropology

Correspondence laalithya@gmail.com Acknowledgements This study would not have been possible without the support of Dr. Sathyapriya Ramana, the Founder and Principal of Narthanasala School of Kuchipudi Dance, Chennai, India. The author would like to sincerely thank the Ethics Committee of Samanjasa Foundation, Chennai, India for reviewing and approving the ethics for this study and guidance regarding ethical matters throughout the conduct 67

of this study.

Roeder L, et al. Effects of Dance on Gait, Cognition, and DualTasking in Parkinson’s Disease: A Systematic Review and MetaAnalysis. J Parkinsons Dis. 2019;9(2):335-49. 20. Karkou V, Aithal S, Zubala A, Meekums B. Effectiveness of Dance Movement Therapy in the Treatment of Adults With Depression: A Systematic Review With Meta-Analyses. Front Psychol. 2019;10:936. 21. Karkou V, Meekums B. Dance movement therapy for dementia. Cochrane Database Syst Rev. 2017;2:CD011022. 22. Meng X, Li G, Jia Y, Liu Y, Shang B, Liu P, et al. Effects of dance intervention on global cognition, executive function and memory of older adults: a meta-analysis and systematic review. Aging Clin Exp Res. 2019. 23. Olvera, A. Cultural Dance and Health: A Review of the Literature. Am. J. Health Educ. 2008;39(6): 353-359. ISSN: ISSN1932-5037 24. Grieser M, Vu MB, Bedimo-Rung AL, Neumark-Sztainer D, et al. Physical activity attitudes, preferences, and practices in African American, Hispanic, and Caucasian girls. Health Educ Behav. 2006;33(1):40-51. 25. Whitehorse LF, Manzano R, BaezcondeGarbanati LA, Hahn G. Culturally tailoring a physical activity program for Hispanic women: Recruitment success of La Vida Buena’s salsa aerobics. J Health Educ. 1999;30(Suppl 2):S1 8-S24. 23. 26. Visram S, Crosland A, Unsworth J, Long S. Engaging women from South Asian communities in cardiac rehabilitation. Br J Community Nurs. 2007;12(1):13-18. 27. Kim C, June K, Song R. Effects of a health promotion program on cardiovascular risk factors, health behaviors, and life satisfaction in institutionalized elderly women. Int J Nurs Stud. 2003;40(4):375-381; 375. 28. Hestyanti YR. Children survivors of the 2004 tsunami in Aceh, Indonesia: A study of resiliency. Ann N Y Acad Sci. 2006;1094:303-307. 29. Harris DA. Dance/movement therapy approaches to fostering resilience and recovery among African adolescent torture survivors. Torture. 2007;17(2): 134-155. 30. Thompson JL, Allen P, Cunningham-Sabo L, Yazzie DA, Curtiz M, Davis SM. Environmental, policy, and cultural factors related to physical activity in sedentary American Indian women. Women Health. 2002;36(2):59-74.

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Images N/A References

1. Alpert PT. The Health Benefits of Dance. Home Health Care Manag Pract. 2010;23(2):155-7. 2. Manmohan Ghosh. The Natyasastra (pp 100-147), Royal Asiatic Society, Kolkata; 2002. ISBN 81-7080-076-5. 3. Manmohan Ghosh. The Natyashastra (pp 148-237), Royal Asiatic Society, Kolkata; 2002. ISBN 81-7080-076-5. 4. Appa Rao PSR. Special Aspects of Nāṭya Śāstra. New Delhi: National School of Drama; 2001. 5. Carolyn J. Murrock CHG. Effects of Dance on Depression, Physical Function, and Disability in Underserved Adults. J Aging Phys Act. 2014;22(3):380-5. 6. Verghese, J., Lipton, R. B., Katz, M. J., Hall, C. B., Derby, C. A., Kuslanisky, G., et al. Leisure activities and the risk of dementia in the elderly. N Engl J Med. 2003;348: 25082516. 7. Verghese, J. Cognitive and mobility profile of older social dancers. J Am Geriatr Soc. 2006; 54(8): 1241–1244. 8. Despina Arzoglou, Vassilis Tsimaras, Georgios Kotsikas, Eleni Fotiadou, Maria Sidiropoulou, Miltiadis Proios, Eleni Bassa. The effect of α tradinional dance training program on neuromuscular coordination of individuals with autism. Journal of Physical Education and Sport. 2013;13(4):563-9. 9. Welling A. What is Dance/Movement Therapy? [Internet]. 2019 [cited 2020May27]. Available from: https:// adta.org/2014/11/08/what-is-dancemovement-therapy/ 10. Angermeyer, M.C., Buyantugs, L., Kenzine, D.V. and Matschinger, H. Effects of labelling on public attitudes towards people with schizophrenia: are there cultural differences?. Acta Psychiatr Scand. 2004;109: 420-425. doi:10.1111/j.16000047.2004.00310.x 11. Hanna, J. Anthropology and the Study of Dance. CORD News. 1973;6(1):37-41. doi:10.2307/1477573 12. Tavormina R, Tavormina MGM. Overcoming the social stigma on mood disorders with dancing. Psychiatr Danub. 2017 Sep;29(Suppl 3):427-431. 13. Shradha Pawar UP. Study of lumbar lordosis and pelvic position in Bharatanatyam dancers. Indian Journal of Scientific Research. 2015;6(2):125-30. 14. Snijders CJ, Hermans PF, Niesing R, Spoor CW, Stoeckart R. The influence of slouching and lumbar support on iliolumbar ligaments, intervertebral discs and sacroiliac joints. Clinical Biomechanics 2004;19:323–9. doi:10.1016/j. clinbiomech.2004.01.006. 15. In a slump? Fix your posture. Harvard Health 2017. https://www.health.harvard.edu/staying-healthy/in-a-slumpfix-your-posture (accessed April 2, 2020). 16. Rodrigues-Krause J, Krause M, Reischak-Oliveira A. Dancing for Healthy Aging: Functional and Metabolic Perspectives. Altern Ther Health Med. 2019;25(1):44-63. 17. Wendy J. Hurd LS-M. Neuromuscular Training. In: Donatelli R, editor. Sports specific rehabilitation. London, UK: Churchill Livingstone; 2007. p. 247-58. 18. Barry V, Stout ME, Lynch ME, Mattis S, Tran DQ, Antun A, et al. The effect of psychological distress on health outcomes: A systematic review and meta-analysis of prospective studies. J Health Psychol. 2019:1359105319842931. 19. Kalyani HHN, Sullivan K, Moyle G, Brauer S, Jeffrey ER,

“IT’S ALL IN YOUR HEAD” A Comprehensive Policy Response to Somatisation in Victoria

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Travis Lines

graphic by Hyun Jae Nam

Introduction Somatisation is a common presentation in the Australian healthcare system that engenders a significant health and economic burden on patients and health systems. To date, the policy response to somatisation has been fragmented and ineffective. This article outlines how somatisation is managed in Australia, using Victoria as a case study, and considers a comprehensive policy response to it. The impacts of somatisation Somatisation encompasses the relationship between mental processes and physical symptoms. It is most commonly associated with physical symptoms that have been directly drawn to a mental process, such as palpitations and breathlessness in panic disorder. [1] However, there is an increasing awareness of the capacity for mental processes to produce or enhance physical symptoms associated with so-called physical diseases.[2, 3] It has long been acknowledged that symptoms of fibromyalgia, irritable bowel syndrome, and chronic pain syndrome are greatly influenced by psychological factors.[4, 5] From a public health perspective, medically unexplained symptoms (MUPS) are the most important form of somatisation, encompassing a spectrum of presentations that range from very mild to severe.[6-8]

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Irrespective of the psychological or physical origins of a physical symptom, it is experienced identically.[9, 10] Consequently, MUPS produce significant distress for patients, and are associated with reduced participation in employment and social activities.[11-13] Despite this, patients with MUPS face significant stigma that restricts their access to evidence-based care.[4, 14-18] Where somatisation does not occur in the context of a diagnosable mental health disorder, it is associated with an increased risk of developing anxiety or depression.[19, 20] Risk factors of somatisation are shared with these disorders.[3, 19, 21] Family and social stress are important predisposing and precipitating factors of somatisation, whilst the social isolation somatisation often produces and the stigma associated with it are perpetuating factors.[22, 23] From a health systems perspective, patients with somatisation are super-users of health resources.[24, 25] Over-investigation and unnecessary treatments constitute a significant risk to patientsâ&#x20AC;&#x2122; health and waste limited healthcare resources.[24, 26, 27] Estimates of the costs associated with MUPS have been 70

varied, with one British case study estimating the annual cost for one patient at ÂŁ209,000 ($522,000 AUD) in 2004.[24] The epidemiology of somatisation There is little evidence regarding the prevalence of somatisation in Victoria, owing to the large degree of heterogeneity in definitions of somatisation, the still murky relationship between physical and mental health and the exclusion of somatisation from surveys of mental health and wellbeing.[28-31] Estimates of the prevalence of MUPS in primary care range approximately 5-50% of all presentations.[8] Though most patients experience mild MUPS, its high prevalence has significant public health consequences. Diagnosable somatisation disorders are rarer, with an estimated prevalence of less than 1%.[1, 7, 32-35] These data highlight the need for better research; however, even the most conservative estimates make clear the enormous scale of the problem. Treatment of MUPS Evidence-based care for somatisation takes a stepwise approach.[6, 14, 22] Psychoeducation is the most important component of therapy, with an empowering diagnosis that allows the patient with somatisation to take ownership of their diagnosis and practise self-care, a critical first step.[14, 15, 22] Patients requiring care beyond psychoeducation will often be referred for specific therapy, for example, cognitive behaviour therapy.[36, 37] Emerging therapies for somatisation include shortterm dynamic psychotherapy and family therapy for children and adolescents.[38-42] Low dose antidepressants are indicated for patients with severe somatisation, including chronic MUPS.[43, 44] The following principles form the mainstay of therapy and appear in many guidelines.[15, 22, 45] 1. Successful communication is therapeutic. 2. Somatisation exists on a continuum. 3. A targeted and tangible explanation of the relationship between the mind and body should be given that is mindful of the patientâ&#x20AC;&#x2122;s language and cultural model. 4. The aims of therapy should be symptom management and self-care. 5. Therapy should understand the predisposing, perpetuating, and precipitating factors of somatisation. 6. A safe and therapeutic environment should be promoted.

7. A broad, biopsychosocial approach should be taken.

[61, 62] Care for patients with somatisation is best coordinated by primary health services in conjunction with community-based mental health services. Making use of the primary care sector and facilitating digital-delivery of CBT to mitigate the need for face-to-face psychology provide significant opportunities as measures to address somatisation.[36, 63, 64]

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Health systems response Although the subject of some criticism, the World Health Organization building blocks of health systems provides a framework with which to describe the health system response to somatisation.[46, 47] Service delivery Patients with mild to moderate somatisation often follow the clinical pathway typical of those with the physical complaint that characterises their illness. [48, 49] Consequently, care is often delivered by the specialist or general practitioner managing the patient’s physical complaint.[2] When a diagnosis of somatisation becomes clear, the patient is often retained by the medical service they were sent to rather than being discharged to primary care or a mental health service.[2] Mild to moderate somatisation is best managed in the community with a general practitioner to coordinate care.[50, 51] This facilitates access to psychology, as well as fostering the continuity of care that is vital to the treatment of somatisation. [52] Victoria has an extensive primary care network with low barriers to access, especially in metropolitan regions.[53, 54] Primary care providers can coordinate care for patients with somatisation and arrange mental health care plans for access to community mental health services.[10, 54, 55] Primary care is widely accepted as being best-placed to manage somatisation; therefore, a realignment of services in a primary care model is necessary and feasible.[6, 10, 50]

Health information systems The Australian government is rolling out My Health Record (MHR), a medical record system designed to harmonises patients’ medical records so that they can be accessed wherever a patient presents.[65] Consumer concerns about privacy, as well as concerns from health professionals about the legal implications and utility of MHR have plagued the roll out.[65, 66] Nonetheless, uptake has been high, and technological advances have seen MHR become increasingly useful as a tool for accessing medical information.[65, 67, 68]

Health workforce Most care for patients with somatisation is delivered by specialist doctors or general practitioners, often in the context of a long relationship to investigate a physical complaint.[56, 57] Consequently, care is often delivered by medical practitioners without sufficient training to treat somatisation.[58, 59] Care for somatisation is straightforward and, when supported by training and clear guidelines, can be implemented by a wide-range of clinicians, especially in a primary care setting.[6]

Access to essential medicines Access to medicines in Victoria is generally excellent, owing to their availability on the pharmaceutical benefits scheme.[69, 70]

In the context of treating and preventing somatisation, MHR presents opportunities and threats. MHR can be used to flag somatisation early and divert patients from unnecessary and harmful investigations and treatments. This facilitates an early transition to proper care. The presence of a diagnosis of somatisation on a patient’s MHR may see them exposed to the stigma associated with somatisation.[17] Consequently, the perception of the patient as a malingerer without ‘real’ symptoms may see them diverted from necessary treatment for a physical illness.[10, 11]

Financing Financing of Victoria’s mental health system is fragmented and inefficient.[71, 72] Hospital-based care in the public system derives the majority of its funding from the state government and, in the private system, from private health insurers.[71] Medicare, which is funded by the federal government, supports the majority of primary care services, including some allied health services.[73, 74] Patients contribute to the funding of mental health services by means of co-payments at general practices, allied health services, and for medications and via pri-

Retaining a professional, effective, and appropriate mental health workforce has long been a challenge in Victoria.[60] Shortages of allied health, nursing, and medical professionals are persistent and efforts to develop and retain a full workforce are failing. 71

vate health insurance premiums.[71]

Nonetheless, the Victorian health system provides several avenues for addressing somatisation. It is well-resourced, with a large primary health workforce and consistent access to medical resources. Moreover, there is active and significant reform of the mental health system, which could provide the basis for a response to somatisation.

Victoria’s mental health system is widely regarded as underfunded.[75] However, the federal and state government have committed to significant funding increases in mental health and have included it as a priority in their health planning.[76, 77] Many mental health programmes in Victoria attract only shortterm funding, making long-term planning challenging.[78]

Policy recommendations Somatisation has a corrosive impact on the psychosocial and physical wellbeing of many Victorians. Moreover, it constitutes a significant burden on the health care system, with healthcare resources wasted on unnecessary and ineffective treatments. These issues occur despite the existence of robust and effective treatment for individuals with somatisation, which could be delivered in the context of Victoria’s healthcare system. Consequently, the following policy recommendations are made.

The availability of increased mental health funding presents an opportunity for policy makers to introduce new programmes.[79] However, fragmented financing, significant cost-shifting, and the short-term nature of health budgets provide significant barriers to the effective planning of mental health programmes.[72, 80] Leadership and governance There is strong pressure for the reform of Victoria’s mental health system, with the federal and state governments both flagging mental health as a policy priority.[76, 77] Victoria is currently undergoing a Royal Commission into Victoria’s Mental Health System. [81-83]

1. Design and implement a Somatisation Action Plan, including clear referral pathways for primary care doctors and a prevention plan. 2. Improve access to mental health services for patients with somatisation across the full spectrum of severities. 3. Implement a prevention strategy for somatisation. 4. Facilitate innovative research into somatisation as a public health issue.

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Somatisation has not featured in discussions about mental health system reform in Victoria.[84, 85] The only time somatisation has featured in the national debate is in the context of Australian Lyme disease. [86] External groups such as BeyondBlue and SANE, which provide leadership in mental health, do not have policies on somatisation and only refer to it in the context of other mental health disorders. International action on somatisation has been limited, although the Dutch and British health systems provide guidelines for addressing somatisation.[14, 15]

These policy recommendations target the various barriers in the Victorian health system to addressing somatisation. They are framed on a Somatisation Action Plan, which clarifies the primary care response and introduces public health responses to somatisation. The delineation of referral pathways for primary care doctors makes use of Victoria’s excellent primary care system, whilst ensuring that the bulk of the care for somatisation is shifted away from hospitals to the community. With the aid of treatment plans for somatisation, primary care doctors are best placed to deal with the majority of patients with somatisation. This provides effective, evidence-based care and reduces the health and economic consequences of over-testing and misdiagnosis. Moreover, it frees limited mental health resources that should be reserved for cases of somatisation with the highest acuity.

Reorganisation of the mental health system is a significant opportunity for meaningful action on somatisation. The under-recognition of somatisation as an issue in mental health and the failure of governments and NGOs alike to provide leadership on the issue is an important barrier to reform. Analysing the response The response of the health system to somatisation is poor, relying on the provision of wasteful specialist care in the context of a system with a fragmented funding model and poorly defined responsibility for somatisation as a health issue.

There is scant evidence for public health respons72

es to somatisation. Nonetheless, public health responses have a long history of success in dealing with complex health problems; consequently, it is recommended that, in addressing somatisation, public health responses be considered.[87]The implementation of any public health response for somatisation would need to occur in the context of a careful evaluation of its effectiveness.

ly associated with somatisation in 840 patients, which may drive bloating. Aliment Pharmacol Ther. 2015;41(5):449-58. 6. Burton C. Beyond somatisation: a review of the understanding and treatment of medically unexplained physical symptoms (MUPS). Br J Gen Pract. 2003;53(488):231-9. 7. Claassen-van Dessel N, van der Wouden JC, Dekker J, van der Horst HE. Clinical value of DSM IV and DSM 5 criteria for diagnosing the most prevalent somatoform disorders in patients with medically unexplained physical symptoms (MUPS). J Psychosom Res. 2016;82:4-10. 8. Jadhakhan F, Lindner OC, Blakemore A, Guthrie E. Prevalence of medically unexplained symptoms in adults who are high users of health care services: a systematic review and meta-analysis protocol. BMJ Open. 2019;9(7):e027922. 9. Lipsitt DR, Joseph R, Meyer D, Notman MT. Medically unexplained symptoms: barriers to effective treatment when nothing is the matter. Harv Rev Psychiatry. 2015;23(6):43848. 10. Stone L. Blame, shame and hopelessness: medically unexplained symptoms and the'heartsink'experience. Aust Fam Physician. 2014;43(4):191. 11. Brownell AKW, Atkins C, Whiteley A, Woollard RF, Kornelsen J. Clinical practitioners’ views on the management of patients with medically unexplained physical symptoms (MUPS): a qualitative study. BMJ Open. 2016;6(12):e012379. 12. Verhaak PF, Meijer SA, Visser AP, Wolters G. Persistent presentation of medically unexplained symptoms in general practice. Fam Prac. 2006;23(4):414-20. 13. Kroenke K. Somatic symptoms deserve our attention. 2016. 14. Chitnis A, Dowrick C, Byng R, Turner P, Shiers D. Guidance for health professionals on medically unexplained symptoms (MUS). Royal College of Psychiatrists. 2011. 15. Hartman TO, Blankenstein A, Molenaar A, van den Berg DB, van der Horst H, Arnold I, et al. NHG guideline on medically unexplained symptoms (MUS). Huisarts Wet. 2013;56(5):222-30. 16. Dickson A, Knussen C, Flowers P. Stigma and the delegitimation experience: An interpretative phenomenological analysis of people living with chronic fatigue syndrome. Psychol Health. 2007;22(7):851-67. 17. Looper KJ, Kirmayer LJ. Perceived stigma in functional somatic syndromes and comparable medical conditions. J Psychosom Res. 2004;57(4):373-8. 18. Rawlings GH, Brown I, Reuber M. Deconstructing stigma in psychogenic nonepileptic seizures: an exploratory study. Epilepsy Behav. 2017;74:167-72. 19. Dijkstra-Kersten SM, Sitnikova K, van Marwijk HW, Gerrits MM, van der Wouden JC, Penninx BW, et al. Somatisation as a risk factor for incident depression and anxiety. J Psychosom Res. 2015;79(6):614-9. 20. Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression. NEJM. 1999;341(18):1329-35. 21. Patel V, Sumathipala A. Psychological approaches to somatisation in developing countries. Adv Psychiatr Treat. 2006;12(1):54-62. 22. Hartman TCO, Lam CL, Usta J, Clarke D, Fortes S, Dowrick C. Addressing the needs of patients with medically unexplained symptoms: 10 key messages. Br J Gen Pract. 2018;68(674):442-3. 23. Hooker C, Stone L. Medically unexplained symptoms and the ethics of diagnosis: what does it mean when the doctor says there’s nothing wrong? Reading the Psychosomatic

Conclusion Somatisation is a significant public health issue that diminishes the health of the community and constitutes a significant economic burden. Despite this, the policy response to somatisation in Australia has been poor. This article describes a set of evidence-based policy recommendations to map out a healthcare response to somatisation in Victoria. About the Author Travis Lines is the National Policy Officer at the Australian Medical Students' Association and a final year Doctor of Medicine and Master of Public Health student at the University of Melbourne. He has an abiding interest in evidence-based public policy and health economics. Conflicts of Interest Travis Lines is a member of the Australian Medical Students’ Association’s rapid response team, which advocates on issues relevant to medical students and the communities they live in, including mental health systems. The views expressed are his and not those of AMSA. Correspondence travis.lines@amsa.org.au

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Acknowledgements N/A References 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®): Am Psychiatr Pub; 2013. 2. Clarke DM, Piterman L, Byrne CJ, Austin DW. Somatic symptoms, hypochondriasis and psychological distress: a study of somatisation in Australian general practice. Med J Aust. 2008;189(10):560-4. 3. Rossi M, Bruno G, Chiusalupi M, Ciaramella A. Relationship between Pain, Somatisation, and Emotional Awareness in Primary School Children. Pain Res Treat. 2018. 4. Åsbring P, Närvänen A-L. Women’s experiences of stigma in relation to chronic fatigue syndrome and fibromyalgia. Qual Health Res. 2002;12(2):148-60. 5. Patel P, Bercik P, Morgan DG, Bolino C, Pintos‐Sanchez M, Moayyedi P, et al. Irritable bowel syndrome is significant-

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in Medical and Popular Culture: Routledge; 2017. p. 54-69. 24. Kinder A, Jorsh M, Johnston K, Dawes P. Somatization disorder—a defensive waste of NHS resources. Rheumatol. 2004;43(5):672-4. 25. Konnopka A, Schaefert R, Heinrich S, Kaufmann C, Luppa M, Herzog W, et al. Economics of medically unexplained symptoms: a systematic review of the literature. Psychother Psychosom. 2012;81(5):265-75. 26. Williams C, House A. Reducing the costs of chronic somatisation. Ir J Psychol Med. 1994;11(2):79-82. 27. Konnopka A, Kaufmann C, König H-H, Heider D, Wild B, Szecsenyi J, et al. Association of costs with somatic symptom severity in patients with medically unexplained symptoms. J Psychosom Res. 2013;75(4):370-5. 28. National health survey: first results 2017-2018. Canberra: ABS; 2018. 29. Health Do. Victorian Population Health Survey 2011–12, Survey Findings. State Government of Victoria Melbourne (AUST); 2014. 30. Parslow RA, Jorm AF. Who uses mental health services in Australia? An analysis of data from the National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry. 2000;34(6):997-1008. 31. Statistics ABo. National survey of mental health and wellbeing: Summary of results. (Catalogue No 43260). 2007. 32. Creed F, Barsky A. A systematic review of the epidemiology of somatisation disorder and hypochondriasis. J Psychosom Res. 2004;56(4):391-408. 33. Mayou R, Kirmayer LJ, Simon G, Kroenke K, Sharpe M. Somatoform disorders: time for a new approach in DSM-V. Am J Psychiatry. 2005;162(5):847-55. 34. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602. 35. Sykes R. Somatoform disorders in DSM-IV: mental or physical disorders? J Psychosom Res. 2006;60(4):341-4. 36. Liu J, Gill NS, Teodorczuk A, Li Z-j, Sun J. The efficacy of cognitive behavioural therapy in somatoform disorders and medically unexplained physical symptoms: a meta-analysis of randomized controlled trials. J Affect Disord. 2018. 37. Tyrer P, Cooper S, Salkovskis P, Tyrer H, Crawford M, Byford S, et al. Clinical and cost-effectiveness of cognitive behaviour therapy for health anxiety in medical patients: a multicentre randomised controlled trial. Lancet. 2014;383(9913):219-25. 38. Russell LA, Abbass AA, Allder SJ, Kisely S, Pohlmann-Eden B, Town JM. A pilot study of reduction in healthcare costs following the application of intensive short-term dynamic psychotherapy for psychogenic nonepileptic seizures. Epilepsy Behav. 2016;63:17-9. 39. Town JM, Driessen E. Emerging evidence for intensive short-term dynamic psychotherapy with personality disorders and somatic disorders. Psychiatr Ann. 2013;43(11):502-7. 40. Edwards TM, Wiersma M, Cisneros A, Huth A. Children and Adolescents with Medically Unexplained Symptoms: A Systematic Review of the Literature. Am J Fam Ther. 2019;47(3):183-97. 41. Kozlowska K. The body comes to family therapy: Utilising research to formulate treatment interventions with somatising children and their families. Aust N Z J Fam Ther. 2016;37(1):6-29. 42. Wortman MS, Lucassen PL, van Ravesteijn HJ, Bor

H, Assendelft PJ, Lucas C, et al. Brief multimodal psychosomatic therapy in patients with medically unexplained symptoms: feasibility and treatment effects. Fam Prac. 2016;33(4):346-53. 43. Creed F, Tomenson B, Guthrie E, Ratcliffe J, Fernandes L, Read N, et al. The relationship between somatisation and outcome in patients with severe irritable bowel syndrome. J Psychosom Res. 2008;64(6):613-20. 44. Biondi M, Pasquini M. Dimensional psychopharmacology in somatising patients. Clinical Challenges in the Biopsychosocial Interface. 34: Karger Publishers; 2015. p. 24-35. 45. Joellenbeck LM, Russell PK, Guze SB. Strategies to protect the health of deployed US Forces: Medical surveillance, record keeping, and risk reduction. National Academy of Sciences Washington DC; 1998. 46. Organization WH. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies: WHO; 2010. 47. Pickton DW, Wright S. What's swot in strategic analysis? Strat Change. 1998;7(2):101-9. 48. Rosendal M, Hartman TCO, Aamland A, Van der Horst H, Lucassen P, Budtz-Lilly A, et al. “Medically unexplained” symptoms and symptom disorders in primary care: prognosis-based recognition and classification. BMC Fam Prac. 2017;18(1):18. 49. Smith RC, Dwamena FC. Classification and diagnosis of patients with medically unexplained symptoms. J Gen Intern Med. 2007;22(5):685-91. 50. Stone L. Managing medically unexplained illness in general practice. Aust Fam Physician. 2015;44(9):624. 51. Cooper A, Abbass A, Zed J, Bedford L, Sampalli T, Town J. Implementing a psychotherapy service for medically unexplained symptoms in a primary care setting. J Clin Med. 2017;6(12):109. 52. Banfield M, Gardner K, McRae I, Gillespie J, Wells R, Yen L. Unlocking information for coordination of care in Australia: a qualitative study of information continuity in four primary health care models. BMC Fam Prac. 2013;14(1):34. 53. McGrail MR, Humphreys JS. Spatial access disparities to primary health care in rural and remote Australia. Geospat Health. 2015. 54. Gonzales HM. Somatisation in primary care: A comparative study of Australians, Latin Americans, Vietnamese, and Polish living in Australia. Psychreg J Psych. 2018;2(1). 55. Meadows GN, Enticott JC, Inder B, Russell GM, Gurr R. Better access to mental health care and the failure of the Medicare principle of universality. Med J Aust. 2015;202(4):190-4. 56. Creed F, Henningsen P, Fink P. Medically unexplained symptoms, somatisation and bodily distress: developing better clinical services: Cambridge University Press; 2011. 57. Isaac ML, Paauw DS. Medically unexplained symptoms. Medical Clinics. 2014;98(3):663-72. 58. Bensing J, Verhaak P. Somatisation: a joint responsibility of doctor and patient. Lancet. 2006;367(9509):452-4. 59. Hudelson P. How do junior doctors working in a multicultural context make sense of somatisation? Swiss Med Wkly. 2005;135(3132). 60. Sutton K, Maybery D, Moore T. Creating a sustainable and effective mental health workforce for Gippsland, Victoria: solutions and directions for strategic planning. Rural Remote Health. 2011;11(1):1585. 61. Newton R, Beasley A, Bosanac P, Castle D, Copolov D, Hopwood M, et al. The challenges facing the public mental health sector: implications of the Victorian Psychiatry workforce project. Australas Psychiatry. 2019:1039856219852284.

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83. Reavley N. Is the Royal Commission into Victoria's Mental Health System an anti-stigma intervention? Aust N Z J Psychiatry. 2019;53(10):946-7. 84. Armytage P, Armytage DM. Submission to the Victorian Commission into Mental Health. 2019. 85. Henley L. COTA Victoria submission. 2019. 86. Brown JD. A description of ‘Australian Lyme disease’epidemiology and impact: an analysis of submissions to an Australian senate inquiry. Intern Med J. 2018;48(4):422-6. 87. Rosen G. A history of public health: JHU Press; 2015.

62. Roche M, Duffield C. Issues and challenges in the mental health workforce development. Contemp Nurse. 2007;25(1-2):94-103. 63. Considine J, Fielding K. Sustainable workforce reform: case study of Victorian nurse practitioner roles. Aust Health Rev. 2010;34(3):297-303. 64. Hedman E, Andersson E, Lindefors N, Andersson G, Rück C, Ljótsson B. Cost-effectiveness and long-term effectiveness of internet-based cognitive behaviour therapy for severe health anxiety. Psychol Med. 2013;43(2):363-74. 65. Kidd R. General practice: My health record-lessons from the opt-out trial. Aust Med. 2017;29(11):20. 66. Muhammad I, Wickramasinghe N, editors. Critical Issues in Implementing and Adopting National e-Health Solutions: Lessons from Australia’s MyHealth Record. Proceedings of the 51st Hawaii International Conference on System Sciences; 2018. 67. Kasteren YV, Maeder A, Williams PA, Damarell R, editors. Consumer perspectives on MyHealth Record: A review. Integrating and Connecting Care: Selected Papers from the 25th Australian National Health Informatics Conference (HIC 2017); 2017: IOS Press. 68. McBride KA, Sonego S, Ferdousi S, Page A. The Impact of My Health Record Use in Primary Care in the Western Sydney Primary Health Network Region: Qual Eval. 2018. 69. Gauld NJ, Kelly FS, Emmerton LM, Buetow SA. Widening consumer access to medicines: A comparison of prescription to non-prescription medicine switch in Australia and New Zealand. PLoS One. 2015;10(3):e0119011. 70. Singh B. Affordability of Medicines, Public Health and TRIPS Regime: A Comparative Analysis. Indian J Health Med Law. 2019;2(1):1-7. 71. Hall J. Australian health care—the challenge of reform in a fragmented system. NEJM. 2015;373(6):493-7. 72. Wilkin M. Cost shifting and the quality use of medicines. Aust Prescr. 2015;38(1):4. 73. Rosenberg SP, Hickie IB. Making activity-based funding work for mental health. Aust Health Rev. 2013;37(3):27780. 74. Booth M, Hill G, Moore MJ, Dalla D, Moore M, Messenger A. The new Australian Primary Health Networks: how will they integrate public health and primary care. Public Health Res Pract. 2016;26(1):e2611603. 75. Allison S, Bastiampillai T. Mental health services reach the tipping point in Australian acute hospitals. The Med J Aust. 2015;203(11):432-4. 76. Health Do. Fifth National Mental Health Plan. Department of Health, Australian Government Canberra, ACT, Australia; 2016. 77. Health Do, Services H. Victoria’s 10‐year mental health plan. State of Victoria. Melbourne; 2015. 78. Stirling Y, Higgins K, Petrakis M. Challenges in implementing individual placement and support in the Australian mental health service and policy context. Aust Health Rev. 2018;42(1):82-8. 79. Health AIo, Welfare. Mental health services in Australia. Canberra: AIHW; 2019. 80. Swerissen H, Duckett S, Wright J. Chronic failure in primary care: Grattan Institute Melbourne; 2016. 81. Hickie I. Time for structural reform in mental health: who is up for the challenge? Aust Health Rev. 2019;43(4):3612. 82. Daley J. Policy priorities for the returned Morrison government. Policy. 2019.

RESHAPING THE ROLE OF MEDICAL STUDENTS IN GLOBAL HEALTH Exploring Decolonised Humanitarianism in the Context of Rural Eswatini Ishka de Silva

graphic by Hyun Jae Nam

ealth is a recognised necessity, both as a human right and a crucial factor in the alleviation of poverty. [1] It has served as the basis for overseas interventions in various contexts, with its interpretation and subsequent consequences evolving through history. In the 19th and early 20th century, it contributed to the moral justification of colonialism. Imperialist activities were condoned through the provision of the supposedly superior Western lifestyle, sanitation, and medicine.[2] Following the liberation of colonised nations, developmental aid became a new avenue for the pursuit of neo-colonial agendas.[3] An increased awareness of the iatrogenic harm international volunteers often inflict has led to a paradigm shift in humanitarian medicine. The volunteer is no longer the omnipotent centre but should aim to support indigenous staff with cultural humility.

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This article explores the harms of previous models of global health, the movement towards decolonised humanitarianism, and reflections on the role of the medical student through a personal experience in rural Eswatini, formerly known as Swaziland. Previous models of voluntourism: The harms and unintended consequences The negative consequences of voluntourism as a commercial enterprise have become extensively recognised in both literature and legislation. A poignant example was when Australia became the first country to declare orphanage trafficking a form of modern-day slavery in 2018.[4] This is because it involves the use of children living in poverty to secure volunteer placements and donations from foreign tourists.[4] Medical overseas volunteering is not free of these abhorrent outcomes.[5] Foreign medical practitioners working in under-resourced countries can cause the undermining and hindrance of local health systems.[5] The lack of continuity of care can result in poor treatment outcomes and higher complication rates.[6] Western evidence-based medicine is less applicable when practiced in communities that differ vastly from the ones in which the guidelines were developed.[7] These can lead to inappropriate and incorrect diagnoses and treatments.[7] Health inequity is intrinsically linked to the social and economic factors that sustain poverty, and volunteers do little to address these. The assumption that well-meaning medical students can remedy the complex and structural factors of poverty and health in a week-long trip is unquestionably naĂŻve. We cannot perpetuate harmful consequences in the name of our learning and education. The desire for medical students to be involved in the health care of those in under resourced health systems should not be abandoned, but it does need to be drastically transformed.

(PDI) is an NGO which works with rural families in Eswatini, many of whom are in constant combat against endemic disease and pervasive poverty. PDI has an Australian and a Swazi team. The Australian team is purely supportive. It is the local team that drives the creation and implementation of projects, which primarily address the social determinants of health. As a member of the Australian team, I travelled to Eswatini with three other medical students in 2019. There is an increasing body of literature that advises on how to conduct ethical and sustainable medical volunteering; constantly emerging key factors include working within pre-existing local systems, pre-departure education, and the creation of long-term partnerships with local organisations.[5] Through intensive planning, education, and collaboration with the indigenous team, we aimed to be involved in a trip that was culturally appropriate and competent.

A new approach: Experience in Eswatini (formerly known as Swaziland) The highest prevalence of HIV/AIDs in the world is found in Eswatini. Almost a third of the country lives with the virus and over half live below the national poverty line.[8,9] Possible Dreams International

The Amandala Sewing Project became the primary focus of our trip. Communities refer families to PDI, and the team proceeds to evaluate their health, as well as any social and economic barriers. In one community where we conducted this field work, we found that it was continuously women who were

The following is quote from Thobela Sibusiso, a PDI leader, explaining this different approach. â&#x20AC;&#x153;We teach our volunteers on the PDI approach to help our communities. This is to empower and support our clients, rather than imposing ideas that will not work or have not been tested. Most of the time, the people in need have ideas on how they can improve their lives; with the proper guidance, they are able to make the most of their ideas. Other volunteers come into the country with ideas which are not known to the communities and, once they leave, all the projects are likely to collapse.â&#x20AC;?

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the sole income providers for their families. A lack of education, employment opportunities, and the injustice that accompanies their gender means that transactional sex is often the only available means of doing this. This income avenue poses several threats to the womenâ&#x20AC;&#x2122;s health and security, further perpetuating poverty and illness. We aimed to assist PDI in providing an alternative income source that was both empowering and sustainable. To ensure that we did not impose our own values or goals, we organised a community meeting between the relevant women and local female leaders. They discussed the kind of change they would like to make and began plans to form an enterprise. PDI found teachers for sewing and business skills with the intention of making uniforms for local groups. We worked with them to create a budget of $2000AUD and fundraised this money. Six months later, the Amandala Sewing Project brought ten women together, made school uniform deliveries to two schools, and is now seeking ways to expand their market. The medical student group gained an intricate understanding of the interplay between poverty and health and had a purely supportive role in the formation of the initiative.

et of life and, thus, we must continue doing everything we can to actualise it for all. As medical students, this can involve taking part in global health initiatives and volunteering our time. However, we must continue working to decolonise global health so that it places local communities at the centre and our desires and inevitable bias in the periphery. About the Author Ishka de Silva is a third-year student at Monash University. She is interested in many areas of public health, particularly the relationship between socioeconomic policy and health. Conflicts of Interest N/A Correspondence ides0002@student.monash.edu Acknowledgements We would like to thank Thobela Sibusiso for the quote he contributed to this piece. Images N/A

New challenges: Difficulties of the new approach Changes in the perspective and manner of overseas volunteering are on route towards minimising the harm that foreign intervenors cause, but this does present a new set of challenges. A significant challenge our team faced was fundraising. During our field work we identified a need for income generation projects and the construction of safe housing. Fundraising is most effective when individuals can donate to specific projects and individuals. For example, child sponsorship programs became popular due to the personal connection a donor can form. [10] However, this can create an enormous gap in time between the community need being identified and the program coming into effect. Projects can become stagnant whilst they wait for funds and communities can lose trust in the organisation. When there is a direct link between donations and particular programs, a cultural bias may be placed on the eventual spending of the funds. The paradigm of aid must shift away from donors assuming they know best and allow the funds to support the intentions of indigenous leaders who have a far better understanding.

References

1. International Conference on Primary Health Care. Declaration of Alma-Ata. Who Chron [Internet]. 1978 Nov [cited 2020 April 10];32(11):428-30. Available from https://www. who.int/publications/almaata_declaration_en.pdf?ua=1 2. Deb Roy R. The untold story of modern science is one of empire and colonial exploitation [Internet]. Quartz India; 2018 Apr [cited 2020 Apr 10]. Available from: https://qz.com/ india/1247577/the-untold-story-of-modern-science-is-oneof-empire-and-colonial-exploitation/ 3. Durokifa A. Neo-colonialism and Millennium Development Goals (MDGs) in Africa: A blend of an old wine in a new bottle. African J. Sci. Technol. Innov. Dev. [Internet]. 2018 May [cited 2020 Apr 14];10(3):355-66. Available from: https:// www.tandfonline.com/doi/full/10.1080/20421338.2018.146 3654 DOI https://doi.org/10.1080/20421338.2018.1463654 4. Australian Modern Slavery Act 2018 (Aus) s 50. 5. Bauer I. More harm than good? The questionable ethics of medical volunteering and international student placements. Tropical Diseases, Travel Medicine and Vaccines [Internet]. 2017 [cited 2020 April 14];3(5). Available from: https://search-proquest-com.ezproxy.lib.monash.edu.au/ docview/1937520311?accountid=12528&rfr_id=info%3Axri%2Fsid%3Aprimo 6. Sullivan H. Voluntourism. AMA J. ethics [Internet]. 2019 Sep [cited 2020 April 22];21(9):E815-22. Available from: https://journalofethics.ama-assn.org/sites/journalofethics. ama-assn.org/files/2019-08/pnar1-1909_3.pdf 7. Crowther H, Lipworth W, Kerridge I. Evidence-based medicine and epistemological imperialism: narrowing the divide between evidence and illness. J. Eval. Clin. Pract [Inter-

Conclusion The human right to health is essential for every fac78

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net]. 2011 Aug [cited 2020 April 10];17(5):868-72. Available from: https://onlinelibrary-wiley-com.ezproxy.lib.monash. edu.au/doi/full/10.1111/j.1365-2753.2011.01723.x DOI: https://doi-org.ezproxy.lib.monash.edu.au/10.1111/j.13652753.2011.01723.x 8. UN Aids. Country- Eswatini [Internet]. 2018 [cited 2020 April 18]. Available from: https://www.unaids.org/en/ regionscountries/countries/swaziland 9. World Food Programme. Eswatini [Internet]. 2019 Sep [cited 2020 April 19]. Available from: https://www.wfp. org/countries/eswatini 10. Rutledge L, Glewwe P, Wydick B. Does Child Sponsorship Pay Off In Adulthood? An International study of Impacts on Income and Wealth. World Bank Econ Rev [Internet]. 2016 Feb [cited 2020 April 21];31(2):434-58. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6010066/ DOI: 10.1093/wber/lhv081

CAN INTERNET SEARCHES PREDICT AN OUTBREAK? A Literature Review on Nowcasting with Google Trends Daniel Bil Abstract Aim: The aim of this literature review is to provide an introductory overview of the use of Google Trends for public health surveillance, its strengths and limitations, and areas for further research. Methods: A literature search was conducted through PubMed to identify publications which used Google Trends data (GTD) or an existing GTD model as a source to investigate an infectious disease. Results: Google Trends has been used to model the incidence of a range of diseases, including influenza, dengue fever, HIV, pertussis, and malaria, with varying degrees of accuracy. Models frequently correlate with reported case data at a negative time lag, providing warnings of outbreaks earlier than traditional systems. Case data can be incorporated into models for greater accuracy. News/media bias, a small population size, and various sociodemographic factors are recurring themes noted to reduce accuracy.

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Discussion: With the potential to monitor disease incidence in real time and improve existing modelling solutions, Google Trends represents an exciting new frontier for epidemiology and public health. However, these tools should be positioned as an adjunct to traditional public health surveillance rather than a replacement. More real-world testing in diverse cultural settings is necessary to better understand its strengths and limitations across the digital divide.

graphic by Hyun Jae Nam

Introduction Since the turn of the century, the Internet has become an increasingly popular way for people to access health information. Search engines, particularly Google, have become a popular choice for many wanting to explore their symptoms and diagnoses due to its accessibility, familiarity, and ease of use. In the past few years, discussion and novel research have arisen on whether data from Internet search queries that are potentially related to a disease could be correlated with real cases. If so, these correlations could be developed into accurate predictive models, unlocking a suite of public health surveillance tools for nowcasting the incidence of a disease in real time. This emerging field has been termed ‘digital epidemiology’.[1]

sample data from the 2007-08 US influenza season with highly correlated (ρ=0.97) results. The subsequent launch of Google Flu Trends (GFT) and Google Dengue Trends, built from a similar methodology,[4] catalysed a surge of academic interest in the new field. However, in 2009 and 2013, GFT suffered setbacks related to erroneous predictions and support for the service ended in 2015. [5] Despite this, its impact on digital epidemiology remains relevant, and the academic interest it has sparked continues to persist. Aim The aim of this literature review is to provide an introductory overview of the use of Google Trends for public health surveillance, its strengths and limitations, and areas for further research.

Google Trends Google Trends (GT) is a freely available online tool developed by Google LLC which allows users to input search queries and retrieve data on their relative search volume (RSV) through the Google search engine over a given period. Searches can be filtered by location and visualised on a line chart and heat map. RSV is reported as a number from 0-100, with 0 representing no searches and 100 representing the peak search volume within the timeframe. Data can then be exported and analysed further with external software.[2]

Method A literature search was conducted in PubMed for the terms “internet”, “search”, and “trend(s) OR query/queries” in the title and/or abstract. Relevant articles were identified based on their title and abstract, as well as appraised based on their method and findings. Articles were excluded if they did not use Google Trends data (GTD) or an existing GTD model (such as Google Flu Trends or Google Dengue Trends) as a source to investigate an infectious disease.

In 2009, Ginsberg et al [3] used search query data from Google Trends to develop a real-time influenza surveillance tool, representing the first major contribution in the field. The model used a selection of 45 weighted search term RSVs to estimate the number of US physician visits for influenza-like illness (ILI) in a given week, as a proportion of all physician visits. The model was fit using historical data from 2003 to 2007 and tested against out-of-

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Results The literature can be divided into two broad categories: correlation studies and modelling studies. Correlation studies can identify relationships between GTD and case data, but do not allow for real-time estimates or predictions to be made. Table 1 lists a selection of significant correlation studies providing contributions to the field.

Table 1: GTD correlation studies. 81

Table 2: GTD modelling studies. et al [13] showed how their model could forecast, 5 weeks in advance, the peak of the 2012 scarlet fever resurgence in the UK. Verma et al [10] showed that the strongest correlations between GTD and chikungunya, dengue fever, malaria, and typhoid fever in India were present at a -2 to -3 week lag. McGough et al [18] showed how GTD models could more accurately predict the spread of the Zika virus than case data models 2-3 weeks into the future. Santangelo et al [11] showed the correlation between measles-related searches and infections in Italy was strongest at a lag of -3 weeks (ρ>0.80).

In contrast, modelling studies attempt to describe the relationship between GTD and disease incidence, allowing for real-time nowcasting using outof-sample data. Table 2 lists a selection of nowcasting studies identified in this review. Another subset of studies explore applications of existing GTD models in new settings, namely Google Flu Trends [24-27] and Google Dengue Trends. [28-30]

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The main measures of correlation strength used in the literature were Pearson’s correlation coefficient (r), Spearman’s rank correlation coefficient (ρ), and coefficient of determination (R2). For ease of comparison, R2 values have been converted to r by taking its square root. Studies typically analysed data at a daily or weekly level, reflecting the temporal resolution provided by Google Trends.

In addition, multiple studies have found that nowcasting models built from both GTD and historic data may attain greater accuracy. Pries and Moat [15] found that nowcasts of influenza levels based on GTD and case data had a mean absolute error 16.0%-52.7% lower than models based on case data alone. Gluskin et al [28] found that accounting for climate factors (maximum temperature and precipitation) alongside Google Dengue Trends data improved accuracy compared to search data alone (r=0.90 and r=0.82, respectively). However, McGough et al [18] identified the possibility that GTD alone may outperform GTD coupled with case data if the case data is flawed.

Strengths GTD models frequently correlate with reported case data with a negative time lag, indicating changes in search volumes may take place earlier than corresponding changes in reported cases. Ginsberg et al [3] hypothesised this could be due to the time required by traditional surveillance systems to compile notification data, delaying their publication.

Limitations News and media bias are a recurring theme throughout the literature. A celebrity diagnosis, drug recall, public health campaign, or other event resulting in unusually high media coverage can increase the volume of search queries from those who are not ill. Google Flu Trends famously overestimated the peak

This suggests GTD models could provide an n-period ahead forecast for changing incidence patterns relative to traditional systems, providing warnings of outbreaks days to weeks in advance. Samaras 82

of the 2013 US flu season by almost double that reported by the CDC, which was believed to have been caused by unusually widespread media coverage. [5] This is mirrored by experiences during the 2014 Ebola epidemic, where GTD in the three countries showed moderate (r=0.640 in Liberia, p<0.001) to insignificant (r=0.232 in Guinea, p=0.07) correlation with case data, with search volumes disproportionately influenced by news coverage locally and overseas.[7] Ho et al [29] noted an increase in the volume of certain dengue-related searches when Michael V, a well-known Filipino celebrity, was diagnosed with the disease in 2013.

infrastructure is lacking or absent. However, much of the existing data in this field is exploratory in nature. More testing against out-ofsample data and trialling GTD models in real-world scenarios is necessary to improve our understanding of digital epidemiology and its capabilities. Areas for further investigation It would seem GTD models are best suited to diseases with a high baseline incidence relative to their news/media coverage. Sociodemographic and population factors, such as size, internet penetration, average age, average education attainment, and information-seeking behaviours all also appear to impact their performance. This may help to explain why certain use-cases, such as influenza and HIV in the United States,[3,21] have been more promising than others, such as Ebola in West Africa or plague in Madagascar.[7,12] Further research into this aspect of digital epidemiology is warranted.

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The degree to which regional incidence can be resolved is also a limitation to the usefulness of GT data. Gluskin et al [28] found that, although Google Dengue Trends showed strong correlation with official data in Mexico at the national level, its reliability varied enormously from state to state (r=0.010.94), with states with low incidence performing worse. Similarly, Strauss et al [30] found the tool performed well as an average over the entire period studied (r=0.87), but its performance suffered during non-epidemic weeks (r=0.65) and the low-incidence seasonal trough in March (r=0.48). Zhang et al [16] also noted significant variation at the state/ territory level in Australia (Ď =0.17-0.76) when analysing correlations in pertussis incidence. Arehart et al [23] found while their US pertussis model correlated significantly with case data at a national level, their state models could not track case data in some states. Ginsberg et al [3] found that their national-level influenza model was less accurate, though still strongly correlated, when applied to an individual state, Utah (Ď >0.90).

GTD models also appear to be highly context sensitive, given their variability in performance between countries, states, and even the same population over time. For the most accurate results, models will likely need to be regularly recalibrated to best fit the underlying populationâ&#x20AC;&#x2122;s search behaviour. For this reason, further investigation into the use of GTD in culturally diverse settings, particularly in poorer and non-Western nations, is necessary to bridge the digital divide. Issues within the literature Given the large proportion of positive findings and the novelty of this area, the possibility of publication bias should be entertained, especially as analyses with GT are generally fast and easy to conduct. Moreover, GTD models can only be as accurate as the surveillance data on which they are trained and measured, and it is logical that any biases present in these data will be reflected in GTD models. Given this interdependency, Internet-based tools are positioned as a possible adjunct to traditional surveillance tools, rather than a replacement.

Sociodemographic factors such as age, birth rate, and education attainment have been noted to generally impact correlation strength, however these findings appear to be less consistent.[16,23,28] Conversely, Gluskin et al [28] found socioeconomic factors including Internet access did not strongly impact the accuracy of Google Dengue Trends. Discussion The potential for Google Trends and other online sources to identify and predict infectious disease outbreaks presents an exciting new frontier for epidemiology. The list of use-cases is vast, from providing earlier responses to outbreaks, to adequate staffing of clinics and emergency departments, and improving the quality of official surveillance where

Several studies lacked thorough documentation or justification of their methodology, such as the search terms used or location(s)/time period queried, making it difficult to draw meaningful comparisons.[31] This points to a need for the adoption of a consistent methodology for conducting research 83

into digital epidemiology, such as those proposed by Nuti et al [31] and Mavragani & Ochoa [32]. This would be a significant step forward in improving results’ validity and replicability.

Comput Biol. 2012;8(7):e1002616. doi:10.1371/journal. pcbi.1002616 2. Google Trends [Internet]. Mountain View, CA: Google LLC; 2006 [updated 2020, cited 2020 May 03]. Available from: trends.google.com 3. Ginsberg J, Mohebbi MH, Patel RS, Brammer L, Smolinski MS, Brilliant L. Detecting influenza epidemics using search engine query data. Nature. 2009 Feb;457(7232):10124. doi:10.1038/nature07634 4. Copeland P, Romano R, Zhang T, Hecht G, Zigmond D, Stefansen C. Google Disease Trends: An Update. 2013. Available from: https://research.google/pubs/pub41763/ 5. Butler D. When Google got flu wrong. Nature. 2013 Feb 14;494(7436):115-6. 6. Cho S, Sohn CH, Jo MW, Shin SY, Lee JH, Ryoo SM, et al. Correlation between national influenza surveillance data and google trends in South Korea. PLoS One. 2013;8(12):e81422. doi:10.1371/journal.pone.0081422 7. Alicino C, Bragazzi NL, Faccio V, Amicizia D, Panatto D, Gasparini R, et al. Assessing Ebola-related web search behaviour: insights and implications from an analytical study of Google Trends-based query volumes. Infect Dis Poverty. 2015 Dec 10;4:54. doi:10.1186/s40249-015-0090-9 8. Domnich A, Panatto D, Signori A, Lai PL, Gasparini R, Amicizia D. Age-related differences in the accuracy of web query-based predictions of influenza-like illness. PLoS One. 2015 May 26;10(5):e0127754. doi:10.1371/journal.pone.0127754 9. Shah MP, Lopman BA, Tate JE, Harris J, Esparza-Aguilar M, Sanchez-Uribe E, et al. Use of Internet Search Data to Monitor Rotavirus Vaccine Impact in the United States, United Kingdom, and Mexico. J Pediatric Infect Dis Soc. 2018;7(1):56‐63. doi:10.1093/jpids/pix004 10. Verma M, Kishore K, Kumar M, Sondh AR, Aggarwal G, Kathirvel S. Google Search Trends Predicting Disease Outbreaks: An Analysis from India. Healthc Inform Res. 2018 Oct;24(4):300-308. doi:10.4258/hir.2018.24.4.300 11. Santangelo OE, Provenzano S, Piazza D, Giordano D, Calmusa G, Firenze A. Digital epidemiology; assessment of measles infection through Google Trends mechanism in Italy. Ann Ig. 2019;31:385-91. doi:10.7416/ai.2019.2300 12. Bragazzi NL, Mahroum N. Google Trends Predicts Present and Future Plague Cases During the Plague Outbreak in Madagascar: Infodemiological Study. JMIR Public Health Surveill. 2019 Mar 8;5(1):e13142. doi:10.2196/13142 13. Samaras L, García-Barriocanal E, Sicilia Miguel-Angel. Syndromic surveillance models using Web data: The case of scarlet fever in the UK. Informatics for Health and Social Care. 2012 Mar;37(2):106-24. doi:10.3109/17538157.2011.647934 14. Ocampo AJ, Chunara R, Brownstein JS. Using search queries for malaria surveillance, Thailand. Malar J. 2013 Nov 4;12:390. doi:10.1186/1475-2875-12-390 15. Preis T, Moat HS. Adaptive nowcasting of influenza outbreaks using Google searches. R Soc Open Sci. 2014 Oct 29;1(2):140095. doi:10.1098/rsos.140095 16. Zhang Y, Milinovich G, Xu Z, Bambrick H, Mengersen K, Tong S, et al. Monitoring Pertussis Infections Using Internet Search Queries. Sci Rep. 2017 Sep 5;7(1):10437. doi:10.1038/ s41598-017-11195-z 17. Kandula S, Hsu D, Shaman J. Subregional Nowcasts of Seasonal Influenza Using Search Trends. J Med Internet Res. 2017;19(11):e370. doi:10.2196/jmir.7486 18. McGough SF, Brownstein JS, Hawkins JB, Santillana M. Forecasting Zika Incidence in the 2016 Latin America Outbreak Combining Traditional Disease Surveillance with Search, Social

Conclusion Google Trends is a fascinating tool w hich could dramatically evolve public health surveillance. The next step for this field i s to move away from exploratory data and into more rigorous testing and real-world application, p articularly in diverse cultural settings across the digital divide. These tools should be positioned a s a n a djunct to traditional surveillance rather than a replacement and should be recalibrated regularly to match the underlying population a nd t heir c hanging search behaviours. More research is needed into methods to correct for the impact of news/media and to adopt a consistent methodological framework for digital epidemiology. Google and Google Trends are also not the only online sources which have potential epidemiological applications. Twitter, Baidu, and online blogs are just examples of data sources which have also been explored in academic literature and represent further potential growth for the field of digital epidemiology. About the Author Daniel Bil is a Doctor of Medicine student at Monash University, and Brand/IT Officer for AMSA Global Health in 2020. He is passionate about the use of technology and communications to improve public health in the digital age. Conflicts of Interest N/A

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Correspondence dbil0002@student.monash.edu Acknowledgements I wish to thank Marisse Sonido, Senior Editor at AJGH, for her invaluable guidance and support. I also thank the peer reviewer, Hyun Jae Nam, Tahlia Harper, and Cees Bil for their helpful insights. Images N/A References

1. Salathé M, Bengtsson L, Bodnar TJ, Brewer DD, Brownstein JS, Buckee C, et al. Digital epidemiology. PLoS

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Media, and News Report Data. PLoS Negl Trop Dis. 2017 Jan 13;11(1):e0005295. doi:10.1371/journal.pntd.0005295 19. Samaras L, García-Barriocanal E, Sicilia MA. Syndromic Surveillance Models Using Web Data: The Case of Influenza in Greece and Italy Using Google Trends. JMIR Public Health Surveill. 2017 Nov 20;3(4):e90. doi:10.2196/publichealth.8015 20. Young SD, Torrone EA, Urata J, Aral SO. Using Search Engine Data as a Tool to Predict Syphilis. Epidemiology. 2018 Jul;29(4):574-578. doi:10.1097/EDE.0000000000000836 21. Young SD, Zhang Q. Using search engine big data for predicting new HIV diagnoses. PLoS One. 2018 Jul 12;13(7):e0199527. doi:10.1371/journal.pone.0199527 22. Oren E, Frere J, Yom-Tov E, Yom-Tov E. Respiratory syncytial virus tracking using internet search engine data. BMC Public Health. 2018 Apr 3;18(1):445. doi:10.1186/ s12889-018-5367-z 23. Arehart CH, David MZ, Dukic V. Tracking U.S. Pertussis Incidence: Correlation of Public Health Surveillance and Google Search Data Varies by State. Sci Rep. 2019 Dec 24;9(1):19801. doi:10.1038/s41598-019-56385-z 24. Malik MT, Gumel A, Thompson LH, Strome T, Mahmud SM. “Google flu trends” and emergency department triage data predicted the 2009 pandemic H1N1 waves in Manitoba. Can J Public Health. 2011 Jul-Aug;102(4):294-7.doi: 10.1007/bf03404053 25. Olson DR, Konty KJ, Paladini M, Viboud C, Simonsen L. Reassessing Google Flu Trends data for detection of seasonal and pandemic influenza: a comparative epidemiological study at three geographic scales. PLoS Comput Biol. 2013;9(10):e1003256. doi:10.1371/journal.pcbi.1003256 26. Cook S, Conrad C, Fowlkes AL, Mohebbi MH. Assessing Google flu trends performance in the United States during the 2009 influenza virus A (H1N1) pandemic. PLoS One. 2011;6(8):e23610. doi:10.1371/journal.pone.0023610 27. Dugas AF, Hsieh YH, Levin SR, Pines JM, Mareiniss DP, Mohareb A, et al. Google Flu Trends: correlation with emergency department influenza rates and crowding metrics. Clin Infect Dis. 2012;54(4):463‐469. doi:10.1093/cid/cir883 28. Gluskin RT, Johansson MA, Santillana M, Brownstein JS. Evaluation of Internet-based dengue query data: Google Dengue Trends. PLoS Negl Trop Dis. 2014 Feb 27;8(2):e2713. doi:10.1371/journal.pntd.0002713 29. Ho HT, Carvajal TM, Bautista JR, Capistrano JDR, Viacrusis KM, Hernandez LFT, et al. Using Google Trends to Examine the Spatio-Temporal Incidence and Behavioral Patterns of Dengue Disease: A Case Study in Metropolitan Manila, Philippines. Trop Med Infect Dis. 2018 Nov 11;3(4):118. doi:10.3390/tropicalmed3040118 30. Strauss RA, Castro JS, Reintjes R, Torres JR. Google dengue trends: An indicator of epidemic behaviour. The Venezuelan Case. Int J Med Inform. 2017 Aug;104:26-30. doi:10.1016/j.ijmedinf.2017.05.003 31. Nuti SV, Wayda B, Ranasinghe I, Wang S, Dreyer RP, Chen SI, et al. The use of google trends in health care research: a systematic review. PLoS One. 2014 Oct 22;9(10):e109583. doi:10.1371/journal.pone.0109583 32. Mavragani A, Ochoa G. Google Trends in Infodemiology and Infoveillance: Methodology Framework. JMIR Public Health Surveill. 2019 May 29;5(2):e13439. doi:10.2196/13439

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EATING PLANTS FOR THE PLANET The EAT-Lancet Planetary Health Diet Explained Wynona Chin and Jacqueline Bredhauer

limate change, regardless of its cause, is an undeniable reality that has been accompanied by a rapidly increasing global human population.[1] In order to feed a projected 10 billion people in 2050, whilst improving the Earth’s environment, radical shifts will need to be made in our food systems.[2] Food systems have the potential to nurture human health and planetary health, but currently, they threaten both. The EAT-Lancet ‘Planetary Health Diet’ offers an opportunity to utilise food as a lever for improving the health of ourselves and our planet. The ‘Why’ Globally, traditional diets have transitioned to a high-calorie and unhealthy Western-style dietary pattern.[2] What was previously high in quality plant-based foods has become a calorically dense diet, high in animal products and characterised by refined carbohydrates, added sugars, sodium, and unhealthy fats.[3] Just as there are negative health impacts of such dietary patterns, environmentally they also pose great risks. The current food production needed to support these dietary patterns are further driving climate change and pollution, exacerbating biodiversity loss and causing strain on water and land resources.[2] As such, there are a multitude of reasons why a systemic global food transformation is needed.

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Health From a health perspective, food is contributing to the double burden of malnutrition: over- and under-nutrition.[4] With increased shifts towards unhealthy diets, driven by rapid urbanisation and increasing incomes, there is a growing global epidemic of obesity and non-communicable disease. [2] Currently, 2.1 billion adults worldwide are overweight or obese,[5] and the global prevalence of diabetes, an example of a diet-related disease, has doubled over the past 30 years.[6, 7] Despite greater availability of food, there may still be inadequate access to nutritious foods.[2] Modern, urban high-calorie diets can be low in quality and, consequently undernutrition and micronutrient deficien87

cies persist alongside an increasing prevalence of diet-related chronic disease.[8] Globally, 820 million people remain undernourished,[9] and 2 billion people are micronutrient deficient.[10] As a result, unhealthy diets pose a greater risk to morbidity and mortality than unsafe sex, alcohol, tobacco, and drug use combined.[11] While overnutrition and obesity increase, and undernutrition and malnutrition persist, current global food systems are failing in their role of promoting and maintaining human health.[2] Sustainability Similar to the role of food in human health, modern dietary trends are degrading the environment despite the potential for food production to enhance environmental wellbeing.[2] Food production plays a critical role in planetary health as it is the leading driver of global environmental change for a variety of reasons.[2] Currently, agriculture occupies 40% of land worldwide,[12] and food production is responsible for up to 30% of global greenhouse-gas emissions,[13] and 70% of freshwater use.[14] Left unchecked, the diversion of water to agriculture can cause aquatic habitat loss, land erosion, and the salinisation of soil.[15] The conversion of natural ecosystems to croplands and pastures, is the largest factor causing species to be threatened with extinction;[16] and a majority of this is then used to grow crops that will eventually serve as animal feed.[15] The overuse and misuse of nitrogen and phosphorus in food production causes the eutrophication (excess algal growth), and the creation of dead zones in lakes and coastal zones [17]. It also causes chemical pollution of ecosystems that then lead to severe health consequences.[18] Marine systems are further threatened by overfishing [19] and the rapidly expanding aquaculture sector.[20] The interaction between the environment, food production, and health is complex and interdependent, but highlights an opportunity for impactful change. Food security With 820 million people undernourished globally,

food security is an existing issue.[9] We are threatened with further food shortages as the global population increases to 10 billion people by 2050, and environmental systems are being pushed beyond safe boundaries to sustain large-scale food production.[2] Food waste is a contributing factor, with an estimated one-third of food being lost or wasted. If food waste were a country, it would rank third after China and the US as the third largest producer of greenhouse gases in the world.[21] Food systems that are resilient to shocks, would: produce low food waste, rely on sustainable food production, and provide food predominantly from primary (plant) rather than secondary (animal) sources.[2] Topically, COVID-19 also has the potential to threaten global food security, meaning there is both opportunity and necessity to pursue changes outlined in the Eat-Lancet report now.[18] Figure 1: The ‘Planetary Health Plate’ [21]

The ‘How’ An Overview of the Planetary Health Diet

plants.[2] This is primarily due to a two-step process of needing to grow large amounts of mono-crop to feed livestock.[2] Placing a larger emphasis on plantbased proteins such as legumes, nuts, and soy simplifies this process as such crops can be grown and harvested for direct human consumption.[2] Other important food system-changes are improved food production practices, and reduced food loss and waste.[1] The individual consumer can contribute to such measures by buying local and sustainably produced food, and by taking steps to reduce household food waste.

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The Eat-Lancet report presents a readily accessible solution to the current impacts of food on human and planetary health: a global shift towards the Planetary Health Diet. The Planetary Health Diet is a healthy reference diet developed according to a comprehensive review of the nutrition literature.[2] It places an emphasis on flexibility, with the intention of being adaptable to a broad range of cultural contexts. Its recommendations promote a low risk of major chronic disease and overall well-being through incorporating: protein sources primarily from plants, soy foods, legumes, nuts, fish, alternative sources of omega-3 several times per week; fat mostly from unsaturated plant sources; carbohydrates primarily from wholegrains; and at least 5 servings per day of a wide and diverse array of fruits and vegetables (not including potatoes). Additionally, it recommends limiting the consumption of saturated fat, refined grains, sugar and red meat, while avoiding the consumption of partly hydrogenated oils and processed red meat. The moderate consumption of animal products such as dairy, poultry and eggs are also an option.

Enacting the change There are a few individual changes that individual consumers can make to align diets with the recommendations set out in the Eat-Lancet report. The first is increasing and diversifying fruit and vegetable intake, so as to consume at least five servings per day. Some starting points for this, include: using fruit and vegetables as snacks; finding ways to incorporate fruit and vegetables into cooking and baking, for example, using mashed banana in muffins, sweet potato in brownies or making zucchini ‘noodles’; aiming to make meals as colourful as possible; and endeavouring to try a new, seasonal fruit or vegetable each week.

Shifting to the Planetary Health Diet is one of three readily implementable food system changes that can be pursued to lessen the impact of food on the environment.[2] The production of animal products has a higher impact on green-house gas emissions, land-use and biodiversity loss than the production of

A second major change is reducing the consumption of animal products. The simplest approach to this is trialling some easy swaps, such as lentils instead of 88

minced meat; chickpeas instead of chicken; tofu scramble instead of scrambled eggs; fortified almond and soy milks instead of cow’s milk; or blended cashew cream in place of cheese. A reduction of meat can involve including meat in most meals but in smaller quantities or consuming primarily vegetarian meals with a few meat-based meals throughout the week. Ultimately, meals should be planned around vegetables, legumes, wholegrains, nuts and seeds. Whilst exclusive vegans should ensure to take a B12 supplement and consider seeking the advice of a dietician, a ‘flexitarian’ approach does not require supplementation.

the other national coordinator of AMSA Healthy Communities. She is passionate about preventative medicine and the creation of social structures that foster healthy living. Acknowledgements N/A Conflicts of Interest N/A Correspondence jacqueline.bredhauer@amsa.org.au wynona.chin@amsa.org.au

Other changes that can be made to lower the environmental footprint of our food consumption include shopping locally, eating seasonally, and reducing personal food waste. The following strategies can target food waste: shopping according to a weekly menu and buying ingredients in specific amounts, storing vegetables well and using them as early as possible to avoid spoilage; freezing excess food; composting food waste; and reconsidering uses for food that is usually thrown out – for example, vegetable scraps and skins can be used to make stock, old bread can be toasted to make breadcrumbs and croutons, old fruit can be blended into smoothies or used in baked goods.

Image Eat. Healthy diets from sustainable food systems: Food Planet Health [Internet]. Stockholm, Sweden: Eat; 2019 [cited 2020 May 15]. Available from: https://eatforum.org/content/uploads/2019/07/ EAT-Lancet_Commission_Summary_Report.pdf References

1. IPCC. Global warming of 1·5°C. An IPCC Special Report on the impacts of global warming of 1·5°C above pre-industrial levels and related global greenhouse gas emission pathways, in the context of strengthening the global response to the threat of climate change. [Internet]. Geneva, Switzerland: World Meteorological Association; 2018 [cited 2020 May 15]. Available from: https://www.ipcc.ch/sr15/ 2. Willett W, Rockström J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. The Lancet. 2019 Feb 2;393(10170):447–92. 3. Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr Rev. 2012;70(1):3-21. 4. Wells JC, Sawaya AL, Wibaek R, Mwangome M, Poullas MS, Yajnik CS, et al. The double burden of malnutrition: aetiological pathways and consequences for health. The Lancet. 2020;395(10217):75-88. 5. WHO | Overweight and obesity [Internet]. WHO. World Health Organization; [cited 2020 Apr 19]. Available from: http://www.who.int/gho/ncd/risk_factors/overweight/en/ 6. WHO. Global report on diabetes. Geneva: World Health Organization, 2016. 7. Zhou B, Lu Y, Hajifathalian K, et al. Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4·4 million participants. Lancet 2016; 387: 1513–30. 8. Troesch B, Weber P, Eggersdorfer M, Biesalski HK, Bos R, Buskens E, et al. Increased Intake of Foods with High Nutrient Density Can Help to Break the Intergenerational Cycle of Malnutrition and Obesity. Nutrients. 2015;7(7):601637 9. Food and Agriculture Organization of the UN, International Fund for Agricultural Development, UNICEF, World Food Programme, WHO. The state of food security and nutri-

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Conclusion The authors of the Eat-Lancet report describe food as being the “single strongest lever to optimize human health and environmental sustainability on Earth”.[2] Shifting to the Planetary Health Diet, alongside transitioning to sustainable food production and reducing food loss and waste, is one readily accessible change that can be made on a global scale to improve the current impacts of food systems on human and planetary health.[2] All this requires is a little time, energy, and creativity in the kitchen. About the Authors Jacqueline Bredhauer is a Doctor of Medicine student at Monash University and one of the national coordinators of AMSA Healthy Communities. She is passionate about public health, lifestyle medicine and social equity. She is looking forward to a career of addressing whole-person and population health as a rural GP. Wynona Chin is a Bachelor of Medicine Bachelor of Surgery student at the University of Tasmania and 89

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tion in the world. Rome: Food and Agriculture Organization of the UN, 2018. 10. WHO, Food and Agriculture Organization of the UN. Guidelines on food fortification with micronutrients. Geneva: WHO, 2009. 11. Global Panel on Agriculture and Food Systems for Nutrition. Food systems and diets: facing the challenges of the 21st century. London: Global Panel, 2016. 12. Foley JA, Defries R, Asner GP, et al. Global consequences of land use. Science 2005; 309: 570–74. 13. Vermeulen SJ, Campbell BM, Ingram JSI. Climate change and food systems. Annu Rev Environ Resour 2012; 37: 195–222. 14. Comprehensive Assessment of Water Management in Agriculture. Water for food, water for life: a comprehensive assessment of water management in agriculture. London: Earthscan and Colombo: International Water Management Institute, 2007. 15. The Lancet Planetary Health. More than a diet. The Lancet Planetary Health. 2018 Feb 1; 3(2): e48 16. Tilman D, Clark M, Williams DR, Kimmel K, Polasky S, Packer C. Future threats to biodiversity and pathways to their prevention. Nature 2017; 546: 73–81. 17. Diaz RJ, Rosenberg R. Spreading dead zones and consequences for marine ecosystems. Science 2008; 321: 926– 29. 18. Lindgren E, Harris F, Dangour AD, et. al. Sustainable food systems—a health perspective. Sustainability Science. 2018 Jun 12; 13: 1505–1517 19. Food and Agriculture Organization of the UN. The state of world fisheries and aquaculture 2016. Contributing to food security and nutrition for all. Rome: Food and Agriculture Organization of the UN, 2016. 20. Klinger D, Naylor R. Searching for solutions in aquaculture: charting a sustainable course. Annu Rev Environ Resour 2012; 37: 247–76. 21. Food and Agriculture Organization of the UN. Food wastage footprint & Climate Change. Rome: Food and Agriculture Organization of the UN, 2011.

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HTTP://AJGH.AMSA.ORG.AU/INDEX.PHP/AJGH/ABOUT/SUBMISSIONS AJGH IS A STUDENT-RUN, PEER-REVIEWED GLOBAL HEALTH JOURNAL. EACH ISSUE CONTAINS ARTICLES ON VARIOUS TOPICS OF GLOBAL HEALTH IMPORTANCE, INCLUDING COMMUNICABLE AND NON-COMMUNICABLE DISEASES, REFUGEE HEALTH, CLIMATE HEALTH, SEXUAL AND REPRODUCTIVE HEALTH, GLOBAL SURGERY, CHILD HEALTH, HUMANITARIAN CRISES, AND HUMAN RIGHTS. 91

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