Conference Book
AMSA Global Health Conference 2008
Conference Book
Disclaimer: Apart from any fair dealing for the purpose of research or study, criticism or review, as permitted under the Copyright Act 1968, no part of this book may be reproduced without written permission from the author. Please direct enquiries to the Conference Convenors. The statements or opinions that are expressed in this book reflect the views of the contributing authors and do not necessarily represent the views of the editor or of AMSA. Every care has been taken to reproduce articles as accurately as possible, but AMSA accepts no responsibility for errors, omissions or inaccuracies contained therein or for the consequences of any action taken by any persons as a result of anything contained in this publication. AMSA or the AMSA Global Health Conference 2008 organisers cannot attest to the accuracy of the information contained within this book. In the interest of furthering medical students’ understanding of international health issues, we invite debate and discussion of any information contained within this book. Effort has been made to obtain permission from copyright owners for use of copyright material. We apologise for any omissions or oversight and invite copyright owners to draw our attention to them, so that we may give appropriate acknowledgement in subsequent editions or reprints.
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Contents Section 2: Issues and Ideas
95-99
56-59
The need for leadership in global health
Earned or mediated sovereignty? An assessment 60-61
My People Are Dying 62-65
Section 1: About the Conference 5
Introduction to the Conference 6
Welcome from the Conference Convenors 7
Welcome from the AMSA President 8
Letter of Endorsement 9-11
Conference initiatives 13-31
Academic Program 34-39
Social Program 40-41
A guide to the campus 42
University of Melbourne Medical Students’ Society 46-48
Melbourne 50-51
Colleges 54
Partnerships
Indigenous by definition, experience or worldview 66-67
Australian Indigenous Health: the gap 68-71
Behind the World Food and Nutrition Crisis: A Long History of Pushing Nature to Its Limits 72-73
Global environment change and health: impacts, inequalities and the health sector 78-79
A global reflection 80-82
Diabetes and the Coca-Cola Era in Kenya 83-85
Aid: A Crash Course 86-87
The Coffee Crisis and Fair Trade Coffee 90-92
Access to Essential Medicines 93-94
Microfinance: Does it really work, or is it just a fashionable word?
100-103
The Face of Equitable Access: Going beyond health to life for all 104-108
World Market Factories: Perspectives on industrialisation and the female labour force 109-114
Impact of displacement and natural disasters on reproductive health: a review of the literature 115-116
Taking a Human Rights Approach to Health - A foundation for improved freedom, justice and peace? Section 3: Getting involved 119-121
AMSA
122-134
GHN and GHGs 135-136
IFMSA
137-145
GHG Projects 146-166
Global Health Experiences 167-168
Global Health Events 172-173
Global Health Conference Organising Committee ‘08
3.
Section 1: About the Conference
Introduction to the Conference “Sometimes it falls on a generation to be great. You can be that generation.” - Nelson Mandela (2005) The Developing World Conference was established in 2005 by members of the Australian Medical Students’ Association (AMSA), in order to fulfil the desire of medical students to meet and discuss the broader issues relevant to global health. The inaugural conference hosted 200 delegates in Sydney, and the 2006 conference in Perth hosted over 250. In 2007, Adelaide took this even further, hosting over 300 delegates in an event that sold out nationwide in less than 12 hours. Speakers included Dr Rowan Gillies, outgoing international president of Médecins Sans Frontières, and Dr Jim Tulloch, Principal Health Advisor to AusAID. From 2008, the conference will now be known as the Global Health Conference (GHC). This represents a change in name, but not in nature of this inspiring event. Maintaining the common goal of educating and empowering medical students with knowledge about global health issues, the Global Health Conference will bring together Australia and New
Zealand’s most motivated medical students and junior doctors to collectively address the complex matrix of factors that contribute to issues of health in developing communities around the world. This year, the theme of the Global Health Conference will revolve around Nelson Mandela’s quote, describing an age of rising global social responsibility, in which it falls upon the current generation not to approach naively those less fortunate, but to unify in principle and action towards a greater goal. Our aim is to inspire, empower and arm delegates with the tangible skills and the knowledge necessary to assist them in bringing about global health equity. The promotional image chosen for the 2008 AMSA Global Health Conference is of a pensive young boy. Children of all ages live on the streets of Manila, Philippines. Even at a young age their eyes express the hardships of their lives. Lacking families, homes and a childhood, many struggle
to survive on their own. This year’s Global Health Conference logo was born from a collective epiphany, after much soulsearching and debate. While it is difficult to represent an event such as this by a simple design, we hope that it has grown to be a distinctive symbol of something much greater. At first glance, in it’s vertical orientation, the logo depicts a person holding up a globe. Nameless and faceless, this little person symbolises anyone who has the desire to contribute to the advancement of our world. As the home country of GHC 2008, Australia was chosen to be the most visible on the globe. A tilt of the head to the right will reveal the other aspect of the logo - the letters ‘g’, ‘h’ and ‘c’. Of course, at the end of the day, it’s just a picture! As much as we hope it lasts in your memory, more important are the experiences, friends, and skills you leave with this July.
Afghanistan - Male life expectancy: 42; Female life expectancy: 43; Under-5 mortality rate (per 1000): 257;
5.
Welcome from the Conference Convenors Welcome to Melbourne for the 2008 AMSA Global Health Conference! Interest in Global Health has been growing at an exponential rate over recent years as leaders look with new fervor to address ever-widening disparities in health outcomes. Global Health represents a holistic approach to considering the matrix of determinants involved – be they cultural, political, economic or environmental – that together impact upon the wellbeing of individuals and communities alike. “Sometimes it falls upon a generation to be great. You can be that great generation.” Nelson Mandela These words, declared by one of the world’s greatest leaders, form the core message of this year’s conference. It is in this spirit and shared-belief that we welcome over five hundred of our region’s future doctors to discuss the health of our world’s citizens – and together generate visions and pathways for change.
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In a world where greater than one-sixth of the population lives in extreme poverty, Mandela calls upon our generation to take action. As future community leaders and health policy-makers, we have the opportunity to play a significant part in upholding our responsibility as global citizens. For some delegates, the 2008 AMSA Global Health Conference represents an exciting start to this journey. For many others, it will be an inspiring sojourn on a journey already begun. In any case, the Conference Organising Committee has developed a program that caters for all delegates, regardless of prior knowledge or experience. Workshops will equip you with the skills to lead advocacy campaigns, organise Global Health events, coordinate developmentbased projects, and analyse the evidence that underpins policy. Keynote addresses by some of the world’s foremost experts will inform you in depth about the key issues impacting upon Global Health, and provide an unparalleled commentary on the current
situation in marginalized communities throughout Australia and around the world. Most importantly, the conference will empower you to take action. This conference provides you with the opportunity to actively engage with the leading individuals and organisations at the forefront of Global Health. By engaging with these groups we hope to present you, both individually and collectively, with the opportunities and means through which to realize our common aspirations. We hope that your experiences throughout these three days will inspire you towards a future career of active advocacy for Global Health issues, and to engage in activities that will ensure the provision of care to those most in need in our world. Enjoy the conference.
Daniel Yore & David Humphreys
Albania - Male life expectancy: 69; Female life expectancy: 73; Under-5 mortality rate (per 1000): 17;
Welcome from the AMSA President On behalf of the Australian Medical Students’ Association (AMSA) Executive, it is my pleasure to welcome you to the 2008 Global Health Conference (GHC) in Melbourne. In all our work for GHC we have felt a palpable buzz from everyone involved as medical students everywhere anticipate the opening of our premier global health event. The convenors of GHC have drawn on the words of Nelson Mandela from London’s Trafalgar Square in 2005 to encapsulate the spirit of this year’s event and the speaker line-up they have drawn is nothing short of remarkable. GHC, promises to be three days of the highest intellectual and philosophical debate about the place of individuals, in an age of rising social responsibility, and the impact that we each have on the health of one another. The Global Health Conference is a major yearly event, and one that draws together students to be informed and to learn from one another, however it is but a part of the ongoing activities of the Association, and especially those of
our Global section. AMSA brings together global health groups from around the country through the Global Health Network and the grass-roots work that goes on in these organisations is what drives the popularity and the expansive growth of global health as a part of our organisation. A conference such as this should do more than just raise awareness; GHC will provide all of you with insight into pertinent global health issues, as well as equipping you with tangible skills required to address these issues. Bring all the information you can from the speakers and the workshops to expand your skills and go back to your Universities and put those abilities to good use. An event like this does not come together overnight, and it was the joint application, of Daniel Yore and David Humphreys, to convene this event early last year that started the wheels turning. Dan and Dave, colloquially D2, have taken this conference in directions undreamed of previously. Their team; Jennifer, Caitlin, Romi, Adam, Sia, Emma, Anny,
Rasha, Madeleine, Prashanti, Hollie, Tim and the many other subcommittee members involved in organising GHC 2008; will make this an event you will not soon forget. Our praise, though unlooked for, should be showered upon this team for their efforts in bringing together these three days in July. Please take the time to seek them out. So again I welcome you to Melbourne, a city of culture, heritage and history and to an event that awaits only you to step forward on behalf of your generation. Enjoy!
Michael Bonning National President Australian Medical Students’ Association
Algeria - Male life expectancy: 70; Female life expectancy: 72; Under-5 mortality rate (per 1000): 38;
7.
t n e m e s r o d n E f o Letter Dear Colleagues, It is with great pleasure that we the undersigned endorse the AMSA Global Health Conference to be held in Melbourne from the 4th-6th July 2008. This event, unique to the Australian Medical Students’ Association, strives to equip our future doctors to think and act, both locally and abroad, to challenge and address global health issues. We believe it essential that the future generation of health practitioners and policy makers are professionals who have a deep-seated commitment to the issues affecting health provision throughout the world. For these reasons each of our organizations commit to supporting this event. Yours sincerely,
Professor Glyn Davis AC Vice-Chancellor, The University of Melbourne Professor Richard Larkins AO Vice-Chancellor & President, Monash University Professor James Angus Dean, Faculty of Medicine, Dentistry & Health Sciences University of Melbourne Professor Steve Wesselingh Dean, Faculty of Medicine, Nursing & Health Sciences Monash University Professor Graham Brown Chair, Nossal Institute for Global Health Professor Brendan Crabb Director, Burnet Institute Reverend Tim Costello AO Chief Executive Officer, World Vision Australia Mr Andrew Hewett Executive Director, Oxfam Australia Mr Jack de Groot Chief Executive Officer, Caritas Australia Dr Sue Wareham OAM President, Medical Association for the Prevention of War
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Andorra - Male life expectancy: 78; Female life expectancy: 85; Under-5 mortality rate (per 1000): 4;
Conference Initiativ
es
Training the Trainer
David Humphreys and Daniel Yore For delegates who wish to develop their practical skills, AMSA, in conjunction with the International Federation of Medical Students’ Associations (IFMSA) will be running a “Train the Trainer” workshop programme during the three days preceding the Conference from the 1st to 3rd of July 2008. Based on the highly successful workshops designed by the Training Division of the International Federation of Medical Students’ Association (IFMSA), the TNT programme aims to equip Australian medical students from across the country with the skills
required to research, prepare and deliver a focused training session on a wide range of topics that are acutely pertinent to the nation’s medical student body. By up-skilling its members, AMSA aims to create an environment where the medical student community is willing and capable of passing on the wealth of knowledge and skills that they possess to their colleagues. As a result, medical students will be further empowered to contribute to the variety of challenges that they will face in the future global healthcare environment. A delegation of 16 Australian students will join our 25 AsPac delegates in the workshops that focus on such skills as research and utilization of resources,
preparations for training sessions, facilitation techniques, presentation and communication skills, and group motivation tools. To complete the formal training accreditation process, every delegate will deliver a training session to a group of general delegates of the GHC. Such training topics may include advocacy and campaigning, proposal writing, project management, and group leadership. A big thankyou must go to Jake Parker, AMSA Global Officer and the six TNT trainers (Sook, Xia, Eric, Gemma, Rebecca & Osama) for their amazing commitment to coordinating these workshops.
Carbon Offsetting Heidi Woolford and Tim Lindsay “The benefits of strong, early action considerably outweigh the costs.” - Dr Nicholas Stern Climate change is one of the greatest challenges facing society today. It will affect the basic elements of life for people around the world – access to water, food production, health, and the environment. Hundreds of millions of people are at risk of suffering hunger, water shortages and coastal flooding as the world warms. Health equality is increasingly limited by environmental sustainability. Renewed urgency has been given to the issue of climate change with the recent release of the Stern review, highlighting the economic consequences of global warming. The Stern review states that if we do not act, the estimated overall cost of climate change will be equivalent to losing at least 5% of global Gross Domestic Product (GDP) each year, now and into the foreseeable future. If a wider range of risks and impacts is taken into account, the estimates of damage could rise to 20% of GDP or more. In contrast, the costs of action – reducing greenhouse gas emissions to
avoid the worst impacts of climate change – is 1% of global GDP each year. This can be achieved only if greenhouse gas levels in the atmosphere can be stabilised between 450 and 550ppm CO2 equivalent (CO2e). Placed in context, the current level is 430ppm CO2e today, and it is rising at more than 2ppm each year. Stabilisation in this range would require emissions to be at least 25% below current levels by 2050.Emissions can be cut through increased energy efficiency, changes in demand, and through adoption of clean power, heat and transport technologies. Cuts in non-energy emissions, such as those resulting from deforestation and from agricultural and industrial processes, are also essential. Immediate and sustained action is needed to reduce greenhouse gas emissions and prepare for the impacts of climate change. Whilst government commitment is essential, everyone plays an important part in contributing to this action that is necessary to save not only our environment, but also our economy. This will require a shift in our behaviour and in the way we use our natural resources. As climate change has an undeniable impact on Global Health, we at the AMSA Global Health Conference see it as critical that we do the utmost to off-
set the Carbon Footprint of GHC2008. As most would remember, during registration delegates were asked to contribute to offsetting the carbon emissions of the AMSA GHC 2008. Thanks to your generous support, close to $1200 was raised which through our association with the Conference Sustainability Partner, Origin Energy, has contributed to offsetting 91 tonnes of CO2 equivalent emissions. But how did we get to this figure and how exactly will your money be used? The calculation of the Conference’s total emissions was a process that we are sure you will agree was very worthwhile. Essentially a three step process, it involved using the Environment Protection Authority website to calculate precisely where our emissions were to come from, transforming data into a total number of CO2 equivalent emissions and finally forging a partnership with an offset provider. Consideration was given to the catering required for the conference, the amount of space occupied by the conference and the total number of beds occupied by delegates. This data was then compiled into an online database available through the EPA website. These results showed that, with the exception of delegate travel, the conference would produce a total of 91
Angola - Male life expectancy: 40; Female life expectancy: 43; Under-5 mortality rate (per 1000): 260;
9.
tonnes of CO2 equivalent. This data was then taken to our Conference Sustainability Partner, Origin Energy, who, again thanks to the generous support of the delegates will offset this with a range of initiatives including tree planting, composting waste and creating energy efficient advocates. Thank you for contributing to the
environmental sustainability of this year’s conference. We ask that you be mindful of your energy usage whilst you are here, by reading the list provided and trying the ticked suggestions. Travel is an additional and significant contributor to emissions, so if you have not already done so, you can also retrospectively offset your travel through Origin’s website: http://www. origingreen.com.au.
Yours in a healthy and sustainable future.
Asia-Pacific Delegation Project David Humphreys and Daniel Yore
ingfully and sustainably, to healthcare needs of communities within Australia and around the world.
The 2008 AMSA Global Health Conference will, for the first time, truly engage a global audience by welcoming delegates from over sixteen different countries throughout the Asia-Pacific region to Melbourne. International delegates from predominately developing communities will be involved in a unique six-day programme that has been fully funded by AusAID, The Sidney Myer Fund and valuable contributions from a number of Australian Global Health Groups. As well as attending GHC2008, delegates will be involved in the IFMSA Training New Trainers Programme that precedes the conference, running from the 1st3rd July.
The past 5 years have seen a phenomenal, unprecedented growth of the Global Health movement within the Australian Medical Student community. To facilitate and support this rapid development, a framework has been established which consists of Global Health Groups (GHGs) at a grass-roots university level, the AMSA Global Health Network (consisting of a representative from each GHG across Australia), and the AMSA Global Health Conference: serving as the culmination of all Global Health-related activity taking place throughout the region during the past year.
The AMSA Global Health Conference is wholly dedicated to addressing health and development issues of developing communities, and is specifically designed for young leaders and health ambassadors in the Asia-Pacific region. As the only event of its kind, the conference is unique in combining theory (presented through keynote addresses from leading academics and policy-directors) with practical skills and experiential learning within a dynamic workshop program. Through this program it is hoped that delegates will be equipped with the knowledge, insight and skills to contribute, both mean-
Through this framework, opportunities have been developed for students to “achieve considerable short- and long-term benefits in the developing world” by involving themselves in fundraising, policy formation, advocacy, education initiatives and elective placements within these communities. As a result, students are now graduating more informed about the issues, equipped with practical skills and knowledge which they are utilizing as young doctors to pursue careers of leadership in health policy direction, foreign aid and relief work, community development projects and Indigenous health.
There exists enormous potential for replicating this success within developing communities throughout the Asia-Pacific region. The repercussions in terms of engaging and empowering young people in such circumstances will have an even more profound effect. Through equipping individual delegates with the necessary skills and the formation of appropriate links and communication pathways, there exists the opportunity to facilitate the growth of global health groups in societies where the concept of student-based initiatives is still being conceived. The results of this will be evident in the short-term through youth-led action, and in the longer-term through fostering a next generation of doctors with invaluable skills in the essentials of global health practice, policy-formation, group and project leadership and advocacy. In today’s global society, reaching out to our region and engaging with our younger generation is an essential first step on the road to sustained cross-cultural understanding, unity, and the reduction of poverty. The Conference Organising Committee would like to thank the generous support of the Sidney Myer Fund, AusAID, The AMSA GHN, Ignite, Insight, Impact and HOPE in making this project possible.
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This logo can be interpreted in two ways. The gray circular element represents a petrie dish. Within the dish is a FEVDBUF JOTQJSF which FNQPXFS vibrant green circle symbolises a cure. The logo also doubles as a person with positive, outspread arms.
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Argentina - Male life expectancy: 72; Female life expectancy: 78; Under-5 mortality rate (per 1000): 17;
This logo is based around the ‘i’ of ‘ignite’. It can also be seen as a human figure, positioned in an energetic, dynamic manner. The logo also
AMSA Global Policy Project Background The AMSA Global Policy project is a proposed venture between the 2008 AMSA Global Health Conference, the AMSA Global Health Network and the AMSA Executive/Council. As the peak representative body of Australia’s 13,000 medical students, AMSA advocates actively on behalf of its members to the Government, media, and the Australian public. The interest in Global Health among the Australian medical student community is phenomenal. Such unprecedented growth in this field has resulted in the formation of Global Health Groups in nearly every medical school in the country. As AMSA’s pinnacle event dedi-
cated solely to addressing Global Health issues, the Global Health Conference represents an ideal opportunity for recommendations to be put forward and policy developed by our country’s most passionate and engaged medical students.
the compilation of recommendations and formulation of relevant, peer-reviewed policy, AMSA will have – for the first time – the means and ability to advocate on global health issues, both internally to its members and publicly.
In its short history, the Global Health Conference has been instrumental in informing and educating medical students about issues concerning Global Health. It is now time for the conference to expand upon this with a practical emphasis. The AMSA Global Policy Project is one initiative that will produce tangible outcomes to this end.
Objectives
Vision The AMSA Global Policy Project will enhance the understanding of medical students throughout Australia regarding contemporary health issues, particularly of global nature and focus. Through
Pertinent health issues of particular relevance to Australia and its place in an increasingly global community will be addressed through the: •
•
Compilation of recommendations resulting from the workshop program of the 2008 AMSA Global Health Conference; Translation of key sets of recommendations into policy for peer-review and endorsement by the AMSA Executive Council.
Training the global health leaders of tomorrow At the Nossal Institute for Global Health we are committed to enhancing global health through research, education, knowledge transfer and development assistance in communities where health is at its poorest. We offer you the opportunity to study with some of Australia’s leading global health professionals who will share their unique experiences, insight, knowledge and hands-on experience.
Our range of short courses, award programs and research higher degrees are designed to encourage and nurture students aspiring to leadership in global public health. To find out more about the work of The Nossal Institute for Global Health and our range of courses visit www.ni.unimelb.edu.au
www.ni.unimelb.edu.au
David Humphreys and Daniel Yore
The world awaits you.
Ranked among the world’s leading universities*, Monash is distinguished by its international perspective. With eight campuses on three continents, a choice of more than 500 postgraduate research and coursework programs, Monash is dedicated to improving the human condition through landmark research outcomes and innovative education programs. Go boldly with us to the world. www.monash.edu/postgrad CRICOS Provider: Monash University 00008C
* Monash was ranked in the world’s top 50 universities by the Times Higher Education Supplement 2007
1958-2008
Introduction to the Academic Program Dear Delegates, Welcome to the academic program of the 2008 Global Health Conference! The Global Health Conference is devoted to informing and educating medical students from around Australia and the Asia-Pacific about current issues pertaining to Developing World Health. This annual conference draws the most passionate and proactive medical students from around Australia who will participate within this innovative programme to inform, discuss and plan towards addressing global health. Over 500 delegates attending the GHC will be presented with a world-class academic program offering a holistic approach towards understanding the complex matrix of economic, social, political and environmental determinants of health in developing communities around the world. Our academic programme features plenary sessions, forums and dialogue to explore pertinent subject matters within global health. This year, we have placed a particular emphasis on Australian Indigenous Health by devoting a plenary forum with high-profile speakers reflecting on the issues concerning Aboriginal Australians over the last five years. Our second forum will focus on global health initiatives and opportunities that exist for
students and young doctors around Australia and overseas. Our ‘Sessions of Dialogue’ will analyse the various approaches taken when striving to achieve development, as well as examining the role of sanctions and the longterm impacts this may have on peace and humanity. Our five academic streams are integrated within the programme to provide opportunities for smaller lectures concentrating on aspects of global health in more detail. Each of the academic streams still encompass, integrate and actively address the many different factors which influence health, merely within the context of each academic stream. Despite larger delegate numbers this year, we have endeavoured to retain the small group workshops to allow for adequate interactive discussion and debate of current issues revolving around global health. These are placed in the context of a case study for the first session, in order to facilitate a more in-depth understanding of the milieu of issues associated with a particular topic. During the second workshop session, an emphasis has been placed on the long-term involvement of students’ in addressing and advocating for these global health issues, which will include opportunities for further discussion and debate, as well as putting forward
Armenia - Male life expectancy: 65; Female life expectancy: 72; Under-5 mortality rate (per 1000): 24;
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policy recommendations AMSA.
for
Pre-conference workshops include the IFMSA “Train the New Trainer” program and other practical skills workshops run by our academic partners, including NTGPE and World Vision. Workshops focusing on skills such as advocacy, campaigning and cross cultural awareness will equip delegates with the necessary skills for tangible social change. 2008 is a year of milestones. Throughout the three days of the conference, we will acknowledge the 60th Anniversary of the World Health Organisation, the 60th Anniversary since the adoption of the United Nations Declaration of Human Rights, and 30 years since the adoption of the Alma Ata Declaration. The academic team would like to offer our sincere thanks to all the incredible speakers who have given up their time to come and address our delegates on such pertinent Global Health issues. In particular, a special note of thanks must go those academics who have not just provided support for the academic team, but also advocated on our behalf for what
A quick note on Speaker gifts… Every keynote speaker present at the GHC 2008 will receive a copy of the recently published “Recipes for Great Living” written by Rob Moodie and Gabriel Gate (signed by the author). Each facilitator has received a box of Australian chocolates from the Koori Cultural Centre in Melbourne.
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has become the largest student-run conference devoted to Global Health. A big thank you must go to Paul Komesaroff, Roger Short, Rob Moodie, Graham Brown, Joe Camilleri and Andrew Hassett. Finally, the academic subcommittee has been working on the academic program for over 12 months. It is testament to their incredible hard work, dedication, enthusiasm and passion for global health issues that we are able to present to you such an outstanding academic program. The subcommittee has spent an extraordinary amount of their time researching, constructing and writing workshop material for which we are all truly indebted. I am truly appreciative of the academic team’s commitment to the 2008 AMSA Global Health Conference and to global health issues on a wider scale. It has been a pleasure to work with such an inspirational group of individuals, and I look forward to working with them again sometime in the future.
greatest achievement of human beings is conversation. Be it conversation at the dinner table or at an international Global Health conference, I believe there are certain issues in our world today that warrant our sustained attention and for which we have a collective sense of responsibility. The success of this depends largely on the contribution we choose to make. I hope that the GHC academic program informs, inspires and empowers all of you to become involved in Global Health. Enjoy!
Jennifer Jamieson Academic Convenor AMSA Global Health Conference 2008
On a final note, a wise professor at the Centre of Dialogue recently said to me that the
Acknowledgements We acknowledge the following people who have taken time to review our workshops and put forward suggestions and comments. It has allowed the academic team to achieve a level of academia we never dreamt was possible!
The GHC Committee Paul Komesaroff Chris Morgan Rob Moodie Roger Short Tilman Ruff Nancy Atkin Andrew Hassett Marion Brown Hayley Messenger Steve Moylan Caitlin Taylor Soren Blau Shirley Goodwin Mick Gooda
Australia - Male life expectancy: 79; Female life expectancy: 84; Under-5 mortality rate (per 1000): 6;
Program Overv
iew
Plenary sessions:
These sessions will have all delegates in attendance to hear highprofile speakers address pertinent subject matters shaping global health. These will take the form of a single address as well as contentious and thought-provoking dialogue.
Sessions of Dialogue:
Development: it’s all about the money… Should development be dominated by the agenda of economists? Historically development has been synonymous with economic development (specifically, economic growth), and it is often assumed that development cannot take place without economic growth. However the 1990s saw the rise of “human development,” for example in Chile. But there are many who still say that development continues to be dominated by the agenda of economists, pointing out that it remains the Bretton-Woods financial institutions that govern development agendas globally. The dialogue arising from this session will endeavour to bring up some crucial questions for delegates regarding what format of development is best for developing world countries and how we can measure this. In what ways will an economic approach to development differ from a social approach, and what will the differing outcomes on health be? What exactly is the best road to take with regard to development?
The United Nations Promoting peace and prosperity… Where does the future lead? The founding of the United Nations in 1945, and its growth to the organization it is today, would be seen by many as one of the global community’s great successes. Yet despite best intentions, numerous
criticisms of structure, power and equal representation pervade. This session of dialogue, comprising views from Australia’s leading experts, will examine the role of the UN in today’s society. Is there a future for the UN in its current role and structure? What reforms should be made to ensure the organisation’s charter is fulfilled to the greatest extent possible? Do we even need a global representative body? Questions of development, sanctions, peace-keeping and international security will all be discussed and questioned, with ample opportunity for questions from the floor. Sanctions are punitive or coercive measures against a state or its nationals, which Article 41 of the UN Charter allows the Security Council to impose sanctions against nations which pose a threat to international peace and security. There are several forms which sanctions can take, including arms embargoes, travel sanction, financial restrictions, import/export bans of certain commodities and the down-grading or suspension of diplomatic ties. It is imperative that we explore and examine the reasons behind why sanctions are implemented and forecast whether there is a predilection for sanctions to promote peace within these states or whether they may in fact impede development for those marginalised individuals and communities affected by poverty.
Forums:
Indigenous Issues Forum:
This year there will a forum of high profile speakers who will be discussing and reflecting on the previous year’s affairs in Australian Indigenous health. In particular, there will be an analysis of the past years since the publication of “The Little Children are Sacred” report, the implementation of the Northern Territory Intervention and the
National Apology. There will be time for a lengthy question and answer session at the end to actively engage the audience.
Getting Involved Where to now?
Forum:
This year there will be time to explore the capacity in which medical students’ have to get involved in the various domains of global health. We will explore the AMSA Global Health Network and the work of two university Global Health Groups. Additionally, some of the largest academic institutions and NGOs will present the various ways in which delegates can become involved as students and as future doctors.
Streamed lectures:
In the 5 academic streams, there will be more focused lectures pertaining to the issues being addressed within that particular stream. The lectures aim to augment and expand upon an individual’s knowledge of these particular issues.
Workshops:
Following inspiration from the Developing World Conference 2007, we are continuing on with their innovative idea of introducing case studies to the conference academic program. This year, an emphasis will be placed on these small group sessions as workshops, where case studies will be used to enhance understanding of a particular issue during day 1. During day 2, we will endeavour to engender a philosophy of advocacy and ongoing commitment to appreciating the complex matrix of factors which influence determinants of health in developing world communities. Delegates will be inspired to create tangible social change, but also motivated to speak out and educate their peers. Appropriate pathways for student involvement in these specific areas will be highlighted for those interested.
Austria - Male life expectancy: 77; Female life expectancy: 83; Under-5 mortality rate (per 1000): 4;
15.
: m a r g o r P c i Academ Friday Delegate registration
8:00 9:00
Introduction and welcome
Convenors, Professor Glyn Davis AC, Professor Richard Larkins AO, Michael Bonning, Professor Joe Camilleri
Plenary address 1
10:00
Sir Gustav Nossal AC
11:00
Morning tea
11:30
Workshop Session 1
13:00
Lunch
14:00
Stream Lectures
Stream One
Stream Two
Stream Three
Stream Four
Stream Five
Associate Professor Bebe Loff, Professor Tim McCormack
Father Frank Brennan, Dea DelaneyThiele
Professor Roger Short, Professor Tony McMichael
Professor Paul Komessaroff
Kon Karapanagiotidis
15:30
Afternoon tea
16:00
Session of Dialogue 1 Professor Joe Camilleri and Dr Brett Parris
17:00 16.
Close Day 1 - Social Program
Azerbaijan - Male life expectancy: 62; Female life expectancy: 66; Under-5 mortality rate (per 1000): 89;
Academic Progr
am: Saturday
Plenary address 2 (Video address):
9:00
Professor Jim Yong Kim M.D., Rev Tim Costello AO
10:00
Plenary address 3
11:00
Morning tea
11:30
Stream Lectures
Julian Burnside QC
Stream One
Stream Two
Stream Three
Stream Four
Stream Five
Associate Professor Damien Kingsbury, Dr Bill Williams
Dr Hugh Heggie, Dr Louis Peachey
Waleed Aly, Professor Helen Keleher
Professor Rob Moodie, Dr Nick Coatsworth
Dr Helen Durham, Associate Professor Trevor Duke
13:00
Lunch
14:00
Workshop Session 2
15:30
Afternoon tea
16:00 17:00
Session of Dialogue 1
John Langmore, Professor Anthony Zwi
Close Day 2 – Social Program
Bahamas - Male life expectancy: 71; Female life expectancy: 77; Under-5 mortality rate (per 1000): 14;
17.
: m a r g o r P c i m Acade Sunday Plenary address 4
9:00
Elizabeth Reid AO
10:00
Plenary address 5 – Indigenous Australia (Forum)
11:30
Morning tea
12:00
Reflections and Conclusions
13:00 14:00
Tom Calma, Pat Anderson, Don Palmer
Stream One
Stream Two
Stream Three
Stream Four
Stream Five
Professor Anthony Zwi
Mick Gooda
Dr Richard Di Natale
Larry Marshall
Dr Deborah Zion
Lunch
Plenary forum: Global Health in Australia
AMSA Global (Jake Parker), Global Health Network (Negin Sedaghat),
Global Health Groups
14:30 Plenary forum: Engaging with global health - Where to now?
15:30
Plenary: Presentation and close
16:00
Close Day 3 – Departure
18.
Bahrain - Male life expectancy: 74; Female life expectancy:76; Under-5 mortality rate (per 1000): 10;
Streams Stream 1: Health, Conflict & the Political Process… “War not only damages our health, but the very fabric of our civilisation.” (Levy & Sidel) War and conflict have a catastrophic impact on the lives of people worldwide. It is of paramount importance to recognise the substantial degree of morbidity and mortality which is implicated by conflict and warfare. In doing so, one must consider that implications of conflict and warfare stretch far beyond the particular moment in time, and can last for years afterwards often in the shape of mental health problems arising from the social and cultural barriers encountered with migration and re-integration into society. War affects not just the individual, but family structures, communities and cultures, as well as entire nations. Within conflict, there is often loss of or violation of Human Rights. There may be diversion of limited resources from public services by damaging underlying infrastructure and
foundations which support such services. There is new evidence to suggest that conflict and warfare has an adverse effect on the environment and is contributing to climate change. Perhaps worst of all, conflict can act to instill a “mindset” of violence, with persons thinking that violence is the natural way to resolve conflict. This can lead to high rates of domestic violence and street crime within a community.
affiliations; and the role of policy and International Humanitarian Law. The repercussions of war will be considered, including reconciliation, Human Rights, the mobilization of humanitarian organizations, the transparency of aid, and the right to the identification of the dead. The concepts of “capacity building” will be discussed, debating differing approaches such as development vs. empowerment.
This academic stream will concentrate on some of the political, social, economic and cultural determinants of health related to conflict and war. Delegates will be asked to consider why conflict occurs, what political processes can lead to conflict, the processes of disarmament and the influences in creating a culture of peace and reconciliation. Students will deliberate the direct and indirect impacts of conflict on health at various stages of an individual’s and nation’s lifespan.
This stream will be a challenging and discussion-provoking aspect to global health. Four lectures will be given by specialists in the area. There will be two challenging workshops running simultaneously over 3 days, encompassing matters involving post-conflict East Timor and small arms violence within the Pacific Islands.
There will be a focus on factors relating to conflict including political groups or “factions” within countries; economic sanctions; working around different political
Reference: Global Health Watch 2005-2006
Stream 2: Indigenous Health: on our doorstep & around the world… “Those who lose dreaming are lost” – Australian Indigenous proverb The spectrum of Indigenous peoples traverses an extraordinary number of cultures. These communities have a unique amount of knowledge and skills, all of which influence and enrich the way they relate to the world around them. Indigenous peoples number over 350 million people in more than 70 countries, with more than 5000 languages and cultures. Unfortunately these populations have often suffered atrocious acts of genocide, displacement, oppression and land expropriation. Even in our contemporary day and age, Indigenous popu-
Bangladesh - Male life expectancy: 63; Female life expectancy: 63; Under-5 mortality rate (per 1000): 69;
19.
with modern society and varying affiliation with traditional ways of life. Hence there is no “blueprint” for the delivery of healthcare to Indigenous populations. Delegates must appreciate that in addressing the political, social and cultural aspects of health inequalities in Indigenous populations, there has to be judicious consideration of historical factors as well as the peoples’ right to self determination. Reference: Global Health Watch 2005-2006
lations still experience racism, poor social integration, poverty and ill-health. All of this acts to threaten the very foundations of their traditional ways of life. Often, poverty and marginalisation can be exacerbated by Western ways of life, with consumerism and imposed modernisation. In Australia, Indigenous issues have been brought to the forefront of our attention in recent years in politically-charged reports such as “The Little Children are Sacred” report on child sexual abuse in the Northern Territory and in interventions such as the Howard government’s Northern Territory National Emergency Response Bill in 2007. Most recently, Kevin Rudd’s apology to the Stolen Generation was welcomed by many Australians, yet simultaneously created a storm of controversy about the long-term solutions to Indigenous health and wellbeing.
standing Indigenous health, both in Australia and overseas. Through four focused lectures and two workshops running each day of the conference, students will gain an understanding of Indigenous Human Rights and self determination of these populations, which are essential to understanding the social, cultural and political barriers to health for Indigenous peoples. Delegates undertaking this stream will discuss Indigenous concepts of health, difficulties encountered with health services and provision; and problems with assimilation into Westernised lifestyles, occasionally with ensuing loss of traditional ways of life. Ultimately Indigenous populations must be considered as a diverse group, all of which have varying degrees of integration
Stream 3: Culture, Environment & Society “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” - WHO This academic stream will endeavour to address three vital determinants of health – the social, cultural and environmental aspects. Through four smaller lectures and two workshops running simultaneously over the three days of the conference, many of the important issues pertaining to society, culture and the environment in developing communities and nations worldwide will be addressed. Much of our attention can be swept up in current molecular technology, genome maps
Whilst many have criticised the inherent paternalism of government responses, inevitably the dialogue which arises as a result is invaluable. The attention of Australia is focused on Indigenous health, which is indisputably a step, albeit it a small one, in the right direction. There is long overdue public acknowledgement of the dire state of affairs of Australian Indigenous Health. This academic stream will consider the foundations of under-
20.
Belarus - Male life expectancy: 63; Female life expectancy: 75; Under-5 mortality rate (per 1000): 8;
and the biochemical structure of new medications. However, life and health are much more complex than this, and society and culture force us to revise and modify our approach to healthcare delivery. Poverty is the largest epidemic worldwide. It underlies most cases of malnutrition, fuels spread of infectious diseases and exacerbates vulnerability to the effects of ill-health. Hence, in order to improve global health, we must address poverty. With the intention of tackling the root causes of poverty, one must address these social, cultural and environmental outcomes of poverty – for example, lack of access to water and appropriate sanitation, illiteracy and education, and housing. As well as this, consideration must be given to cultural beliefs and traditions surrounding health. Health inequalities are a major cause for the increasing levels of poverty seen worldwide. The assets of the top 3 billionaires are worth more than the combined GNP of all least developed countries and their 600 million people. Inequalities are not just seen at global levels, but also national and community levels. Delegates will be asked to consider and debate the social barriers to health and how we can act to address issues such as poor housing, societal inequities, poor education, and lack of access to clean water & sanitation. Particular illnesses and health conditions, for example HIV, can also break down traditional family structures and increase class discrepancies within a community. Using HIV as an example, one of our workshops will focus on addressing the social and cultural implications of HIV on health and poverty. An understanding of how the poverty cycle can exacerbate some of these issues is a key objective, as well as the approaches which can be undertaken to interrupt this cycle. Public health approaches are now often being incorporated into socioeconomic
policies in order to improve global health. More recently, Al Gore has been integral in re-igniting global dialogue on climate change. Delegates undertaking this stream will also be asked to consider the direct and indirect impacts of the environment on health as one of the biggest threats to poverty and human health. Discussion surrounding “climate refugees” and the ensuing social and cultural barriers to health must be considered. The other workshop within this stream will address the root causes of climate change and the implications this can have on developing communities, often the communities least responsible for the effects of climate change. Debate surrounding the provocation of poverty by climate change through loss of agricultural systems, emergence of particular infectious diseases, destruction of freshwater supplies, humanitarian emergencies, threatened food security and migration from rural areas to urban shanty towns will also be embarked on by delegates. Reference: Global Health Watch 2005-2006
Stream 4: Global Health and the “Big Guys”: international health policy and development “The rich world dominates the training of Ph.D economists,
and the students of rich-world Ph.D programs dominate the international institutions like the IMF and the World Bank, which have the lead in advising poor countries on how to break out of poverty. These economists are bright and motivated; I know, I have trained many of them. But do the institutions where they work think correctly about the problems of the countries in which they operate? The answer is no.” - Jeffrey Sachs Much is made of global vs. grassroots approaches towards development as being polar opposites, both striving to address root causes of poverty. Many consider that development is primarily driven by the policies and politics of the “Big Guys”, e.g. the insurmountable World Bank, the IMF, the UN, the WHO, the G8, emerging superpowers and the relentless influence of pharmaceutical companies. This academic stream aims to address the roles and responsibilities of some of these large organisations and corporations, including the scandals and challenges which they are involved in. Delegates undertaking this stream will come away with an understanding of the influences surrounding economic disparities on a global, national and community level. Through four focused lectures and two workshops running simultaneously for the duration of the confer-
Belgium - Male life expectancy: 77; Female life expectancy: 82; Under-5 mortality rate (per 1000): 5;
21.
ence, globalization and the economic determinants of health will be introduced and scrutinised. The implications of international trade rules and regulations on the health of developing countries, and the way in which policy can be stacked in favour of rich countries and multinational corporations will be debated. Corporate Social Responsibility and its role in profiteering for the interests of global corporations vs. advancing social justice and minimizing environmental impacts will be debated. Generic drugs and patent-circumventing legislation pertaining to medicines in the developing world will also be considered. There will be a particular emphasis on access to essential medicines for the key players in the infectious disease world - e.g. TB, malaria, HIV. Strategies to make essential medicines more accessible and affordable will be considered by delegates undertaking this stream. A systematic review of the relationship between pharmaceutical companies and the developing world will be made, including the actual contribution made by companies and how to incentivise them to become involved in developing and distributing drugs for poorer nations. The economics of such an access gap within developing countries must be appreciated, including poorly resourced healthcare systems, the inadequate amount of
research in developing countries, the financial burden of medicines in developing countries and the lack of political will for financing of public healthcare. This academic stream will feature as an integral, yet highly challenging and thought-provoking component to global health. References: Global Health Watch 2005-2006
Stream 5: Marginalised Populations: migration, assimilation and human rights “They have a right under international law to claim asylum from persecution. That is what they are doing. They have committed no crime - they are innocent. Yet they are locked up indefinitely. People are at breaking point because they feel the hopelessness of it all.” - Julian Burnside QC Delegates undertaking this stream will have the opportunity to attend four lectures focusing on marginalised populations and the implications this has on the health of individuals, families and communities at large. Populations considered will include refugees, asylum seekers, internally-displaced people, women, children, orphans, people with disabilities and minority ethnic groups. The barriers to equitable health will be examined, including the stig-
matization encountered by these groups, as well as legal barriers, lack of education and empowerment, and specific health problems of each group. The role of the doctor must also be considered with regard to counteracting stigmatisation and appreciating the problems specific to each group. The ethics of “duty to treat” vs. the legal system must also be contemplated. One of the workshops will examine the entire refugee story - e.g. the displacement, migration, life in a refugee camp, internal displacement, integration into foreign society, and the social, cultural & psychological effects this can have. The access to healthcare by refugees and asylum seekers varies worldwide, and scrutinisation of policies by different countries will be undertaken. The second workshop, running simultaneously, will focus on issues affecting the health and wellbeing of women and children in developing communities and the barriers to this fundamental right. Gender inequality and discrepancies in education, employment, Human Rights and economic policy will be introduced, with their ensuing implications on health and poverty for women and children. Armed conflict and domestic violence experienced by women, particularly those living under foreign occupation, will be touched on. The stimulating and thoughtprovoking lectures and workshops will challenge students to consider the various approaches which can be taken by health professionals to address the inequities experienced by marginalized populations in order to create a peaceful and just world. One must recognize the vital importance of Human Rights and individual freedom based on a primary foundation of equality across all populations. References: Global Health Watch 2005-2006
22.
Belize - Male life expectancy: 65; Female life expectancy: 74; Under-5 mortality rate (per 1000): 16;
Speaker Biographies
Plenary sessions, debates & forums Pat Anderson
Pat Anderson is an Alyawarre woman renowned nationally and internationally as a powerful advocate for the health of Indigenous peoples. She has extensive experience in all aspects of Aboriginal health, including community development, advocacy, policy formation and research ethics. Pat was formerly the Chief Executive Officer of Danila Dilba (the Aboriginal communitycontrolled health service in Darwin) and has also been Chair of the National Aboriginal Community Controlled Health Organisation (NACCHO), the peak national Aboriginal health organisation. She was the Executive Officer of the Aboriginal Medical Services Alliance Northern Territory. Pat is a prolific writer and has had many essays, papers and articles published. She has also spoken before the United Nations Working Group on Indigenous Peoples. Recently, she is most famously recognised as the co-author of the Little Children are Sacred report into abuse of Indigenous children in the Northern Territory. This report stirred the previous government to implement the controversial NT Emergency Intervention Plan, despite Pat’s recommendations of thoughtful and meaningful consultation with the Aboriginal people and their communities. Pat was awarded Australia’s Sidney Sax Public Health Medal at the 2007 PHAA annual conference.
Julian Burnside QC
A Human Rights’ lawyer and advocate, Julian Burnside was admitted as a barrister of the Supreme Court of Victoria in 1976, and appointed a QC in 1989. He quickly became renowned for his pro-bono legal work for asylum seekers, including acting for Liberty Victoria in the Tampa litigation. He founded the organisation “Spare Lawyers for Refugees,” a non-profit support and advocacy
network for people held in Australian immigration detention centres. In 2004 Julian was awarded the Human Rights Law Award by the Human Rights and Equal Opportunity Commission. Last year, he made headlines again when acting for Bruce Trevorrow where he successfully claimed the first compensation for damage as a member of the Stolen Generation against the state of South Australia. At the end of last year, he was duly awarded the Australian Peace Prize.
Tom Calma
Mr Tom Calma is the Aboriginal and Torres Strait Islander Social Justice Commissioner and acting Race Discrimination Commissioner. He is an Aboriginal elder from the Kungarakan tribal group and a member of the Iwaidja tribal group whose traditional lands are south west of Darwin and on the Coburg Peninsula in Northern Territory, respectively. Previously, he managed the Community Development and Education Branch at the Aboriginal and Torres Strait Islander Services where he worked with remote Indigenous communities to implement community-based empowerment and participation programs. In 2003, he became Senior Adviser of Indigenous Affairs to the Minister of Immigration, Multicultural and Indigenous Affairs. He was appointed Commissioner in July 2004 and
remains a leading voice on Indigenous Affairs within Australia.
Joe Camilleri
Professor Joe Camilleri is the director of the Centre for Dialogue and a prominent academic figure in the study of International Relations. He has written and lectured extensively on Europe and the United States in international relations, governance and globalisation, human rights, North-South relations, international organisations, the United Nations, and the Asia-Pacific region. Joseph Camilleri is actively engaged in international research, education and advocacy on issues of human rights, civilisation dialogue, global governance reform, peace and security. He is a Fellow of the Australian Academy of Social Sciences, and the recipient of St Michael’s Award for Distinguished Service to the Community. At La Trobe University he coordinates the Bachelor of International Relations and the Master of International Policy Studies. Professor Camilleri will be giving an introductory discourse during the opening ceremony for the GHC, reflecting on the nature and importance of dialogue. For Camilleri today’s world poses immense risk but also unparalleled opportunity. The question is how best to reduce the risks and take advantage of the opportunities. Conversation may not be the whole answer, but it is
Benin - Male life expectancy: 54; Female life expectancy: 55; Under-5 mortality rate (per 1000): 148;
23.
distinguished professional, including being awarded a MacArthur “Genius” Fellowship in 2003; being named one of America’s 25 best leaders by US News & World Report in 2005; and being named one of the 100 most influential people in the world by Time magazine in 2006. He was a contributing editor to the 2003 and 2004 World Health Report, and his edited volume Dying for Growth: Global Inequity and the Health of the Poor analyzes the effects of economic and political change on health outcomes in developing countries.
John Langmore
a crucial, yet often neglected, component of the answer. Additionally, he will also be a speaker within the Session of Dialogue: “It’s all about the money” reflecting on the role of development and the social, political and economic influences surrounding this.
and Human Rights at the Harvard School of Public Health as well as the Professor of Medicine and Social Medicine at Harvard Medical School. Dr. Kim returned to Harvard in December 2005 after a threeyear leave of absence at the World Health Organization (WHO).
Tim Costello
While on leave, Dr. Kim was director of the WHO’s HIV/AIDS department, a post he was appointed to after serving as advisor to the WHO director-general. Dr. Kim oversaw all of WHO’s work related to HIV/ AIDS, focusing on initiatives to help developing countries scale up their treatment, prevention, and care programs, including the “3x5” initiative designed to put three million people in developing countries on AIDS treatment by the end of 2005. Dr. Kim has 20 years of experience in improving health in developing countries. He is a founding trustee and the former executive director of Partners In Health, a not-forprofit organization that supports a range of health programs in poor communities in Haiti, Peru, Russia, Rwanda, Lesotho, and the United States. An expert in tuberculosis, Dr. Kim has chaired or served on a number of committees on international TB policy.
Rev. Tim Costello attended Monash University to study law and education, followed by theology at the International Baptist Seminary Rueschlikon in Switzerland, and a Master’s in Theology at the Melbourne College of Divinity. He was ordained as a Baptist Minister in 1986, and later became Mayor of St Kilda in 1993. From 1995, he was the executive director of Urban Seed, a Christian organisation which strives to provide hospitality and outreach services to homeless people. In 2004, he was appointed CEO Director of World Vision Australia. He is also a member of the National Aid Advisory Council and in 2005, he was made an officer of the Order of Australia in recognition of his “service to the community through contributions to social justice, health and welfare issues, international development assistance, and to the Baptist Church.”
Jim Kim
Jim Yong Kim trained dually as a physician and medical anthropologist receiving his M.D. and Ph.D. from Harvard University. Dr. Kim holds appointments as François Xavier Bagnoud Professor of Health
24.
He has conducted extensive research into effective and affordable strategies for treating strains of TB that are resistant to standard drugs. While at WHO, Dr. Kim was responsible for coordinating HIV efforts with the TB department. He has been recognized on numerous occasions as a global leader and
John Langmore is an Australian academic and politician. He is a Professorial Fellow in the Political Science, Sociology and Criminology Department at the University of Melbourne. He worked as a lecturer in economics at the University of Papua New Guinea from 1969 to 1973. He was also the former Economic Advisor to the Australian Treasurer and MP for the ACT seat of Fraser in the Australian House of Representatives. From 1997 to 2002, John was also the Director of the UN Division for Social Policy and Development; and Representative of the International Labour Organisation to the UN. At the time of his appointment in 1997, he was the most senior Australian official in the United Nations Secretariat. He has published extensively on political, economic, social and, strategic issues relating to Australia and the global context including the United Nations. His most recent books have been: Dealing with America: the UN, the US and Australia, U of NSW Press, 2005 and To Firmer Ground: Restoring Hope in Australia.
Sir Gustav Nossal
Sir Gustav Nossal studied medicine at Sydney University and later came to Melbourne to work with Macfarlane Burnet in medical research. At the age of 35, he became director of the Walter and Eliza Hall Institute for Medical Research whilst also becoming Professor of Medical Biology at the University of Melbourne. In 1993, he became Chairman of the committee overseeing the World Health Organisation’s Vaccines & Biologicals Program and in 1998 he became the Chairman of the Strategic Advisory Council of the Bill
Bhutan - Male life expectancy: 62; Female life expectancy: 67; Under-5 mortality rate (per 1000): 70;
and Melinda Gates Children’s Vaccine Program.
analysing the role of social and economic development.
He was knighted for his groundbreaking work in immunology and made a Companion of the Order of Australia. He was named Australian of the Year in 2000. Currently, he is Chairman of the Advisory Committee of the Global Foundation. Sir Gus’ influence has formed and shaped the scientific affairs of Australia for three decades, and continues to do so. The Nossal Institute for Global Health at the University of Melbourne was named in his honour.
Elizabeth Reid
Don Palmer
Don Palmer spent 15 years as an Anglican Priest in Melbourne, Mildura, London and Bathurst, where he first became absorbed with Indigenous affairs. He has been CEO of Glass Box for twelve years involved with corporate television and an award-winning documentary film maker. Don was a member of the ABC Advisory Board and was awarded a Winston Churchill Fellowship. He was Chairman of the BCBA – a charitable umbrella group for 22 community organisations on Sydney’s North Shore. Following his experience as a carer during three years of his wife’s dialysis and subsequent transplant, Mr Palmer was involved in developing the Jimmy Little Foundation. The Jimmy Little Foundation was established to help improve kidney health in Aboriginal and Torres Strait Islander communities across regional and remote Australia. Don has experience in health promotion with the NSW Department of Health and is currently a Director of Jimmy Little Projects.
Brett Parris
Dr Brett Parris is a research fellow at the department of econometrics and business statistics at Monash University. He is also the chief economist and team leader for the economics, climate and natural resources team at World Vision. His research interests range from economic development policy, poverty and overseas aid and the interactions between economic development, climate change, conflict and public health on a wider scale. Brett Parris will be participating in the Session of Dialogue “It’s all about the money”, examining and
Elizabeth Reid graduated from Oxford and was working at ANU when she was selected as adviser to Prime Minister Gough Whitlam in the women and child welfare area. During her work with Whitlam, she was the Australian Representative to the United Nations forum on the Role of Women in Population and Development. Elizabeth helped resource community initiatives and women’s services such as women’s refuges and rape crisis centres, stressing the need for all Cabinet submissions to include an assessment of their impact on women. Elizabeth and her work came under extreme pressure, both in the way of accolades and criticism. She attracted a high profile in the media, as well as the hopes, expectations, scrutiny, gratitude and criticism of feminists and women all over Australia. Reid took on ‘quasi-ministerial status’, receiving more letters than anyone except the Prime Minister. Later, she was the founding director and project manager of the UN Asian & Pacific Centre for Women and Development and then Principal Officer in the UN Secretariat for the 1980 World Conference of the Decade for Women. She then worked for USAID and for the Peace Corps based in Zaire, Burundi, Rwanda and Thailand. Additionally, she worked as a consultant on HIV / AIDS strategies, education and policy in Australia, Zaire and the Pacific. Elizabeth moved to New York to work on the UN Development Programme as Programme Director for Women in Development, then as Policy Adviser to the Administrator on HIV/AIDS and Development. From 1992, she was Director of the HIV and Development Programme. Later, she was Resident Coordinator of the United Nations, and Resident Representative of the UNDP in Papua New Guinea. In 2001 Elizabeth was made an Officer of the Order or Australia for her work on women and on the HIV epidemic. In the same year she was also named on the Centenary of Federation Honour Role of Women.
Academic Stream Speakers Stream One: Damien Kingsbury
Associate Professor Damien Kingsbury is Associate Head of the School of International and Political Studies. He teaches Approaches to Political Development, Political Development in South-East Asia, Conflict Resolution and Development. Dr Kingsbury is also a frequent commentator for and contributor on regional political affairs to domestic and international media (e.g. Radio Netherlands, Radio Singapore Inetrnational, The Times Higher Education Supplement, Time magazine, AP, Reuters, The Age, SBS Television, ABC Radio, Voice of America, BBC World Service), as well as writing articles and reviews for journals and other publications, notably The Age and the Australian Book Review. Dr Kingsbury is a regular contributor on Tuesday mornings on ABC774 Jon Faine program, discussing international affairs, and Radio Singapore International’s monthly ‘Eye on Asia’ program. Dr Kingsbury has written and edited or co-edited a number of books, including: ‘Political Development’, Routledge, London, 2007, and ‘Violence in Between: Conflict and Security in Archipelagic Southeast Asia’ (MAI/ISEAS 2005).
Bebe Loff
Associate Professor Bebe Loff is the Head of the Human Rights and Bioethics Unit in the Department of Epidemiology and Preventive Medicine and is currently a Victorian Health Promotion Foundation Senior Research Fellow. She coordinates the Master of International Health and the Master of International Research Bioethics at Monash University. Prior to this, she was responsible for the legislative programmes of Ministers of Health in Victoria. Bebe has worked in various capacities for a number of United Nations agencies including the World Health Organization, the Office of the High Commissioner for Human Rights and UNAIDS. She has been a mem-
Bolivia - Male life expectancy: 64; Female life expectancy: 67; Under-5 mortality rate (per 1000): 61;
25.
ber of several ethical review committees including that of the World Health Organization and the Australian Health Ethics. Additionally, she was an Australian correspondent for The Lancet and a regular human rights commentator.
Tim McCormack
Tim McCormack is the Foundation Australian Red Cross Professor of International Humanitarian Law. He is also the Foundation Director of the Asia-Pacific Centre for Military Law. Tim is a graduate of the University of Tasmania (LL.B. Hons. - 1982) and of Monash University (Ph.D. - 1990) and was the first Australian recipient of a Golda Meir Postdoctoral Fellowship to the Hebrew University of Jerusalem in 1989. In 2003 he was awarded a University of Tasmania Foundation ‘Outstanding Graduate’ Award. He has taught various graduate and undergraduate courses in several Australian Law Schools (Tasmania, Monash, ANU and Melbourne) and at the Universities of Virginia, Auckland and Jerusalem. His special research interests are in the fields of International Humanitarian Law, International Criminal Law, Arms Control and Disarmament and International Law, and the Use of Force. Tim was a National Vice-President of Australian Red Cross (1999-2002) and chaired the Australian Red Cross National Advisory Committee on International Humanitarian Law (1994-2002). In 2001, he was awarded the Australian Red Cross Medal for outstanding volunteer service to the organization. Tim acted as amicus curiae on International Law matters to Trial Chamber III of the International Criminal Tribunal for the Former Yugoslavia for the trial of Slobodan Milosevic from 2002 until the death of Milosevic in 2006. He also provided Law of War advice to the Defence Team for David Hicks from 2003 - 2007. In that capacity he traveled to Guantanamo Bay, Cuba to attend the US Military Commission proceedings against David Hicks in March 2007. He continues to participate with Australian Government delegations to multilateral treaty negotiations in worldwide, including New York, Geneva, The Hague and Rome.
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Bill Williams
Bill is one of the current vice presidents of MAPW (the Medical Association for Prevention against War). His special areas of interest include nuclear weapons, uranium mining, nuclear waste, the health effects of radiation and the underlying roots of violence. Dr Bill Williams first joined MAPW in 1983 out of concern about the nuclear industry, which he saw as the greatest threat to global health. Bill notes that as medical professionals, there is “no point improving the nation’s collective cholesterol level if we poison the earth for our grandchildren.”
Anthony Zwi
Professor Anthony Zwi has a longstanding commitment to promoting evidence-informed humanitarian interventions and health system development in resource-constrained and unstable or fragile settings. His research focuses on community, service and policy responses to natural disasters and conflict, and seeks to facilitate service delivery in fragile states; in the last few years his work has had an emphasis on Timor-Leste, the Solomon Islands, Sri Lanka and Cambodia. He led teams which developed the Health and Peacebuilding Filter, a tool to assess health-related initiatives in conflict-affected settings, and another which studied the performance of the Ministry of Health in Timor-Leste during the recent internal conflict and population displacement. He is the lead investigator of an ARC-funded study examining mental health policy in countries emerging from conflict and disaster; and is co-director of the TimorLeste Health Care Seeking Behaviour Study, currently under way. He is actively engaged in building capacity to conduct research which builds the evidence base to inform healthy public policy, development cooperation, and international and global health more generally. Anthony publishes widely and is a consultant or member of the editorial boards of The Lancet, Global Public Health, Indian Journal of Medical Ethics and Conflict and Health. In addition, he teaches international health and development and supervises a number of research students working on global health issues. He
Chairs the Steering Committee and is an investigator on the AusAIDfunded Knowledge Hub on Human Resources for Health.
Stream Two: Dea Delaney Thiele
Ms Delaney Thiele was appointed CEO of NACCHO (National Aboriginal Community Controlled Health Organisation) in February, 2003. Dea holds a Post Graduate in health Management from the University of Armidale and is currently working towards a Masters in Population Health from Deakin University. She has worked in Aboriginal health for the past 16 years in organisations such as AMS Redfern, the Aboriginal Health and Medical Research Council of NSW and Daruk AMS in Western Sydney. Dea has been an active community member through membership on a range of Boards, including several Aboriginal Community Controlled Health Boards at the Local, State and National level, the Westmead Children’s Hospital and the Western Sydney Area Health Board.
Hugh Heggie
Dr Hugh Heggie has been providing primary health care in some of the most remote Aboriginal communities in the Northern Territory. During that time he has acted as supervisor to medical students, junior doctors and GP registrars often for all learner groups simultaneously. Dr Heggie is currently the Senior GP for Gunbalanya Community Health Centre, Oenpelli West Arnhem Land. Hugh and his team provide medical services to the community of some 1500 predominantly Aboriginal people, including emergency services, acute & chronic disease management and public health programs. Hugh will share his insights into teaching and learning in extremely remote locations when back-up is hundreds of kilometres away and relate the joys, frustrations, challenges and the satisfaction of teaching in a milieu where the roads may be cut due to routine wet season flooding, communications may fail, and there are no x-ray, pathology or specialist facilities available.
Louis Peachey
Bosnia and Herzegovina - Male life expectancy: 72; Female life expectancy: 78; Under-5 mortality rate (per 1000): 15;
Dr. Louis Peachey is a medical educator at the Mount Isa Centre for Rural and Remote Health, teaching undergraduate medicine and pharmacy. He was the Founding President of the Australian Indigenous Doctors’ Association and past President of the Pacific Region Indigenous Doctors Congress. Dr Peachey is a fellow of the Australian College of Rural and Remote Medicine. His research interests revolve around rural, remote and Indigenous health.
Frank Brennan
Father Frank Brennan AO, a Jesuit priest and lawyer, is Professor of Law in the Institute of Legal Studies at the Australian Catholic University. He is also Professorial Visiting Fellow in the Faculty of Law (University of NSW), and has been the Director of the Uniya Jesuit Social Justice Centre in Sydney. He is an Officer of the Order of Australia (AO) for services to Aboriginal Australians (1995), and together with Pat Dodson he shared the inaugural ACFOA Human Rights Award (1996). His contact and involvement with Aboriginal Australians began early in his priestly ministry, when in 1975 he worked in the inner Sydney parish of Redfern with priest activist Fr Ted Kennedy. In 1997, Father Brennan was Rapporteur at the Australian Reconciliation Convention, and in 1998 he was named a Living National Treasure during his involvement in the Wik debate. Subsequently, he was appointed an Ambassador for Reconciliation by the Council for Aboriginal Reconciliation. In 2001-2002 Father Brennan spent 18 months in East Timor as Director of the Jesuit Refugee Service and was awarded the Humanitarian Overseas Service Medal for his work. Frank’s father, Sir Gerard Brennan, was a former Chief Justice of the High Court of Australia.
Stream Three: Waleed Aly
Waleed Aly is an Australian lawyer, prominent writer and Muslim community leader. As a member of the executive committee of the Islamic Council of Victoria and the
council’s head of public affairs, he is a frequent commentator on contemporary religious issues and spokesperson for Australia’s Muslim community. Waleed is regularly invited to address audiences of academics, businesses and community leaders, as well as senior Australian politicians. He was commended in the 2005 Walkley Awards for Excellence in Journalism in the category of Commentary, Analysis, Opinion and Critique.
Richard Di Natale
Dr Richard Di Natale was the lead Senate candidate for the Victorian Greens in the 2007 federal election. He is an international public health specialist and currently works on HIV prevention and drug treatment in developing countries. He has worked as a GP in remote indigenous communities, rural farming communities and urban community health centres. He graduated with a medical degree from Monash University and has a Masters in Public Health and a Masters in Health Sciences. He is a Fellow of the Australian Faculty of Public Health Medicine and a Fellow of the Australian College of Rural and Remote Medicine. Di Natale also runner-up for the position of lord mayor of Melbourne in 2004.
Helen Keleher
Professor Helen Keleher is Head of the Department of Health Science, School of Primary Health Care, at Monash University. Helen’s research has resulted in studies on mental health promotion, health inequalities, gender and social inclusion and building capacity for health promotion in the workforce. Her teaching areas include health promotion, health systems and policy, and community capacity building. Currently, Helen holds an appointment to the Women and Gender Equity Knowledge Network of the World Health Organisation’s Commission on the Social Determinants of Health. She is the immediate past National Convenor of the Australian Women’s Health Network and was convenor of the 5th Australian Women’s Health Conference in 2005. She is a past Vice-President of the Public Health Association of Australia, and is a long-standing member of the Australian Health Promotion Asso-
Botswana - Male life expectancy: 51; Female life expectancy: 52; Under-5 mortality rate (per 1000): 124;
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ciation, the International Union of Health Promotion and Education, and the International Society for Equity in Health.
Tony McMichael
Professor Tony McMichael, medical graduate and epidemiologist, was previously Professor of Epidemiology at the London School of Hygiene and Tropical Medicine (1994-2001). His primary research interest currently focuses on global climate change and human health, and encompasses studies at local, national and international levels. During 2001-2007 Tony was Director of the National Centre for Epidemiology and Public Health. His pioneering research and writing on the health risks of climate change was developed in conjunction with his central role in the assessment of health risks for the UN’s Intergovernmental Panel on Climate Change (1993-2007). He has been an advisor and consultant on environmental health issues to WHO, the UN Environment Program, the World Bank and other international bodies. During 20082009 he is President of the International Society of Environmental Epidemiology.
Roger Short
Based at the University of Melbourne, Professor Roger Short is a highly respected reproductive biologist. He is also professor-atlarge at Cornell University in the United States, and a visiting fellow of Green College, Oxford. In 1989 he was a consultant to the Global
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Program on AIDS of the World Health Organisation in Geneva, where he was involved in designing strategies for the integration of HIV prevention and family planning programs. Roger has published more than 350 scientific papers in a variety of scientific journals. One of his main research interests has been in the transmission of HIV infection where he has focused on the evolution of human reproduction and shed new light on the causes of the human population explosion. He has been actively involved in novel contraceptive research and development in resource-poor countries for over 20 years. He also helped cross a camel and a llama to produce the world’s first “Cama.”
Stream Four Nick Coatsworth
Dr Nicholas Coastworth is one of Médecins Sans Frontières Australia’s most passionate International Field Workers. Most recently returned from Darfur, Sudan where he was Project Coordinator, Nick has also worked with Médecins Sans Frontières in Congo Brazzaville and Chad. Currently Senior Medical Registrar at Royal North Shore Hospital in Sydney, Nick also lectures in Public Health at the University of Western Sydney. Nick writes for a variety of Australian digital and print publications about medical and humanitarian issues and has been widely in-
terviewed by the Australian media on these subjects. Nick was President of the Australian Medical Students Association in 1999.
Paul Komesaroff
Paul Komesaroff is a practising physician and Professor within the Faculty of Medicine at Monash University. He is Director of the Monash Centre for Ethics in Medicine and Society, the Clinical Ethics Service at the Alfred Hospital, and the Health Ethics Archive. He is also a member of the Ethics committees of the International Diabetes Institute, the US Endocrine Society, the Alfred Hospital, Chair of the Scientific and Research Committee of the Australasian Menopause Society, and convener of the Global Reconciliation Network. Additionally, Paul is the Ethics Convenor of the Royal Australasian College of Physicians, and a member of the board of Australians Donate. A passionate educator and student mentor, Paul is extensively involved in the teaching of ethics and the philosophy of medicine at both undergraduate and postgraduate level. He has researched widely and is the author of over 200 peer reviewed articles and 10 books. He is the Chair of the editorial board of the Journal of Bioethical Inquiry, honorary ethics editor for the Internal Medicine Journal, and Editorial associate of ethics for the Journal of Clinical Endocrinology and Metabolism.
Larry Marshall
Larry Marshall is the Project Officer
Brazil - Male life expectancy: 68; Female life expectancy: 75; Under-5 mortality rate (per 1000): 20;
for the Centre for Dialogue where he is responsible for two projects involving the Muslim Community in Victoria. He coordinates the ‘Young Muslim Leadership Training Program’ and the visits by Islamic Scholars to Australia. Larry is also the Project Officer for the ‘International Network of Universities’ (INU) on a project to coordinate a Masters Program in ‘Global Citizenship and Peace’ across eight international partner universities. Larry was born in Sri Lanka. He migrated to Australia in his high school years and studied at La Trobe University where he completed an honours degree in Politics and Economics. He taught commerce and humanities in high schools for ten years and then volunteered to work overseas with ‘Australian Volunteers Abroad’, spending the next four years doing development work in the Philippines. He has worked as a radio journalist in Community Radio and at the ABC. He returned to La Trobe University to take a Masters in Media and Cinema Studies and is currently completing a PhD in International Politics.
Rob Moodie
Professor Rob Moodie is an internationally renowned figure in public health and health promotion, and is currently the Chair of Global Health for the Nossal Institute of Global Health. He was former CEO of VicHealth between 1998 and 2006. He has over 30 years of experience in arranging and executing health promotion programs across Australia, Asia, Africa and the Pacific, which includes working on AIDS’ programs in Cameroon and Uganda and working for MSF within refugee camps in Sudan. He was the inaugural director of country support for UNAIDS. He currently chairs the technical advisory panel of Avahan, the Bill and Melinda Gates Foundations’ HIV prevention program in India.
Stream Five Trevor Duke
Associate Professor Trevor Duke is the Director of the Centre for International Child Health in the University of Melbourne’s Department of Paediatrics. CICH is Australia’s
only World Health Organization Collaborating Centre for Child and Neonatal Health, and works with WHO and country partners, with a focus on improving child survival in developing countries. This involves a program of research, capacity development and training for local health professionals, child health policy and health systems development. CICH is contributing to WHO’s child survival strategy in the Western Pacific region, and leading its global strategy of improving hospital care for children (www. ichrc.org). Areas of the research include acute respiratory infection aetiology and case management, oxygen systems, vaccine preventable disease epidemiology and surveillance, improving the quality of paediatric care in remote hospitals, tuberculosis and neonatal care. Trevor is an Intensive Care Consultant at the Royal Children’s Hospital, and Adjunct Professor of Child Health in the School of Medicine at the University of Papua New Guinea. He believes that the current generation of Australian medical students can make life-long contributions to global health as core parts of their medical ongoing careers.
Helen Durham
Helen Durham is the current Program Director for Research and Development at the Asia Pacific Centre for Military Law (APCML) and a Senior Research Fellow at the University of Melbourne. She currently teaches ‘Women, War and Peacebuilding’ and ‘International Criminal Law’ in the LLM program at the University of Melbourne, where she graduated with a Doctorate of Juridical Science.
She has undertaken short field missions to Myanmar and Aceh. She was part of the ICRC delegation at the negotiations for the International Criminal Court in New York and Rome. She was national manager of IHL in the Australian Red Cross. Currently, she continues to provide advice to the ICRC regarding IHL treaties.
Konstandinos Karapanagiotidis
Kon is a lawyer, Human Rights advocate and the founder and coordinator of the Asylum Seeker Resource Centre (ASRC), Australia’s largest asylum seeker aid, health and advocacy organisation. He has worked with marginalised communities including the homeless, survivors of sexual abuse and asylum seekers for the past 14 years as a social worker, lawyer and educator. Kon has a strong commitment to human rights and social justice and has been advocating for an end to Australia’s inhuman refugee policies. Kon and the ASRC have been recognised for their work with a number of awards including the HREOC human rights award, St Michael’s medallion and PILCH pro bono award for their contribution to human rights.
Deborah Zion
Dr Deborah Zion teaches ethics in under-graduate medicine at Monash Malaysia, and in the Masters of International Research Bioethics, Masters of Public Health, and Masters of International Health. She is the lead investigator for an ARC funded project titled ‘Caring for asylum seekers in Australia: Bioethics and Human Rights” with Associate Professor Bebe Loff, examining issues around health-care practice in the absence of human rights.
Her studies involved research at New York University, the UN and the ICTY in the Hague for which she was a recipient of a Evans Grawemeyer Scholarship and a Queens Trust Fellowship. Before joining the University, Helen was Regional Legal Adviser for the International Committee of the Red Cross (ICRC). This position involved assisting Governments in the Pacific region ratify and implement international humanitarian law (IHL) treaties.
Brunei - Male life expectancy: 76; Female life expectancy: 79; Under-5 mortality rate (per 1000): 9;
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Workshops
Stream One
Workshop 1.1 Small Arms in the Pacific – “Taem to Guns, Hem Finis Nao” This workshop will examine the global problem of small arms proliferation and its impact on health. This will be used as an example of how politics and conflict can destroy the fabric of a community and deprive it of the most basic needs. The focus will be on the civil war in the Solomon Islands which occurred between 1998 and 2003. Delegates will unravel how guns entered communities, how they were used and the effect they had on the lives of villagers caught in the war zone. Additionally there will be discussion of some basic ballistics and gunshot trauma management. Once an understanding of how politics can produce a small arms problem, delegates will distil how it can be ended, also by using political processes. Options will be explored for helping affected communities ‘on the ground’ and for campaigning domestically to have this issue put on the local political agenda. Workshop 1.2 Rebuilding Health in PostConflict Timor-Leste In this workshop delegates will consider the systemic and social challenges of rebuilding a healthcare system in the wake of a complex humanitarian emergency, focusing on post-independence Timor-Leste in 1999. In the first session delegates will identify the key international, government, military and civilian participants in the post-conflict rebuilding process and examine the political process surrounding the reconstruction of a major metropolitan hospital after long-term civil unrest. Working through a guided negotiation scenario we will identify priorities, source and allocate resources, and formulate performance benchmarks. Stu-
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dents can then focus on pathways for health professionals to make meaningful contributions to an emergency response. We will explore practical, ethical and effective pathways for doctors to contribute to the management of a complex humanitarian emergency.
Stream Two Workshop 2.1 Improving Health from Within This workshop will examine the role of Aboriginal Community Controlled Healthcare Services (ACCHS) and their value in providing effective and culturally appropriate community healthcare to Indigenous communities. Delegates will examine and gain an understand of the vital role played by Aboriginal Healthcare Workers in a community health setting, as well as exploring the value of cultural sensitivity training programs for medical staff working in Indigenous communities. This workshop aims to deliver an appreciation of the complex interplay of social, cultural, spiritual and political factors which can impact upon Aboriginal health. The relative values and challenges within Indigenous settings will be explored. Delegates will then seek to compare and contrast existing primary health models within Indigenous communities around the world. We will explore ideas for future models within Australia, whilst questioning the value for the importation and role of these global Indigenous models in Australian Aboriginal health. Workshop 2.2 Transgenerational Impact of Stolen Generations A fictitious scenario of an Indigenous family whose members, both old and young, are impacted by the experiences of Stolen
Generations is presented in an urban Melbourne hospital, during an interaction with the hospital’s Koori Liaison Officer. The factors which affect their social and emotional wellbeing are discussed. In particular, possible reasons for the younger Aboriginal man’s involvement with the justice system will be examined and the long-term effects discussed. Participants are encouraged to seek solutions which can improve the health and social outcomes of this Aboriginal family through empowerment.
Stream Three Workshop 3.1 Lukautim yu yet long AIDS ‘PNG protect yourself against AIDS’ This workshop will allow delegates to participate in discussions surrounding the case of an HIV positive individual in Papua New Guinea (PNG). Through we will explore both contributing factors and consequences of HIV in a social context. Effects on the individual and the broader effects on community and society will be considered. Additionally, delegates will develop a brief understanding of PNG-specific culture and geography, as the case study will be explored with particular emphasis on the effects of geographical location, cultural beliefs, poverty status, social situation and disease progression. We will aim to understand some of the locally significant factors for HIV transmission in PNG including the impact of the poverty cycle on disease progression. Workshop 3.2 Climate Refugees This workshop explores the relatively new concept of climate refugees and the ways in which the changing environment impacts upon the health of individuals and communities. Delegates will explore the effect of climate change
Bulgaria - Male life expectancy: 69; Female life expectancy: 76; Under-5 mortality rate (per 1000): 12;
from the community level to a global level. They will discuss the concept of the poverty cycle and the manner in which variations in climate can exacerbate this. The workshop will also explore issues of rural-urban migration and the problems encountered by such a transition. For the second part of the workshop, delegates will consider practical avenues through which these issues may be addressed.
Workshop 4.2 Global Players in Health This workshop will examine the close connections between malaria and poverty, in particular some of the barriers to accessing healthcare services in developing regions. Delegates will develop an understanding of the major organizations involved in delivering health to developing regions and appreciate some of the economic determinants of healthcare in such settings.
Stream Four Workshop 4.1 Access to Essential Medicines This workshop will examine the global players in the challenges associated with access to essential medicines. It will consider this in the context of antiretroviral medicines and look at the social, cultural, political and economic barriers to accessing these drugs. Delegates will gain an understanding of patents, compulsory licensing, generic drugs, the TRIPS agreement and the Doha declaration. The workshop will delve into further detail by examining a more recent case in Thailand and the opinions and stances of various stakeholders.
Stream Five Workshop 5.1 The Journey of a Refugee Within this workshop delegates will discuss the underlying issues which prompt migration and be able to define the various categories of migrants. We will appreciate the complex social, management and cultural challenges which may arise in refugee camps and the impact of these issues on the health of refugees. Through a hypothetical case study, delegates will also gain a basic understanding of Australia’s current migration policy. The barriers faced by migrants in Australia when accessing appropriate healthcare and
brainstorm ways in which these issues will be examined as well as exploring the various social theories concerning the settlement of migrants into new communities (e.g. assimilation, integration, multi-culturalism) debating the positive and negative aspects of these models. Workshop 5.2 Human Trafficking and Sexual Exploitation Delegates undertaking this workshop will gain an insight into the myriad of cultural, social, political, economic and environmental factors which make people vulnerable to exploitation, trafficking and slavery. Students will appreciate the various grassroots initiatives to assist these vulnerable groups, as well as the various macro initiatives which are campaigning at a national and international level to shift attitudes towards the vulnerable and improve their health outcomes. Exploration of the pros and cons of legalising prostitution will also be explored. There will be discussion of practical initiatives for delegates to actively contribute to, encompassing ways to optimise health outcomes working within the present system and avenues to campaign for change of the system.
Burkina Faso - Male life expectancy: 46; Female life expectancy: 49; Under-5 mortality rate (per 1000): 204;
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: m a r g o r P l a Soci t h g i N y a d s r Thu Entertainment: Monash University World Music Orchestra The Monash University World Music Orchestra is a representation of modern multicultural music in Australia. Playing traditional and modern music from around the world, this ensemble has created its own style by mixing a variety of musical traditions with modern instrumentation and young creative players. The Monash University World Music Orchestra is about creating a culturally integrated, musically sophisticated and artistically evolved Australian musical experience. Truly a group that is not to be missed!
Entertainment: Apollo Jazz Band The Apollo Health Music Society is a student group in the Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne. Now in its seventh year, it comprises
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The 2008 Global Health Conference brings you a vibrant and exciting social line-up to complement our outstanding academic programme. What better way to have fun with the amazing new friends you have made throughout the day! Our social nights are not to be missed, so bring out the dancing shoes and put on those party hats as you experience the finest entertainment Melbourne has to offer!
World of Music Come along to Brunswick Town Hall, truly one of Melbourne’s most beautiful buildings, for a night of musical and culinary delights! Let your ears feast on the sounds of the Monash University World of Music Orchestra while your stomach feasts on the taste sensation that is Lentil as Anything! And just in case you need over 60 medicine, dentistry, physiotherapy and biomedicine students in ensembles such as choir, orchestra, jazz band, fusion band, rock band, chamber strings, chamber choir and chamber winds. Notable performances have included carols in the Starlight Room of the Royal Children’s Hospital and pops concerts at BMW Edge, Federation Square. Members of Apollo are also active in the Australian
to take time out to catch your breath, make sure you check out the amazing electives photo exhibition. To whet your appetite for future global health action, your friendly Global Health Group representatives will be on hand and would love you to stop by and say hi! This is the only place to be to start your conference experience with a bang!
Food: Lentil as Anything Lentil as Anything is a unique establishment among the restaurants of Melbourne: serving a number of inner suburbs, it operates on the principle that the customer pays what they believe the food is worth. In this way, Lentil as Anything is able to assist countless marginalised people who would otherwise be unable to afford meals. In addition, Lentil as Anything provides services such as English tutoring, driving lessons and crisis accommodation to a number of groups in the community. Doctors’ Orchestra. Tonight features the highly sought-after Apollo Jazz Band in its new configuration with first to fourth year medical students who are here to prove that immense musical talent can be found in medical school. Let yourself be carried away by expressive vocals and mellow saxophone solos!
Burundi - Male life expectancy: 48; Female life expectancy: 50; Under-5 mortality rate (per 1000): 181;
Social Program: Friday Night Funky Footwear and Hilarious Hats
Entertainment: Dance Connection
As you delve deep into the back of your wardrobe, you now realise why you bought 3 pairs of clogs from Holland and those 23 Vietnamese farmer hats ... wear them proud as we showcase head and footwear of the world! It’s time to step back and chill out as we bring you some funky, chilled out tunes from local Melbourne artists. Dig into a quality dinner provided by Afghan Gallery before being blown away by the vibrant talent that is Sol Nation – an event not to be missed! And before your night is over, make sure you hit the dance floor as we bring to you dancing, Latin American style!
Entertainment: Sol Nation SOL NATION is more than a band, it’s a meeting of nations and cultures - East Timorese, Indigenous and Australian. Drawing its members from some of Australia’s top world and reggae groups, including Mista Savona, The Dili Allstars and the Briscoe Sisters, Sol Nation embodies Melbourne’s multiculturalism and is a living testament to what can be achieved through music - bridging cultures, languages and borders.
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Dance Connection is a vibrant and dynamic organisation specialising in Latin dancing. Their enthusiastic and energetic teaching is sure to get those hips swinging as you dance the night away (be it Salsa style, Bachata or Cha Cha Cha!) It doesn’t matter if you’re a novice with two left feet or the next Fred Astair, Dance Connection will make Latin seem like a breeze and leave you wanting more!
East Timorese vocalist Paulo Almeida is the voice of Sol Nation, soaring and weaving through the music in a mixture of languages, a product of his life experience living in several different countries during his homeland’s occupation by Indonesia. Languages include English, Portuguese and his mother tongue Tetum. Paulo is supported by the very gifted Indigenous songstress Deline Briscoe, whose rich voice and deep musicality magnify the stories and messages told through Sol Nation’s music. To perform their music live, Sol Nation have brought together an eight piece mixing superb
musicianship with a charismatic stage presence that creates an exuberant, colourful and exciting live show. Stylistically the music draws its influences from Indigenous and Jamaican reggae, traditional East Timorese folksong, African dance music and hiphop. The band has used music to highlight the problems faced by the people of East Timor, and to push for International justice on their behalf. With a strong global conscience and a commitment to presenting high energy and infectious music to audiences around the world, Sol Nation is a unique Australian musical experience.
Burundi - Male life expectancy: 59; Female life expectancy: 65; Under-5 mortality rate (per 1000): 82;
: m a r g o r P l a Soci t h g i N y a d r u Sat
All Things African
It’s hard to believe that your conference experience is nearly over‌but wait: there is still one amazing night of fun to be had! Get along to Ormond Hall for a night of all things African. Dancing shoes, drumming hands and a funky costume are a must for what will be a truly global experience. With African drumming workshops and dancing performances to be enjoyed by all, this night of music and fun will cap off a truly amazing conference and leave you counting down the days until GHC 2009!
EIUJvg Entertainment: Mzuri Dance Company Mzuri Dance Company is a vibrant and exciting performance group specialising in African
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dance and music. Be prepared to be captivated by the rhythm of the drums and the stamping of feet as Mzuri Dance brings a taste of Africa to you. With vast experiences across a number of different events and festivals, Mzuri can make even the most clumsy of us
look like kings of the dancefloor. Mzuri provides both a drumming workshop and interactive dace performance, so bring along your dancing shoes and drumming hands and get ready to shake it African-style on the dance floor! Ungependa kucheza dansi!
Cambodia - Male life expectancy: 62; Female life expectancy: 66; Under-5 mortality rate (per 1000): 89;
A guide to the campus
The University of Melbourne, Parkville Sarah Heynemann, Anny Huang and Emma Leitinger Your host for GHC this year is the oldest medical faculty in Australia. So you say, “I should expect crumbling walls and cadaveric ghosts wandering the halls”? On the contrary, here is an insiders’ guide to the campus ... plus some historical stuff as well, because we are rather proud of our uni. The Med Building (K12)
On the corner of Royal Parade and Grattan streets, see the med building in all its glory. It may be somewhat old and ugly, with elevators which get stuck at least once a day, a common
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room which doesn’t smell quite right, and terrible climate control, but several hundred med students still call it home. The Faculty of Medicine was established in 1862, making it the oldest in Australia. The founder was Anthony Colling Brownless, who now has the biomedical library named in his honour. It was he who decided to change the medical course from four to five years in the hope of providing a better education than in Britain, where the course was four years. More recently the course was extended to six years for undergraduates due to a research year known as “Advanced Medical Science”. In 1999, the curriculum was changed to include the well-known Problem-Based cases, and is now be-
ing changed to all graduate entry; the “Melbourne model”. The Faculty has grown in many ways since it first began nearly 150 years ago. Originally, it was only the Faculty of medicine, but now includes physiotherapy, dentistry, biomedical sciences, behavioural sciences, nursing, and more recently, the schools of population and rural health have also been established.
Old Arts Building (G14)
Despite its name, the Old Arts building is relatively young, being completed a good 70 years after the university was established. It has only become the “old” arts building since the construction of the New Arts or “Babel” building. It has had many uses over the
Cameroon - Male life expectancy: 50; Female life expectancy: 52; Under-5 mortality rate (per 1000): 149;
years, even accommodating the law faculty at one point, but is now back in the hands of the Arts faculty. This lovely building, with its clock tower, quadrangle, and vaulted passages, is the iconic image of Melbourne University, featuring in most of the University’s advertising material, and many happy couples’ wedding photos! The quadrangle was actually built in instalments, the first completed in 1855, and it wasn’t fully enclosed until 1969. It combines private residences for the professors, teaching spaces, accommodation for the Registrar, a council chamber, examination hall, library and museum.
South Lawn (J15)
So this is where all the truly important conferences go on – what is the colour of so-and-so’s ball dress, what did Britney do this time, which team won the soccer. Just don’t walk past on a bad hair day, during semester it is the hotspot of student socialisation during lunchtime – you are just bound to bump into someone!
Union House (E15)
The University Union was founded on the motion of John Monash to ‘unite and bring into closer fellowship the members of the different schools to enable those who have entered upon their professional careers to keep up an active connection with the University, and to promote the common interests of members and the interests of the University’. The aim was undermined somewhat by the refusal of the Medical Students’ Society (formed 1879) to participate. Set up in a poky room on the west side of the Quadrangle building, it published a magazine called the University Review and conducted smoke nights, socials and debates. Women students were granted separate rooms in the east wing to set up a similar body which they dubbed the Princess Ida Club . At much the same time students formed a range of more specialised groups, including the Science Club (1888), the Engineering Students’ Society (1889), Historical Society, Musical Society, Philosophical Society, Law Society, University Militia and Christian Union. If you somehow aren’t getting fed enough by the sumptuous conference catering, Union House holds all things you could want food related. For coffee (and particularly hot chocolate for those not typically attached to a caffeine drip during semester) – Pronto Pizza on
the outside is the place to go. The chicken and sundried tomato paninis are deeelicious and will leave you feeling satisfied. Plus now that you have ticked off your healthy meal of the day, Donut King will treat those of you suffering from Krispy Kreme withdrawal symptoms (if you’re really desperate a short excursion to Melbourne Central is required!). There is even a mini supermarket for the essentials such as the toothbrush you forgot to pack in your last minute rush! However, our personal pick out of all the food outlets at Union House is the Co-op. Located on the second floor of the building, it stocks a wide range of organic vegan pies (the pumpkin and tofu ones are especially nice), burgers and deserts, not to mention an endless supply of yummy warm lentil dhal to warm you up on cold days.
Sports Centre & Beaurepaire Centre (D14-17)
For the sport nuts amongst shuffle on over to the college side of campus for the uni gym. Swim some laps in the pool, work on those biceps in the weights room, shoot some hoops, or challenge someone to hit a shuttle back and forth. Outside is for the up-and-coming Ronaldinos, also a running track and tennis courts. Best to flash a membership card that you swiped from one of your new found Melbourne friends however, as prices have gone up this year due to non-compulsory Student Union membership. Also pack-mentality for midnight outings past Tin Alley advised from resident college students.
Student (O25)
Health
Service
If you find yourself with the sniffles (remember that you are attending a health conference with no fewer than a gazillion med students), the real doctors can be found here.
Castro’s Café (Between Physics and Elizabeth Murdoch Building E19)
Well allegedly this gives Baretto’s a reckoning for the best mocha trophy, also yummy home-made soups, exotic pies, all while soaking up the ambience of good music, funky staff (not my words!) outside in a canopy of green leafy trees. Be sure to try the honky-tonk hot chocolate! It may not be the remedy for the world’s health problems, but it may just be the secret ingredient for the magic happy pill.
University of l a c i d e M e n r u o b l e M Students Society Dear Delegate, On behalf of the University of Melbourne Medical Students’ Society, welcome to Melbourne for the 2008 AMSA Global Health Conference. This year’s conference venue, the historic University of Melbourne, is nestled in one of Australia’s foremost biomedical research precincts and home to the University of Melbourne Medical Students’ Society (UMMSS), one of your two host “medsocs” for both GHC and Convention. Established in 1880 with the aims of arranging lectures on medical topics as well as social functions, UMMSS continues to represent, educate, inform and entertain medical students to this day. With our 1800strong membership encompassing an incredibly diverse range of students, UMMSS is a veritable United Nations of medicine. Our students come from every populated continent on the planet bringing a wealth of experience and insight to an event such as the Global Health Conference. The various medsocs at each of the medical schools provide incredible opportunities to get involved with global health. Many are associated with or function in conjunction with the Global Health Groups (GHG) that make up AMSA’s Global Health Network (GHN). From fundraising, organising volunteer trips, providing lectures and seminars and organising other events, the GHGs are a great way to learn more and provide an avenue to make a real difference.
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If your medical school doesn’t currently have a GHG I urge you to get together with some like-minded individuals and get one running. If you need help, the AMSA GHN members will go out of their way to help make your GHG a success. Even without a GHG, medsocs have a great ability to rally medical students to a cause. For a cause such as global health, there should not be any difficulty in gathering together students with a shared view about how they would like to see the world change. So get in touch with your medsoc, and get working on global health. UMMSS involvement in global health has been boosted recently with the induction of the Local Exchange Officer of IFMSA’s SCOPE Program into the Society’s structure. It is hoped that this new relationship will encourage more of our members to go on international exchanges as well as provide the resources to better support visiting exchange students coming to Melbourne. Being involved with the Medical Students’ Society has inspired me to seek more from my medical degree than just medical training and I have found my extra-curricular activities to be incredibly rewarding. I hope that by attending the AMSA Global Health Conference that you are also inspired and strive to be the great generation that Nelson Mandela has told us we can be. Jonathan Galtieri President The University of Melbourne Medical Students’ Society www.ummss.org.au
Canada - Male life expectancy: 78; Female life expectancy: 83; Under-5 mortality rate (per 1000): 6;
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Let’s stop maternal and child deaths
Act now, so that we no longer live in a world where: • One in every 12 children in Cambodia dies before their fifth birthday. • One hundred times more women lose their lives during childbirth in Timor Leste than in Australia. Inspire your community to help improve maternal health and reduce child mortality.
Take action and join us today at makepovertyhistory.com.au
5526 MPH Child Maternal Health Poster 1706.indd 1
17/06/2008 12:47:04
Melbourne
Raymond Wen Background Unlike other Australian capital cities, Melbourne began its life as an unofficial settlement, owing its existence to enterprising Tasmanian settlers. In June 1835, John Batman and his party landed at a site six miles up the Yarra, and declared ‘this will be the place for a village’ (near the site of the Immigration Museum). Later that
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year, John Pascoe Fawkner’s party (Fawkner and his family not being on board) sailed up the Yarra in their 55 tonne Schooner ‘Enterprize’ and anchored at the site which Batman had earlier chosen and proceeded to construct the settlements first home. And so the five men and a woman of Fawkner’s party became the bona fide founders of Melbourne. It was not until 1837 that Sir
Richard Bourke, the Governor of New South Wales, arrived in present day Melbourne and instructed Assistant Surveyor-General Robert Hoddle to lay out the town. Melbourne’s CBD owes its unique streetscape to that time. Its relatively wide roads owes its existence to Hoddle’s insistence on ninety-five feet wide roads, whilst its unique “Little” streets owe there existence to Governor Bourke, who proposed every sec-
Central African Republic - Male life expectancy: 48; Female life expectancy: 48; Under-5 mortality rate (per 1000): 174;
you could visit while meandering through the streets of Melbourne. • Federation Square is a must. Even if its just to try and walk in heels on the tiles that are laid down everywhere. It has a Melbourne Visitor Centre, providing information to practically anything and everything that is available in Melbourne. An excellent place to start your tour of Melbourne. Right near Flinders St. Station. You’d have to be blind to miss it. • Lose yourself in Melbourne Laneways…meander through the treasure-filled laneways of Melbourne. You never know what you’re going to find! It’s all too easy to lose yourself in their opulent bars and exclusive restaurants that you’ll find. • Want some peace and quiet away from the hustle and bustle? Well you’ll be glad to know Melbourne has world famous gardens minutes away from anywhere in the city! (We are the garden state after all!) Carlton Gardens and the Royal Exhibition Building are World Heritage Listed sites. The Royal Botanic Gardens feature over 10,000 species and 50,000 individual plants. Others worth a mention are the Fitzroy and Treasury Gardens and Royal Park. • If you’re a historical buff, why not visit Captain Cook’s Cottage. Located in the Fitzroy Gardens off of Lansdowne street it has been brought to you all the way from the faraway land of England. There’s also the Old Melbourne Gaol and Ned Kelly’s armour at the State Library of Victoria. • Then there is the Crown Casino/Entertainment Complex. Situated on the banks of the Yarra, it’s made to impress. There’s the added advantage that it’s open 24 hours, 7 days a week while you’ll be in Melbourne. Grab a bite, catch a movie, or window shop through some of the most opulent stores around! Don’t forget to catch a glimpse of the flaming towers on the riverbank at night – on the hour! • Eureka Skydeck - for the brave, make a trip into this glass cube that projects 3 metres out from the building. Let’s not forget to mention you’re 300 metres above ground. Need I say more? Located at Riverside Quay, Southbank
ond street be made a narrow lane. Keep an eye out as you explore Melbourne – those little streets and the lanes branching off them hold real gems!
What to see in Melbourne
Melbourne is renowned as the cultural centre of Australia. There are so many restaurants, bars and theatre productions to visit, as well as museums, art galleries, and shopping complexes If you’re planning to stay longer to soak up the culture here’s a list of some sightseeing places Chad - Male life expectancy: 46; Female life expectancy: 47; Under-5 mortality rate (per 1000): 209;
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• There are Galleries upon galleries in Melbourne. An array of public galleries are scattered around the city ranging from the Ian Potter Centre in Fed Square and NGV International to the Australian Centre for Contemporary Art. Other galleries include the Melbourne Museum situated right next to the IMAX theatre and an abundance of galleries scattered along Flinders Lane. For a more Historical view on Melbourne, visit the Immigration Museum, Maritime Museum and the Gold Treasury Museum. • For the Shopping Lovers amongst you, Melbourne is amazing…Bourke Street Mall, Melbourne Central, DFO are just a few places to shop in the
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city. There’s also Chapel Street, Bridge Road, Chadstone Shopping Centre…the list goes on. For those with expensive tastes, head down to Collins Street to browse through leading international brand-names and other unique and exclusive stores. Don’t forget to explore Melbourne’s network of lanes and arcades for some quirky shops! Selling everything from coins to spells to antique books. • Check out Queen Victoria Market, the largest open-air market in the Southern Hemisphere! • There’s also the Melbourne Zoo and the Melbourne Aquarium for animal enthusiasts • Why not stop off at the Arts Centre to catch a play, production
or musical? • Melbourne is renowned for its restaurants. Rather than listing dozens upon dozens of good restaurants that you have to visit, here are the name of a few restaurant districts; Chapel Street, Brunswick street, Lygon Street, Degraves Street, Flinders Lane… you get the idea Interested in finding out more about what Melbourne has to offer? Visit these websites for more information and start exploring! www.thatsmelbourne.com.au www.visitvictoria.com www.visitmelbourne.com
Chile - Male life expectancy: 75; Female life expectancy: 81; Under-5 mortality rate (per 1000): 9;
Ormond College
Khai Lin Kong Built in 1879 on the 10 acres land allotted to the Presbyterian Church, Ormond College is today easily recognised with its soaring clock tower and imposing stone brick building. Located at the College Crescent of The University of Melbourne, it was named after Francis Ormond, a western district pastoralist in Melbourne, who made generous contribution to the foundation of the College. Since its opening in 1881, the number of residents had risen from a mere 20 to more than 300 today. It currently houses 325 students, local and international,
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as well as 30 tutors and academics. The diversity of students ensures a vibrant and interactive community. Seminars, discussion meetings, debates and visiting speaker programmes are frequently held, forming an interactive platform between students and other academics to discuss issues of current and common concern. Residents from Ormond College have also involved themselves heavily in many sporting and cultural activities. The Choir of Ormond College is internationally renowned for its extraordinary performances in traditional sacred music and new secular mu-
sic in different languages. Formed in 1985, it has since then conducted 11 international tours and produced numerous recordings, from Bach to Britten. This Choir leads the Ormond College chapel service every Sunday and occasionally makes appearances in various public events. Apart from being located close to the university oval and Princes Park, Ormond college has a gym, a netball court and tennis courts. It fields teams in a variety of sports and participates in the competition for the intercollegiate sports trophies—Cowan Cup and Holmes Shield. Other residents also compete at intervarsity, national and international levels.
China - Male life expectancy: 72; Female life expectancy: 72; Under-5 mortality rate (per 1000): 24;
Trinity College
Vivien Li Founded in 1872 by the first Anglican Bishop of Melbourne, Trinity College is the oldest residential college at the University of Melbourne, and is based on the model of the Cambridge and Oxford colleges. It was the first college in Australia to admit females, first as non-residential students in 1883, and then later establishing a women’s residential section, which has now become Janet Clarke Hall. In fact, in 2007, female students comprised the majority of the 1737 students at Trinity College. Approximately 90 academic staff members are also employed by the college as
tutors and lecturers. Among the Trinity alumni are 35 Rhodes Scholars, past Governor Generals and leaders in various fields, such as medicine, science, law and business. The main campus is situated north of the university, but there are several other buildings occupied by staff and students. Facilities available at Trinity include 270 single student rooms each with telephone and internet access, shared bathrooms, Grand Dining Hall, laundry, common rooms, library, art collection, TV lounge, as well as a small gymnasium, squash and tennis courts. Various lecture and tu-
torial rooms are also accessible. One can hardly miss the striking Trinity Chapel, which was built in 1917 and is used for regular services and is home to the Trinity College choir. Surrounding all this are some pleasant gardens and lawns, which can be enjoyed by all Trinity students. Trinity College offers various academic programs for students of all levels. These include the residential programme, Foundation Studies for overseas students preparing for undergraduate university entry, theological school, indigenous initiatives, international summer schools and short courses.
Azerbaijan - Male life expectancy: 71; Female life expectancy: 78; Under-5 mortality rate (per 1000): 21;
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Australian College of Rural & Remote Medicine The Australian College of Rural & Remote Medicine (ACRRM) is the national peak professional body for rural medical education and training in Australia. Following accreditation by the Australian Medical Council and inclusion in Medicare, ACRRM is now a second college of General Practice and provides the opportunity for medical students to train for a career specifically in Rural and Remote Medicine. ACRRM manages a range of exciting student support programs including the popular John Flynn Placement Program, MRB and BMP Support Schemes, and the Prevocational GP Placements Program. For more information on student support, or training as a rural doctor, visit our booth or go to the ACRRM website at www.acrrm.org.au
Exotic Work and Play Let us organise and pay for your next Adventure!
NTGPE organises clinical placements for Australian Medical Students and Junior Doctors in extraordinary Island and remote Aboriginal communities.
s r o t n e M l a c Clini odation m m o c c n A o i t a t Orien l... Trave me i t ss this e l d ike n e Sp ing l l e e f
ture, Challenge, Opportuni Adven ty,
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unity t r o p p O Diversity, Adventure, Challenge, Programs funded by the Australian Government
From the Partnerships Co-ordinator Allow me to introduce you to the team that have created the supporting network for GHC2008. A mix of Monash and Melbourne dedication has seen the fostering of cherished relationships for these three days of phenomenal exchange. Let me explain. To begin with, one may indeed ask what the difference between sponsorship and partnerships is. And so in fact, did I, upon entering the role within this dynamic committee. In fact the difference runs deeper than its superficial glint, and reflects the general ethos of this unique conference. We made it a key endeavour to seek organisations and institutions that value social responsibility, ethical engagement and sustainable program development to actively promote at the conference. As each of us desire those we admire, we drew partnerships based on esteem, and with this aphorism sought to provide a founding basis for the conference. If the academic program is there to put you in touch with great individuals, then the partnerships program is there to put you in touch with organisations. The partners’ safari is there to give you a tour of the institutions that value this conference, that value each of the inspired people who have chosen to come, and whom we value for their energy and engagement. Someone once said that behind every great leader is a great partner. Behind this great event then is a great team and network of support, that it has been a privilege to be a part of. Caitlin Keighley Partnerships Coordinator
The partnerships team (left to right): Tim Lindsay, Hollie Spence, Caitlin Keighley, Mabel Leung, Jasmine Zhu, Nelu Jayawardena (Absent: Tim Fazio, Adam Flavell, David Humphreys, Daniel Yore)
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Congo - Male life expectancy: 53; Female life expectancy: 55; Under-5 mortality rate (per 1000): 126;
Section 2: Issues and Ideas
Health, Conflict & the Political Process
Earned or mediated sovereignty? An assessment Excerpts from an article by Associate Professor Damien Kingsbury Sub-state and separatist conflict, long a feature of the global political landscape, took on a new lease of life in the post-World War II period of decolonisation, and more recently in the postCold War era world, in which previously client states lost their strategic usefulness. Millions of people have been killed in post WWII separatist conflicts, notable among which were those of Biafra (Nigeria), Eritrea, Darfur (Sudan), Bangladesh, Chechnya, Nagorno-Karabakh, Bosnia, Kosovo, East Timor, Sri Lanka, the frontier states of Burma and so on (also see Lacina 2005). Dozens of self-determination movements continue to exist1, many of which employ violence and in some cases practices defined as ‘terrorism’ in pursuit of their claims2. Within this context, there has been considerable effort given to finding methods of resolving such conflict. One such recent method or process is that of ‘earned sovereignty’.
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In that earned sovereignty has been proposed as a standardised method for resolving separatist claims, it has increasingly come to take shape around a core set of ideas. Key characteristics of shared sovereignty are generally claimed to include: 1. being a multi-stage process 2. the sharing of sovereignty, where the state, or an international organization, and the substate entity may each exercise some sovereign authority and functions over the territory in question for a specified period a. the conditional devolution of sovereignty in a given territory through the phasing out of preceding sovereign authority and the phasing in of a replacement sovereign claim b. the conditionality placed upon such sovereignty c. constrained or limited sovereignty (including options for autonomy, federalism or confederation) 3. the necessity of building new institutions or adapting existing institutions prior to the determination of final status, often with the assistance of the internation-
al community, by which a state is able to manifest its organisational capacity 4. a mechanism for the determination of the final status of the territory in question, where the relationship between the existing state and the aspiring state is resolved, usually by a vote of the aspiring state’s population and with the consent and under the supervision of the international community. (Williams and Pecci 2004:4, see also Hooper and Wiliams 2004, Scharf 2003) At its most basic, earned sovereignty entails the conditional and progressive devolution of sovereign powers and authority from a ‘parent’ state to a sub-state entity (the aspirant state) under international, preferably multinational, supervision. Earned sovereignty would generally be available through a peace process as a multi-stage approach to address the issue of the final political status of the sub-state entity, or as a peaceful recognition of the legitimacy of a claim to test sub-state desire for separate status. The case of East Timor can be seen to reflect a number of
Cook Islands - Male life expectancy: 71; Female life expectancy: 75; Under-5 mortality rate (per 1000): 19;
1975 and 1999, Aceh between 1976 and 2005, West Papua from 1969, and as claimed by both the government of Sri Lanka and the LTTE at the time of writing). Beyond these issues (although in some cases overlapping) are, as previously noted, those of what is meant by the term ‘earned sovereignty’, and if the term itself is not at least partially misleading and, to parties to conflict resolution, unhelpful.
elements of ‘earned sovereignty’, through the assertion of a claim, international mediation, a UN supervised monitoring and ballot, international peace-keeping and institution building. As a working definition, therefore, earned sovereignty is intended to act as a ‘compromise between self-determination and the sanctity of borders’ (Graham 2000). Given that, in the postWestphalian period, the sanctity of sovereign borders has been regarded as a foundation stone of international relations (e.g. see Waltz 1979), the notion of such compromise is by definition an anathema to the idea of sovereignty. This ‘realist’ conception of absolute state sovereignty has been qualified or undermined by various aspects of the globalisation paradigm, in particular the globalisation of economies, in which states are subject to externally defined economic patterns, and communications and information/ideas, in which states may be challenged by the spread of and access to ideas that question or challenge their authority. More to the point is that sovereignty being possessed in full or not at all reflects an absolute, somewhat artificial and often arbitrary dualism, and a failure to see beyond the state/secessionist paradigm so described.
Earned sovereignty’s negative aspects
While ‘earned sovereignty’ is a legitimate attempt to work past some of the problems of the state-secessionist dichotomy, it also has a number of negative features. These include it being reliant on international goodwill (which may be undermined by disinterest or ‘realist’ strategic self-interest) and being reliant on the agreement of the sovereign state to in principle dismember its territory (usually in contravention of the state’s constitution)3. Very often, such an agreement is also reliant upon the majority peoples of the state to accept such an outcome (Sri Lanka’s 1987 autonomy bill led to majority Sinhalese rioting (NYT 1987, while Indonesia’s 2006 Law on the Governing of Aceh was a diluted interpretation of the 2005 Memorandum of Understanding peace agreement). A further difficulty is the common and usually unresolved issue of minorities within the proposed new state4. And, not least, there is the problem of a mediated outcome not being the preferred method of achieving independence by the aspirant state (a negotiated settlement as opposed to settlement by force of arms, as had been pursued in East Timor between
In this respect, the term ‘earned sovereignty’ is a literal and theoretical misnomer, as it implies a relationship involving the free (in the sense of will) exchange of goods (labor for goods) or benefits within free exchange or market-type environment. In reality, the exchange rarely happens in a free environment, has few elements of reciprocity and implies goods or benefits largely away from the pre-existing sovereign authority and, other than where the cost of retaining the territory exceeds the benefit of so doing, only towards the ceding state or territory. To this end, a more appropriate descriptor of this process might be ‘mediated secession’. However, given the explicit outcome and the extent to which this would be likely to cause offence, a more subtle but similarly accurate term might be ‘mediated sovereignty’, in that this implies that changes to the status of sovereignty within a standardised process are achieved One of several issues is that the transference of sovereignty, or conditionalities placed around sovereignty, inevitably requires a process of mediation, as noted, by an international actor. This usually also implies some monitoring or peace keeping process and, assuming its success, some institution-building capacity. In this, the role of the mediator is critical in being able to ensure that the negotiating ‘game’ is played by the rules of relative fairness of opportunity to participate, so that the negotiating parties believe they are getting a reasonable opportunity to put
Costa Rica - Male life expectancy: 76; Female life expectancy: 80; Under-5 mortality rate (per 1000): 12;
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their claims and to sustain a position that protects the basic interests of their constituency. In so far as transference of or conditionalities around sovereignty are implied, the mediator has the delicate task of assessing and to some extent adjudicating on what is agreeable, what is practically possible, and what is normatively desirable. In this, the mediator must be able to adjudicate on an ad hoc or needs basis, while maintaining impartiality to all but outcomes that comply with conventional international norms and standards (e.g. upholding basic human rights values, etc).
‘Earned’ sovereignty?
The question arises as to what, precisely, is meant by a term such as ‘earned sovereignty’? There are two answers to this question, the first relying on a semantic but important distinction, which raises a series of further issues, and the second conforming to the generally accepted political process that is intended to be defined by such a term. In the first instance, ‘earned sovereignty’ begs the question of what sovereignty is. In common usage, sovereignty implies that a sovereign authority has the complete capacity to compel compliance with that authority within and over a specified and delineated territory. The definition of territorial boundaries was, historically, not distinct, with this lack of territorial distinction continuing to
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be reflected in separate language or ethnic groups residing in territory claimed on behalf of another ethnic group or within a state with which they do not identify. That is, the formalisation of state boundaries has delineated states in ways which have often included, for purposes of territorial neatness or strategic necessity, pre-existing ethnic minorities. Returning to the idea of sovereignty as the claim of a people to self-determination, or of a nation to a state, raises the first principle questions of what is sovereignty intended to achieve, and for whom, and the second principle question of whether sovereignty once proclaimed and recognised becomes absolute and inviolable? If sovereignty predicated upon ‘the people’ is intended to manifest and protect their interests via self-determination, then in the first instance ‘the people’ themselves must be unified within a common political identity. If this identity is to have meaning, it must be a reflection of their will, that is, voluntary, rather than compelled. If, however, the people are not one but ‘peoples’, and these constituent groups do not regard their interests as being in common and, moreover, occupy a specific and usually contiguous territory, they can reasonably lay claim to a separate sovereignty. With the possible exception of strategic interest – and this would be
“Returning to the idea of sovereignty ... raises the first principle questions of what is sovereignty intended to achieve, and for whom ...” more appropriately negotiated via treaties between parties than compelled inclusion - the claim of a dominant constituent group has no rational prior claim to the territory occupied by another group. Should it assert such a claim, it then undermines the basis of its own claim to territory, and manifestation as a state. That is, if the idea of sovereignty is to assert authority over a specific territory in pursuit of the commonly identified interests of a politically bonded group of people then, short of strategic interest, a state should have little concern over whether or not a geographically specific, differentiated political bonded group within its claimed territory seeks its own territorially based self-determination as a new state. Where claims against this are made, they generally reflect the above noted strategic interest, often combined with economic interest, and the protection of minorities within the claimed territory, as has occurred in Sri Lanka, Aceh, West Papua and Mindanao.
Conflict Resolution?
Recognising that such conflicts arise for what approximates to the above noted reasons, the question arises as how to resolve such claims and, in particular, the violence that is often associated with them. Despite relatively few successful cases of state devolution or dismantling (excluding the USSR, former Yugoslavia and the ‘velvet divorce’ of former Czechoslovakia), a number of models of such devolution have been proposed to either achieve such devolution or otherwise address separatist claims. Most proposed (and actual) conflict resolution processes have involved some type of external mediation, independent monitoring (or peace-
Côte d’Ivoire - Male life expectancy: 62; Female life expectancy: 66; Under-5 mortality rate (per 1000): 89;
making or keeping), institutionbuilding and a ballot to determine the views of the people on whose behalf claims for independence are being made. This may result in grievances being addressed, often through devolved or autonomous authority, or independence. This then brings the process of negotiation back to first principle issues; principally what does each party claim, why do they claim it, and can the underlying concerns that inform their claim be met by an alternative arrangement. In most cases of separatism, the claim for a new state is based on the failure of the existing state to adequately address the legitimate concerns of a territorially specific ethnic group. This is usually as a consequence of the failure of the state to regard its citizens both as equal and their concerns as equally important. This then raises the question of the origins and nature of the state, and whether this can be changed to accommodate the legitimate grievances of separatist claimants, whether there is sufficient capacity to change or trust in such change, or whether the conflict has become so bitterly entrenched that the only option is for a divorce. Assuming no capacity for state change, then divorce, i.e. separatism, may be the only practical option; assuming complete capacity for state change, it is likely that the concern informing separatist claims can be addressed within the radically altered state; and assuming a limited capacity for state change, then partial sovereignty, autonomy, federation or confederation may be an acceptable solution. The proposal put here is that separatist conflict can be resolved through a variation of the ‘earned sovereignty’ approach, and that separatist conflict resolution theoreticians and practitioners may need to spend more time at the drawing board to reconstruct a basic set of principles which might, with a sensitivity for the various nuances, be applied
in a more circumspect mediated environment. This is not to deny, as noted above, the legitimacy of many separatist claims. But it is to note that such claims are invariably contested, and that any mediated resolution model cannot at the outset assume a broad direction, much less a particular outcome. The process, then, requires mediation, and regardless of how the parties resolve their differences and the status of the sovereignty which reflects that resolution, the outcome will be a ‘mediated sovereignty’.
(e.g. East Timor), international pressure or the relative inability to contain or resolve the claims of the separatist movement and the excessive cost implied to the state (e.g. Aceh). 4. This refers to both further minorities as well as residual elements of the original majority, e.g. Sinhalese and Muslims in the claimed Tamil Eelam and Gayo, Alas and ‘transmigrant’ (predominantly Javanese) minorities in Aceh and similar ‘transmigrant’ and economic migrant minorities in West Papua.
Associate Professor Damien Kingsbury is a speaker at the AMSA Global Health Conference 2008. For program and author biographical details, please refer to page 23.
Selected references
Damien welcomes feedback at : damien.kingsbury@deakin.edu. au
Endnotes
1. Assuming no regard, for the capacity of separatist movements, there are almost one hundred separatist movements, with many more parties associated with such separatism (see Broadleft 2005). The Open Directory Project (2008) lists 383 territorial disputes, although many of these could not be claimed as separatist. The UN Unrepresented Peoples’ Organisation has 69 members, although this is not an exhaustive representation of separatist claimants. 2. ‘Terrorism’ can be most simply be described as employing the use or threat of violence to compel a person, people or organization to undertake actions against their wishes. This is generally, although not accurately, applied to non-state actors. 3. Reasons for states voluntarily dismembering or otherwise reaching a negotiated conclusion may include recognition of the inappropriateness of inclusion of the disputed territory (e.g. republics of former USSR, Yugoslavia), lack of international recognition of inclusion or illegality of inclusion under international law
Broadleft 2005. Movements for National, Ethnic Liberation or Regional Autonomy 14 February 2005, http://www.broadleft.org/ natliber.htm accessed 4 March 2008. Graham, L. Self-Determination for the Indigenous PeoplesAfter Kosovo: Translating Self-Determination ‘Into Practice’ and ‘Into Peace’. ILSA (International Law Students’ Association) Journal of International and Comparative Law, 2000. pp 455-465. Hooper, J. and Williams, P. 2003. ‘Earned Sovereignty: The Political Dimension’ Denver Journal of International Law No 31, 2003. Lacina, B. 2005. ‘Understanding and Explaining the Severity of Civil Wars’, paper presented at the annual meeting of the International Studies Association Honolulu, Hawaii, Mar 05, 2005. Scharf, M. 2004. ‘Earned Sovereignty: Juridical Underpinnings’, Denver Journal of International Law and Policy Vol 31, No 3, 2004. Waltz, K. 1979. Theory of International Politics McGraw-Hill, Columbus. Williams, P. and Pecci, F. 2004. ‘Earned Sovereignty: Bridging the Gap between Sovereignty and Self-Determination’, Stanford Journal of International Law Vol 40, No. 10. 2004.
Croatia - Male life expectancy: 72; Female life expectancy: 79; Under-5 mortality rate (per 1000): 6;
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Indigenous Health
My People Are Dying Don Palmer Tjungurrayi Jimmy Little Foundation
The last group of Australian Aboriginals to encounter white culture walked out of the vast Gibson Desert in 1984. They were greeted by one of their own, a Pintupi Aboriginal Health worker named Marlene Nampitjinpa. She still works in her traditional country some six hundred miles west of Alice Springs. Today diabetes, heart disease, kidney disease – a tsunami of chronic diseases of unparalleled proportions – is shaking her people, the most ancient of all cultures, to the core. I asked Marlene what message would she like carried to the people at this conference. She said, “Please tell them: ‘My people are dying’”. Today, in hundreds of remote communities, people suffer from poor education, severely restricted opportunities, racism and appalling health. While people in Third World nations like Ghana
and Morocco risk death to try to flee their impoverished countries to find a better life, the Pintupi, Pitjantjatjra, Walpari and Arrente and others refuse to move from their Country. In any other society where there was such extreme social disadvantage and endemic injustice, people would leave their land and become refugees. But this is not the case in Central Australia. For these people feel so deeply connected to their Country that if they do not “sing it up” then not only have they failed in their timeless responsibility, but the land itself will cease to be. At the heart of this sense of connectedness is the message that the Western world is just now painfully realising. There is one planet – some say “one Mother” - and unless we exercise our global citizenship then there is no future for mankind. The people of the desert have always known this, and it is one of many things we can learn from them.
However our national record of learning from our Indigenous people is not impressive. Recent responses to the shameful crisis in Indigenous communities have repeated, almost perfectly, the known mistakes of previous failed projects; one solution for every situation, no consultation, denigration of the elders, compulsion, no clear definition of what success would look like and inadequate resources to support the health of communities in the short and long term. During the ill-conceived Health Intervention of the previous Federal Government, which has the continued support of the current government, there was a program of mental health checks. Of just over one thousand checks five people were recommended for follow up. Two were already receiving treatment. The others were people who were part of the team and were so disturbed by what they saw that they requested psychiatric counselling.
Cuba - Male life expectancy: 76; Female life expectancy: 80; Under-5 mortality rate (per 1000): 7;
The reports were stacked in a cupboard in Alice Springs awaiting someone who could actually make sense of the information. Once again we see the relentless phenomenon of these people being measured, evaluated, researched but with no outcome for them. The famous eye surgeon Dr Fred Hollows had a simple policy: no survey without service. The importance of this simple and powerful approach is still not fully respected. Every researcher, be they medical, ethnographical or anthropological, ought to give at least as much as they get, probably even more. There are already health workers – doctors, nurses and others - who are doing extraordinary things in the heart of this nation. They have to fight for every dollar and every resource to even approach providing the health equity and health justice that most Australians think is available to everyone. Until recently
there was only one nephrologist in Alice Springs. His case load was over three hundred – about ten times the usual case load. Down the road the Pintupi people and their friends have to sell curries in the street market to help them pay for their own dialysis services. All of these people are remarkable on any measure. More remarkable people are required not only to deliver culturally appropriate health care, but also to lobby state and federal government to make this nation become a just and equitable one as quickly as possible. Otherwise Marlene Nampitjinpa’s worst fears will surely come true.
“Recent responses to the shameful crisis in Indigenous communities have repeated, almost perfectly, the known mistakes of previous failed projects...”
Don Palmer is a speaker at the AMSA Global Health Conference 2008. For program and author biographical details, please refer to page 23.
Cyprus - Male life expectancy: 79; Female life expectancy: 79; Under-5 mortality rate (per 1000): 4;
Indigenous Health
INDIGENOUS BY DEFINITION, EXPERIENCE OR WORLDVIEW Professor Chris Cunningham and Professor Fiona Stanley AC The word “indigenous” has a number of common usages that differ from the dictionary definition which is literally “to be born” in a specific place1. These common usages have tended to define indigenous by the experiences which a group of peoples share, experiences which are often in sharp contrast to other groups of peoples who may now reside in the same countries. Certainly around the Pacific Rim, indigenous peoples such as Australian Aboriginal and Torres Strait Islanders, Kanaka Maoli of Hawai’i, Samoan, Tongan, Tuvaluan and other Pacific First Nations Peoples, and the Māori of New Zealand, have a disturbingly similar pattern of health and social status which contrasts with the largely dominant (in num-
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bers) populations in their countries. As Professor Ring and Dr Brown describe in their editorial2, it is Australian Aboriginal and Torres Strait Islanders for whom the greatest differences exist. Yet even in countries where Indigenous people fare much better, such as in Canada, USA and New Zealand, differentials persist, with the New Zealand Pakeha (European) population continuing to make gains in terms of both life and health expectancy3. Around the world a number of alternative nouns are preferred to the word “Indigenous”. In Australia where Indigenous people lived for at least 40,000 years prior to invasion and colonisation, the term Aboriginal and Torres Strait Islander (ATSI) is appropriate and acceptable. In Canada and the United States, the term First Nations is used in reference to the Indian, Metis and Inuit populations, where-
as in Hawai’i the term Native Hawai’ian still finds favour. Of course many groups prefer their own language, the Māori of New Zealand use “Tangata Whenua” or “people of the land” in preference to the usual “Māori”, which was brought into common usage by the colonising Victorian English who, unaware of the meaning, ironically deemed the indigenous population to be the “ordinary” inhabitants, rendering themselves extra-ordinary in the process4. The cultural renaissance experienced by many indigenous peoples has resulted in the use of local names of identification, which serves both to increase a sense of self and reinforces a connection to prior heritage, as well as educating the dominant populations about this important part of their history. This practice has been incorporated into an increasing tendency to acknowledge tradi-
Czech - Male life expectancy: 73; Female life expectancy: 80; Under-5 mortality rate (per 1000): 4;
tional indigenous ownership by many non-indigenous people, for example, at meetings where local indigenous people give a welcome to a particular piece of land in local language and non-indigenous people acknowledge their former ownership. Yet this preference for associating indigenous peoples with their land may hold the best clue to a galvanising definition. A recent Māori recipient of a prestigious Churchill Fellowship, Dr Te Ahukaramu Charles Royal5, offers an attractive definition of indigenous people based on what he terms “worldview”: “’indigenous’ is taken to mean those cultures whose worldviews place special significance or weight behind the idea of the unification of the human community with the natural world.” Royal contrasts three major worldviews: Western, Eastern and Indigenous. A (Judeo-Christian) Western worldview tends to see God as external, with man being made in (his) image and God in (his) Heaven ‘above’. In contrast an Eastern worldview tends to focus internally and concentrates on ‘reaching within’ through meditation and other practices. Based on his research, Royal asserts that the authentic indigenous view is neither of these. Rather, indigenous worldview takes definition from the relationship with the world (whenua in Māori terms) and sees people as organically integral to it, with humankind having a seamless relationship with nature - seas, land, rivers, mountains, flora and fauna.
“... very little has been achieved on the ground, and [our] experience is that the threats to indigenous people are growing rather than diminishing.”
Photo: Geoffrey Harper
If we accept that Indigenous people have an integral association with nature, then it is easy to see the validity of an argument which has been presented by many people. This argument, which is included in the editorial by Foliaki and Pearce6, suggests that the dislocation of most Indigenous peoples from their lands through colonisation has compounded the effects of introduced diseases on health outcome. The direct linkages between the current health status of ATSI people in Australia and the various practices that followed invasion/colonisation and the removal of people from land and culture are well established7. That this pattern is so similar across all colonised indigenous groups is one rationale for having a dedicated theme issue of the journal devoted to Indigenous health. We believe it vital that there is
a much greater understanding of these linkages by those currently trying to develop appropriate solutions and services to improve Indigenous outcomes. In Australia, there is currently a debate about “symbolic” versus “practical” reconciliation8,9, with the latter approach suggesting that it is best not to acknowledge the history and its influence on current outcomes, and to move forward to improve living conditions and other activities to enhance well being in ignorance of the root causes. There is now a significant body of evidence from many indigenous research groups to show that the most effective programs are those which acknowledge the devastating impact of removal of people from their land, removal of children from their families (and from their culture) and the marginalization of people from accessing any of the advantages of the dominant
Democratic People’s Republic of Korea - Male life expectancy: 64; Female life expectancy: 68; Under-5 mortality rate (per 1000): 55;
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Photo: Laura Port
culture (education, employment) which would have enabled them to participate and control their own lives 10,11,12. This is evidence of the major importance of the social determinants of health and how they have impacted intergenerationally on these populations - seen again and again in all colonised Indigenous groups. The similarity of the patterns of alcohol abuse, domestic violence, high rates of preventable infections now rarely seen in developed countries such as rheumatic fever, very high rates of “lifestyle“ diseases particularly Type II diabetes and heart and renal disease, is just extra-ordinary. It is basically seen in every colonised Indigenous population studied as described by Foliaki and Pearce in their editorial6. Indigenous birth rates are higher than those of their dominant populations and their population pyramids are similar to those seen in developing countries, with high deaths rates in middle age and older people and large numbers under 15 years. This will translate into
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larger proportions of Indigenous people in these countries which makes the need for preventive and life enhancing services even more urgent. We believe that it is vital that sustainable solutions to Indigenous health problems must address and acknowledge this history. Many indigenous populations now have a diverse profile13, although the level of integration with other populations varies greatly. While the First Nations peoples of North America have been concentrated on reservations, Australia’s Aboriginal and Torres Strait Islander population and Māori are significantly more integrated within the populations of their countries. Many Pacific nations are still dominated by their indigenous populations within their island states. Yet diversity, and distance (both geographic and genealogical), do not lessen the attachment of indigenous peoples with their lands and their worldviews. Neither is their distinctiveness lessened; many groups assert their difference and a renaissance of language and culture is being demonstrat-
ed, for example in the education system in New Zealand from preschool (Te Kohanga Reo) through to university (wananga)14. Sadly, this is not the case in some areas of Australia with frightening evidence emerging that the culture and language of the Aboriginal and Torres Strait Islander peoples is disappearing or has disappeared. August, 2004 will mark the end of the United Nations Decade for Indigenous People. The anniversary this year was celebrated in England with the launch of a report on health and well being among indigenous peoples15. This research report reflects the views of the less-well researched indigenous peoples from Laos, Cambodia, Guatemala, Burma and Namibia. It concludes with emphasis somewhat critical of the decade: “very little has been achieved on the ground, and [our] experience is that the threats to indigenous people are growing rather than diminishing. While global and national policies are needed, there is also a need
Democratic Republic of the Congo - Male life expectancy: 46; Female life expectancy: 49; Under-5 mortality rate (per 1000): 205;
for action now.” Increasingly, we witness indigenous-led approaches to health research and health service provision based on indigenous methodologies and worldviews. Some approaches incorporate many contemporary and western developments; still others prefer a return to more ‘authentic’ cultural delivery employing traditional medicines and practices such as spiritual and traditional healing approaches. These are vital issues for the development of effective services to improve health, wellbeing, educational success and participation of Indigenous peoples. This theme issue focuses on indigenous people, indigenous health and indigenous health research. The indigenous experience can be described as ‘distinct yet diverse’, many similarities are obvious, such as the disparity in health outcomes and the experience of colonisation, yet significant differences can be identified. This theme issue is an opportunity to share these similarities and differences, to learn from the ways that have been most effective to improve outcomes. It is this sharing of experiences, voices and models for development that need to be transferred among nations to move rhetoric into action for indigenous peoples everywhere. Reprinted from the Student British Medical Journal (2003; 11: 349-392) with permission from the authors. Professor Chris Cunningham is of Ngati Toa and Ngati Raukawa. He is the Director of the Research Centre for the Maori Health and Development at Massey University, New Zealand. He also serves on a number of committees concerned with Maori health and research. Professor Fiona Stanley AC is CEO of the Australian Research Alliance for Children and Youth and the Director of the Telethon In-
stitute for Child Health Research. In addition, she is the UNICEF Australian ambassador for Early Childhood Development and a lecturer in paediatrics and child health at the University of Western Australia. She was one of the key contributors in the international collaboration that discovered the link between folic acid in pregnancy and spina bifida in babies. She has also worked in indigenous health and public health for many years. Professor Stanley was named Australian of the Year in 2003.
References
1. Allen RE, editor. The Concise Oxford Dictionary of Current English. London: Clarendon Press; 1990. 2. Ring I, Brown N. The health status of indigenous peoples and others. BMJ. 2003 Aug 23;327(7412):404-5. 3. Ajwani S, Blakely T, Robson B, Tobias M, Bonne M. Decades of Disparity - Ethnic Mortality Trends in New Zealand 1980– 1999. Wellington: Ministry of Health; 2003. 4. Williams HW. Dictionary of the Māori language. 7th, reprinted 1992. ed. Wellington: Government Print Publications; 1994. 5. Royal TAC. Indigenous Worldviews - A Comparative Study. Wellington: Te Wananga-o-Raukawa; 2003 Contract No.: Document Number. 6. Foliaki S, Pearce N. Changing pattern of ill health for indigenous people. BMJ. 2003 Aug 23;327(7412):406-7. 7. Preparatory Committee for World Conference. Indigenous Peoples and Racism: The Report of the Regional Meeting of Indigenous Peoples of Australia, New Zealand, Canada, Hawaii and the United States held at Sydney, Australia, 20-22 February 2001.; 2001 Contract No.: Document Number. 8. Council for Aboriginal Reconciliation. Roadmap for Reconciliation. http://www.austlii.edu.au/au/ other/IndigLRes/car/2000/10/; 1999 [updated 1999; cited]; Available from: http://www.austlii.edu.au/au/other/IndigLRes/
car/2000/10/. 9. Editorial. Jackie Huggins: The Symbolic and the practical. The Australian. 2003. 10. Human Rights and Equal Opportunity Commission. Bringing Them Home: Report of the National Enquiry into the Separation of Aboriginal and Torres Strait Islander Children From Their Families. Sydney: Human Rights and Equal Opportunity Commission; 1997 Contract No.: Document Number. 11. Gordon S, Hallahan K, Henry D. Putting the Picture Together, Inquiry into Response by Government Agencies to Complaints of Family Violence and Child Abuse inAboriginal Communities. Perth: Department of Premier and Cabinet; 2002 Contract No.: Document Number. 12. Aboriginal Affairs Planning Committee. Royal Commission into Aboriginal Deaths in Custody: Government of Western Australia Implementation Report. Perth: Government of Western Australia. 13. Durie MH. Ngā Matatini Māori: Diverse Māori Realities. A Paper Prepared for the Ministry of Health. Palmerston North: Department of Maori Studies, Massey University; 1995 Contract No.: Document Number. 14. Durie MH. Te Mana, Te Kāwanatanga: The Politics of Māori Self-Determination. Auckland: Oxford University Press; 1998. 15. Health Unlimited. Utz´ Wach´il: health and well being among indigenous peoples. London: Health Unlimited; 2003.
Denmark - Male life expectancy: 76; Female life expectancy: 81; Under-5 mortality rate (per 1000): 4;
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Indigenous Health
Australian Indigenous Health: the gap Nick Cominos The University of Sydney With the first sitting of the Rudd Labour Government, Australian Indigenous affairs have again been thrust into the spotlight and, given the alarming facts that attest to an enormous gap in socioeconomic equality, not a moment too soon. Nowhere is this inequality felt more acutely and urgently than in Indigenous Health. The life expectancy of Aboriginal and Torres Straight Islander Australians stands 17 years below that of the general population, and in the period 1999-2003, there were three times as many deaths from all causes amongst Indigenous Australians. Infant mortality is three times higher than for the general population, and low birth weight and malnutrition are not uncommon, setting children on a ‘back foot’ when it comes to health and wellbeing later in life.
Other areas requiring urgent improvements include children’s health, mental health and women’s health and primary prevention. Following his formal apology to the stolen generation on Februrary 13, 2008, Prime minister Kevin Rudd pledged to tackle the enormous challenges facing Indigenous Australians by setting up a bipartisan ‘war cabinet’ to be led by himself and the leader of the opposition. The most ambitious and significant goal of this taskforce is ‘to close the gap in life expectancy within a generation’,
over a period of 35-40 years. Why does this ‘gap’ exist, and what went wrong? The reasons are historical, political, socioeconomic and cultural, and are closely related to parallel problems with education and accommodation. Broadly speaking, Governments have varied their responses to the problems facing Indigenous Australians, swaying between policy objectives that reinforce a right to ‘self determination’ and those which seek to limit harm and regulate undesirable outcomes such as crime, alcoholism and welfare dependence.
Photo: Megan Hamilton
Diabetes, respiratory disease, cardiovascular disease, infectious diseases, and alcohol and drug related conditions ranging from cancer to accidents and injuries, are all major causes of morbidity and mortality amongst adults in this population.
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Djibouti - Male life expectancy: 53; Female life expectancy: 58; Under-5 mortality rate (per 1000): 130;
Though negatively characterized as ‘laissez-faire’ and ‘paternalistic’ politics respectively, many Indigenous leaders now agree that the way forward lies somewhere in the middle: rights of self determination must be balanced by shared responsibilities. The impact of policy shifting, combined with the loss of cultural identity and removal from family that has resulted from government actions in the past, contributes to alcoholism, antisocial behaviour and feelings of helplessness and despair. Socioeconomically, many Indigenous Australians feel (and indeed are) excluded from the effects of our vibrant and developing economy and our growing ‘resources boom’. They are disadvantaged in fields such as property and assets, employment levels and income and in some areas, as a result of the former Howard Government’s relatively recent and controversial Northern Territory intervention, have had their rights to spend income restricted. Socioeconomic disadvantage and accompanying educational disadvantage, with and without subsidies and welfare, invariably leads to limited health care resources and under-use of existing health care services. Many Indigenous Australians live in cramped, ‘developing world’ conditions, without adequate sanitation and cooking facilities. Many cannot or do not purchase appropriate clothing and footware for themselves and for their dependents. Under these conditions, infectious diseases, malnutrition and unhealthy behaviour can lead to respiratory illness, cardiovascular disease, diabetes, low birth weight of infants and many other conditions. Finally, cultural factors are also relevant to health. Indigenous communities, numbering thousands across Australia, have varying beliefs and practices when it comes to health care, caring for the sick, choosing and administering medicines and therapy and delivering palliative care to the sick and dying. These beliefs can be very different to western ap-
proaches in medicine and health care delivery, and when not carefully discussed, accounted for, incorporated into protocol and respected by governments and health care workers, they can form the basis of a ‘cultural divide’ and add to mistrust, misunderstanding and under-use when it comes to primary care, hospitals and public health initiatives. So what can we do to help? Broadly speaking, at the level of policy, goal should be to continue the process of reconciliation, thereby improving trust through consultation with Indigenous communities, and sharing property, knowledge, rights and responsibilities. For the above reasons, a boost in health care resources alone cannot ‘close the gap’. That being said, three specific health goals aimed at closing the life expectancy ‘gap’ would be: 1) An urgent increase in the number of health care workers (particularly with regard to priority areas: GPs, Paediatrics, Women’s Health, Drug and Alcohol, Allied health etc) ‘on the ground’, that is, where they are needed most, in disadvantaged communities. 2) Immediate improvements in accommodation, employment opportunities and education in disadvantaged communities. 3) Community consultation, evaluation and information in the field of public health and epidemiology, with corresponding increases in cost-effective public health campaigns aimed at primary, secondary and tertiary prevention. As would be the case with any enormous challenge, these goals are interlinked. ‘Closing the gap’ is a task from which Australians cannot afford to disengage, leaving the work to Governments, health care workers and Indigenous Communities.
cal student, can help achieve this goals now:
1. Raise awareness of the
issues in your own communities, and amongst peer groups.
2. Look into and support campaigns aimed at closing ‘the gap’.
3. Contact your Universi-
ty’s medical program curriculum unit and request more coverage of Indigenous Health issues.
4.
Familiarize yourself with the fascinating, vast and varying histories and cultures of Indigenous Australians.
5. Get up to date on con-
temporary Indigenous issues, using a variety of media (the web, radio, television, papers, meetings and so on).
6.
Spend your elective term in the field of Indigenous health.
7. Set up or become part
of an on- or off-campus awareness/fundraising/ advocacy group.
8.
Get as much clinical experience as possible with Indigenous Patients.
9.
Get as much experience and knowledge as you can in the field of Indigenous Public Health.
10.
When you graduate, choose a career in Indigenous Health!
Here are ten ways you, a medi-
Dominica - Male life expectancy: 72; Female life expectancy: 76; Under-5 mortality rate (per 1000): 15;
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Culture and Environment, and its Impact on Health
Behind the World Food and Nutrition Crisis: A Long History of Pushing Nature Beyond Limits Professor Tony McMichael Most public and policy discussion about food production and marketing is in relation to economic and commercial issues, and consumer safety issues. In developed countries we take our food supplies for granted. Yet to live in an era of relative food abundance is, in long historical terms, an extraordinary experience. As for all other animal species, the basic hunter-gatherer Homo sapiens is a species that views food as sustenance and survival, not as commodity. Food shortages, nutrient deficiencies and periodic famines have long been widespread experiences for humans. Indeed, many of our behavioural
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and metabolic tendencies – to relish sugar and fat, to overeat in response to visual cues, and to store surplus food energy as adipose tissue – reflect survival-enhancing selection pressures from ancestral experiences in a world of precarious and variable food supplies.1 Those same tendencies, in modern wealthy societies, have become the source of much of the non-communicable chronic diseases that now prevail. Thus, the health risk, for many, has become easy access to too much energydense food, in place of earlier situations of too little food. Yet there is no guaranteed continuation of this abundance. The year 2008 brought widespread surprise and shock at
the looming food shortage for the world’s still-growing and higher-consuming population. World food prices (especially of rice and other cereal grains) have risen dramatically, recently, as production levels, global stocks and the willingness to trade essential grains have declined. This global food crisis may well indicate that, for the first time, humankind faces ecologicallydefined limits to food security at the global level. The UN’s World Food Program anticipates a growing inability to maintain current feeding levels and an increase in the number of under-nourished and hungry people.2 That number has already crept up over the past ten years, from around 800
Dominican Republic - Male life expectancy: 66; Female life expectancy: 65; Under-5 mortality rate (per 1000): 29;
million to around 820 million.3 This remains a huge, global, public health challenge – and the current crisis is an ominous signal of non-sustainability. At the time that the ‘food crisis’ was unfolding, the World Bank and the UN released coincidentally a comprehensive report of the International Assessment of Agricultural, Science and Technology for Development.4 This massive report concluded that radical reform of the world’s food production methods is needed; while our production methods barely match population growth, they are doing increasing environmental damage. That is, those methods are not sustainable – and would almost certainly become even more widespread and damaging as world population grows. The global human population has increased from one billion in the 1820s to 6.7 billion today. A total of nine billion by 2050 is projected.5 All readily farmed land has been pressed into use, and much of it has been degraded. There are no major new regions to occupy (other than by clearing more rainforest) – although climate change may extend potential farmland to higher latitudes. Freshwater supplies are over-exploited and declining in many regions – and, in a warming world, the loss of mountain glaciers and snow-fall will further reduce river flows. Meanwhile, the replacement of small farm-holdings and crop diversity with broad-acre monoculture farming has diminished the genetic versatility and resilience of world agriculture.4,6
“To live in an era of relative food abundance is, in historical terms, an extraordinary experience ... yet there is no guaranteed continued abundance.”
This stretching of environmental resources beyond limits is part of a longer narrative. Throughout the ages humans everywhere have exploited the local food-producing environment to the limit of its carrying capacity (i.e., the population size sustainable over, at least, the near term). With advances in culture and increases in environmental intervention, food systems have become increasingly intensified and productive – and the duly expanded populations have then become dependent on that level of continued production. Often, however, those systems have failed.1,6 The taming of fire over half a million years ago enabled meat and fibrous tubers to be cooked, chewed and digested. This increased the carrying capacity of the local environment – and yielded more hunters. Gains in tool-making and hunting skills, greater numbers of hunters, and wasteful exploitation of food sources wiped out many large edible species during the later millennia of the Old Stone Age (around 15-40,000 years ago). Those species losses, plus the environmental changes as Earth warmed after the last glaciation (from around 15,000 years ago), necessitated intensive harvesting of local plant foods and the do-
mestication of amenable animal species in many regions. Farming thus evolved in various regions from around 10,000 years ago, and human numbers began their next upwards surge. This surge was further amplified by the emergence of large, socially stratified, urban populations, able to exploit the rural peasantry. The development of food trade between early city-states allowed yet further regional population increases. In many regions farm yields were inherently precarious, vulnerable to weather reversals and to eventual exhaustion from over-exploitation of forest, soil and water.1 The greatest population surge of all, in absolute terms, resulted from the second agricultural revolution beginning in late eighteenth century, via mechanization and, then, the huge one-off bonus of fossil carbon energy. Our immediate forebears, not needing to account for the units of energy input required nor for the longer-term environmental and climatic consequences, have created a modern bonanza of food – and human numbers have increased around eight-fold since around 1800. Now, however, there is growing world-wide evidence that we face limits to future gains.2,4 There are several generally recognised com-
Côte d’Ivoire - Male life expectancy: 70; Female life expectancy: 76; Under-5 mortality rate (per 1000): 24;
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ponent causes: the rising costs of fuel-energy and (hence) fertilizers, the diversion of arable land from food to biofuel production, the impacts of climate change in some regions as drying trends emerge, the rapid increases in meat consumption as consumer preferences change in developing countries, and speculation and hoarding via international futures markets. And, in the background, population numbers are rising. Those various causal factors are interconnected – and climate change is playing an increasing contributory role. The looming oil shortage, the switch into biofuels, and changes in regional rainfall patterns are part of the climate change narrative. That, in turn, is a consequence of the now widely-shared expansionary drive to generate wealth, nurture national population growth, clear land, intensify trade, foster larger consumer markets, and achieve gains (for some, if not yet for all) in material comfort and convenience. The related rapid rise in levels of meat production presents a major environmental and climatic threat – the latter via the very large volume of greenhouse gas emissions from that sector.7 The UN Food and Agricultural Organization, in 2006, labelled this prob-
lem as Livestock’s Long Shadow.8 The oft excessive consumption of meat – evident in developed countries and, increasingly, in developing countries – also requires a great diversion of plantbased food energy (especially grains); much caloric energy is lost in converting feed-grains to edible meat. Indeed, much of the world’s grain production is now fuelling either the tanks of cars or the stomachs of ruminant livestock. Global climate change, with its manifest risks to human health and survival, stands out as the world’s most clearly defined and recognized large environmental issue.9 Meanwhile, the world’s growing difficulties in maintaining food security underscore the wider systemic challenge that we all face, globally, in seeking a sustainable way to live, with sustainable numbers. Professor Tony McMichael is a speaker at the AMSA Global Health Conference 2008. For program and author biographical details, plese refer to page 26.
References:
1. McMichael AJ. Human Frontiers and Disease: Past Patterns, Future Uncertainties. Cambridge: Cambridge University Press, 2001.
2. Sheeran J. The challenge of hunger. The Lancet 2008; 371: 180-81. 3. Food and Agricultural Organization. The State of Food Insecurity in the World, 2006. Rome: FAO, 2007. http://www.fao.org/ SOF/sofi 4. World Bank and UN World Food Program. IAASTD (International Assessment of Agricultural, Science and Technology for Development) Report. Washington, DC: World Bank, 2008. http:// www.agassessment.org/ 5. UN Population Division (Department of Economic and Social Affairs). World Population Prospects: the 2006 Revision. See: http://esa.un.org/unpp 6. Wright R. A Short History of Progress. Melbourne: Text Publishing, 2004. 7. McMichael AJ, Powles J, Butler CD, Uauy R. Food, livestock production, energy, climate change, and health. The Lancet 2007; 370: 1253-63 8. Food and Agricultural Organization. Livestock’s Long Shadow. Rome: FAO, 2006. http://www. fao.org/docrep/010/a0701e/ a0701e00.htm 9. World Health Organization. World Health Day, 2008: “Protecting Health Against Climate Change”. http://www.who.int/ world-health-day/en/
Egypt - Male life expectancy: 66; Female life expectancy: 70; Under-5 mortality rate (per 1000): 35;
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Culture and Environment, and its Impact on Health
Global environment change and health: impacts, inequalities and the health sector Professor Tony McMichael Human actions are changing many of the world’s natural environmental systems, including the climate system. These systems are intrinsic to life processes and fundamental to human health, and their disruption and depletion make it more difficult to tackle health inequalities. Indeed, we will not achieve the UN millennium development health goals if environmental destruction continues. Health professionals have a vital contributory role in preventing and reducing the health effects of global environmental change.
Problems of focus
In 2000 the United Nations set
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out eight development goals to improve the lives of the world’s disadvantaged populations. The goals seek reductions in poverty, illiteracy, sex inequality, malnutrition, child deaths, maternal mortality, and major infections as well creation of environmental stability and a global partnership for development. One problem of this itemisation of goals is that it separates environmental considerations from health considerations. Poverty cannot be eliminated while environmental degradation exacerbates malnutrition, disease, and injury. Food supplies need continuing soil fertility, climatic stability, freshwater supplies, and ecological support (such as pollination). Infectious diseases cannot be stabilised in
circumstances of climatic instability, refugee flows, and impoverishment. The seventh millennium development goal also takes a limited view of environmental sustainability, focusing primarily on traditional localised physical, chemical, and microbial hazards. Those hazards, which are associated with industrialisation, urbanisation, and agriculture in lower income countries, remain important as they impinge most on poor and vulnerable communities. Exposure to indoor air pollution, for example, varies substantially between rich and poor in urban and rural populations. And the World Health Organization estimates that a quarter of
El Salvador - Male life expectancy: 67; Female life expectancy: 75; Under-5 mortality rate (per 1000): 25;
the global burden of disease, including over one third of childhood burden, is due to modifiable factors in air, water, soil, and food. This estimated environment related burden is much greater in low income than high income countries overall (25% versus 17% of deaths - and widening further to a twofold difference in percentages between the highest and lowest risk countries). Heavy metals and chemical residues contaminate local foods, urban air pollution causes premature deaths, and waterborne enteric pathogens kill two million children annually. These relatively localised environmental health hazards, though, are mostly remediable. Meanwhile, a larger scale, less remediable, and potentially irreversible category of environmental health hazard is emerging. Human pressures on the natural environment, reflecting global population growth and intensified economic activities, are now so great that many of the world’s biophysical and ecological systems are being impaired. Examples of these global environmental changes include climate change, freshwater shortages, loss of biodiversity (with consequent changes to functioning of ecosystems), and exhaustion of fisheries. These changes are unprecedented in scale, and the resultant risks to population health need urgent response by health professionals and the health sector at large.
“... a quarter of the global burden of disease, including over one third of childhood burden, is due to modifiable factors in air, water, soil, and food.”
Fig 1 | Relations between human induced global environmental changes affect health and social policy responses. True primary prevention (path 1) reduces or eliminates the human pressures on environment. A more defensive type of prevention is attained through adaptive interventions to lessen risk (path 2), particularly in vulnerable communities
Who will be affected
The health effects of global environmental change will vary between countries. Loss of healthy life years in low income African countries, for example, is predicted to be 500 times that in Europe. The fourth assessment report of the Intergovernmental Panel on Climate Change concluded that adverse health effects are much more likely in low income countries and vulnerable subpopulations. These disparities may well increase in coming decades, not only because of regional differences in the intensity of environmental changes (such
as water shortages and soil erosion), but also because of exacerbations of differentials in economic conditions, levels of social and human capital, political power, and local environmental dependency. These differential health risks also reflect the wider issue of access to global and local “public goods.” Most of the world’s arable land has now been privatised; stocks of wild species (fish, animals, and wild plants) are declining as population pressures and commercial activities intensify; and freshwater is increasingly
Equatorial Guinea - Male life expectancy: 46; Female life expectancy: 47; Under-5 mortality rate (per 1000): 206;
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becoming subject to market pricing. Social policies should therefore pay particular attention to the health inequalities that flow from unequal access to environmental fundamentals. Availability of safe drinking water illustrates the point about access to what, historically, was common property: 1.1 billion people lack safe drinking water, and 2.6 billion lack basic sanitation. Beyond diarrhoeal disease, water related health risks also arise from chemical contamination such as arsenic as a cause of skin pigmentation, hyperkeratosis, cardiovascular disease, neuropathy, and cancer.
Role of social conditions
The relation of environmental impoverishment to health risks and inequalities is complex. Environmental degradation impairs health, while health deficits (for example, malnutrition or depletion of the workforce from AIDS) can amplify environmental mismanagement. This causes inequalities in both health endangering exposures and health outcomes. India provides a good example of the complexity of these relations. The country’s average life expectancy is relatively low but is expected to improve with industrialisation and modernisation. Industrialisation is contributing to the rapid increase of coal burning in India, and the resultant addition to global emissions and climate change amplifies health risks worldwide. These health risks will affect the world’s most vulnerable populations.
“... the predicted drying in sub-Saharan Africa could increase the incidence of HIV infection, as impoverished rural farming families move to cities where conditions foster sex work and unsafe sex.” 74.
The risks to population health from environmental change have far reaching implications for prevention strategies (fig 1). Global changes result in loss of natural resources. Resolution of these risks therefore requires a different approach from that used for the more familiar challenges presented by time limited and reversible local environmental contamination.
Climate change and health
Human induced global climate change is now an acknowledged reality. We have taken a long time to recognise the resultant health risks, current and future, and their unequal effects around the world, but the topic is now attracting much attention. Risks to health will arise by direct and indirect pathways and will reflect changes in both average climate
conditions and in climatic variability. The main risks are: • Effects of heat waves and other extreme events (cyclones, floods, storms, wildfires) • Changes in patterns of infectious disease • Effects on food yields • Effects on freshwater supplies • Impaired functioning of ecosystems (for example, wetlands as water filters) • Displacement of vulnerable populations (for example, low lying island and coastal populations) • Loss of livelihoods. Extreme weather events, infection, and malnutrition will have the greatest health effects in poor and vulnerable populations (box 1). In sub-Saharan Africa over 110 million people currently live in regions prone to malaria
Eritrea - Male life expectancy: 61; Female life expectancy: 65; Under-5 mortality rate (per 1000): 74;
epidemics. Climate change could add 20-70 million to this figure by the 2080s (assuming no population increase, and including forecast malaria reductions in West Africa from drying). Any such increase would exacerbate poverty and make it harder to achieve and sustain health improvements. Some links between climate change and human health are complex. For example, the predicted drying in sub-Saharan Africa could increase the incidence of HIV infection, as impoverished rural farming families move to cities where conditions foster sex work and unsafe sex. The recent report of the Global Environmental Change and Human Health project gives a good summary of the major categories of current and predicted health effects of global environmental changes other than climate change.
Roles for doctors and other health professionals
The spectrum of potential strat-
egies to reduce health risks is wide, commensurate with the diversity of threats to health posed by climate change and other global environmental changes. Local policies and actions, both to mitigate environmental change at source and to adapt to existing and unavoidable risks to health, will often need support from health attuned policies at provin-
Box 1 | Africa and climate change Africa is very vulnerable to climate change because of other environmental and social stresses. The economy depends critically on agriculture, which accounts for two thirds of the workforce and up to half of household incomes and food. • Climate models predict regional increases in mean temperatures of several degrees centigrade by 2100, a decline in summer rainfall in southern and northern Africa and some increase in west and east Africa. Drying, plus the demands of population growth and economic development, will exacerbate regional water scarcity • Falls in crop yields due to 1-2°C warming by 2050 would add an estimated 12 million additional Africans to the 200 million currently undernourished • Extreme events such as flooding change will affect food availability by damaging roads, storage, and markets—floods in 2000 in Mozambique damaged about 10% of farmland and 90% of irrigation, displaced two million people, and affected up to 1.5 million livelihoods (mostly in poor rural areas) • Livestock viral diseases such as east coast fever, foot and mouth disease, blue tongue virus, Rift valley fever are climate sensitive. Regional increases in temperature and rainfall could affect tsetse fly habitat and hence trypanosomiasis in livestock • Climate change and agricultural downturn in Africa may force populations to move, generating conflicts over territory. Pastoralists forced to search for grazing land because of wells drying up may partly explain the Darfur crisis in Sudan
cial, national, and international levels. For example, community programmes to mosquito-proof houses will need to be reinforced by improvements in the national surveillance of infectious diseases and in outbreak warning systems. Doctors and other health professionals have particular knowledge, opportunity, and, often, political leverage that can help ensure—through advocacy or direct participation—that preventive actions are taken. Actions include promoting public understanding, monitoring and reporting the health effects of environmental change, and proposing and advocating local adaptive responses (box 2). Various websites list and discuss actions for doctors to take, both individually and collectively (box 3). For example, the US Centers for Disease Control and Prevention lists 11 functions for the public health system and practitioners for responding to climate change. And Doctors for the Environment Australia has run a successful, continuing, national campaign of patient education by distributing posters and pamphlets for use in doctors’ waiting rooms.
Adaptive strategies to lessen health risks
Many local actions can be taken
Estonia - Male life expectancy: 67; Female life expectancy: 79; Under-5 mortality rate (per 1000): 6;
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Box 2 | How health professionals can promote adaptive strategies • Public education, especially through healthcare settings such as doctors’ waiting rooms and hospital clinics • Preventive programmes—eg, vaccines, mosquito control, food hygiene and inspection, nutritional supplementation • Health care (especially mental health and primary care) for communities affected by environmental adversity • Surveillance of disease (especially infectious disease) and key risk factors • Forecasting future health risks from projected climate change • Forecasting future health risks and gains from mitigation and adaptation strategies • Health sector workforce training and in-career development Strategies that extend beyond health sector: • Early warning systems for impending extreme weather (eg, heat waves, storms) • Neighbourhood support schemes to protect the most vulnerable people • Climate-proofed housing design, urban planning, water catchment, and farming practices • Disaster preparedness, including capacity of the health system to reduce the vulnerability of communities and populations. These will vary considerably between different regions of the world, and in relation to prevailing socioeconomic conditions and available resources. During Australia’s recent prolonged drought (2001-7), some rural health doctors reported that fostering and supporting communal activities (community choirs, social gatherings, financial advisory networks, etc) increased local resilience against depression associated with loss of livelihood. Climate change and other large scale environmental changes are unlikely to cause entirely new diseases (although they may contribute to the emergence of new strains of viruses and other microbes that can infect humans). Rather, they will alter the incidence, range, and seasonality of many existing health disorders. Hence, existing healthcare and public health systems should provide an appropriate starting point for adaptive strategies to lessen health effects.
Preventive action Although
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adaptive
strategies
will minimise the effects of climate change, the greater public health preventive challenge lies in stopping the process of climate change. This requires bold and far sighted policy decisions at national and international levels, entailing much greater emissions cuts than were being proposed a decade ago. Scientists have concluded that we need to prevent atmospheric carbon dioxide concentrations exceeding 450-500 ppm to avoid the serious, perhaps irreversible, damage to many natural systems and ecological processes that a global average temperature increase of 2-3oC would cause. This requires early radical action
“ ... community programmes to mosquitoproof houses will need to be reinforced by improvements in the national surveillance of infectious diseases and in outbreak warning systems.” as today’s concentrations are approaching 390 ppm (compared with 280 ppm before industrialisation). Health professionals, acting through citizens’ or professional organisations, have both the opportunity and responsibility to contribute to resolving this momentous issue. Improving awareness of the problem is the first step. Since 1993, doctors from 14 countries (including six low income countries) have had a central role in the Intergovernmental Panel on Climate Change’s assessment of the health effects of climate change. We should also add this topic, including its relevance to health professional activity, to the medical curriculum. The health sector, meanwhile, must minimise greenhouse gas emissions from its own infrastructure, especially hospitals. Health researchers should act to
Box 3 | Environmental websites helpful for doctors and other health professionals Centers for Disease Control and Prevention (US) (www.cdc.gov/nceh/climatechange) Doctors for the Environment Australia (www.dea.org.au) Global environmental change and human health project (www.essp.org/en/joint-projects/health.html) Intergovernmental Panel on Climate Change (www.ipcc.ch) International Society of Doctors for the Environment (www.isde.org) Medact UK (www.medact.org/env_climate_change.php)
Ethiopia - Male life expectancy: 55; Female life expectancy: 58; Under-5 mortality rate (per 1000): 123;
minimise greenhouse gas emissions from their own studies.
Conclusion
The Stern report, in 2006, highlighted the potentially great damage to the world’s economic system from unconstrained climate change. The greater risk, however, is to the vitality and health of all species, including humans, if current trends continue to weaken the earth’s life support systems. The health professions have a crucial role in promoting public understanding of this fundamental association and health protecting responses to it. Professor Tony McMichael is a speaker at the AMSA Global Heealth Conference 2008. For program and author biographical details, please refer to page 26. Reprinted from the British Medical Journal (2008; 336: 191-194) with permission from the author.
References:
1 McMichael AJ. Population health as the ‘bottom line’ of sustainability: a contemporary challenge for public health researchers. Eur J Public Health 2006;16:579-81. 2 UN. Millennium development goals. New York: UN, 2000. 3 Butler CD, McMichael AJ. Environmental health. In: Levy B, Sidel V, eds. Social injustice and public health. Oxford: Oxford University Press, 2005:318-36. 4 WHO. Fuel for life: household energy and health. Geneva: WHO, 2006. 5 Zhang J, Smith K. Household air pollution from coal and biomass fuels in China: measurements, health impacts, and interventions. Environ Health Perspect 2007;115:848-55. 6 Prüss-Üstün A, Corvalán C. Preventing disease through healthy environments. Towards an estimate of the environmental burden of disease. Geneva: WHO, 2006. 7 Intergovernmental Panel on Climate Change. Climate change 2006: impacts, adaptation and vulnerability. Cambridge: Cambridge University Press, 2007.
8 Corvalan C, Hales S, McMichael AJ. Ecosystems and human wellbeing: health synthesis. Geneva: WHO, 2005. 9 McMichael AJ, Butler CD. Emerging health issues: the widening challenge for population health promotion. Health Promot Int 2006;21(suppl 1):15-24. 10 WHO/Unicef Joint Monitoring Programme for Water Supply and Sanitation. Meeting the MDG drinking water and sanitation target: the urban and rural challenge of the decade. Geneva/New York: WHO/Unicef, 2006. 11 Karim MM. Arsenic in groundwater and health problems in Bangladesh. Water Res 2000;34:304-10. 12 Hassan MM, Atkins PJ, Dunn CE. Social implications of arsenic poisoning in Bangladesh. Soc Sci Med 2005;61:2201-11. 13 McMichael AJ, Woodruff RE, Hales S. Climate change and human health: present and future risks. Lancet 2006;367:859-69. 14 Haines A, Kovats RS, Campbell-Lendrum D, Corvalan C. Climate change and human health: impacts, vulnerability, and mitigation. Lancet 2006;367:21019. 15 Hulme M, Doherty R, Ngara T, New M, Lister D. African climate change: 1900-2100. Climate Res 2001;17:145-68. 16 Desanker P, Magadza C, Allali A, Basalirwa C, Boko M, Dieudonne G, et al. Africa. In: McCarthy J, Canziani O, Leary N, Dokken D, White K, eds. Climate change 2001: impacts, adaptation, and vulnerability. Cambridge: Cambridge University Press, 2001:433-67. 17 Desanker P, Justice C. Africa and global climate change: critical issues and suggestions for further research and integrated assessment modeling. Climate Res 2001;17:93-103. 18 Parry ML, Rosenzweig C, Iglesias A, Livermore M, Fischer G. Effects of climate change on global food production under SRES emissions and socio-economic scenarios. Global Environ Change 2004;14:53-67. 19 Hirji R, Johnson P, Maro P, Matiza-Chiuta T. Defining and
mainstreaming environmental sustainability in water resource management in southern Africa. Washington, DC: World Bank, 2002. 20 Baylis M, Githeko A. The effects of climate change on infectious diseases of animals. London: UK Government Foresight, 2005. 21 Barrios S, Bertinelli L, Strobl E. Climatic change and rural-urban migration: the case of subSaharan Africa. J Urban Econ 2006;60:357-71. 22 Abdalla A. Environmental degradation and conflict in Darfur: experiences and development options. Addis Ababa: University of Peace, 2006:87-94. 23 UN Environment Program. Darfur. a post-conflict assessment. Nairobi: UNEP, 2007. 24 Earth System Science Partnership. Global environmental change and human health: science plan and implementation strategy. www.essp.org/fileadmin/redakteure/pdf/GEC_HHSciPlan.pdf. 25 Frumkin H, Hess J, Luber G, Mahlay J, McGeehin M. The public health approach to climate change. Am J Public Health (in press). 26 Sustainable Trials Study Group. Towards sustainable clinical trials. BMJ 2007;334:671-3. 27 Stern N. The economics of climate change: the Stern review. Cambridge: Cambridge University Press, 2007.
Fiji - Male life expectancy: 66; Female life expectancy: 72; Under-5 mortality rate (per 1000): 18;
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The “Big Guys”
A GLOBAL REFLECTION Professor Rob Moodie The world is decidedly an unfair place. Which country we live in, and where we fit into the social and economic landscape in that country will most likely have a profound impact on how we live and how healthy we are. The United Nations (UN) and the still wonderfully inspiring Declaration of Human Rights were borne of the rubble of a global war. They were borne of a collective desire to make the world a fairer and better place. Were these efforts worth the investment and has the world benefited? The report card says yes, but the student must do better! Millions of people have risen out of poverty and there have been some spectacular increases in life expectancy. A terrible global disease eradicated and many others dramatically curtailed. The body charged with health of the globe is the World Health Organisation (WHO). It is a huge responsibility. But, as WHO itself recognises health is much more than what microbe we may have contracted, so many others organisations play a key role in our health, such as United Nations Children’s Fund (UNICEF), the United National Development
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Program, the United Nations Population Fund, the World Bank, the Global Fund for AIDS, TB and Malaria, let alone the United Nations Office on Drugs and Crime, the World Food Programme, the Food and Agricultural Organisation and the United Nations Environment Programme. And as we shall see below it may be the World Trade Organisation that has the most important impact on the health of our globe. As the different arms of the United Nations system have become more specialised and complex it has become increasingly difficult for it to act as a united and integrated whole. A problem not unlike our own national and state governments. An example was the advent of AIDS. It resulted in the creation, 10 years ago, of the Joint United Nations Programme on AIDS (UNAIDS) to coordinate the world’s response to the multifaceted challenge of HIV. More recently, large private philanthropic organisations such as the Bill and Melinda Gates Foundation, Atlantic Philanthropies and the Bloomberg Initiative have added new and generally welcomed contributions to the global mosaic of health organisations. Some of the most brilliant, inspir-
ing and genuinely compassionate people have and do work with WHO, as they work for the other UN organisations. But others have become mired in a bureaucracy that still has six regional fiefdoms where jobs are dependent on patronage, and merit has yet to be the top selection criteria. National governments complain, but when changes are suggested to anachronistic structures and systems it is some of these same governments, the member states, who resist. Working for the UN is complex – it is like being in an administration where there are 200 members of Parliament but no formal political parties. In the first few years of the UNAIDS existence it felt like being at a dysfunctional family’s Christmas dinner – all the UN agencies knew they had to be around the table, but under real sufferance! Despite this, in my view, we need the UN and organisations like the WHO. If we shut them down today, we would need to create like organisations tomorrow. Just as we need effective and transparent national governments we need effective and transparent international government. A major determinant of our global health is global capitalism. Don’t
Finland - Male life expectancy: 76; Female life expectancy: 83; Under-5 mortality rate (per 1000): 3;
get me wrong I’m not against business. After all one of the best things someone can do for their own health is get a productive job. Similarly if there is no wealth creation, there would be no public health, nor would there be any foreign aid without industry. I am just against exploitative, nasty businesses – the tobacco industry and the land mines industries are two to start with. It is very hard to say that either is needed nor do they have any redeeming features whatsoever. I happen to be writing this when teaching in the Master of Public Health course at Eduardo Mondlane University in Maputo, Mozambique. It is fascinating to see the British American Tobacco at work here. They have just released, with great fanfare, their corporate social responsibility strategy - while producing a product that if taken as directed will kill half the people who use it!
And I am against industries that show no restraint – junk food and junk drink industries, pharmaceutical and alcohol industries – where only the commercial bottom line and the shareholder return really count. And it is in developing countries where the unfairness really kicks in. They have the greatest need for investment, whilst having least national regulation. This leaves them the least control over some of the most errant businesses. The creation and maintenance of a health workforce is one of the most unfair features of our globe. If you can pay then you can attract. A journalist friend was in the outer reaches of Malawi, and she asked the paramedic who ran the AIDS clinic, where all the doctors were? The answer: “Manchester”. Surely Australia should be training our own health workforce. Otherwise every doctor we recruit from South Africa
and even the UK directly or indirectly drains the brains out of an already dramatically depleted health workforce in sub Saharan Africa. Where’s the morality, let alone the fairness in this? And then we give overseas aid – giving with one hand and taking with the other. The world is not fair. The UN is not perfect. This to me is all the more reason that we should engage with the wonderfully rich and varied globe that we happen to be spending time on. There are truly great people in very corner of the globe – find them and work with them. By listening, by being respectful, by learning and by giving we can leave the world as a better place. Professor Rob Moodie is a speaker at the AMSA Global Health Conference 2008. For program and author biographical details, please refer to page 27.
France - Male life expectancy: 77; Female life expectancy: 84; Under-5 mortality rate (per 1000): 5;
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The “Big Guys�
Diabetes and the CocaCola Era in Kenya David Liew University of Melbourne In a country where the only way to get ahead in life is by foot, the growing threat of diabetes in Kenya is taking an enormous toll. While sub-Saharan Africa often conjures up images of malnutrition, HIV and tuberculosis, type 2 diabetes in countries like Kenya is causing an increasing burden of disease. Unsurprisingly, developing-world aspiration and its consequences on lifestyle in Kenya go some way to explaining this rising threat. Through my limited time on elective in Nairobi, I was able to get a sense of the deeplyrooted elements in Kenyan society which underlie this disturbing trend. What I saw in the hospital one day into my first Kenyan foray provided me with a stark contrast to the home comforts I left behind. My first ward round took me past patient after patient with debilitating foot ulcers eating through to bone - a far cry even
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from the specialised diabetic foot unit where I had clerked patients in Melbourne. That specialised unit, with its multi-disciplinary approach, prides itself on only resorting to amputation in 11% of cases, approximately half the rate of those treated in the general health system. Even with fine medical staff in a missionsponsored hospital, not a single one of the patients I saw on that ward round on my first day in Kenya avoided amputation. There is no doubt that developing-world access to medical staff, poor monitoring and poor diabetic control for the majority contributes to the severity of the pathology; a disregard for appropriate footwear (barefoot on rocky ground) must be a factor as well. However, to borrow from some well-worn medical wisdom, it is important to look beyond the diabetic feet and to look at the people with diabetes. In a country where diabetes virtually did not exist twenty years ago, where did all the diabetes come from?
It is not just in the hospital where pathology exists; the hints of the rising tide of diabetes are everywhere. One cannot pass by any heartland Nairobi medical clinic without noticing hand-painted signs proclaiming the availability of blood sugar testing for those who can afford it. More prominent than this are the ubiquitous red-and-white signs plastered on the roadside everywhere. CocaCola has an undeniable grip on the soul of Kenya, a grip which seems to bring most Kenyans pride. An hour-and-a-half after landing in Nairobi for the first time, Kenyan hospitality took me to a middle-class wedding celebration and it was here that the place in Kenyan society that the Coca-Cola company and its products hold became perfectly obvious to me. Not only were CocaCola soft drinks the beverages of choice, displayed ornamentally on the high table, but key to the formalities was the ceremonial mixing of Coca-Cola and Fanta to show the inseparability of the couple.
Gabon - Male life expectancy: 56; Female life expectancy: 60; Under-5 mortality rate (per 1000): 91;
Photo: David Liew
“... it is important to look beyond the diabetic feet and to look at the people with diabetes. In a country where diabetes virtually did not exist twenty years ago, where did all the diabetes come from?�
it should anchor a health promotion strategy that Kenya should treat as a priority if it does not wish to face an increasingly large health burden that would have significant economic and societal consequences.
Seeing soft drinks so prominently involved in such an important moment in the lives of two everyday Kenyans helped me open my eyes to the pervasiveness of Coca-Cola and the prestige associated with it which I would be constantly reminded of for the duration of my trip. I was fortunate enough to visit some more remote areas with the development aid organisation I volunteer for, Global Aid Partnerships, and often drinking water would not be available but Coca-Cola would be. I was offered CocaCola at the houses of the rich and the houses of the poor. Even at the airport amongst traditional wooden carvings for sale I spotted an intricately carved CocaCola bottle. Coca-Cola rules the roost without discriminating for class or tribe. It unifies Kenyan society with dreams of the good times that Coca-Cola advertising has a tendency to reference so readily. The country might be divided on politics, mobile phone carrier and football team but the presence of Coke is somewhat reassuringly ever-present. It is easy for foreigners to lap up such symbols of familiarity in an otherwise starkly different culture and to even become nostalgic over the glass bottles and retro labels which
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seem stuck in the same 1960s time-warp as downtown Nairobi’s architecture. The more unpleasant reality is that, with culturally imperialistic overtones, CocaCola embodies desirability in a society aspiring to a Western, and particularly American, life. And with this blind reliance on Coca-Cola comes an almost unlimited exposure to the harmful effects of simple sugars in the bloodstream. Like remote Aboriginal communities for whom Coca-Cola subsidised for transport costs contributes to highly increased rates of type 2 diabetes, there can be no doubting that, for all strata of Kenyan society, Coca-Cola’s dominance leads to the same. But what can be done? Even a simple bridging solution such as sugar-free colas would face significant barriers. Coca-Cola Light, as it is known, is derided in the face of the ‘big man’ attitudes which run through the fabric of the Kenyan mentality. At best, Kenyans consider it pretentious, at worst, a sign of weakness. Promoting better nutrition, in particular water and vegetables in lieu of the Kenyan staples of Coca-Cola, chips and nyama choma (the Kenyan national dish of barbequed meat), might seem like a far-off dream for a country with significant societal problems. The reality is that
Despite these barriers, inspiration might be drawn from the way Kenya dealt with the last great threat to the nation’s health. Over the last couple of years, the prevalence of HIV has apparently halved from approximately 13% to 6%, no mean feat given the laudable government policy of fully subsidising anti-retrovirals. This has largely been achieved through an extensive public education program, correcting myths, encouraging openness and promoting safe sex methods. Cartoons were used to remove the perceived dour edge from the message, giving it more street credibility and less the feel of a school lecture. This campaign is evidence that public health education campaigns can be successful in Kenya and there is no reason why some change, bridging or otherwise, cannot be achieved on a wide scale. In recent months, violence related to the result of the Kenyan general elections, which I was privileged enough to observe during my elective visit, appeared to be causing a threat which loomed over Kenyan society and looked to be signalling possible widespread genocide and civil war. Through a carefully-engineered intervention, change is being effected and hope is possible. A carefully crafted response could also provide a similar outlook for the fight against type 2 diabetes. Kenya may face an increasing potential health burden secondary to Coca-Cola’s special place in Kenyan society but, with appropriate focus, there might be reason for hope. For more information about electives in Kenya or Global Aid Partnerships (GAPS) email david. liew@gaps.org.au or visit www. gaps.org.au.
Gambia - Male life expectancy: 57; Female life expectancy: 61; Under-5 mortality rate (per 1000): 114;
The “Big Guys”
Aid: A Crash Course Dr Hamish Graham What do you think of when you read about ‘aid’? For many it conjures up images of the work of non-government organisations (NGOs) such as Medecins sans Frontieres (MSF) or World Vision. However, despite the prominence of such NGOs, they account for a tiny amount of aid (less than 10%) when viewed alongside government contributions.
Terminology
Most discussions about ‘aid’ are actually referring to that which originates from governments. This is correctly termed official development assistance (ODA). Countries that contribute ODA are members of the Organisation for Economic Cooperation and Development (OECD). The OECD provides an avenue for discussion and collection of official aid statistics. ODA can be given ‘bilaterally’ (government to government) or ‘multilaterally’ (government to multilateral institution). The latter institutions then distribute funds as subsidised loans according to certain criteria.
Definition of Aid
The OECD Development Assistance Committee (DAC) defines aid as follows : Those flows to developing countries and multilateral institutions provided by official agencies, including state and local governments, or by their executive agencies, each transaction of which meets the following tests: (a) It is administered with the promotion of the economic development and welfare of developing countries as its main objective. (b) It is concessional in character, and conveys a Grant Element of at least 25%. The important points to note here are : • ‘developing countries’ – to receive funds, a country must be classified as a developing country (however, this includes many highly developed countries such as Israel, Turkey, a number of EU members, and even Saudi Arabia). • ‘multilateral institutions’ – these institutions include the International Monetary Fund (IMF),
World Bank and regional development banks. • ‘official agencies’ – the funds must originate from governments (even if it is given through an NGO or private corporation). • ‘main objective’ – although moderately successful at excluding such things as ‘military aid’, the test of being in the interest of recipients is so subjective it has little influence in reality. . • ‘25% grant element’ – the funds do not have to be gifts (i.e. 100% grant), but can be loans if their interest rate is significantly below market rate.
Anomalies
There are many anomalies in the provision of aid that mean the quantities of aid do not necessarily serve the interests of recipients as you might expect.
Mixed Motives
ODA has been flowing since the 1940s. However, it may surprise you to find that the dominant motives behind this are not necessarily humanitarian . (a) Political motives have been
Georgia - Male life expectancy: 66; Female life expectancy: 74; Under-5 mortality rate (per 1000): 32;
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the primary motives particularly for the USA. Until the end of the Cold War in the 1980s their overseas development programs were explicitly for the restriction of Soviet influence (it has now become a tool of the ‘war on terror’) . The US’s biggest recipient of aid is Israel (which receives more aid per capita than almost any other country on earth)!
Photo: Kelami Ata
(b) Economic motives relate to gaining economic benefits for donors. Around 90% of Australian aid goes to companies who will then make a profit (The Packer family company GRM is one of the biggest aid ‘providers’) . This means the vast majority of Australian ‘aid’ actually ends up back in Australia – talk about boomerang aid! (c) Humanitarian motives are often undermined by the conflicting prudential motives above. This has unfortunately meant that recipient interests are frequently undermined in favour of donor interests.
Loans
The amount of aid given does not necessarily reflect the amount of money available to recipients. In the wake of the 2004 Tsunami the Australian Government announced a $1 billion aid package to Ache - $500 million must be paid back. Yet when it comes to reporting quantities of aid - the entire amount loaned is counted as aid (even if the loan is to be fully repaid)! The provision of aid via loans has created a huge debt burden on developing world countries. Many countries picked up very low interest loans (sometimes negative gross interest) in the 1970s from private banks (whose coffers were swelling from oil money) while demand for investment funds were weak. When interest rates increased developing countries were left in massive debt with a 400% increase in annual debt-service payments!
Domestic Use
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A disturbing trend recently is for the aid budget to be spent through other government departments to cover domestic expenses. For example, international students studying at Australian universities are given a notional subsidy to attract them. This originally came from the Federal government’s Education budget – but since 1984 it now comes from the ODA budget (for students from ‘developing’ countries). Another example is that the processing of asylum seekers (both onshore and offshore) is funded by ODA. Is the ‘Pacific solution’ really aiding the people
of the Pacific?
Aid to the Rich
Allocation of aid has little relation to the poverty of recipients – despite clear evidence that it is in these places that aid is most effective . The vast amount of Australian ODA goes to tiny Pacific states with little population, while the more populous and poorer states in sub-Saharan Africa get comparatively little (PNG receives around $50 per capita). Ex-Soviet states continue to get comparatively high amounts of aid (Slovakia receives around $60 per capita). Meanwhile, the
Germany - Male life expectancy: 77; Female life expectancy: 82; Under-5 mortality rate (per 1000): 5;
poorest countries are neglected – Niger and Sierra Leone ranked last in Human Development Index (HDI) scores but only receive around $15 per capita. India (home of a huge proportion of the world’s poor and a proven successful recipient of aid) receives only $1.50 aid per capita.
chance at achieving the Millenium Development Goals (MDGs). Yet only a couple of countries have achieved this. Australia languishes near the bottom contributing only 0.3 percent of GNI (that’s including the recent increases announced by the Government).
Cheapskate
Future Directions
Despite the anomalies of aid, it is still a crucial element in responding to human poverty and suffering around the world. The UN’s target for donors is 0.7 percent of GNI – calculating that this would give the world a reasonable
Aid is needed. Aid can make a positive difference. But, as the Make Poverty History campaign advocates – we need more and better aid.
Resources
OECD DAC (http://www.oecd. org/dac/) – access their annual Development Cooperation Reports and access up-to-date figures and destinations of aid. AidWatch (http://www.aidwatch. org.au/) – an independent NGO devoted to monitor Australian aid, highlight its shortcomings and campaign for effective solutions. New Internationalist (2005), The World Guide 2005-2006, New Internationalist, Oxford.
Ghana - Male life expectancy: 56; Female life expectancy: 58; Under-5 mortality rate (per 1000): 120;
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The “Big Guys”
The Coffee Crisis and Fair Trade Coffee Khai Lin Kong University of Melbourne The effective breakdown of the International Coffee Agreement in 1989 marked the end of a managed coffee market. As the prices for raw coffee bean plummeted subsequently, it was also the end of stable incomes and the beginning of hardships for many small-scale coffee growers worldwide. With 70% of coffee growers operating on a small-scale level, declining coffee prices mean that many of them fail to receive sufficient cash from coffee to recover costs and provide essentials for their families. At the end of 2001, the price of coffee reached its lowest in 30 years. Coffee growers were receiving only 25% of what they would have received in the 1960s. World Food Programmes reported that this “coffee crisis” has left 30,000 Hondurans in hunger, and another 400,000 temporary and 200,000 permanent coffee workers unemployed. There has also been report of Colombian coffee farmers switching their crops from coffee to the more lucrative coca for cocaine manufacturing.
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On the other side of the world, where Nescafe and Maxwell House appear side by side in KMart next door to Woolworths, the coffee roasting and retail market is booming. Whilst the earnings by coffee producing countries fell from US$10-12 billion to US$5.5 billion from the early 1990s to 2002, the value of retail sales of coffee in developed countries increased from US$30 billion to US$70 billion. Taken together, this data implies that international traders and roasting companies in developed countries were receiving an increased amount of income from the retail coffee market, at the same time when raw coffee bean prices plummeted. The striking difference between benefits received by developing countries and developed countries after coffee trade liberalization has received consideration by many economists, who cite declining global price of coffee due to oversupply of coffee beans as the main cause. Compared to the importers, roasters and the retail market in developed countries, coffee farmers generally have more difficulty responding and adapting to these declining global prices. One contributing
factor is that the extensive labour and time required for growing and harvesting coffee beans means coffee farmers struggle to reduce the production costs in response to the fall in coffee bean price. In addition, the majority of coffee growers are based in poor rural areas in third world countries, with limited financial and technological capacity to switch to an alternative crop. Following coffee trade liberalization, the governments of many coffeeproducing countries withdrew their support for coffee farmers, further aggravating their hardships. On the other hand, roasters in developed countries are able to employ various strategies such as marketing, branding, and flavouring to maintain the retail price of coffee. The recent increase in demand for soluble coffee has allowed roasters to maximize their profit by using less expensive raw coffee beans. In short, coffee trade liberalization and the subsequent coffee crisis have had vastly different impacts on producers in developing countries and traders and roasters in developed countries, such that whilst the former is struggling to make a living, the latter have succeeded in maintaining and increasing their profits.
Greece - Male life expectancy: 77; Female life expectancy: 82; Under-5 mortality rate (per 1000): 4;
How does fair trade coffee work? This skewed distribution of benefits following coffee trade liberalization favouring those in developed countries has led to an outcry against the current model of coffee trading. This has led to the emergence of the fair trade coffee movement as an alternative for coffee drinkers who disagree with current coffee trading practices. Fair trade is a social justice movement aimed at alleviating poverty among smallscale farmers in developing countries by setting a fixed minimum price for the sale of coffee beans, which is maintained even when coffee bean prices in the conventional market fall below this level. Conversely, when coffee bean prices rise above this minimum price, goods traded in the fair trade market will be priced according to the conventional coffee market with an extra premium. Two main groups of organizations, Fair Trade Labelling Organizations International (FLO) and Fair Trade Federation, establish fair trade standards for importers, exporters and producers of a particular commodity. Coffee products sold through the fair trade network that meet these standards are certified as ‘fair trade’ They are also involved in promoting fair trade products in the Northern hemisphere, where most fair trade consumers live. Therefore, fair trade is an alternative trading system that links ‘ethically minded Northern (hemisphere) consumers’, with ‘democratically organized groups of poor Southern (hemisphere) producers’ . Together with tea and cocoa, coffee has become the backbone of the fair trade system. In Europe, Japan, USA and Australia, sale of FLO certified coffee has risen from 11.8 tonnes in 1999 to 52 tonnes in 2006. Australia has the fastest growth in the sale of fair trade coffee, which are sold at most major supermarkets. There are currently 241 FLO certified organizations of producers in
more than 15 countries, increasing the profits of producers by 40 million Euros. Does it work? While there has been a rapid expansion in the fair trade coffee market, there are still doubts regarding its benefits to producers in the third world. Although major advocacy organizations such as Oxfam have documented the life changing moments for the coffee growers worldwide after engaging with the fair trade network, questions have been raised about its long-term benefits and sustainability. This article will attempt to portray arguments on both sides as objectively as possible. Survival of small-scale coffee growers One of the most obvious benefits is the fixed minimum price offered in the fair trade system. When the global coffee bean prices are above the established fixed minimum price, the prices of coffee bean in fair trade system will rise accordingly. However, in time of low global prices, producers will still be paid a fixed minimum price. For many smallscale producers, this guaranteed minimum income means a difference between survival and bankruptcy. A study in Nicaragua shows a four times reduction in self-reported risk of losing land among coffee producers who are associated with alternative trade markets (which includes fair trade market) compared to other coffee producers. Producers participating in the fair trade system also have a more secure market for their product, as coffee importers in the North are required by FLO to establish long-term purchasing agreements with producer groups to ensure stability in trading and income. Improving product quality, capacity building and better living conditions When coffee bean prices are high, the higher income received by coffee growers allows further economical and social invest-
ment. For example, in response to the coffee crisis, coffee farmers in Chiapas, Mexico, formed a co-operative named Kulaktik and started trading through the fair trade system. Since then, Kulaktik has been using the premium derived from fair trade to invest in better techniques for harvesting and preparing coffee for export. This increases the value of coffee bean produced and allows sales to be maintained at a higher price. In addition, Coocafe, the only Costa Rican fair trade coffee co-operative, has provided almost 1000 scholarships for farmers’ children, helped maintained local primary schools and established income-generating schemes for women. ISMAM, an organic and fair trade coffee co-operative in Chiapas, Mexico, is also conducting courses on improving quality of production, health, sanitation and women’s rights. The benefits of higher prices of fair trade coffee are summed up by the following statement by a Peruvian coffee producer: “The higher price we get when we sell coffee to Cafedirect means that now our cooperative can afford to pay a doctor who will give treatment to our members…the price difference meant that I can afford more food for my family and send my children to school…for the first time.” Co-operatives such as ISMAM and Coocafe also provides loan for their members, allowing participating coffee growers to start diversifying their crops to other crops and to prevent over-dependence on coffee sales. Thus, the extra income received from selling products through fair trade networks has not only improved coffee growers’ living conditions, but also provided an opportunity for them to become more competitive and less dependent on the current global coffee markets. Direct market access Co-operatives registered with FLO usually sell their coffee directly to a licensed international trader
Guatemala - Male life expectancy: 65; Female life expectancy: 71; Under-5 mortality rate (per 1000): 41;
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or roasting company based in a consumer country. This direct access to the international market avoids numerous intermediaries (or ‘middle men’) between producers and consumers and ensures members of co-operatives retain a larger share of the retail prices. Furthermore, fair trade co-operatives can also influence the price offered to other coffee growers in the conventional market. The higher price offered by fair trade co-operatives attracts sales from more farmers in preference to other intermediaries. In response to the scarcity in their coffee bean supply, non-fair trade intermediaries began to increase the prices they offered to farmers. In addition, direct market access also facilitates contact between co-operatives and international importers, which promotes better access to market information by the producers. This equips them with better
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price negotiating power and allows them to develop and adapt their products in response to consumer demand. For example, by using the information and resources gained through fair trade networks, Coocafe has managed to sell the remainder of their nonfair-trade-labelled coffee in the conventional market at higher than normal prices. Participating in fair trade system has provided coffee growers an opportunity to continue adapting and improving themselves to survive and compete in the global market. Whilst fair trade coffee has many advantages, few studies have investigated the limitations of this system. Limited market for fair trade coffee The market share of fair trade labelled coffee is still limited despite a drastic increase in sales
recently. It ranges from around 0.1% to 3% in local markets of France and Switzerland respectively. Due to this small market share, many producers can only sell 10 to 15% of their coffee under fair trade conditions, with the rest sold through intermediaries, exporters or traders in the conventional trading system. This limits the amount of extra income that is available for coffee growers. Furthermore, a limited market reduces the number of small-scale coffee farmers who can benefit directly from fair trade system. The central role of co-operative in fair trade network Co-operatives play a crucial role in the fair trade network, especially when it comes to the usage and distribution of income received from trading in the fair trade or conventional markets to individual farmers. It is widely
Guinea - Male life expectancy: 51; Female life expectancy: 55; Under-5 mortality rate (per 1000): 161;
agreed that the greatest benefit from fair trade to individual farmers and the co-operative is the opportunity to become more competitive by investing the extra income in capacity building programmes. This investment is, however, strongly dependent on the decision made by the co-operatives management. Therefore, the efficiency, integrity of co-operatives management and the extent to which their decision can be influenced by individual farmers become critical to ensure the benefits from fair trade are effectively utilized and shared by all farmers. A case study in Mexico showed that only a small number of co-operatives (mostly non-fair trade affiliated) possess this high level of management. Since fair trade certification is only given to co-operatives that demonstrate efficient management, this means that the majority of the co-operatives in developing countries are denied the benefit of the fair trade system. These co-operatives require assistance by other NGOs, donors or institutions beyond the fair trade system in building up their capacity to compete in the more volatile conventional market. Lack of incentives in high quality production Although few studies demonstrate that fair trade system assists coffee farmers in improving the quality of their products, one study argues that fair trade does not provide incentive for high quality production. A case study in Costa Rica found that the majority of the fair trade co-operatives operate in areas ‘ill-suited for prime coffee growing’. The artificially marked-up price offered by fair trade allows these co-operatives to remain in the global coffee market, while producing low-quality coffee bean. Furthermore, at times when global coffee prices are lower than the fixed minimum price offered by fair trade system, there is an incentive for small scale farmers to sell their higher quality coffee to the conventional market (where higher prices are offered for higher
quality coffee) and their remaining lower quality coffee beans to fair trade system (where price is fixed regardless of the quality of coffee bean). This allows farmers to maximize their income, whilst continuing to produce low quality coffee beans. The problem with excessive supply of coffee bean Excessive supply of coffee beans is a main factor that drove their price downwards. Although participation in fair trade system can ensure a relatively higher income for the coffee growers, this could, theoretically, encourage their dependence on the fair trade coffee market, further perpetuating the existing situation of excessive supply. Few studies have documented this excessive supply among fair trade coffee growers. This risks causing further declines in coffee bean prices in the future, which could have devastating consequences for coffee bean growers not participating in the fair trade system. Conclusion? From the readings, it is clear that fair trade system has the potential to contribute in poverty alleviation, or at least in relieving the humanitarian crisis that was brought upon the small scale coffee growers after coffee trade liberalization in 1989. Yet the limitations of fair trade system demonstrate that it, by itself, is insufficient to solve the problems encountered by small-scale coffee farmers. Generally, smallscale coffee farmers need to be truly empowered and equipped to be competitive in the global market. Furthermore, it is also crucial to ensure that fair trade affiliated co-operatives are not dependent on the fair trade system. This necessitates coffee growers to continuously improve the quality of their coffee beans, diversify to other products and increase their resilience to the volatile conventional market. Fair trade could provide the financial opportunity to implement their activities, but technical and information support from local government or
other NGOs are also required. Diversification to other crops also requires favourable local policies and elimination of trade barriers on agricultural crops imposed by many developed countries. Last remark The documents published by Oxfam, FLO and Eldis provide an enlightening range of different arguments which portray the pros and cons of the current fair trade system. Nonetheless, these varying perspectives, ranging from passionate, heart wrenching stories of hardships faced by coffee farmers, to the cold, apathetic, neo-liberal assertion of the inevitable ‘constructive destruction’ in trade liberalization, clearly show that there are commonalities to both sides of the issue: that the humanitarian crisis is real, that empowerment of small-scale farmers is essential; and that fair trade coffee, with its limitations, is only part of the multifaceted strategies to overcome the current crisis. Notes: 1. Coffee growers and producers will be used interchangeably. 2. Fair trande standards can be found on the FLO-CERT website, found at http://www.flo-cert.net/ flo-cert/main.php?lg=en. 3. Fair trade labeling organizations mainly work with co-operatives made up of individual small-scale coffee farmers owning land less than 12 hectares. They are also required to have management that is democratically elected. 4. Fair-trade co-operatives still trade in the conventional market. This is because the relatively small size of fair trade market cannot absorb most of the products. The remainder is sold through the conventional market. 5. A free market concept. It states that trade liberalization will lead some losses by other parties but is usually accompanied by gain in other more efficient new players.
Guinea-Bissau - Male life expectancy: 46; Female life expectancy: 51; Under-5 mortality rate (per 1000):
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The “Big Guys”
Access to Essential Medicines Article courtesy of IFMSA Spain The WTO and the TRIPS Agreement Understanding Patents: A patent provides the patent holder with legal means to prevent others from making, using, importing or selling the new product for a period of time. The TRIPS Agreement (Agreement of Trade-Related Aspects of Intellectual Property Rights) sets out the minimum level of protection of patents, copyrights and trademarks, including patents for pharmaceutical products. Patent holders may now keep generic versions of a medicine off the market in every WTO (World Trade Organization) member country. Before TRIPS was implemented in 1994, patents were granted for terms of 5 to 7 years, but now TRIPS establishes a minimum of 20 years for products and production processes. Consequently, TRIPS leads to a trans-national market monopoly where none existed before. This usually results in the impossibility of producing generic and
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cheaper versions of patented drugs, and as a result, higher prices for medicines in a market free of competition.
but they were given extra time to comply with the agreement and postponed its introduction until January 1st, 2016.
The TRIPS Agreement: The United States and other countries pushed for the introduction of the intellectual property issue in the international trade agenda. After some years of hard talks, the Uruguay Round of the General Agreement on Tariffs and Trade negotiations resulted in the introduction of the TRIPS Agreement, an event that heralds a fundamentally new era for developing countries.
There are some aspects of flexibility under TRIPS that may help countries to ensure access to medicines through their respective national public health policies. Two important safeguards in the TRIPS Agreement are parallel importing and compulsory licensing. Parallel importation allows a country to import a patented product marketed in another country without the consent of the patent-holder, enabling the import of those lower-priced products. On the other hand, compulsory licensing enables a government authority to license the use of a patented invention to a third party or government agency without the consent of the patent-holder, under a number of conditions, including circumstances of extreme need or a national emergency.
In attempt to balance the longterm objective of providing incentives for future research and development of new medicines, and the short term objective of allowing people to access the treatment they need, the TRIPS Agreement would provide strong protection standards and obligations for WTO members. In industrialised countries, TRIPS came into effect in 1996. In some developing countries it entered into force in 2000. Finally, the socalled “least developed countries” had to implement TRIPS in 2006
However, despite the formulations of these exceptions, developing countries had some difficulties putting them into practice, due to pressure from some coun-
Guyana - Male life expectancy: 63; Female life expectancy: 66; Under-5 mortality rate (per 1000): 62;
tries, as well as pharmaceutical companies. So … What’s the problem? Despite the arguments of the necessity of patent protection to sustain research and development of new drugs, according to a report of MSF, of 1223 new drugs commercialised from 1975 to 1997, only 13 were specifically for tropical diseases, and only 4 of them resulted directly from research of the pharmaceutical industry. Obviously, this is not satisfactory. TRIPS does not encourage adequate research and development for the “diseases of the poor” because poor countries do not provide sufficient profit potential to motivate investment by pharmaceutical companies. Today, the TRIPS Agreement prioritises commercial interests rather than protection of public health. In fact, it threatens public health. The pharmaceutical industry is one of the most profitable in the
world, and those profits far exceed what is necessary for supporting their research and development. The current situation will be even worse in the near future. The TRIPS Agreement has been recently implemented in many developing countries, and consequences of this are now becoming visible. This will have even more importance when full implementation will include least developing countries. If new medicines are produced for diseases such as AIDS, malaria and tuberculosis, they will be unaffordable and inaccessible for the population in need. Some specific examples India & Novartis Drugs produced by companies in India are among the cheapest in the world, because until recently, India did not grant patents on medicines. India is one of the few developing countries with pro-
duction capacity to manufacture quality essential medicines. By producing cheaper generic versions, India became a source of affordable essential medicines. As a WTO member, India has to comply with the rules set out by the WTO, such as the TRIPS, which obliges the WTO countries to grant patents. India changed its patent law in 2005 and as a result, Indian generic manufacturers will not be able to produce cheaper generic versions of these medicines, which will not only have an impact on India domestically, but also on other countries that import Indian generics. Novartis applied for a patent in India on a cancer drug, which the company markets under the brand name Gleevec/Glivec in many countries. The patent was rejected in India in January 2006 on the grounds that the drug was a new form of an old drug, and therefore was not patentable under Indian law. In other countries
Haiti - Male life expectancy: 59; Female life expectancy: 63; Under-5 mortality rate (per 1000): 80;
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tant problem in China. China began granting product patents on medicines in 1993, and fully implemented the TRIPS in 2001 as a condition of joining the WTO. China now faces a growing AIDS epidemic. The drug regimen (3 drugs) was generically available in China, but the WHO does not recommend that regimen. The problem is that GSK has the monopoly on one of the drugs used in the recommended regimen, and had not made the drug available in the dosages required when the national programme began.
where Novartis has obtained a patent, Gleevec is sold at $2600 per patient per month. In India, generic versions of Gleevec are available for less than $200. Brazil & U.S. Brazilian health officials and nongovernmental organisations accused the United States of threatening a critical element of the anti-AIDS program as part of a trade dispute over Brazil’s effort to manufacture more generic drugs. The dispute was part of a larger campaign by developing nations to get large pharmaceutical companies to lower the prices of their drugs, whose generic versions often cost 80% to 90% less than the brand-name product. The US government complained to the WTO about the Brazilian patent law, arguing that this law forced international companies to make products in Brazil and thus violates WTO rules.
medicine, but 39 international companies immediately filed suit to block it. In the three years in which the companies have tied up this legislation in the courts, more than 400,000 of South Africans have died of HIV/AIDS, almost all of whom lacked access to affordable treatments. In letters sent internationally to company headquarters, Médecins Sans Frontières and Oxfam called on 39 pharmaceutical companies to immediately and unconditionally drop their legal challenge to the South African law. On 2001, the case would open before the High Court. What had begun in 1998 as a dispute over medicine and trade law ended as a world-wide public relations disaster for the companies.
If Brazilian companies cannot manufacture them, then the prices are just going to continue to be exorbitant, which means that people are going to die over a purely economic question.
Over six weeks, 300,000 people from more than 130 countries signed an international petition launched by MSF calling on the companies to drop the case. The European Parliament passed a resolution urging the companies to drop the case, a position echoed by ministers from a number of European governments.
South Africa & Pharma Nelson Mandela signed a law aimed at improving access to
China & GSK As in many countries, access to essential medicines is an impor-
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Another problem China faces is that it does not benefit from many of the discounted prices that drug companies sometimes offer to developing countries (“voluntary differential pricing”). Like other countries categorised as (lower) middle-income, China often does not get access to the prices offered to Least Developed Countries, which results in drugs being priced at wealthy-country levels. The irony of all this is that capacity to generically produce all needed first and second-line ARVS exists in China. China is currently the leading producer of the raw materials necessary for ARV production, and has significant capacity to scale-up production volumes of both raw materials and finished products. China has recently adopted into national law the WTO decision (“August 30th”) allowing production of drugs under compulsory license predominantly for export. However, China has not yet issued a compulsory license for a medicine so patents continue to block the production of many drugs. The TRIPS Agreement (Agreement on Trade-Related Aspects of Intellectual Property Rights) can and should be interpreted in a manner supportive of WTO member’s right to protect public health and, in particular, to promote access to medicines for all.
Honduras - Male life expectancy: 67; Female life expectancy: 73; Under-5 mortality rate (per 1000): 27;
The “Big Guys”
MICROFINANCE: Does it really work, or is it just a fashionable word? Anny Huang University of Melbourne Microfinance. It’s one of the buzz-words of development in the twenty-first century. If you haven’t yet heard of Nobel Peace Prize laureate Mohammed Yunus and his Grameen Bank, you soon will. Since its conception, it has been regarded as “the world’s hot idea to reduce poverty”1. Initially set up to provide small loans with low interest to the poor, they have now expanded to include services such as savings deposits and insurance, with the goal of alleviating poverty and empowering the poor from a grassroots level. However, the question of whether these benefits apply equally to all households within the target communities has since been posed. The greatest criticism of microfinance schemes is that while they are of some benefit to poor households, they are an ineffective method of poverty alleviation for the extreme poor, due to various economic, environmental and social reasons. However, from an alternative point of view, the poor and the extreme poor have different
starting points. Therefore, the disparity between the financial benefits of microfinance schemes for the poor and that for the nonpoor, while still significant, may not be as great as described in the development literature.
First, some terminology
Microfinance essentially includes five products: credit, deposit services, insurance, financial advisory services and advocacy services. It differs from conventional banking in that it targets the poor, who are spurned by other banks due to the fact that they are regarded as unreliable. Furthermore, the poor lack sufficient collateral, which insures the bank against unreturned loans. Microcredit, therefore, is a subset of microfinance. It is one of the services offered at microfinance institutions, whose goal is for the poor to use the money that they have loaned through microcredit schemes to set up small businesses and become self-sufficient. However, as we shall soon see, this does not always happen.
Low participation?
One of the key reasons behind the disparity in outcomes for the poor and the extreme poor is the difference in the level of participation in microfinance programs. Evidence from Bangladesh suggests that in many cases, microfinance programs fail to reach the “vulnerable poor”2. This is to a certain extent due to decisions on the part of the microfinance institutions (MFIs), which may set limits such as maximum age requirements3,4. However, for the most part, the low participation rates of the extreme poor are due to the interplay between various factors, ranging from lacking “minimum clothing required to attend (committee) meetings”3 in situations where group loans are taken out, to fearing threats from the local elites3. Furthermore, the extreme poor are reluctant to take out loans due to the risks involved. They are apprehensive about being unable to repay the loans in time and being forced to sell their possessions as a consequence3. The inflexibility of the repayment conditions offered by some MFIs is yet another deterrent for the extreme poor3.
Hungary - Male life expectancy: 69; Female life expectancy: 78; Under-5 mortality rate (per 1000): 7;
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Poor results?
Not only are the extreme poor less likely to participate in microfinance programs, they are also more likely to drop out and less likely exit poverty as a result of their participation5. This is because many of the extreme poor use the money loaned to them by MFIs to pay existing debts to local moneylenders or to other MFIs3,4, and only a small proportion use the loan to establish microenterprises. Furthermore, of the small percentage of the poor who do engage in microenterprises, most choose to undertake activities with low returns, which are classified as “survival” enterprises5. Once again, this is due to the contribution of various factors, such as poor infrastructure or a lack of access to resources. More personal reasons such as a lack of understanding of market conditions and a lack of confidence engaging in non-traditional activities may lead to saturation of the local markets due to increased competition in offering a limited range of goods and services5. In addition, there are social factors influencing the choice of occupation of the individual, including the caste system in certain countries. Individuals who belong to the extreme poor category are more likely to belong to the lower castes also, and there may be social restrictions on the type of enterprise that these individuals may undertake5. In areas where there is no caste system, there may still be social rules prescribing the type of work that is suitable for men and women, or for individuals of particular backgrounds. Therefore, although investing microcredit loans in survival activities may result in low returns, many individuals in the extreme poor category have no choice but to undertake these activities.
Critiquing the critics
Although the reasons given above contribute to a significant difference in the outcome of microfinance programs in the poor and extreme poor populations,
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the actual difference may not be as great as claimed by most authors, who place emphasis on crossing the poverty line. In an article about the situation in Sri Lanka, Shaw states that microenterprise does not benefit the extreme poor as much as the poor, yet her data show that almost a quarter of the extreme poor participants in microenterprise had “graduated to ‘poor’ status” and that a similar proportion of poor participants had exited poverty5. This may demonstrate that due to a lower starting point, none of the households with extreme poor status were able to exit poverty in the period of study, but may have reaped similar benefits as the poor households. Further investigations should be undertaken, using alternative indicators such as percentage of income change. In the meantime, however, we should also look to other solutions, like the Oxfam Buffalo Bank, to decrease the
gap between the extreme poor and the poor.
References:
1. Editorial, New York Times, 1997. Micro-Loans for the Very Poor, February 16 2. Amin, Rai, Topa, Does microcredit reach the poor and vulnerable? Evidence from Northern Bangladesh, Journal of Development Economics 70 (2003), p. 60 3. Meyer, The demand for flexible microfinance products: Lessons from Bangladesh, Journal of International Development 14 (2002), p. 353 4. Ahmad, Distant voices: the views of the field workers of NGOs in Bangladesh on microcredit, Geographical Journal 169 No. 1 (March 2003), p. 69 5. Shaw, Microenterprise Occupation and Poverty Reduction in Microfinance Programs: Evidence from Sri Lanka, World Development 32 No. 7 (2004), p. 1247
Iceland - Male life expectancy: 79; Female life expectancy: 83; Under-5 mortality rate (per 1000): 3;
The “Big Guys”
The need for leadership in global health Stephen R Leeder, Susan U Raymond and Henry M Greenberg Global health! Why should you, dear Reader of the Medical Journal of Australia and probably of the medical persuasion, read on? We offer you three reasons. First, given your concern for people’s health and wellbeing, you are already equipped to confront the major pressing global health problems of today — you have the right attitudes and values. Second, the drivers of the global health agenda are in great need of medical advice: failed diagnosis abounds. Third, the challenges in global health for the coming decades are far more familiar to you, as a medical practitioner in a highly economically advanced nation, than was the case when the only threat to world health was infectious disease. So please do read on! Others share our view about the importance of medical engagement with global health. In reviewing the contribution that the immense United Kingdom National Health Service could make to global health recently, its previous chief executive officer, Lord Nigel Crisp, provided a report that specifies how, through shared policy development, assistance with workforce development and sharing information — ideas
and reports of success — medicine can indeed make a profound contribution to global development.1
Global health and international health: is there a difference?
“Globalisation” is generally taken to imply that global economic and financial interests and multinational industries now shape and even determine our destiny. It is the scale of these forces that surprises us: China’s trade, reaching to every country, generates a surplus that grows by US$1 billion a day!2 In line with the popularity of the word “global” in general, the star of global health is rising and that of international health is falling. In 1950, PubMed listed 54 papers on global health and 1007 on international health, but by July 2005, the listings were 39 759 and 52 169.3 A search for “global health” on the BMJ website lists 1181 papers published between 1998 and June 2007. It does not help the cause of the sick and dying to debate for long whether this change in terminology — from international to global — means anything profound. Nevertheless, as Confucius urged us when wondering how best to govern the state (or globe), “if language be not in accordance with the truth
of things, affairs cannot be carried on to success”. So, is there a real difference between “international” and “global”? English journalist George Monbiot argued persuasively that there is, or should be.4 “International” suggests the primacy of nations, whereas “global” opens the door to new forms of polity in which decisions are made and supported by global laws that transcend pooled national interests. Disarmament, he suggests, will never be complete so long as nations have a collective say, referring always to the bottom line of their self-interest in the matter. But it is conceivable that a globalised world might legislate the abolition of all arms. If universal disarmament were discussed at the United Nations, no country would agree to give up all its weapons and so the discussion would stop. To tackle the consequences of the billions of lethal weapons in the world, we need a form of global governance, Monbiot says. The disengagement of Australia and the United States from the Kyotobased debates about global climate change illustrates how, when an international rather than a global perspective is adopted, problems are perpetuated, or at least incompletely solved. Global problems require leaders who recognise new
India - Male life expectancy: 62; Female life expectancy: 64; Under-5 mortality rate (per 1000): 76;
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models of diplomacy and engage in the frustrating and difficult conversations that are essential for confronting them as a global community. Think for a moment not only of climate change, but also of obesity, tobacco and ageing; Box 1 describes the current international efforts to reduce the burden of tobacco. Are these problems that will yield satisfactorily and permanently to international, rather than global, action?
Human flourishing and globalisation
On balance and for the majority, globalisation has brought immense benefits to humanity. Here we are looking at the economic effects of globalising trade, commerce and financial institutions. Associated with globalisation, the past two decades have witnessed tremendous progress in the health of all but the poorest countries, and that progress seems set to continue. There are 50 countries deemed least-developed by the UN, where poverty remains a high hurdle.7 However, in line with progress elsewhere, data from the World population prospects: the 2006 revision suggest that many of these countries will achieve at least several core health development goals by 2020.8 The Center for Global Development highlights improvements
1 | Testing the limits of international health The World Health Organization Framework Convention on Tobacco Control is the world’s first international public health treaty, and entered into force in 2005.5 There are now 148 countries that are parties to the treaty, which seeks to reduce tobacco consumption through proven control mechanisms such as taxation, restrictions on advertising, and public health education.5,6 Much now depends on the signatory countries enacting enabling legislation to permit the appendiceal protocols to take force. The extent to which the protocols will, indeed, be enacted relies on the political will of the countries concerned and the extent to which tobacco industry lobbies against such enactment. The strength of the treaty lies in its binding requirements on the signa-
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in global health gained through a range of successful large-scale interventions.9 Fertility rates in developed and least-developed countries are converging. Fertility in developing countries has decreased from six children per woman in 1960 to around three today.10 The UN estimates that, by 2050, three out of every four countries in the less-developed regions will be experiencing belowreplacement fertility.4 By 2050, life expectancies in the least-developed nations will be within 10 years of those in developed nations. At the world level, life expectancy at birth is likely to rise from 65 years today to 74 years in 2045–2050.11 The prevalence of contraceptive use is 70%–80% in many countries.12 Between 1980 and 1998, maternal mortality declined by 42% in Mexico, 43% in Argentina, 58% in Chile, and 35% in China.13 Although the estimated number of women worldwide who die each year from causes related to pregnancy and child-bearing is 585 000, 90% of these deaths are in the least-developed nations of Africa and Asia.14 But, as with any dramatic technological progress, some people have been — and continue to be — left behind, even worse off, as the majority surge forward. Equity tory countries. The weakness of the treaty lies in the arbitrary way in which countries may interpret, develop and then enact the treaty clauses. The United States has signed but not ratified the treaty, and neither has China nor Indonesia. Nevertheless, the treaty moves many countries that previously had taken a timid or null approach to tobacco control in the direction of better health through less use of tobacco. The treaty is a landmark in international health — there is nothing that matches it for strength and likely effect. It is an example of the best that can be achieved through international action that must, by virtue of the political structure of the participating nations, look to preserve their own interests first, including the strength of economies that, in some cases, depend on the tobacco industry. Nevertheless, we can perhaps still aim for a global approach in which people take precedence over national economies.
poses a major problem: there are wide gaps between the health status of the poor and other socially and economically disadvantaged marginalised groups, and the rich and privileged, both globally and within countries and regions.15 As such, aggregate statistics regarding “global health” need to be interpreted with caution.
Priority setting in global health
The nature of the world’s health problems has changed significantly in recent years. The breadth and depth of challenges facing the global community were brought into the full light by the World Health Organization’s publication of global burden of disease (GBD) estimates for 2002.16 The GBD presents a picture of current patterns of disease everywhere, measuring their effects as causes both of death and of suffering and disability. The study shows that commonly held views of what ails the globe are not always accurate. The GBD is a set of health intelligence for the world. It shows that malnutrition is the greatest global burden, followed by HIV, then depression, heart disease and stroke, and then cancer. The study also examined factors that raise the risk of these problems, chief among which is tobacco. There are a billion obese people in the world,17 but obesity is not always on the agenda of conferences on nutrition, which are more often exclusively concerned with undernutrition. The GBD study points to the importance of tobacco, and there are five million deaths a year attributable to it,18 many occurring among poorer people in struggling economies. Compare these deaths with the four million a year from HIV and the attention that they attract. The women’s health movement continues to focus its attention on obstetric health and neonatal survival, with the addition of HIV19 — all worthy things to do. But women in much of the developing world, during their years of family formation, are two to four times more likely to die of heart disease or stroke than obstetric causes and HIV. However,
Indonesia - Male life expectancy: 66; Female life expectancy: 69; Under-5 mortality rate (per 1000): 34;
these diseases, say aid agencies that ignore them, are diseases only of postmenopausal women who, it is implied, are of no value or special interest. How on earth would one raise aid for such people? How on earth indeed, when even the basic facts about these matters do not inform debates or modify attitudes. The inaccurate use of global health intelligence leads to a lack of breadth of vision and what economists term allocative inefficiency. Allocative inefficiency arises when a factory committed to making nuts and bolts produces nuts 10 times more frequently than bolts. An example of this in health is when an exciting or devastating disease, especially if exotic in origin (with SARS as a recent example) fills all our visual fields, causing us to overlook more mundane but ultimately more important issues. Because so much effort in aid is driven by topic-specific funding, and because this concentrates often on one thing (HIV or peri-obstetric maternal wellbeing), academics may overlook their responsibility to tell the truth, be seduced into truncating their message, and focus their
attention on one illness or problem to the exclusion of all others. This is despite the evidence that the best health development effort addresses fundamental social, political and economic determinants, and may well have multiple diseases on its agenda.
A new order of leadership
The World Bank is taking on an increasing role in determining health-related priorities in developing countries,3,20 with significant implications for the WHO because of the bank’s funding role. At the same time, there have been significant increases in philanthropydriven global health partnerships — namely the Bill & Melinda Gates foundation, which notably does not prioritise chronic disease-related initiatives, but which has done splendid work regarding HIV.21 The current WHO Commission on Social Determinants of Health, chaired by Sir Michael Marmot, may well bring into the open the power of society and the global reach of commerce in the determination of health and not simply specific diseases.
Would a concept of global health that began with comprehensive intelligence about health and disease stand a chance of success? Yes, indeed — but do not underestimate the political courage needed to make it work. It would require countries to sign on to cut their self-interested export of unhealthy products, such as tobacco and mutton flaps, the latter being an obnoxious trade in which both the US and Australia participate, shipping high-fat offal to the Pacific nations.22 It would require leadership of a different order. Perhaps if British ex-Prime Minister Tony Blair had concentrated on the reduction of poverty in Africa and been spared the agony of Iraq, he might have been the first truly global leader. Perhaps in his new incarnation as Middle East envoy he will become so. Leadership of this style would expand the agenda of global health to include the emerging epidemics of serious and long-term illnesses such as heart disease and stroke in the developing world.23 It would encourage aid agencies and global health academia to fight the real
Iran - Male life expectancy: 69; Female life expectancy: 73; Under-5 mortality rate (per 1000): 35;
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war, instead of selected sections of it that suit current political whims and academic institutions. Hard work, to be sure, but the interesting possibility is this. If we could do it with health, maybe we could transfer what we have learned to other areas of international and global importance. Climate change is a current global concern that will require concerted global effort. However, the lack of a global forum and policy through which to address this has meant that action is languishing: there is insufficient impetus for action at the national level. What then should be our practical response and what could Australian leadership in global health hope to achieve? Given the nature and potential solutions for our current global health problems, it is encouraging to see academia in Australia responding by creating institutes and centres of global health, such as the George Institute initiated by the University of Sydney (http://thegeorgeinstitute. org) and, more recently, the Nossal Institute at the University of Melbourne (http://www.ni.unimelb. edu.au). Competition among these centres makes good sense by harnessing academic ambition and pointing it towards these problems. These centres have been successful in attracting support from foundations. By their location, they create opportunities for scientists in many disciplines to explore the significance of their work for health beyond our shores. It will be interesting to see if faculties of law can be drawn in to these institutes as major players, together with political scientists, to explore how their reach might become more global and less international (in the narrow sense) with time. The drive to do something about health beyond our shores, although it must harness vested and self interest (in the detection and halting of incipient epidemics that may threaten us, for example), can also burn the alternative, nonfossil fuels of humane values and ethical energy. Altruism is a deep vein in the hearts and minds of many students entering medicine, and remains among many doctors in practice. We see countless examples of its local application, despite the tangle of insulating tape
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that masquerades as bureaucratic regulations. But our compassion cannot sensibly stop at our shores. Discussions about equity in access to health care and to the things that make for good health in Australia should be set within the context of truly desperate global inequities, as the stimulus to go beyond national boundaries in the pursuit of fairness in health. Australia is a small player in the global game, but we should not underestimate our pulling power. Our influence is perhaps greatest in the Asian and Pacific setting, and can be exercised when political leadership is sensitive to our geography and the competing and different cultures of our neighbours. Were an enlightened Australian federal government to establish a multibillion dollar foundation for global health, as it could easily afford, it would then be in a position to assume a leadership role. This could extend to an interest in finding common, regional solutions to the chronic and infectious diseases of the region, committing biotechnology to this task, and offering in-depth education and training opportunities for future regional leaders. This is a moment of great global challenge, and is recognised as such in relation to the environment, sustainability and peace. An Australian federal government committed to looking out to espouse health and humanitarian outreach to the world, rather than in to find reasons for squabbling with our own states, could be just what the world needs. A profound ethical challenge stares us in the face if we take global health seriously — to apply our energies in making the world, by any and every means, a healthier and more sustainable place for all people, not just for us. Those who wish to lead us in global health endeavour should point to ways in which this goal can be achieved, then push forward, and be prepared for many to follow. Article reprinted from the Medical Journal of Australia (2007; 187 (9) 532-535) with permission from Martin B Van Der Weyden MD, Editor, Med J Aust. Professor Stephen Leeder AO is the Director of the Australian Health Policy Institute at the University
of Sydney, and the Co-Director of the Menzies Centre for Health Policy. In addition, he was the Dean of the Faculty of Medicine at the University of Sydeny from 1996 to 2002. From 2003-2004, Stephen worked in the Earth Institute and the Mailman School of Public Health at Columbia University, New York. It was here that he developed an internationally-recognised report on the economic consequences of cardiovascular disease in developing countries. Stephen has also served as the National President of the Public Health Association. Dr Susan Raymond is the Executive Vice President of Research, Evaluation, and Strategic Planning for Changing Our World, a philanthropic organisation based in the USA Prior to this, Susan was a project officer at the World Bank and a senior consultant to the U.S. Agency for International Development and to various private organizations including the Carnegie Corporation, specializing in healthcare and international economic research. She has led the formation of private foundations in Poland, Croatia, and Hungary and written business plans for foundations in India and Thailand. Susan is a member of the Advisory Board of the Center for Global Prosperity in Washington, D.C., and an Associate Research Scientist at the Institute of Human Nutrition at Columbia University. Dr Henry Greenberg is Associate Director of Cardiology, St. Luke’s Roosevelt Hospital and Associate Professor of Clinical Medicine at Columbia University College of Physicians and Surgeons. He has a longstanding interest in international aspects of cardiovascular health, especially in the Russian Federation. He is currently a consultant to the Center for Global Health and Economic Development at the Earth Institute, Columbia University.
References
1. Crisp N. Global health partnerships: the UK contribution to health in developing countries. London: COI, 2007. http://www.dfid.gov. uk/pubs/files/ghp.pdf (accessed Oct 2007). 2. Jeffrey S. Lost in translation. The Economist [Internet] 2007; 17 May. http://www.economist.com/background/displaystory.cfm?story_
Iraq - Male life expectancy: 48; Female life expectancy: 67; Under-5 mortality rate (per 1000): 47;
id=9184053 (accessed Jun 2007). 3. Brown TM, Cueto M, Fee E. The World Health Organization and the transition from: “international” to “global” health. Am J Public Health 2006; 96: 62-72. <PubMed> 4. Monbiot G. The age of consent: a manifesto for a new world order. London: Flamingo, 2003. 5. World Health Organization. Updated status of the WHO Framework Convention on Tobacco Control. http://www.who.int/tobacco/framework/countrylist/en/ index.html (accessed Jul 2007). 6. World Health Organization. WHO Framework Convention on Tobacco Control. Geneva: WHO, 2003. h t t p : / / w w w. w h o . i n t / t o b a c c o / framework/WHO_FCTC_english.pdf (accessed Oct 2007). 7. United Nations Office of the High Representative for the Least Developed Countries, Landlocked Developing Countries, and Small Island Developing States. List of least developed countries. http://www. un.org/special-rep/ohrlls/ldc/list. htm (accessed Jun 2007). 8. United Nations Population Division. World population prospects: the 2006 revision population database. Geneva: UNDP, 2007. http:// esa.un.org/unpp (accessed Jun 2007). 9. Center for Global Development. Millions saved: proven successes in global health (2007 edition). CGD Brief March 2007. http://www.cgdev.org/content/publications/detail/14493 (accessed Oct 2007). 10. United Nations Population Fund.
State of world population. Geneva: UNFPA, 2003. http://www. unfpa.org/swp/2003/pdf/english/ swp2003_eng.pdf (accessed Oct 2007). 11. Earthtrends. Population, health and human well-being — demographics: life expectancy at birth, both sexes. http://earthtrends. wri.org/text/population-health/ variable-379.html (accessed Jun 2007). 12. The future of fertility in intermediate fertility countries. New York: Department of Economic and Social Affairs, Population Division, United Nations Secretariat, 2002. http://www.un.org/esa/population/ publications/completingfertility/RevisedPEPSPOPDIVpaper.PDF (accessed Oct 2007). 13. World Health Organization. Mortality database. http://www. who.int/healthinfo/morttables/en/ index.html (accessed Jul 2004). 14. Brands A, Yach D. Women and the rapid rise of noncommunicable diseases. World Health Organization, 2002. (NMH Reader No. 1.) http://whqlibdoc.who.int/hq/2002/ WHO_NMH_02.01.pdf (accessed Oct 2007). 15. Gwatkin D. Health inequalities and the health of the poor: what do we know? What can we do? Bull World Health Organ 2000; 78: 315. <PubMed> 16. World Health Organization. Burden of disease project [website]. http://www.who.int/healthinfo/bodproject/en/index.html (accessed Jun 2007).
17. World Health Organization. Overweight and obesity. http:// www.who.int/dietphysicalactivity/ publications/facts/obesity/en/ (accessed Jun 2007). 18. World Health Organization. Tobacco free initiative [website]. http://www.who.int/tobacco/en/ (accessed Jun 2007). 19. Raymond SU, Greenberg HM, Leeder SR. Beyond reproduction: women’s health in today’s developing world. Int J Epidemiol 2005; 34: 1144-1148. <PubMed> 20. Adeyi O, Smith O, Robles S. Public policy and the challenge of chronic non-communicable diseases. Washington, DC: World Bank, 2007. 21. Bill and Melinda Gates Foundation. Global health: priority diseases and conditions. http://www.gatesfoundation.org/globalhealth/pri_ diseases/ (accessed Sep 2007). 22. Evans M, Sinclair RC, Fusimahohi C, Liava’a V. Globalization, diet and health: an example from Tonga. Bull World Health Organ 2001; 79: 856-862. <PubMed> 23. World Health Organization. Preventing chronic disease: a vital investment. Geneva: WHO, 2005. 24. United Nations Environment Program Ozone Secretariat. Key achievements of the Montreal Protocol to date. UNEP, 2004. http:// ozone.unep.org/Publications/MP_ Key_Achievements-E.pdf (accessed Oct 2007). 25. Greenpeace USA. US withdraws from Kyoto Protocol. http://www. greenpeace.org/usa/news/u-swithdraws-from-kyoto-prot (accessed Jul 2007). 26. Kyoto Protocol to the United Nations Framework Convention on Climate Change. 1997. http://unfccc. int/resource/docs/convkp/kpeng. html (accessed Oct 2007). 27. European Commission. Emission trading scheme (EU ETS). http://ec.europa.eu/environment/ climat/emission.htm (accessed Jul 2007).
Ireland - Male life expectancy: 77; Female life expectancy: 82; Under-5 mortality rate (per 1000): 4;
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Marginalised groups
The Face of Equitable Access: Going beyond health to life for all Lee Yung Wong University of Melbourne He sat across from me in his simple white shirt and chequered longyi, a sarong-like garment typically worn by Burmese men. We had just met – I as a naïve, spoilt, cultured medical student; he as a simple, yet passionate young man working among people with HIV/AIDS. I shook his firm, tanned hands that had probably given care and comfort to more people than mine ever will. I initially saw him as just a source of useful data and eye-catching phrases which would be useful in the qualitative thesis I was putting together. What did he know about research? After all, he had graduated from a Burmese university, from an allegedly farcical education system. My preconceptions lingered as he began his story, talking about his motivation to be involved with people with HIV/AIDS, a challenging field in light of Myanmar’s
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health performance: ranked second-to-last in the world. Yet, it was nothing but another statistic for the world to ponder momentarily before it moved on to bigger and better things.
him. And of how he visited a village where they had almost nothing and the nothing they had was being submerged by flood waters, as was the norm every rainy season.
From his simple answers he implied that to him, money did not matter, neither did personal fame. He had a certain purity of heart; in imperfect but adequate English he told me how he relied heavily on Christian principles to pursue good and to make a difference in people’s lives.
He painted a picture of a country where electricity sometimes ran for only a few hours a day, of people who had no freedom to vote, much less access to proper health care. Of people with HIV who faced constant and numbing rejection from family and society. He recounted lessons learned working in the diverse collectivistic Burmese community and how he stuttered embarrassingly and insensitively while conversing with sex workers who were forced to sell their bodies for their children.
And this he did by visiting people with HIV/AIDS – termed ‘sufferers’ by some Burmese – in their homes, encouraging them to live longer and more positively. Other days were spent in the office, calculating budgets and getting through the necessary red tape, liaising with health officials. His eyes sparkled as he told of a colleague who adopted some HIV orphans even though the family was poor and how that inspired
The fact that they were lacking resources was putting it mildly. I couldn’t help but draw parallels with the Australian society I was familiar with that kicked up a ruckus at the least hint of in-
Israel - Male life expectancy: 79; Female life expectancy: 82; Under-5 mortality rate (per 1000): 5;
efficiency in the medical system. Oh, how I wished that patients did not have to empty their pockets to pay for health care, where doctors did not have to resort to leaving the hospital early to work privately in the evenings for that little bit more, where people were accounted for, and did not have to confront rising unemployment in the workforce. What sort of treasure trove could health research unearth for these people when a majority of them could not speak or understand the complex English scattered all over academic texts? English, after all, had been slowly eradicated from everyday life much like a dangerous disease, even though Myanmar had previously experienced many years of British rule. And again, I wondered if simply giving assistance was enough. After all, many benevolent organizations had been giving aid for years, yet the people still had a ‘needs-ask’ mentality instead of taking ownership of the problem. I wondered if these organizations were too busy chasing targets or simply sitting too high up for the people to reach. And so I listened, slowly sickened and horrified somewhat by my own disease, a disease of arrogance. Oh, I had noble intentions: I wanted to save the world like everyone else. Per-
haps, as Nietzsche aptly put it, we fool ourselves into becoming a function of the herd, following the ideas and ideals of ‘good research’ as defined by society. Likewise here I was, seeing the developing-cum-needy world which ‘created problems’ through tinted glasses that came from my own world, the ‘better’ one which solved those problems with an air of superiority. In the first place, the two worlds seemed completely different and not many were willing to traverse the ever-increasing distance. Whereas some, who did, were no better than men on the moon, deluding themselves into believing they have conquered it with the first few steps before retreating to normality and familiarity. Maybe that was simply the way things were, but I was not satisfied with status quo. In the first place, perhaps it was the very belief in these worlds – our own perception which depicted them as needy – that created the chasm and made equitable access so difficult. I asked people with HIV what they thought about the support and help that they were getting. I was not the least bit surprised that they spoke approvingly of the physical and emotional care. They simply wanted to matter to society, to be worried about, to find solace in each other. As
communities flourish around the globe, health care has evolved to revolve around a ‘treat disease – cure disease’ medical system, valid for thriving societies where governments work hand in hand with their people. But in such a deprived context as this, far more important to them was what they regarded as ‘heaven’: the place and space where they could freely meet and smile and laugh, to enjoy the little nuances that make life, away from ‘suspicious eyes’ and gossip. This was what they perceived as important, more so in the face of neither being able to access nor afford HIV medical treatment. Perception is, ultimately, the most important thing in communicating a message, more so the very message that they matter. That their lives matter and thus their health matters; and if they really matter to us, then we should sit with them on the floors of their simple wooden huts and reach out with firm, caring hands – hands that do not always need to be filled with material things or offering services, just with messages of care. Perhaps there is something in the attitudes of health-care workers like this man opposite me, from which we can glean the secrets of equity. Thus, we see that the solution is simple, free and applicable to the individual, yet has far-reaching
Italy - Male life expectancy: 78; Female life expectancy: 84; Under-5 mortality rate (per 1000): 4;
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Photo: Melissa Tang
â&#x20AC;&#x153;And so I listened, slowly sickened and horrified somewhat by my own disease, a disease of arrogance.â&#x20AC;?
consequences. It is not to stick people in a line to get needles stuck into them and then ship them back to their homes. Neither is it to campaign or to wait for more resources or governments to rise up out of their slumber. We do things that puff up our pride and reduce our guilt, when we already know that health goes beyond curative care, even preventative care. Paradoxically, in a setting so ‘backward’ compared to what I am familiar with, far from the fast pace and cutting edge of a society that I pride myself in, he is on the right path to making people matter. As he spends tireless hours working and giving himself while juggling time for his wife and newborn son, this is how the isolated peoples of Myanmar might be able to perceive health care in action; not covered up in the sheepskins of self-suffi
cing good intentions but in love, pure love. Whether in the midst of the sparsest resources, where whole villages do not have access to health care or the reverse situation where hospital buildings sit devoid of people, the methods to reach the community may differ but the attitudes that we have should be the same. It is these very attitudes that will tip the scales to win over a people that fi nd it hard to trust or even accept the meagre health care available; whether their situation was compounded by ignorance or apathy was irrelevant. Is not that what equitable access is, raising people up to an equal and deserved sense of self-worth so that they may make the right decisions to avoid risky behaviour and still find joy in the midst of affliction and stigma? Equitable access to health care
in terms of utilizing proper resources and setting up medical systems and programmes will always be a challenge. Hence, we should reconsider our fruitless discourse about the best method to convince the community, or our endless search for the best infrastructure to increase their accessibility. Instead, let each one of us be the access. First and foremost, let us be the solution. The crux of the matter is so simple it is almost utopian, yet it is often forgotten. I see the glow in the eyes of the young man, beauty and optimism that conveys hope to the stigmatized and forgotten, and I sense that this is where the two worlds come together and even disappear. In his words, “there is no difference between them and us”. This is the face of equitable access – going beyond health to life for all.
Marginalised Groups
World Market Factories: Perspectives on industrialisation and the female labour force Anny Huang University of Melbourne The latter half of the twentieth century was marked with the rapid industrialisation of many developing countries. This process has resulted in production being relocated to developing countries with the creation of “world market factories”, which specialise in the low-cost mass production of goods such as clothing, electrical appliances and car parts for export to the developed world.1,2 As of 1994, these factories provide over four million jobs worldwide, with most of the employees being young women.3 The reasons given for the preferential employment of women are that they have greater manual dexterity and patience, and are more suited to carrying out monotonous and repetitive tasks. However, some feminists argue that other unmentioned reasons for the high rates of female employment in-
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clude the assumption that women are less likely to form unions, more docile and more tolerant of abusive working conditions. 1,2,4 As well as detailing the reasons behind the recruitment of women, there is extensive literature about the living and working conditions and the empowerment or disempowerment of the women who are already working at such factories. So far, opinion has been largely divided between emancipation and exploitation.5 However, these arguments about whether or not industrialisation benefits women define the idea of “benefit” differently, with some papers focussing on the income of the factory women, whereas other papers address the health problems that affect women factory workers. This essay will argue that industrialisation benefits women in many areas, but is not beneficial in others. Furthermore, these benefits vary across different regions of the developing
world, and depend on other factors such as culture, legislation, employee demographics and the working conditions within each individual factory. Several authors have used macroeconomic and demographic data to measure the degree of benefit of industrialisation to women, arguing that the participation of women in the labour force is indicative of the status of women in society.6 Earlier modernisation theorists propose the idea that female labour force participation would increase with industrialisation, due to increased access to labour markets and economic resources.4 However, many feminists argue that due to the gender-based division of labour, most of the new opportunities would be open to men only, resulting in the marginalisation of women and the withdrawal of women from the labour force.4,6 More recent research shows that neither of these two proposed
Jamaica - Male life expectancy: 69; Female life expectancy: 75; Under-5 mortality rate (per 1000): 32;
theories takes place. Instead, the relationship between the participation of women in the labour force and the degree of industrialisation is a U-shaped curve, initially decreasing with the introduction of industrialisation and subsequently rising, due to the interplay of the factors highlighted in the theories of both the modernists and the feminists.6 Therefore, if this curve is the only factor considered, industrialisation is ultimately beneficial for women. However, the arguments and proposals put forward above all rely on the assumption that increased labour force participation is beneficial to women, which may not always be the case. For example, in the research carried out by Hancock,7 many Sri Lankan factory women considered their occupations “a poor substitute” when compared to the housewife lifestyles of their mothers. Other reasons supporting the claim that increased labour force participation may not benefit women are given later in this essay. Furthermore, it is rare that female labour force participation
will follow the smooth curve that has been proposed. For example, in South Korea, there has been a steady increase in the labour force participation of women since the early 1960s, which is due firstly to increased numbers of women in both blue collar and white collar jobs, but is also due to the migration of young people to the city, which increases the participation of elderly women in farming activities.4 This means that the changes in female labour force participation due to industrialisation are less straightforward than originally postulated, and may not always be beneficial to women. However, proponents of the view that industrialisation benefits women do not argue on the basis of demographic data alone. An important argument is that factory work increases women’s incomes. This leads to a greater ability to contribute to the household financially, which is then followed by increased authority, status and decision-making powers in the family.5,7,8 In some cases, the woman factory worker even achieves recognition as the head
of the household, with increased contribution of males to household chores.5 For many women, a higher income also leads to increased economic autonomy, where they are able to choose to spend the money on themselves or even invest in gold, land and cattle. In Bangladesh, where most women are expected to pay dowry to their husbands, the financial independence of women factory workers has meant that many of them are now exempt from paying dowry.8 As well as this, the opportunity to earn an income enables single mothers to become independent.3 A “new working-class consciousness” of class and gender subordination emerges from this sense of self-determination.8 Women have a greater awareness of their rights and organise protests, sitdowns and strikes, even though the formation of workers’ unions has been banned in many Free Trade Zones to attract investors.1,2,8 In the smaller workers’ organisations, achievements that have been documented include petitioning for the management to improve infrastruc-
Japan - Male life expectancy: 79; Female life expectancy: 86; Under-5 mortality rate (per 1000): 4;
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ture and working conditions, 1,8 while larger organisations such as the Peter Claver Women’s Housing Cooperative in Jamaica have succeeded in projects such as offering its members training programs and the purchase and provision of quality housing for women workers.3 Even in the absence of workers’ organisations, female factory workers may form informal groups where each member of the group contributes to a collective insurance fund.8 As well as providing economic confidence, factory work provides valuable skills to women with a limited education. Provided that she is willing to learn, a factory worker has a reasonable degree of job flexibility, as she will be able to find better jobs in other factories in some cases, or move into higher-paying jobs such as tourism in other cases.3,8 Furthermore, in regions where voting is not compulsory, there is a positive relationship between factory work and voting behaviours, and a greater proportion of factory workers believe that they are able to exert influence on the government.5 The increased living standards of men as a result of industrialisation are also positively correlated with the belief in equal rights for women.9 This represents an extraordinary empowerment of women and is one of the greatest benefits of industrialisation to women in the la-
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bour force. However, this degree of empowerment does not occur at factories in all regions of the world. An increased wage income does not always translate into having increased decision-making powers at home. For example, in his study of female Sri Lankan factory workers, Hancock reports that many women were forced to hand their salaries over to their husbands and parents-in-law once they returned home.7 Elson and Pearson also mention that in 1970s Malaysia, husbands were jealous of the fact that during working hours, their wives were under the control of the factory management.2 Consequently, they exercised stricter controls on their wives at home, preventing them from achieving economic autonomy or being recognised as the breadwinners of the family, even though the women were the main contributors to the household income. At the level of the society, public disdain of women factory workers and the view that women factory workers have lower moral standards contribute to a decrease in the status of women once they commence work at “world market factories”.7 Therefore, the degree to which having an increased income may empower a woman depends among many other factors on her culture and the values
of the society around her, as well as her living conditions and arrangements, and whether or not she is married. Moreover, many of the arguments in favour of the empowerment of women by industrialisation compare women factory workers to unemployed women in the developing world. However, Ver Beek shows that at a typical factory in Honduras, approximately 60% of first-time factory workers had been employed previously in other sectors, meaning that in many cases, comparisons should not be made between factory workers and the unemployed.5 Therefore, although factory work may benefit many women, this occurs to varying degrees, depending on the individual woman. Proponents of the view that factory work exploits women generalise women to an equal degree in their arguments. They argue that women factory workers have low wages and endure long working hours, with frequent compulsory overtime.2,4,7,10 The nature of the job is often described as the three Ds: difficult, dirty and dangerous.4 As well as this, the pay is often delayed, if not irregular or withheld, and overtime pay is frequently undercounted.1,8 Jobs are commonly unstable and insecure, with frequent firings, especially during recessions.4 When this occurs, the women who are dismissed are often those who have work-induced or work-related illnesses that cause them to be less productive.2 Working conditions are far from ideal, causing health problems such as musculoskeletal injuries, fatigue, vision and hearing problems, skin conditions and respiratory illnesses.1,11 In addition, workplace hazards such as toxic substances are often inadequately labelled, and fire exits are lacking in most factories, despite the frequency of fires.1,8 Gender discrimination of female workers by male supervisors can be found many workplaces, and may take the form of sexual harassment or pregnancy discrimination. The former may range from propositioning to
Jordan - Male life expectancy: 69; Female life expectancy: 74; Under-5 mortality rate (per 1000): 5;
rape, while the latter may be as extreme as â&#x20AC;&#x153;punching women in the abdomen to prevent viable pregnanciesâ&#x20AC;?.1,10 All of the above lead to heightened levels of stress and anxiety among women factory workers.1 In addition, the factory management may attempt to prevent the empowerment of women by organising events such as beauty contests to reinforce the femininity of the women factory workers.2 The social stigma attached to being a woman factory worker also contributes to the anxiety
ally inferior. The influx of factory workers into the US-Mexican border region has resulted in a population explosion, with the majority of workers living in shanty towns.1 Infrastructure is poor in these areas, and crime rates are high, with approximately three hundred young women factory workers murdered in the town of Cuidad Juarez to date.10 In other areas, women factory workers may not be better off nor worse off than their non-factory-
of many workers. In several developing world societies such as Sri Lanka, factory jobs are considered as work for women with low moral standards, as many of these women must leave their family and villages to work in free trade zones, where they are able to socialise freely with men and where they often live in boarding houses.7 In the predominantly Muslim society of Bangladesh, this move from rural to urban areas involves breaking the practice of purdah.8 Consequently, women factory workers are frequently taunted, harassed
and molested on their way to and from work.7,11 As production deadlines draw near, compulsory overtime shifts may extend until as late as 3a.m., exposing women who are returning home at that hour to an increased risk robbery, assault and rape.8 As well as this, the stigma of being a factory worker has meant that many single women are unable to find husbands, or that they marry abusive men in order to leave their factory jobs.7,11 Security is also an issue in societies where the factory women are not looked down upon as being mor-
worker counterparts, meaning that there is no benefit in factory jobs. One of these areas is education, which includes the opportunities available to employees for continuing education.5 In his study of factory workers in Honduras, Ver Beek also argues that other factors such as overtime, stress, supervision, childcare and crime may be no different between those who work in factories and those who do not, but the difference that is commonly perceived is due to the compari-
son of factory workers to workers in the developed world.5 In addition, in his quantitative analysis, Ver Beek discovers that male Honduran factory workers are more frequent targets of crime than their female counterparts.5 The discrepancy between Ver Beekâ&#x20AC;&#x2122;s data on Honduran crime rates and the data from the Cuidad Juarez murders is most likely due to the social, cultural, environmental and political differences between Honduras and
Kazakhstan - Male life expectancy: 59; Female life expectancy: 70; Under-5 mortality rate (per 1000): 29;
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Mexico. These differences are also applicable when comparing Asian and Central American women factory workers. Central American societies do not view female factory workers as morally suspect. Therefore, Central American women factory workers are free from the social stigma related to their jobs and do not have the same problem in finding a partner, but are harassed for other reasons that are related to the high crime rates in the shanty towns. Also, the majority of South Korean women factory workers are married,4 meaning that they are also less likely to have problems finding husbands. By law, Mexican companies are required to grant workers paid maternity leave. Therefore, in order to save costs, pregnancy discrimination is practised more aggressively in Mexican factories than in the factories in other countries.1 Furthermore, in the export processing zones in Jamaica, Barbados and Belize, most companies abide by the local laws and pay workers sick leave and maternity leave. In Jamaica, export companies in conjunction with the Free Zone Authorities have installed facilities for workers such as clinics, canteens and on-site banking.3 This indicates that although industrialisation has many negative effects, they are not felt in the same way and to the same degree by all factory workers. Finally, one of the best indicators of whether industrialisation has benefited women in the labour force must surely be the opinions of the women themselves. In his study of Sri Lankan women factory workers, Hancock states that 91% of respondents reported that their lives had improved due to their factory jobs, while 63% of respondents reported that their lives were better than those of their mothers in at least some areas.7 Similarly, reports an overall job satisfaction of 96% among his Honduran respondents.5 These results show that despite its negative effects, industrialisation does have some benefits for female workers. However, these
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benefits do not apply across all areas, and whether or not there is a net benefit depends on the interplay between the positive and negative effects of industrialisation, which in turn depend on various factors relating to the individual and his or her society. Differences in the starting point of the individual, as well as cultural, social and environmental differences leads to industrialisation benefiting some women in some areas, some women in other areas and some women in no areas at all, with all three outcomes applicable to a large section of the workforce.
References:
1. Abell, H 1999, “Endangering women’s health for profit: health and safety in Mexico’s maquiladoras”, Development in Practice, vol. 9, no. 5, pp. 595-599 2. Elson, D & Pearson, R 1989, “‘Nimble Fingers Make Cheap Workers’: An Analysis of Women’s Employment in Third World Export Manufacturing”, Feminist Review, Spring, pp. 87-107 3. Dunn, L 1999, “Export processing zones: a Caribbean development dilemma”, Development in Practice, vol. 9, no. 5, pp. 601-605 4. Park, K A 1995, “Women Workers in South Korea: The Impact of Export-Led Industrialization”, Asian Survey, vol. 35, no. 8, pp. 740-456 5. Ver Beek, K A 2001, “Maquiladoras: Exploitation or Emanci-
pation? An Overview of the Situation of Maquiladora Workers in Honduras”, World Development, vol. 29, no. 9, pp. 1553-1567 6. Mammen, K & Paxson, C 2000, “Women’s Work and Economic Development”, Journal of Economic Perspectives, vol. 4, no. 4, pp. 141-164 7. Hancock, P 2006, “Women, work and empowerment: A portrait of women workers in two of Sri Lanka’s Export Processing Zones”, Norwegian Journal of Geography, vol. 60, pp. 227-239 8. Zaman, H 2001, “Paid Work and Socio-Political Consciousness of Garment Workers in Bangladesh”, Journal of Contemporary Asia, vol. 31, no. 2, pp. 145-160 9. Miller, K A 1984, “The Effects of Industrialization on Men’s Attitudes toward the Extended Family and Women’s Rights: A Cross-National Study”, Journal of Marriage and the Family, vol. 46, no. 1, pp. 153-160 10. Moffat, A 2005, “Murder, Mystery and Mistreatment in Mexican Maquiladoras”, Women & Environments International Magazine, issue 66/67, pp. 19-21 11. Lynch, C 2002, “The Politics of White Women’s Underwear in Sri Lanka’s Open Economy”, Social Politics, Spring 2002, pp. 87118 12. (See also) Elias, J 2005, “Stitching-up the Labour Market. Recruitment, Gender and Ethnicity in the Multinational Firm”, International Feminist Journal of Politics, vol. 7, no. 1, pp. 90-111
Kenya - Male life expectancy: 52; Female life expectancy: 55; Under-5 mortality rate (per 1000): 121;
Marginalised groups
Impact of displacement and natural disasters on reproductive health: a review of the literature Geordan Shannon University of Newcastle The past decade has seen an increasing focus on health consequences following human conflicts and natural disaster. With the event of the Asian Tsunami, Sudanese conflict, Peru Earthquake and Hurricane Katrina, the worldwide community has become more aware of both the immediate and long term aspects of aid after a humanitarian or natural disaster: from the emergency medical response and refugee management and the long term aspects of rehabilitation and re-developing infrastructure and economies. Moreover, many of the countries in proximity to the “Ring of Fire”, an area of increased tectonic plate activity (affected by the Tsunami, earthquakes and volcanoes), are close geographical neighbours to Australia. Australia, therefore, is in
an ideal political and geographical position to supply their neighbouring countries with Aid after the event of a natural disaster. There are, obviously, quite pronounced differences between the politico-socio-cultural aspects of a natural disaster compared to a human-made disaster such as war. However, interestingly, there many similarities with regards to how they effect communities and people. Women and children’s healthcare during and after a disaster have also required a unique and coordinated response, although it has been focused on to a lesser degree. Women and children are some of the most vulnerable groups of people during the aftermath of a disaster: they comprise 80% of all affected people, they are the most affected in terms of their family structure, loss of children, ability to find employment and also many as-
pects of reproductive medical care are thrown into disarray. Fundamental human rights during peacetime and wartime, stability and disaster, include the right to reproductive health care, and are particularly important to uphold in groups of migrants or displaced persons. These rights are founded in three bodies of international law that directly address the situations faced by this group (http://image.thelancet. com/extras/03art4174 webappendix.pdf). Over the past few years, increasing attention has been paid to the link between human rights and health and, particularly, reproductive health. As Bartlett et al state, humanitarian programmes often appropriately focus on immediate survival needs in the traditional early response to a disaster. For example in 1993, the Women’s Commission for Refugee Women and Children found few or no reproductive health services offered
Kuwait - Male life expectancy: 77; Female life expectancy: 79; Under-5 mortality rate (per 1000): 11;
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in eight refugee sites visited in Africa [7]. However, Bartlett et al again make the interesting point that reproductive health is essential for the long-term survival of communities, and believe it is an obligation of humanitarian agencies to address these concerns early in their response. Following an intense training week on natural disaster management and relief during the Asian Collaborative Training on Infectious diseases Outbreak and Natural Disasters (ACTION project) conference in Phuket, Thailand, 2007, I chose to look further into the effect of a natural disaster on the delivery of Reproductive Healthcare, through reviewing the current literature on the situation.
event of a natural or humanitarian diaster. Further to this, a few case/control studies were identified that examined the reproductive health of migrants versus non-migrant groups after a disaster. The strength of the available data was the fact that many studies examined large groups of people, however the weakness of the data was the heterogeneity of the groups studied: it is difficult to generalise the response of people to a disaster. Also, the data from a disaster can be notoriously inaccurate due to unidentified and missing people, and chaotic organisation, although the WHO and UN, resources I have used, are the world leading bodies and the most reliable resources to comment on situations like these.
Available Literature
Forced Migrants
On reviewing the literature, I found multiple articles examining the complexity of medical care and human rights during and after a disaster. Many of these papers were retrospective cohort studies, deconstructing and critiquing the response of humanitarian agencies to the
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35 million people live as forced migrants worldwide [2]. There are many complex factors involved in the circumstances of their displacement, including environmental hazards, armed conflict, and social, economic, and political influences. An IDP, or Internally displaced person, is
someone who is displaced within the borders of their own country, whereas a Refugee is defined as a person who crosses an international border in their flight [2].
Female Vulnerability
Women are at a greater risk of death in both the emergency situation and in the role of survivors of a disaster. Interestingly, the mortality rate of women compared to men after the Indian Ocean Tsunami was 3:1 [10]. The many proposed factors behind this statistic include the traditional clothing of many Asian women, which is long and restrictive to movements, and womenâ&#x20AC;&#x2122;s long hair and accessories, which became tangled in debris underwater. Many women were unable to swim, as they were not taught to swim as a child and it is often the case that menâ&#x20AC;&#x2122;s professions, not womenâ&#x20AC;&#x2122;s, required some ability to swim or knowledge of the ocean, such as fishermen. In addition, in the immediate period after the initial disaster, many women returned at once to search for children, and were injured or killed in the aftermath.
Kyrgyzstan - Male life expectancy: 63; Female life expectancy: 70; Under-5 mortality rate (per 1000): 41;
In the situation of armed conflict situations, it is women who often have no access to means of selfdefence or transport away from danger. They are also extremely preoccupied with the protection of their children, and, in many cultures, women are socially and culturally vulnerable and disempowered.
Photo: Megan Hamilton
The myriad of health and social issues for female survivors of the emergency phase of a disaster include unemployment, poverty, sexual violence, rape, and prostitution to support themselves or their family financially.
Pregnancy
Each year 210million women become pregnant, 130million give birth, and 15% experience complications of the birth (1/3 of which are life threatening) [7]. It is estimated that in affected countries during the Tsunami 150,000 women pregnant and 50, 000 in 3rd Trimester. Of these women, only 40,000 pregnant women survived. Of the Tsunami affected areas, 8300 women were pregnant in India, 1380 of who were in the 3rd trimester, 5000 births were anticipated in Feburary 2005 in Sri Lanka, and in Banda Aceh, 6000 pregnant displaced women remained after the Tsunami [3]. Areas of disaster and conflict often experience large challenges in reproductive healthcare prior to the disaster situation, often due to third world conditions and health provision. Poor standards of pre-conflict maternal and neonatal health in developing world countries are a huge problem, which is amplified hugely in the event of a disaster. Living in a shelter, after the event of a forced displacement places a huge psychosocial and physical load on a woman. This leads to an increased incidence of spontaneous and induced abortions, preterm labour and small for gestation babies, and decreased identification of perinatal risk factors due to the chaos and break-
down of healthcare services [3]. Further to this, there are concerns for the long-term healthcare of women who relocate to another country as a refugee or asylum seeker, and poorer antenatal care and access to healthcare services. A UK Confidential Enquiry into Maternal Deaths expressed concern that mortality in women from non-Englishspeaking ethnic groups was twice that of native-born women, however, a case-control study of the obstetric performance of ethnic Kosovo Albanian asylum seekers in London showed that there was no significant difference in the perinatal outcomes of native speakers versus migrant groups in the study [10]. The similarity in obstetric and foetal outcomes between the study and control groups was perhaps attributed
to the fact that many immigrant groups appear to have better outcomes due to family support and relatively lower intake of alcohol and nicotine.
Healthcare
Poverty of affected communities and poor access to quality health care are factors in the poor reproductive health of many women in a natural or humanitarian disaster situation. The UN Millennium Goal of halving maternal mortality by the year 2000 is still far from being achieved [9]. In South East Asia maternal deaths account for 1/3 of all maternal deaths worldwide and 3million children in the same region died before their 5th birthday [10]. In addition, each conflict or natural disaster affects healthcare
Lao Peopleâ&#x20AC;&#x2122;s Democratic Republic - Male life expectancy: 59; Female life expectancy: 61; Under-5 mortality rate (per 1000): 75;
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staff and may affect regional facilities and infrastructure. There was a high mortality of healthcare staff as a result of the Tsunami, and destruction of infrastructure, facilities, and hospitals. For example, there was a disproportionately high loss of life of Midwives in Indonesia secondary to Tsunami [10].
Sexual violence, HIV, Contraception and Sterilisation
It is known that there is a heightened incidence of sexual violence in the situation of forced displacement and chaos [10]. Not only are there physical and psychological ramifications of the assault, but also the woman is placed at a higher risk of contracting a sexually transmitted diseases. Social conditions promoting spread of HIV and STIs include community disruption, a chaotic political climate and environment, and displacement; most of these factors are present after a humanitarian or natural disaster. Other factors such as increased rates of prostitution, poverty, and overcrowding in shelters also contribute to the spread of sexually transmitted diseases and increased rates of sexual violence. Intriguingly, it is not only the victims of displacement or the disaster who are the perpetrators of bad sexual health habits; the arrival of foreign military, relief workers, and reconstruction workers also are proposed factors that increase the transmission of STIs [10]. As with the use of contraception after a disaster, in many countries there is poor pre-displacement education about preventing spread of HIV and STIs and quite a high pre-disaster prevalence of HIV and other STIs.
such as government and community education programs about STIs and birth control. Thailand actually had a high use of contraception secondary to a large campaign to control the spread of HIV, compared to Southern India, where the rate of contraception use was low [10]. Despite this, there are huge barriers to the distribution of contraception such as the oral contraception pill and condoms in the disaster situation due to lack of physical access to various areas and general lack of medical supplies and access to all forms of medicine including contraception. In Banda Aceh during the one month period post-Tsunami, requests for forms of contraception totalled 80 000; only 16000 out of this 80000 requests were met [10]. Interestingly, the patterns of sexual behaviour after disasters has not been studied, but it is, however, known that many affected and displaced persons require a high level of emotional support
and may seek this through sexual relationships. An often unseen reproductive health problem in displaced people is womenâ&#x20AC;&#x2122;s grief over the loss of their children and how this shapes their outlook on becoming pregnant again. Many women however are unable to reproduce again due to prior sterilization procedures [10]. For example, 44% of women Tamil Nadu were sterilized before the age of 27years. Loss of children for women can bring with it loss social status, self esteem, and economic security [10].
Long Term Maternal Outcomes
In terms of safe reproductive health, the review of available information on maternal and child outcomes suggest that poor pregnancy outcomes are common in many war-affected populations and may be worse during the acute phase of an emergency. However, the data suggest
Use of forms of contraception in immediate post-disaster period depends on the level of pre-disaster education, community awareness and availability of contraception. For example, people from different countries affected by the Tsunami had variable rates of pre-displacement use of contraception, depending on factors
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Latvia - Male life expectancy: 65; Female life expectancy: 76; Under-5 mortality rate (per 1000): 9;
that once stabilization occurs, adverse pregnancy outcomes may be no more common than in host or home countries [7]. The findings of a study of maternal mortality among Afghan refugees in Pakistan [1] indicate that the maternal mortality ratio and lifetime risk of maternal death was significantly lower in the women who were migrants than the corresponding women who remained in the unstable situation in Afghanistan. This may demonstrate a positive effect of migration to a nation with a more stable healthcare system amongst other things. Likewise, the study performed on a group of Kosovo Albanian asylum seekers in London[10] showed that there was no significant difference in the perinatal outcomes of native speakers versus migrant groups in the study, this being attributed to the effect of the environment to which women migrate on their own health standards. And, as the UNHCR enquiry into refugee health in1998 concluded, the positive outcomes for refugee groups who are in a stable setting is mostly due to the higher availability of services. In Yoong et al’s study, most of the maternal deaths in the refugee population, however, were preventable and many women
References: 1. Bartlett LA, Jamieson DJ, Kahn T, Sultana M, Wilson HG, Duerr A. Maternal mortality among Afghan refugees in Pakistan, 1999–2000. Lancet 2001;359:9307 2. Bartlett L, Purdin S, McGinn T Forced migrants—turning rights into reproductive health Lancet 2004; 363: 76–77 3. Carballo M, Hernandez M, Schneider K, Welle E Impact of the Tsunami on reproductive health J R Soc Med 2005;98:400–403 4. Cook RJ, Dickens BM, Fathalla MF. Reproductive Health and Human Rights: Integrating
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faced multiple barriers to healthcare. Therefore the impact of migrating to a more stable environment after a disaster has positive impacts on maternal and child health; however there are still huge barriers to healthcare in these migrant populations that must be address to stop preventable deaths. This finding is particularly relevant to the effective long-term provision of healthcare to migrant groups in Australia.
Conclusion
Reproductive healthcare problems occur in all populations, including those who are displaced or who are migrants. In many situations, developing world communities who are affected by humanitarian or natural disaster often have a poor standard of reproductive and sexual healthcare prior to the event and this, clearly, affects the health of a population post-disaster. The issues of reproductive health are important also for the long-term survival of a community, and must be addressed further in the post-disaster period. There are now multiple resources available to assist displaced women and refugees, including the MISP (minimum initial service package) and the Emergency Reproductive Health Kit (from
Medicine, Ethics, and Law. Oxford: Clarendon Press, 2003 5. Evans I. Book Review: Reproductive Health and Human Rights: Integrating Medicine, Ethics, and Law Journal of the Royal Society of Medicine, Volume 97 January 2004 6. McGinn T. Reproductive health of war-affected populations: What do we know? Int Fam Plann Perspect 2000;26:174 –80. 7. O’Heir J, NM, Pregnancy and Childbirth Care Following Conflict and Displacement: Care for Refugee Women in Low-Resource Settings MNJ Midwifery Womens Health 2004;49(suppl1):14 –18 © 2004 by the
UNFPA) [7]. The MISP addresses various women’s health needs during a disaster by providing basic kits in various areas including clean delivery sets, professional midwifery kits, management of abortion complications, suture of cervical and vaginal tears, vacuum extraction, surgical and other life-saving interventions, and blood transfusion [7]. The World Health Organisation developed an Interagency Field Manual which was made available in 1999 and it promotes the provision of quality healthcare, including care during pregnancy and childbirth (full text of the Field Manual is available at http://www.unfpa. org/emergencies/manual/index. htm or http://www.unhcr.ch/cgibin/texis/vtx/publ). It is hugely important for healthcare professionals involved in this field to not only understand the impact of a disaster on all aspects of human life in order to effectively provide aid, but also to understand aspects of reproductive medicine that are affected by natural disasters and conflict, and to respond to women’s needs accordingly. This will ensure the people who are most affected by a natural disaster are cared for and will ensure the long term survival of communities.
American College of NurseMidwives. 8. UNHCR. Reproductive health in refugee situations: An interagency field manual. Geneva: UNHCR, 1999. 9. WHO. Reduction of maternal mortality: A joint WHO/UNFPA/ UNICEF/World Bank statement. Geneva: WHO, 1999. 10. Yoong W. Wagley A. Fong C. Chukwuma C. Nauta M. Obstetric performance of ethnic Kosovo Albanian asylum seekers in London: A case-control study. Journal of Obstetrics and Gynaecology. 24(5)(pp 510-512), 2004. Date of Publication: Aug 2004.
Lebanon - Male life expectancy: 68; Female life expectancy: 72; Under-5 mortality rate (per 1000): 31;
Marginalised groups
Taking a Human Rights Approach to Health
A foundation for improved freedom, justice and peace? Jenny Jamieson University of Melbourne
ly entitled to our human rights without discrimination.
2008 will see the 60th Anniversary since the United Nations Declaration of Human Rights was adopted and proclaimed by the General Assembly in 1948. It is worth asking ourselves today: has the adoption of this declaration made a significant impact? Has it been a foundation for improved freedom, justice and peace worldwide? And if not, why should we strive as health professionals to take a Human Rights approach to health?
Universal Human Rights are often expressed and guaranteed by law in the forms of treaties, customary international law, general principles and other sources of international law1. International Human Rights Law lays down obligations of Governments to act in certain ways or to refrain from certain acts, with the purpose of promoting and protecting Human Rights and the fundamental freedom of individuals or groups3.
Human rights are rights inherent to all human beings, transcending nationality, place of residence, sex, national or ethnic origin, colour, religion, language, or any other status1. Essentially this means that we are all equal-
There are both positive and negative Human Rights. Positive Human Rights obliges individuals or institutions to do something for someone else (i.e. active). In contrast, negative Human Rights oblige individuals or institutions to refrain from doing something (i.e. passive). For example:
• The right for legal representation (positive) • The right not to be tortured (negative) The distinction between these is by no means black and white. For example, the right for freedom of speech is a negative right (as it must not be revoked), yet the means to implement this within a society make it a positive right as well. Human Rights are integral to health, as stated by the WHO Constitution: “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being...” The protection and promotion of health is thus inextricably linked to Human Rights preservation 4 . The Right to Health has been enshrined in many international Human Rights treaties, as well
Lesotho - Male life expectancy: 40; Female life expectancy: 44; Under-5 mortality rate (per 1000): 132;
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as within national constitutions worldwide4. The Right to Health stipulates that governments must generate conditions in which all citizens may be as healthy as possible. These conditions can range from accessibility of health services to adequate housing and nutritious food. However, the Right to Health does not confer the right to be healthy4. What is the advantage of taking a Human Rights approach to health? Essentially this approach has a strong framework, socially and legally, for describing health in a holistic manner. The right to health has a “core content”, i.e. a minimum essential level of the right. The key elements of this include: • • • • •
essential primary health care minimum essential and nutritious food sanitation safe drinking water essential medicines
Similarly, on a public health level, health policies and programmes can be used to promote or violate Human Rights in their design or implementation4. Taking a Human Rights approach to health, allows the opportunity to analyse existing and proposed policy. For example, the anti-retroviral scale-up plan in Uganda can be analysed with regard to marginalized populations. Does their plan include an effort to reach marginalized populations? Does the law in Uganda provide full equal rights for women or does the potential for gender-based discrimination against women receiving required ARV treatment exist?
surrounding stigma. The MSF clinic in Ubuntu, Cape Town, has numerous posters around the township promoting the concept of seeking treatment. Recommendations on a national level should seek to involve all stakeholders to ensure the full recognition of Human Rights. This may involve multiple organizations, including governments, hospitals, pharmaceutical companies and NGOs. Recommendation on a global level need to arise from leading organizations such as the WHO and the UN taking a tougher stance on this, rather than allowing healthcare delivery to be dictated by global institutions such as the World Bank, the IMF and trans-national corporations. What can medical students as future health professionals do about this? On an individual level we can appreciate and acknowledge the certain advantages of approaching health from a Human Rights standpoint. As future doctors we can act as advocates for Human Rights and promote dialogue within the community to raise awareness of Human Rights violations. On a national level, we can speak out against the marginalization of certain communities within our country who do not have the benefits of receiving equal medical treatment, such as asylum seekers. On a global scale, we can become involved in reputable organizations, such as
Physicians for Human Rights, to mobilize other health professionals to promote health, dignity and justice and promote the Right to Health for all6.
References
1. Office of the High Commissioner for Human Rights www. ohchr.org 2. Global Health Watch, 20052006 3. IFMSA policy: The Monterrey Declaration on the Fundamental Right to Health, 2008. 4. World Health Organisation http://www.who.int/hhr/en/ WHO 5. Medicins Sans Frontieres www.msf.org 6. Physicians for Human Rights http://physiciansforhumanrights. org/
This could be done by making recommendations for policy and programs on individual, family and community levels. In the case of Uganda, this could endorse the community teaching and promotion of HIV treatment as an important step, aiming to minimize
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Liberia - Male life expectancy: 43; Female life expectancy: 46; Under-5 mortality rate (per 1000): 235;
Section 3: Getting Involved
Destinations Australia
Australian Medical Students’ Society Page 119 Global Health Network Page 122 Global Health Groups Page 123 Red Party Page 144 The Mirrar People of Jabiru Page
Fiji Fiji Village Project Page 137
Ghana
Dabaa Medical Centre Project Page 142
India
Medical students unite in Pakistan to India Peace March Page
146
168
Cameroon ... and Aboriginal Australia Page 153
Nepal
MAPW seeks student representatives at the Global Health Conference Page 168
Cambodia
Cambodia Calling Page 164
Cameroon
Cameroon ... and Aboriginal Australia Page 153
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Nepal Project ‘08 Page 140
Papua New Guinea
Paiga Clinic: Health issues in a Papua New Guinean Highlands
friend ...” Page 151
Thailand
Remote Medicine: Thai Style
Page 149 The Asian Collaborative Training on Infectious Disease, Outbreak and Refugee Management Page
167
Zambia
Mwandi Page 161
Global
International Federation of Medical Students’ Associations Page
135
Village Page 155
South Africa
“Welcome to South Africa, my
Libya - Male life expectancy: 70; Female life expectancy: 75; Under-5 mortality rate (per 1000): 18;
Australian Medical Students’’ Association The Australian Medical Students’ Association (AMSA) is the peak representative organisation for the 12 000 students studying at Australia’s 19 medical schools. As a medical student you automatically become a member of the AMSA family. Whether you’re an undergraduate, graduate, local or international, rural or metropolitan student, AMSA has so much to offer and so many opportunities for you to get involved. Check out the AMSA website www.amsa.org.au and subscribe to AMSA for the full range of AMSA Members Benefits.
Advocacy
AMSA works closely with key stakeholders to improve medical education in Australia and raise awareness of rural, indigenous and global health issues. Through AMSA National Council to meeting with key stakeholders and raising the BIG issues in the media, AMSA wants to know what affects YOU.
Community
AMSA promotes medical student involvement in the community through a number of initiatives. Get involved through the National Blood Drive, the National Charity Drive and our online Community Bulletin Board.
Events
AMSA has an extensive calendar of events that’ll have you going off like a frog in sock. Enter Convention, Global Health Conference and the National Leadership Development Seminar into your diary today.
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Global
AMSA coordinates a number of global initiatives and networks with medical student societies from all over the world. Join AMSA’s Global Health Network or meet others from around the world through the International Federation of Medical Student Associations.
Membership
Our Subscribe to AMSA service offers an ever expanding range of members benefits designed specifically with you in mind. We offer a range of Scholarships, Bursaries and Competitions, a National Mentoring Scheme and the AMSA AMEX Gold Credit Card.
Vol. 42, No. 1 May 2008
The
Is it a bird? Is it a plane? No, it’s the pinnacle of med student publications! Edition.
Publications
AMSA has a range of publications to keep you entertained while you toil through PBHell. Stay up-to-date with all our greatest reads – Panacea, Intern and Residents Guide and our monthly e-newsletter, Embolus.
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TS’ THE AUSTRALIAN MEDICAL STUDEN ASSOCIATION PRESENTS....
Clinical Training and You Med Ed Survey ‘07 PSWP Get a GP with Dr Feelgood
And for the first time...
GHN’s VECTOR!!!
ThE INteRN & ReSidENt GuiDE 2008
Rural Bursaries
Songs vs. Study The Truth About Costa Rica
AMSA National Leadership Development Seminar 2008 Coming in September to a Parliament House near you!
•
Do you want to gain vital skills in lobbying, communication, presentation, media and the maintenance of professional relationships? • Do you want to network with like-minded colleagues as well as policy-makers? • Do you want the chance to question and debate current policy-makers? If you answered ‘yes’ to any of these questions, then AMSA’s National Leadership Development Workshop is for you!
Stay tuned for more or visit www.amsa.org.au. Coming this September...
Leading the way Most of your peers are members of Avant and enjoy the benefits that come with being part of Australia’s largest medical indemnity provider. For access to leading indemnity products, member benefits, support and representation contact us today.
Freecall 1800 128 268 www.avant.org.au
Global Health Network “Our expectant eyes are fixed on the youth of every generation.” As a part of our generation of youth and young adults, medical students are increasingly making more significant contributions to the world around us. Involvement in global health is but one contribution. Like other medical students across the world, Australian medical students have proven that young adults can lead successful global health projects and enterprises at all levels of society, be it local, national or international. Some examples include awareness projects, fund-raising events for charities/NGOs or out-reach projects in developing countries. As with any individual effort towards any project, comes a group effort. In this case, global health groups across Australia attract individuals to become involved in global health projects and empower students to implement new projects/ideas, becoming even more skilled in their interests. Similarly, as with any group effort, comes a collective effort of support, networking and li-
aison. And this is the AMSA Global Health Network (GHN). The GHN is a committee of GHN Representatives from every global health group at Australian medical schools. As the committee moves into its fourth year, since it first started with DWC 05, much progress has been made. The GHN website has been updated and made more user-friendly (please visit: www.ghn.amsa.org.au); Vector, the national publication of the GHN, is now also a supplement in the AMSA Panacea, reaching out to as many medical students as possible; the GHN is now officially (and proudly!) recognized as an AMSA Committee under AMSA Global, with recent regulations & bylaws development; national advocacy with respect to medical student knowledge of the MDGs commenced (super-thanks to everyone who participated in the MDG Survey!); and finally, a national project with en-mass involvement from global health groups across Australia is being discussed. At the AMSA GHC, the GHN Committee 07/08 will be handing over to the new GHN Committee 08/09. We extend best wishes to the new committee
Vector Magazine: The Vector magazine is the official magazine of the AMSA Global Health Network - and continues to grow in leaps and bounds! Now an insert into the AMSA Panacea magazine, the magazine reaches all medical students Australia wide. It includes the most demanding and complex issues surrounding health distribution worldwide.
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Massive congratulations must be extended to Cara Fox and Nicola Sandler for their fantastic work producing – Indigenous Issues, Students Without
and are assured of the ever growing initiatives of the GHN …future opportunities are endless! We have also enjoyed working with the fabulous GHC Convenors and team and extend a huge thank you for putting together an incredible program for AMSA GHC 2008. We greatly appreciate our involvement with the AMSA GHC and look forward to being of more assistance in the many years to come! We also extend a warm welcome to the visiting delegates from the Asia-Pacific region – it is wonderful to have you here – the first step in many to come towards developing stronger links and more meaningful Asia-Pacific network. And so, amongst the intense burst of international consciousness, energy, inspiration, and socializing, it’s a perfect time to get connected with your global health group. Enjoy reading the following pages filled with everything global, the “Aussie way” – that’s right, Australia’s very own global health groups! Negin Sedaghat AMSA GHN Chair 07/08
Borders and Connections this year. Please check out these editions at www.ghn.amsa.org. au/vector! We hope for even greater success from Vector’s newly elected Editor and Layout Designer, Nelu Jayawardena and Leanne Hoang, as they shape this magazine from GHC ‘08-GHC ‘09. Do you have the gift of penmanship? Want to showcase your experiences to other meddies? Or want to join the mailing list? Then email us on vectormag@ gmail.com to be a part of it all!
Global Health Groups The University of Adelaide: Insight - Simon Harley Insight is Adelaide University’s Global Health Group. Although founded within the medical school in 2004 by medical students, Insight has always been open to students from any degree. Over the past two years, this concept has been pushed harder and succeeded with a huge number of students from outside the medical school joining. Of late, there has especially been much enthusiasm within the Dentistry school, however many Nursing, Development Studies and Arts students have also showed strong interest. With the constant increase in members every year not only from incoming 1st years, but also from the wider university community, Insight now see they have an even greater potential to Educate, Inspire and Empower students from all over the university to help alleviate the imbalance that exists between developed and developing world health systems. Building on many of last year’s successes which included the inaugural Insight Photo Exhibition, Insight/AMSS Talent Night, numerous education forums, the Zonta Birthing Kit Workshop and the annual Development Fund Dinner, Insight also wishes to add to their entertainment repertoire, the Insight Red Party, an initiative of the Global Health Network. Fortunately, entertaining is not the extent of our capabilities; last year Insight was granted a $50,000 donation from the Meyer’s Foundation to help build student accommodation in Kompian, PNG. The accommodation will be built for university students from Adelaide who wish to reside in Kompian whilst undertaking a 4 week SCAP, ie. Special Community Ambulatory Placements, in this town (another initiative set up by Insight)
One of Insight’s primary aims is to work with the Medical School to influence the curriculum and expand its teaching on health issues in the developing world. The International Health Stream entails the study of social determinants of health in low-income developing countries and of our own indigenous population. Course content focuses on poverty, politics and the need for appropriate aid development from high-income countries. In addition to existing programs within the curriculum, ie. International Health, International Primary Health Care and the aforementioned SCAPs in PNG and India, Insight is excited about a new program in the pipeline - a 6wk International development field trip, which will be in collaboration with the Rural Health School, Departments of Public Health and of General Practice.
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Insight will continue to build on existing relationships with various communities and hospitals around the world including Kompian and Velore, as well as forging new relationships with communities in India, Malaysia, Nepal and Ghana. Insight sees these placements as having a vital role in raising awareness and exposing students to the health systems and the people of these communities. The Insight Development Fund will continue to support students’ placements every year financially and any member can apply. Partnering with the Development Fund is the Insight Aid Project which will advertise for, collect and send supplies and medications with the successful applicants to the community in need. For more information, please visit our website at www.amss.org.au/ insight
Lithuania - Male life expectancy: 65; Female life expectancy: 77; Under-5 mortality rate (per 1000): 9;
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Australian National University: EnSIGN - Negin Sedaghat The global health group at the ANU is EnSIGN (Engaging Students In Global Health Network), which is also a sub-committee of the ANU Medical Students Society. The group started in August 2006 with its inaugural meeting organized by the first-ever “International Health Officer” on the MedSoc. Since then, the group has been involved in organizing both local and international projects. EnSIGN has three broad goals, which include: 1. Support and create opportunities for health development both locally and internationally. 2. Promote and engage in global health issues 3. Contribute towards sustainable elective placements One of our achievements over the past year has been our recent collaboration with the local rural health club (ARMS). We organized a Universal Children’s Day Seminar, “Indigenous Child Health – challenges for the future”. This was held at the National Museum of Australia. We were all encouraged by the experience and hope to continue the tradition in the future. The event was attended by both medical students and members of the public. Our two most successful local projects are the Teddy Bear Hospital and Clowns In Crisis. The Teddy Bear Hospital was a lot of fun, not only for the primary school children, but also the medical students. We were particularly delighted when the children all mentioned that their favorite part of the teddy bear hospital experience was seeing the doctor! We would especially like to thank the ANU Clinical School of Medicine and Dr Sue Packer for supporting us with this project and making it a wonderful success. Clowns In Crisis involved medical students letting go of their professional attire to don clown costumes, bringing smiles to the faces of many paediatric and adolescent patients at The Canberra Hospital. Every year,
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since we started, we’ve had a lot of students participate and we especially thank CANTEEN for its support in kind, by way of gifts for the children. Our only and biggest international project, involving contributions from almost everyone, is the Fiji Village Project. This is our transnational project with New Zealand and Fiji School of Medicine medical students. We organized our inaugural trip in January of this year and we are most happy to report that we operated within budget, achieved our aims and had a great time too! The future for EnSIGN sees students starting up new projects in a range of areas. Yes, we are expanding our interest areas and getting more and more students involved! These include Refugee Health, where we are looking towards setting up some bursaries and mentoring programs. Also, Indigenous Health, in which we are hoping to instigate a similar philosophy to that trialed, with success, in Fiji. And finally, an Anti-Tobacco project in which we will be collaborating with ASH (Action on Smoking and Health) Committee in Canberra. We will also continue to support the Fiji Village Project, and will be busy organizing the next phase of the project for January 2009. Amie Rieseberg and Shruti Jayachandra are the current Co-Chairs of EnSIGN, and feel free to contact them for more information about any of our projects: u4365957@ anu.edu.au (Amie) or u4365286@ anu.edu.au (Shruti) Also, our GHN Rep, Negin Sedaghat is contactable on: u4289548@anu. edu.au We’re looking forward to a fabulous GHC08 and some serious inspiration to take back with us!! For a description of the EnSIGN Fiji Village Project, please see page 133.
Luxembourg - Male life expectancy: 77; Female life expectancy: 83; Under-5 mortality rate (per 1000): 4;
Bond University: MAD - Akhil Gupta Making A Difference (MAD) is Bond University’s Global Health Group (GHG) operating under the umbrella of the Global Health Network (GHN). We are a relatively new GHG and have recently developed our individual mission statement: “MAD seeks to encourage Bond Medical Students to participate in, learn about and raise awareness of issues surrounding local and international health”. We aim to complete this mission through our upcoming website and a variety of other initiatives including seminars, debates, newsletters fundraising events. Apart from these local MAD events, one of our major goals is to enable our Medical Students to make the most of any Global Health opportunities that come our way. Global Health projects and events that other medical students have been successfully involved in have unfortunately slipped passed in recent times. In the coming years, we hope to increase the opportunities that Bond Medical Students have to be actively involved in these projects and events and solidify Bond University’s Medical school as an active member in the Global Health Network. As a relatively new GHG, we also hope to form partnerships and affiliations with other established GHGs throughout Australia. The Global Health Conferences of 2008 and 2009 will be the keystone events that will aid in this process and hopefully through these part-
nerships, Bond University and its Medical Students will become a more active member of national global health projects in the years that follow. We are in the process of developing a global health newsletter, published on a monthly basis informing our students of recent events, upcoming events and other global health projects. This newsletter will also include some humbling articles about local and global health from a variety of authors, both within our student body and from doctors working in the wider community. In the coming years we also hope to establish a website for our GHG. Ultimately we aim to distribute the newsletter throughout the University, and not limited to the medical faculty as is currently the case. Our website will open up global health issues to the University as a whole. Also we have established a semester calendar that will ensure our GHG holds a “token event” every semester. Most likely to be held in week 4 of each semester, this event will be related to global health issues and in the upcoming 082 semester, it will take the form of a seminar/debate regarding refugee health. MAD is a relatively new GHG. We have much scope to develop as an organization and for this reason we are excited for our growth in the coming years.
Flinders University: HHRG - Bjorn Cartledge The Health and Human Rights Group (HHRG) of Flinders University is a student run organisation primarily made up of medical students, but open to all disciplines. We are apolitical and focussed only on making a difference to health in settings where the basic human rights of health are not being ful-
filled. So that means we are concerned with Indigenous health and refugee health here in Australia and developing world health internationally. We have projects and sub-committees that address each of these concerns and an annual program of speakers and seminars to raise
Madagascar - Male life expectancy: 57; Female life expectancy: 61; Under-5 mortality rate (per 1000): 115;
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awareness of key issues in our members. And that is how we define our activities – we are committed to both action and education. We are active in many ways, from enabling members to launch their own project with our HEAT grant awarded annually; involving members as volunteers with Zonta International, the Australian Refugee Association (and many more besides) and running our own aid projects. We have a project under development in West Timor and are delighted to be launching Project2 this year which is an ambitious initiative with an Indigenous community project and Nepalese community project united under the one banner. The inclusion of an Indigenous project and International project within the same initiative reflects our commitment to the universal rights to health, and while the two projects of Project2 are vastly different in both method and objective, the fundamental principles underlying everything we do are identical.
Education is our other key objective. We raise awareness about issues and opportunities amongst our members and peers with our speaker series featuring prominent speakers and representatives from prominent organisations that share our vision, as well as with seminars and a quarterly members newsletter. This is the day-to-day work of the HHRG and something of great value – we aim to inspire and interest people in the provision of healthcare in the challenging environments of the developing world, indigenous health and refugee specific healthcare. The HHRG has a vitality and enthusiasm that lends itself to growth. With a steadily rising membership and the launch of Project2 this year, we are continuing the trend of recent years and raising the awareness of global health and human rights issues while making a significant contribution ourselves. For a description of the HHRG Nepal Project, please see page 136.
Griffith University: HOPE4HEALTH - Jessica Hamlyn HOPE4HEALTH is a Griffith University organisation founded by medical students in 2006. HOPE4HEALTH aims at improving health outcomes in local, rural, indigenous and international communities. The aims of the organisation are achieved through 1. Educating and raising awareness amongst our members with regard to health issues in each of our four focus areas. 2. Providing opportunities for members to experience working in areas of need with a view to continue working in such areas after graduation. 3. Direct fundraising for an annually chosen project or charity through our annual corporate events. HOPE4HEALTH has evolved into 2 separate sectors: HOPE4HEALTH Club draws members from Griffith University’s Faculty of Health. Currently HOPE4HEALTH has just over 400 members. Student members of HOPE-
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4HEALTH have access to events and activities that aim to educate and promote student interest in health issues. These include the - Horizons Seminar lecture series with guest speakers from the national and international medical community. Approximately 6 seminars are held per year. - Rural health trips that are aimed at enabling students to gain a positive experience of rural life and work. Trips planned for 2008 H4H include visits to Weipa, Rockhampton and Stanthorpe. - Cherbourg Indigenous Health workshops that are held in conjunction with Griffith University and the Gold Coast Hospital. - Teddy Bear Hospital project which targets the local Gold Coast primary school community. The project aim is for students to take the first steps in preventative medicine with workshops designed to educate young children in staying healthy. HOPE4HEALTH Corporate is the
Malawi - Male life expectancy: 49; Female life expectancy: 51; Under-5 mortality rate (per 1000): 120;
primary fundraising arm of HOPE4HEALTH with a series of annual events planned. Last year, the Jazz Dinner Dance and the HOPE4HEALTH Cup Golf Day successfully raised over $60,000 dollars that will go toward the Dabaa Medical Centre in Ghana, West Africa. These events will be run again in 2008 with the aim of reaching similar targets for the Royal Flying Doctor Service (Queensland). HOPE4HEALTH corporate events are targeted at the Gold Coast professional community particularly those in the medical field.
Event Dates for 2008 include - ‘The Great Gatsby’ Jazz Dinner Dance at the Gold Coast Convention and Exhibition Centre on Saturday 10th May, 2008. - HOPE4HEALTH Cup Golf Day held at Hope Island Resort Golf Club on Thursday 2nd October, 2008. For more information please see our website at www.hope4health. org.au or email info@hope4health. org.au . For a description of the HOPE4HEALTH Dabaa Medical Centre Project, please see page 138.
James Cook University: SANTE - Ian Marr Started in 2006 SANTÉ has developed a number of programs over the last 2 years that helped to both promote awareness and raise funding for developing world health issues. 2007 was a year of achievements with the success of the Red Party, a major event that involved 5 bands and raised almost $5000 for the Kangemi slum clinic in Nairobi, Kenya. This fund raising party was used as a launching pad to purchase badly needed surgical and medical supplies in a riot ravaged Kenya. Many thanks go to the organizing committee and GHC delegates around Australia for their assistance. Combined with this was the now annual support drive for a village in western PNG. Previous years has seen the village the recipients of school supplies and clothing. This time students raided their mothers, grandmothers, and in some instance brothers sewing cabinets for materials to go towards starting small business enterprises for unemployed PNG women. Included also in 2008 were a number of guest speakers including students presenting on elective experiences, and Dr Bruce Hayes, a missionary doctor from Nepal. With 10 years experience co-coordinating medical programs throughout all of rural Nepal Dr Hayes spoke
on many practical issues in developing world health. 2008 is planned to be equally as productive. ‘Run to the Water’ set down for early August, is a 6km journey reminding runners of the average distance traveled in Africa and Asia each day by women and children to fetch water. In alignment with the African Well Fund this money will go towards building wells in many desperate communities across the continent. Also in the wings is the university wide collection of sanitary products. With the price of sanitary products in Zimbabwe half the average monthly wage millions of women have been forced to use newspaper, rags and in some cases even leaves and bark as a substitute to sanitary pads and tampons. SANTÉ’s coordinated collection is to be distributed in Zimbabwe by ACTSA, Action for Southern Africa, under their Dignity Period campaign and hopes to halt this crisis faced by so many. Further to this themed forum nights (Africa, Asia, & Middle East) and nights promoting students elective experiences, doctors work in the developing world, and international aid organizations will be regularly filling any gaps in the already busy schedule. Any time spent away from this will be used to facilitate fund raising events including movie premier nights and
Malaysia - Male life expectancy: 69; Female life expectancy: 74; Under-5 mortality rate (per 1000): 12;
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raffles…oh and I suppose a little medicine. Thanks to all those already in-
volved and for those who want to be please contact riley.savage@ jcu.edu.au We would love your help!
Monash University: Ignite - Nadine Ata Mission: To work in partnership with local and international communities in the creation and ownership of sustainable health initiatives. Ignite is Monash University’s Global Health Group (GHG) which aims to inspire, empower and network people (primarily health students) to take an informed approach into advancing health standards globally. Ignite began in 2004 by Monash medical students passionate about improving global health standards, primarily in the developing world. The group has evolved to have a current membership of more than 400 people, with members from a range of year levels of the Monash MBBS course, post-graduate doctors and students from other fields. The group have five primary objectives: To educate others about global health issues. To support and foster our passion to create sustainable global health improvements. To provide avenues for practical involvement in communities with major health needs. To empower members to respond to global health concerns. To support partners through raising money and promoting their work. Ignite is a member of the Global Health Network (GHN), a committee of the Australian Medical Students Association (AMSA). Through the AMSA GHN, Ignite communicates and networks with other Global Health Groups from Australian medical schools. Ignite also maintains links with MUMUS and WILDFIRE, the Monash University medical student society and rural health club respective-
ly. The group does this primarily through joint events such as trivia nights and the Monash Pre-Clinical Careers and Cocktails Evening. Ignite is incorporated as a non-profit organisation – Ignite Global Health Group Inc. Ignite runs a number of educational and social events throughout the year. These include a series of Educational Seminars held in conjunction with the Burnet Institute. Other events range from an annual dinner, trivia night, movie nights and a photo exhibition to showcase students’ photos from placements in developing communities. Some of these events raise funds for Ignite’s partners (listed below). Ignite ensures up-to-date information is available to all members via the website (www.ignitehealth.org. au) and a monthly email newsletter. Please email ignite.inthealth@ gmail.com to be a subscriber to this newsletter and keep up to date about our exciting initiatives. The group has formed partnerships with a number of international groups who have had interactions with medical students in the past. These include: All Bengal Children’s Welfare Home, Kolkata, India; Ibulanka Community Health Centre, Ibulanka, Uganda and the Hillside Health Care Clinic, Belize. Ignite has an open structure which allows and encourages all members to contribute to initiatives of the group. Ignite holds monthly meetings with a core committee to ensure smooth operations of the group. Additional meetings are held at Monash University’s Clayton Campus to facilitate campus based activities. All members are welcome to attend all meetings.
The University of New South Wales: MSAP - Lucy Deng
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Mali - Male life expectancy: 45; Female life expectancy: 48; Under-5 mortality rate (per 1000): 217;
The UNSW Medical Students’ Aid Project (MSAP) is an initiative aiming to deliver under-resourced hospitals in developing countries with much of the basic medical supplies that we take for granted in Australia. Used or superseded equipment are collected from various companies, hospitals, clinics and doctors throughout the year and sent to hospitals, mostly nominated by elective students, according to their needs. MSAP is currently in its seventh year of operation. In 2007, we sent more than A$159,000 worth of equipment and textbooks to 21 institutions in 10 different countries. These included the hospitals attended by our students undertaking elective terms as well as three special cases – the Mae Tae Clinic in Thailand, which caters for large number of refugees; our Pacific neighbours in Tonga at Prince Wellington Hospital and finally the new medical school at Université Protestante au Congo in the Democratic Republic of Congo. Commitment to global health One of our projects for 2007 was to help establish a library of undergraduate textbooks for the new medical school at the Université Protestante au Congo in Kinshasa, Democratic Republic of Congo. MSAP recognises that the training of health professionals in countries such as the Congo is essential to create truly sustainable improvements in public health. We were able to donate over 800 recent-edition, high yield textbooks with an estimated value of over A$57,000. MSAP continues to play a leadership role in providing training to other Australian and international medical schools interested in establishing similar projects to ours. In 2007, delegates from MSAP
provided training sessions at the International Federation of Medical Students’ Associations General Assembly in Canterbury, UK, as well as at the AMSA Developing World Conference in Adelaide. Commitment to efficacy and transparency MSAP committee recognises that we have a responsibility to our benefactors and beneficiaries to ensure that aid which we send overseas is used to improve health care for impoverished communities. In 2007, we asked hospitals receiving aid to sign a memorandum of understanding acknowledging this and prohibiting the further resale or commandeering of supplies donated by MSAP. We also obtained photographic evidence of aid handover at the various destination institutions. Finally, we requested students undertaking placements in our partner hospitals to assess compliance with the terms of donation and to provide us with feedback as to how the MSAP process could be improved in future. The vast majority of aid proved to be received and used as intended, providing us with reassurance that our policy of providing aid that is targeted to local needs, infrastructure and staff expertise is working well. The future In 2008, MSAP has undergone a committee restructure to streamline its operations to maximise efficiency and cost-effectiveness in the delivery of aid. We will continue the review the evaluation process for our donations to ensure the aid delivered is targeted and appropriate. Finally, we will to continue advocate the MSAP model as there is much potential to salvage wasted equipment in the industrialised world which can be safely put to use elsewhere.
The University of Newcastle: Wake Up! - Alp Atik Wake Up! had a groundbreaking year in 2007/08 with recordbreaking membership numbers
and a succession of successful events. Most recently, we held the inaugural “Australia and Beyond
Malta - Male life expectancy: 77; Female life expectancy: 81; Under-5 mortality rate (per 1000): 6;
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Photo Competitionâ&#x20AC;?, in which medical students submitted photos they had taken on overseas adventures, placements or otherwise. The best 50 of these were displayed in the outpatient clinics of John Hunter Hospital â&#x20AC;&#x201C; the tertiary hospital of the Hunter area. After the photos are displayed in the hospital for 3 months, they will be transferred to Charlestown shopping centre, the major shopping centre of the Hunter area, for a further 3 months! The grand final of the photo competition, in which the winner and runner-up for 4 different categories (humour, picturesque, community/ cultural, med-related) were chosen by a panel of special guests including the Dean of Medicine at the University of Newcastle, was
held in conjunction with our annual Birthing Kit Night. Over 100 students assisted us in preparing over 1000 birthing kits in 1 hour! Thank you to all our sponsors, especially MDA National, MIPS, GP Club and the Herald. Other events for the year included a refugee health week, clinical placement info sessions for junior years and movie nights. We hope for continued success in the coming year, with increased involvement from our first and second years especially! For more information, please visit our website: http://wakeup-newcastle. blogspot.com or join our Facebook group: http://www.facebook.com/ group.php?gid=2384183149.
The University of Queensland: TIME - James Ricciardone TIME was established in 2005 at the University of Queensland (UQ) by a group of students who didnâ&#x20AC;&#x2122;t want to wait until they were doctors to make a difference. Since then, TIME has received extensive and enthusiastic support from students and doctors and is committed to continue to grow and to become a integral part of the medical student experience at UQ. Our main goal as an organisation, is to raise awareness and encourage involvement in global health issues. We do this through a range of projects and activities which are coordinated by and implemented by students. This co-ordination and implementation at the hand of UQ students is an integral part of the TIME ethos. TIME as an organisation is but a tiny cog in the global health wheel. However, by encouraging fellow students to be a part of that wheel, by being aware of global health issues, both here in Australia and overseas, and to be actively involved in those issues, then we can help move that move a little bit further. TIME Projects Our flagship project is the Medical Aid Project where medical students deliver medical supplies and
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equipment to hospitals in developing communities during their electives in Years I and IV. In 2007, we raised over $4000 and delivered over $10,000 worth of supplies to hospitals and communities in 30 different communities around the world. Our aim for the medium term is to set up sustainable partnerships with hospitals and communities, to build relationships that do not just last for one short elective but for many years to come. Our Elective Programme As part of the TIME goal to raise awareness and encourage involvement in global health issues, we organise a number of activities that surround the Year I and IV elective. We encourage students to become involved in communities that are less fortunate than middle class Australia and experience electives in developing economies, in Indigenous communities, rural Australia or even a low socio-economic suburb of Brisbane. We hold an Electives Seminar in March that allows for a forum with returned students and discussion with other students on their impending adventure! We follow it up with an Electives BBQ in July.
Mauritania - Male life expectancy: 55; Female life expectancy: 60; Under-5 mortality rate (per 1000): 125;
Social Events As much as we love waving the global health flag at TIME, it would not be possible without the success of our Social Events. In 2007, we began a task of ensuring that our events while crazy and exciting times for fellow med students, were concurrently able to be sustainable fundraising tools for TIME. In the last two years, we have expanded our Social Programme to accompany our flagship fundraising event, TIME Trivia 2008, to include a Fashion Parade, an International Beer Fest, and a brand new International Band Night in June, where we have invited bands from various ethnicities in Brisbane for what is planned to be an eclectically fun night! The TIME horizon Our baby legs at TIME are growing, and as we reach our five year anniversary, we are acutely aware
of the importance of making TIME a sustainable organisation that continues to grow and be a part of the UQ med student experience for years to come. Our goal for 2008 is to create sustainable sponsorships and to ensure that our fun social events have maximum fundraising potential. Indigenous health is an area that is very political at the moment and for good reason. The disparities in health status between Australian and Torres Strait Islanders and the rest of Australia is something that we at TIME feel Australians should be thoroughly ashamed of. In 2008, TIME is working on initiatives to better integrate Indigenous issues into TIME’s projects and initiatives and to ensure that when students think of “global health” they do not forget of our own issues in our backyard.
The University of Melbourne: VSAP - Aaron Wong The Victorian Students’ Aid Program (VSAP) is a volunteer organization that works alongside medical students to deliver donated health-care resources to disadvantaged communities in the developing world. A medical student going on an elective forwards us the wishlist of an underprivileged medical facility. We gather the requested donations, package the items, solve the logistical issues, and assist the medical student in coordinating the delivery. Our vision is that all doctors will have essential medical supplies to treat their patients. We hope that one day, all countries will have access to basic medical equipment and that medical supplies in developed countries will not go to waste. Following the 2005 Australian Medical Students Association Developing World Conference in Sydney, University of Melbourne students established VSAP as an emulation of the Medical Students Aid Project from the University of New South Wales. With the support of staff from the Medical Faculty, the organization was officially launched
in October 2005. From Nov 2005 – Feb 2006, $2000 worth of aid was sent alongside students to East Timor, Guatemala, Tanzania, and Vanuatu. From Dec 2006 – Feb 2007, $9900 worth of aid was sent to Ethiopia, Guatemala, Solomon Islands, Thailand, Uganda, Vanuatu, Vietnam, and Zambia. From Dec 2007 – Feb 2008, VSAP sent $15480 worth of medical equipment and supplies to Cameroon, Papua New Guinea, Solomon Islands, Tanzania, Thailand, Uganda, and Zambia. While disposable medical supplies such as gloves, surgical masks, syringes, needles, and dressings have been the bulk of our donations, essential medical equipment donations are steadily increasing. From 2006 – 2007, VSAP helped in the delivery of a pulse oximeter to Uganda and an ultrasound machine to Zambia. From 2007 – 2008, we have sent two nebulizers machines, a pulse oximeter, and a defibrillator to the Solomon Island, as well as a capnograph and an anesthetic monitor to Papua New Guinea.
Mauritius - Male life expectancy: 69; Female life expectancy: 76; Under-5 mortality rate (per 1000): 15;
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The University of Sydney: Global HOME - Lucy Cho Global HOME is a organisation consisting of students from The University of Sydney who share an interest in international health. Our mission is: “To inspire and encourage medical students to promote health opportunities and medical equality globally.” So far Global Home has undertaken projects within the university community in order to raise awareness about international health and development issues and to facilitate participation in overseas or internal health projects. By holding information events based on countries such as Timor Leste or organisations such as MSF or charities such as Dr Sujit’s IIMC we hope to encourage and support our student base to go and see for themselves the kinds of changes that they can make in the world. We now have students
who have worked in ambulatory clinics in Timor, in the outskirts of Calcutta and a growing population of students who already come to medicine with international health experience under their belt. Global Home is dedicated to helping the University produce graduates who will be inspired and in turn inspire others to see the multitude of ways that being a doctor can make a difference to people who can’t take good health for granted. This year Global Home will be taking the message to more students via information evenings such as “Postcards from Wherever”, social events, elective assistance and advocacy nights. We encourage University of Sydney students to check out http://globalhome.redbrick. com.au/wp/ and get involved.
The University of Tasmania: IMPACT - Kate Visagie IMPACT has enjoyed a very successful year since the new committee came to force in April 2007. Our one ongoing project for operating under the umbrella of IMPACT continued, with the collecting and distribution of medical supplies donated locally and taken by students on electives. We are constantly bombarded with more items and are looking at improved ways to distribute equipment. One of our greatest contributions was last year, when we supplied Vanuatu with its only ECG machine and $100 worth of supplies for it. Our ‘Foods of the World’ initiative was continued in style with our annual Indian night, and an inaugural Indonesian night. The Indian night was quickly booked out with about 40 people filling the upstairs of a local Indian restaurant. After an enjoyable meal, we heard from a guest speaker from the Royal Hobart Hospital, who shared insights and comparisons between Indian, English and Australian hospitals. There was a raffle with some sought after goodies that raised quite a bit of additional money to
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contribute a total of $600 towards Sevalayah, an orphanage in India that we have been supporting for several years. The Indonesian night provided us with our most popular event to-date, and it was our first time to join forces with the Indonesian Students Society at UTAS. One hundred people were in attendance to enjoy delicious authentic Indonesian food, as well as cultural entertainment and to listen to a speech by an Australian Red Cross (ARC) representative who shared details of where the money raised would go (mainly towards ARC Blood Services in Aceh province, Indonesia). Ticket sales combined with a raffle, and an auction of some bigger ticket items helped us raise $2100. Another event held in 2007 was a documentary screening at both the Hobart and Sandy Bay campuses. The Valley, filmed and directed by Tasmanian, Roger Scholes, had some amazing footage of Ethiopia and some of their long standing but very much still relevant health and development issues in Ethiopia.
Mexico - Male life expectancy: 72; Female life expectancy: 77; Under-5 mortality rate (per 1000): 35;
2008 began with the usual and extremely popular O-Week stall to welcome new members. Whilst the fairy floss provided a sweet draw card, many were attracted by the friendly faces and stories of the projects IMPACT is involved in. To welcome the new members, and also provide another opportunity to join up new members, we held two lunch events. At the Sandy Bay campus we offered a BBQ, with plenty of time for some of the committee members and regular volunteers to meet the new first year members, as well as some familiar faces from second year. The second catered to the clinical school years and was held in conjunction with the Tasmanian University Union. At that time we also announced the winner of the jelly bean jar competition which we had
run to raise money for the Asia Pacific delegates to attend GHC. We have just concluded our final event for the year 2007-2008 with the hosting of our annual Electives Night, presented in conjunction with the UTAS rural health society, Rustica. Years 5 and 6 speakers shared exciting stories from their Tasmanian, as well as mainland and international electives placements. Most excitedly, this was our first time to run a teaser for the RED PARTY which we have already begun to organise for September 2008. And with the new committee extremely passionate about Global Health and surging with new ideas and enthusiasm, this next should prove to be our most successful yet.
The University of Western Australia: Interhealth - Irene Dolan & Tim Lin WAMSS Interhealth came of age in 2007. It was a year in which we launched our 3 major projects, namely Red Party, LINCS and ICHRC. Based on a model created by MedSin UK, Red Party was a major success. A sea of red filled the Leederville Hotel with a massive turnout despite the driving rain on the night. For just one night it was possible to talk to people about the global impact of AIDS while going out and having a great time. In the end twenty five thousand dollars was raised for Oxfam Australiaâ&#x20AC;&#x2122;s AIDS Orphan Nutrition program in South Africa. LINCS (Local & International Needs Contributions Scheme) had been running since 2005 as a low key one woman project to provide unwanted medical supplies for students to bring with them on their electives to communities with limited resources. Last year LINCS was totally restructured to a model inspired by MSAP from UNSW. With a seven member committee and the backing of UWA, LINCS was finally resourced to raise its profile and actively seek sponsorship and community support. LINCS raised over eight thousand dollars worth
donations of brand new equipment and financial support in addition to the donation of massive amounts of used medical equipment. Also in 2007, UWA joined Melbourne University on the list of medical schools around the world participating in the International Child Health Review Collaboration (ICHRC) to produce evidence based guidelines for paediatrics in settings where resources are limited. This year promises to be a huge year for Interhealth as we aim to continue to grow on the gains made last year. Red Party and LINCS will continue as our flagship projects and should be bigger and better in their second year. ICHRC will grow massively this year as UWA has agreed to include ICHRC as an accredited option for 4th year students doing their research projects. With a massive response from our recent projects night where we presented project ideas for students to get involved, we will start several new projects this year. And with the Western Australian Medical Student Society (WAMSS) and our Faculty fully behind us and keen to get involved this year, we have a pretty good
Micronesia - Male life expectancy: 67; Female life expectancy: 70; Under-5 mortality rate (per 1000): 41;
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chance. For a description of the Interhealth
Red Party Project, please see page 140.
The University of Western Sydney - Zenith Lal Out here at UWS we have been working hard to get global health up and running and an effective group in the ears to come. In only our 2nd year as a medical school interest from students in international health issues is building as we learn more and witness the remarkable work being done by the AMSA Global Health network as well as Global Health Groups across all Australian medical schools.
With a huge interest in the registration of this year’s global health conference and a larger UWS GHC contingent than ever, we are really looking forward to further establishing global health at the University of Western Sydney so that in years to come it can be as successful and prosperous as other Global Health groups in representing and advocating for issues relating to medicine at an international level.
Wollongong University: Health Over Wealth - James Hodgkinson The Graduate School of Medicine at the University of Wollongong opened its doors to its 1st cohort of student on January the 26th 2007. Amongst the sheer terror and blind faith we all struggled into the unknown that awaited us. Luckily, a small group was lucky enough to attend the 2007 Developing Worlds Conference. These students returned enthusiastic and motivated to establish a Global Health Group (GHG) at our school. As our cohort was working its way through the minefield of establishing a medical student’s society there was little time left for the GHG to be established. With the dedication of a few students we were able to host our only fund raising event for the year before students turned to hermits for the prevailing barrier exams. We organized a Red Party at the largest hotel in town and as we are only 80 strong, I sent some very willing and able male colleagues to drum up support for the party from the nursing department. With their three years of 160 students we thought what we lack in number we could make up in ingenuity. So it was held, the 1st Annual Red Party. By all accounts it was a great night with many, if not all attendees going well beyond the call of
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duty, there were the cheerleaders complete with pom-poms and pig tails through to Stuart’s flaming red two piece dress that collected more than the wandering eye from the local steel workers. At the end of the night we raised $500 for UNICEF to buy birthing kits to prevent the transmission of AIDS to newborns in South East Asia, we all got free entry into the local gay night club (not that there’s anything wrong with that) and we started what we now hope to be our major fund raiser for coming years. This year sees an influx of highly motivated members willing to help me establish our constitution, develop our website, attend the conference and play our part in the Global Health Network and even more importantly our part in health care in developing communities. The coming year sees our GHG hoping to forge a close working relationship with medical groups in East Timor, PNG or other Pacific nations. We would like to acknowledge the tremendous support and help we have received from other GHG’s along our short road and we look forward to developing a closer working relationship in the years to come.
Monaco - Male life expectancy: 78; Female life expectancy: 85; Under-5 mortality rate (per 1000): 4;
International Federation of Medical Students’ Associations Yara Abo The International Federation of Medical Students’ Associations (IFMSA) was founded in 1951 and is officially recognised by the World Health Organisation and the United Nations as the International Forum for medical students. It represents over one million medical students from one hundred member countries around the world, with the aim of developing “culturally sensitive students of medicine, intent on influencing the trans-national inequalities that shape the health of our planet.” Within the IFMSA, there are committees related to improving medical education, building exchange programs as well as advocating for public health, human rights and peace, and reproductive health. Formally, these make up six standing committees within the IFMSA: Human Rights and Peace (SCORP), Medical Education (SCOME), Public Health (SCOPH), Reproductive Health including AIDS (SCORA), Professional Exchange (SCOPE) and Research Exchange (SCORE). Structure: • Executive Board: President, Vice President for Internal Affairs, Secretary General, Treasurer • Standing Committee Directors • Support Division Directors: Publications, I.T., Training,
• •
Projects, Alumni Liaison Officers for standing committee Regional Coordinators
each
The National Member Organisations (NMOs i.e. member countries) generally each have a medical students association that follows the structure of the IFMSA and its standing committees. In Australia however, we differ in that our medical students’ association (the Australian Medical Students’ Association - AMSA) was organised before becoming a member of the IFMSA; thus, we do not have formal standing committees and representatives (national and local officers) within these committees. However, many of the roles within AMSA’s current structure reflect the aims of each of the standing committees of the IFMSA.
What the IFMSA does:
• Encourages medical students to establish trans-national healthfocused projects that address the broader social, political, ethical and environmental issues that influence health. • Organises biennial General Assemblies (GA), held for all member nations of the IFMSA. At these conferences, a number of issues which involve the IFMSA are tabled and discussed, with new initiatives shared amongst countries, and collaborations forged. At each GA, a different theme is chosen as the focus. The March 2008 meeting was held in Mon-
Mongolia - Male life expectancy: 62; Female life expectancy: 70; Under-5 mortality rate (per 1000): 72;
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terrey, Mexico with the theme of “Migration and Health”. Thirteen Australian medical students attended and learnt of the many projects currently taking place, while creating links with colleagues from around the world. Delegates also left the conference realizing the great potential for the IFMSA to grow and develop into a larger and more influential representative of medical students globally. The
August meeting will be held in Ocho Rios, Jamaica, with the theme of “Nutrition and Health”. How you can get involved: All medical students are able to apply to attend a General Assembly. Your GHN representative will advertise that AMSA is calling for applications twice a year, approximately three months before each general assembly. By becoming involved in
your University’s Global Health Group, you can help to further develop current projects or start your own project aimed at tackling global health issues. For more information visit www. ifmsa.org
Some of the exciting projects happening around the world (there are many more!):
Project
Activity
Asian Collaborative Training on Infectious Diseases, Outbreak, Natural Disaster and Refugee Management (ACTION)
Indonesia
Awareness of Medical Students about Tuberculosis and Their Role in Controlling Its Epidemic
Egypt, Kuwait, Lebanon, Pakistan, Nepal, others
Awareness Strategies for Pollution from Industries
Greece, Belgium, UK, Spain, Romania, Bulgaria, others
Calcutta Village Project
Italy, India
Ghana Health Education Initiative
Ghana
IFMSA Anti-TB Campaign
Many IFMSA NMOs
International Campaign on Malaria (ICOM)
Canada, Finland, Nigeria, UK, Peru, Ecuador, Sudan, Tanzania
International Standards on Medical Education
Turkey, Egypt
Kenya Village Project
Kenya
Kumba Village Project
Cameroon
Lebanon Refugee Project
Lebanon
Malaika Village Project
Tanzania
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Montenegro - Male life expectancy: 72; Female life expectancy: 76; Under-5 mortality rate (per 1000): 10;
Fiji Village Project Negin Sedaghat EnSIGN, Australian National University The Fiji Village Project started with the formation of EnSIGN, the global health group at ANU. It was at its inaugural meeting in August 2006 that medical students from ANU decided they would focus their international efforts and contributions on the South Pacific region. Having been
inspired by the work of student groups within the IFMSA, we decided that a project involving transnational collaboration between medical students would be a great way to get started. We already had connections with the Fiji School of Medicine Students Association (FSMSA), and so, this ended up being the natural step forward. The first task at hand was to come up with a project proposal. We weren’t entirely sure what to do and after hours of searching on the internet, reading numerous reports and communicating with our IFMSA contacts did we sort of have an idea! The initial idea was to do something along the lines of “Village Concept Projects” that have stemmed from the IFMSA. We thought this would be the best project simply because they had been so successful when run by other students in other parts of the world, such as the US and Denmark. The project seemed to
not only benefit students but also, and importantly, the communities in which they were run. This led us to October 2006, when we sent a preliminary project proposal to the FSMSA. We asked for their review and response, with the hope that everything would come back very positive. …And it did! All systems were go. Although there were minor hiccups and confusions along the way, we managed to stay in touch (all via e-mail, msn, skype etc!) and keep the momentum going. Along the way, New Zealand medical students joined us. We hadn’t even really started and the project was already growing and gaining much interest. Our major action towards setting up the project was the feasibility trip conducted in July 2006. We called it a feasibility study simply because we still weren’t sure if such a project would be meaningful and sustainable.
Morocco - Male life expectancy: 70; Female life expectancy: 74; Under-5 mortality rate (per 1000): 37;
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“The students introduced us not only to what they exactly do to contribute to public health development in Fiji, but also gave us an introduction to Fijian culture and way of life.” Further, none of the specifics of the project were identified. July 2006, Suva, Fiji, saw two medical students from the ANU and one medical student from FSM lead the feasibility trip. It was here that we discovered the amazing public health work that FSM students do as part of their curriculum. Being completely handson, we were privileged to join the students on their public health community attachments, visiting villages and attending village action plan meetings with them. The students introduced us not only to what they exactly do to contribute to public health development in Fiji, but also gave us an introduction to Fijian culture and way of life. Lots of laughs were had and a lot of work was done within two weeks to organize the specifics of the project.
these include, Rotary International – Suva Rotary Club; the Department of Public Health, Fiji School of Medicine; South Pacific Islands Geosciences Commission; WHO – Suva Office; Fiji Medical Association; Sub-Divisional Medical Team – Navua; Fijian Ministry of Health; Fijian National Centre for Health Promotion; Village Chiefs and spokespersons in the Veivatuloa Tikina; staff from the Australian National University and University of Auckland were
also consulted. So, by the end of it all, we had lots and lots of ideas on our plate. At the conclusion of the feasibility trip, it was decided that the Fiji Village Project would work with Nabukavesi Village in January 2008. This was based on criteria that we developed in terms of need and potential for sustainability. Our goals were focused on three main areas: 1. Education on water safety and sanitation;
The team visited seven villages in the Veivatuloa Tikina, Namosi Province, close to Suva, Fiji. All of the villages visited didn’t have access to clean water. Further, every village prioritized water accessibility and safety as their most important problem. This was particularly so, because water problems in the villages are more complex, financially burdensome and require expertise. Furthermore, this priority is included in Millenium Development Goal 7, to reduce by half the number of people without access to clean water, which is also consistent with the International Decade For Action, Water for Life, 2005-15. Again, we made our second natural step forward…our focus would be on water accessibility and safety. We consulted with numerous professionals, organizations and community groups. Some of
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Mozambique - Male life expectancy: 49; Female life expectancy: 51; Under-5 mortality rate (per 1000): 138;
“The village welcomed us and we were able to achieve all of our goals within two weeks in January 2008!.”
2. Rainwater harvesting system for the village school; and 3. Health Screening to replenish the lost medical records of the local hospital due to severe flooding in 2004. From here, Australian, New Zealand and Fijian medical students started fundraising. We received both sponsorship and assistance in kind, with major contributions from Rotary Pacific Water for Life Foundation, the University of Auckland, Faculty of Medicine and Health Sciences and the Canberra Medical Women’s Society. We also received numerous individual donations, as well as contributions from the FSMSA, Medical Students for Global Awareness and the ANUMSS. We extend a heartfelt thank you to all of our sponsors and supporters for making the FVP a huge success. …And yes, ‘twas a blast! We had
approximately 30 students from Australia, New Zealand and the South Pacific islands participate. Not only did medical students participate, but also dentistry and public health students. The village welcomed us and we were able to achieve all of our goals within two weeks in January 2008! We are now looking forward to organizing our next phase of the project in January 2009 – with a particular focus on evaluation and consolidation.
relations in the South Pacific region! If you would like a copy of the international report of the FVP, please e-mail: u4289548@anu. edu.au.
The future holds great opportunities, with UPNG and US students showing interest to get involved and further expansion to other areas of the South Pacific, such as the Solomon Islands and Samoa – and yes, that means YOU can get involved. It’s been great not only to experience community empowerment and health development, but also to form some stronger and meaningful
Main points: 1. Much preparation is required - this project has taken about 1.5 years of preparation 2. The project is based on the “Village Concept Projects” of the IFMSA 3. A feasibility trip was conducted prior to the official launch of the project 4. Our focus is on accessibility to clean water which we see as our contribution to achieving MDG 7 5. The project is motivated by not only public health development but also professional development in the South Pacific region 6. The FVP International Report details all our activities and achievements
Myanmar - Male life expectancy: 57; Female life expectancy: 63; Under-5 mortality rate (per 1000): 104;
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Nepal Project ‘08 Lauren Finlay and Marcus Yip Health and Human Rights Group, Flinders University Eight Australians, under the Health and Human Rights Group (HHRG) at Flinders University, ventured to Nepal in the first two weeks of 2008, to implement a Personal Health Program at two children’s homes, while having the time our their lives. HHRG aims to empower people into improving health on an individual, community, national and international level, with the underlying principle of health as a basic human right. We are committed to the ideal that one group, one person and one idea can make a difference to people’s lives, health and, ultimately, their human rights. This ideal led Kate Brennan, the co-president of HHRG for 2008, to create the Nepal Project for
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the children’s homes supported by Hope For Himalayan Kids (HFHK), an NGO based in Nepal. HFHK, the eight Australians (seven medical students and one teacher) and eight Nepalese medical students implemented a personal health program that encompassed Nutrition, Personal Hygiene, Exercise, First Aid, Health Monitoring and Life Skills to assist residents to realise their potential through empowerment, skills and education. HHRG Nepal Project 2008 Objectives for Person Health Program were: 1. By July 2008, adolescent (10 – 16 yrs) sexual and reproductive health knowledge and attitudes will be improves through culturally appropriate, age specific and gender sensitive education strategies. 2. Adolescents will achieve a basis understanding of nutrients of concern in typical Nepalese diet (Vitamin C, Vitamin C, Protein, Iodine, Iron, Calcium), such that
they can identify food sources and recognize the effect of dietary deficiency on health. 3. To increase participation in regular physical activity and increase awareness of the health benefits of exercise, especially amongst girls. 4. A health monitoring system that maintains a regularly updated health profile of each child will be established. 5. Increase the practice of basic personal hygiene and understanding of its’ importance in maintaining good health in children of all ages. 6. Increase the first aid skills of adolescents 7. Encourage children and ado-
lescents to explore the “bigger picture” of life through goal setting, discussion of future profession, and an International Day. 8. Increase sustainability of participants’ new knowledge and positive health behaviour outcomes after completion of Personal Health program. The children were not only excited to have new faces to interact with, but were extremely willing to learn. Our educative goals were achieved through many interactive games, role-playing simulations and creative media, such as the use of UV fluorescent glitter glue to aid us in our personal hygiene education and a first aid education resource kit. First aid included learning techniques for basic bandaging, immobilisation, the recovery position and choking. However, the most useful resource was our Nepali medical counterparts, translating, teaching and learning for us and with us. This experience between the medical students has created friendships that will last a lifetime, not to mention the foundation and potential for an extremely rewarding professional and international relationship in the future. It was fulfilling to see the kids interested and eager to explore the different cultures on ‘international day’. More inspirational, however, were the kids’ aspirations
for their own future, with noted acknowledgement by themselves of the need for education in order to reach their chosen life goal. It was such a privilege to be a part of the Sahara and New Ray of Life children homes. To share, teach, play and learn, while forming a bond with these vibrant children, was an experience of a lifetime. It is truly inspiring and uplifting to see these children thriving, even after having suffered such adversities in their young lives. We will never forget them and we cannot wait to return, eager to follow the blossoming of their bright futures.
ly donated money and equipment so this wonderful project could happen, Flinders School of Medicine, Avoca Hotel, Lifesource Pty Ltd, Mentone Educational Centre, National Geographic, Rebel Sport, T Shirt City, Twin Bays. To raise money, the Flinders students held Kaffeehaus, a talent night where students displayed their various “talents” and cakes and liqueur coffees were available to buy, and a concert. Visit http://www.hopeforhimalayankids.org/ for more information.
We had many sponsors who kind-
“More inspirational, however, were the kids’ aspirations for their own future, with noted acknowledgement by themselves of the need for education in order to reach their chosen life goal.” 141.
Dabaa Medical Centre Project Claire Cuscaden and Marty Brewster HOPE4HEALTH, Griffith University Griffith University’s global health group, HOPE4HEALTH (H4H) was established in 2006 with the aim of improving health outcomes for Local, Rural, Indigenous and International communities. In H4H’s foundation year they were approached by a local Gold Coast charity called The Watson Foundation that had already begun work on an amazing project. Their goal was to build a single doctor clinic in the rural area of Dabaa in Ghana, West Africa but they needed support to raise the required funds. H4H became involved and only two years on, what were initially modest expectations of financial assistance has evolved into a multi-million dollar aid package in which H4H has played a key role in securing. Within this time frame the
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sustainability of the project has also been assured with an official relationship established with the Ghanaian Government Ministry of Health. Known in the colonial era as the ‘Gold Coast’ of West Africa, Ghana proved an ideal location for the project for several reasons. A constitutional democracy, Ghana presently enjoys relative peace and stability for the region. Ghana also has an economic need. Although the country is in a far more secure position in comparison to other developing nations, their modest prosperity is not sufficient for the sustainability of the population. To date Ghana still relies heavily on international aid and debt relief. In particular there is a need for improved health services in Ghana. The health of the Ghanaian population is not as dire as other countries where AIDS is endemic. However preventable diseases
are still rife in the population, claiming the lives of 1 in 9 children every year. Maternal health in Ghana also represents a particular concern with the incidence of maternal mortality 90 times higher than that in Australia. Initially H4H planned to make a contribution of $50,000. Fundraising ideas for the year included the traditional student parties for our members but H4H also envisaged larger scale events which would ensure the $50,000 target would be met. Two events were drafted with the intention of bringing in more substantial amounts. A black-tie event ‘Out of Africa’ Jazz Dinner Dance designed for 450 people was scheduled with the aim of raising money through ticket sales as well as grand and silent auctions. A corporate golf day was also marked in the calendar and teams were booked to compete for the inaugural ‘HOPE4HEALTH Cup’ at Hope Island Resort. These two
Namibia - Male life expectancy: 59; Female life expectancy: 63; Under-5 mortality rate (per 1000): 61;
“... only two years on, what were initially modest expectations of financial assistance has evolved into a multi-million dollar aid package in which H4H has played a key role in securing.” large corporate events successfully raised over $60,000 for the project. All of these events were entirely student coordinated with H4H members doing marketing and promotions, event management, working as ushers and even staffing cloak rooms. The two student targeted events named ‘Ghana-Get-On-It’ and ‘GhanaGet-Groovy’ were run on a smaller scale yet proved significant in their role of increasing student awareness and encouraging involvement in H4H’s Dabaa Medical Centre project as well as contributing another $5,000 to the project. Project momentum had been generated which was not only confined to Griffith University’s medical and dental students. Hearing of the project, the Chairman of the Queensland State Committee of the Royal Australian College of Surgeons, Dr Chris Perry became heavily involved. Inspired by his own history with Ghana where he spent time as a surgical registrar, Dr Perry proved indispensable to the H4H team as an advocate and advisor throughout the year. As a sheer coincidence, Dr Perry had already planned to visit Ghana in early 2007 and agreed to investigate the suitability of the proposed hospital site and to ensure the necessary due diligence had been undertaken before any funds were sent overseas. Armed with a few of H4H’s Ghanaian contacts, this special ‘mission’ of Dr Perry’s even took him to a private meeting with the Ghana-
ian President, Mr John Kufour, to discuss plans for the hospital and ways in which the Ghanaian government could assist. The land purchased by The Watson Foundation was chosen on a need basis. Not only was the land relatively cheap, but the site was also 16 kilometres from the nearest medical facility. As a result of Dr Perry’s visit, the facility’s management was handed over to the Ghanaian Government Ministry of Health. An agreement was reached with the Ministry of Health guaranteeing staff and funding for the hospital. This hopefully ensures that the facility will be well utilised and sustainable, an important factor which sees H4H’s efforts providing health benefits to the population well into the future. Also reading about H4H’s efforts in ‘The Courier Mail’ were members of a Brisbane based Lions Club which specialises in sourcing medical equipment from health facilities throughout Queensland. Lying in storage were some 200 hospital beds, 4 operating tables, sterilisers, trolleys, cots, wheelchairs and AppleMAQ computers. All of this equipment was near new, in good working order and valued at over $1 million. The involvement of the Lions Club brought further interest within the Gold Coast community. Further funding from a Gold Coast philanthropist will cover half of the shipping costs of the medical equipment to Ghana. This equipment will be used not only to equip the Dabaa Medical Cen-
tre but also to refurbish a much larger facility called Holy Family Hospital, Nkawkaw. So momentum for the Dabaa project continues to grow, and the need to raise funds has at this moment not ended. With the generous donation of medical equipment comes the need to make up the cost of shipping. This is an issue that is on the current agenda for H4H with plans already underway to raise a further $20,000 to complete the job and facilitate over $1 million of hospital equipment to be sent in 10 containers to Ghana. The Dabaa Medical Centre project provides H4H with a great return for the efforts invested. For medical students, the Holy Family Hospital at Nkawkaw will provide students with the opportunity to work in a hospital overseas that they have been personally involved in. Several H4H members are planning to complete elective placements there over the next few years. The project has also encouraged and increased student awareness in global health and demonstrated the momentum that such a project can create. H4H’s focus project for 2008 has now shifted to Rural health and we are currently fundraising for the 80th Anniversary of the Royal Flying Doctor Service. The major event planned for 2008 is ‘The Great Gatsby’ Jazz Dinner Dance to be held on Saturday 10th May, 2008.
“The two student targeted events named ‘Ghana-Get-On-It’ and ‘Ghana-Get-Groovy’ were run on a smaller scale yet proved significant in their role of increasing student awareness...” Nauru - Male life expectancy: 59; Female life expectancy: 64; Under-5 mortality rate (per 1000): 30;
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Red Party Irene Dolan WAMSS Interhealth, University of Western Australia The concept of the Red Party is simple - a huge party with a red theme (the internationally recognised colour of AIDS) with all proceeds going to an AIDS organisation. The format has been used all over the world as a way of raising awareness and funds for various AIDS organisations. I first heard the idea from Medsin UK who ran a Red Party in Manchester. The party was a great success and after hearing the simple, fun and reproducible concept I thought it would be easy to run one at the University of Western Australia with the help of Interhealth (our Global Health Group) and WAMSS (our student society.) After submitting a project proposal to both Interhealth and
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WAMSS and gaining the support of both groups, I started recruiting for the committee. I was met with overwhelming interest and enthusiasm with 30 applications for 6 committee positions. I then decided to create 2 subcommittees, the 10 positions were hotly contested with 40 people applying in total. We chose to donate the money raised to Oxfam Australia’s South African AIDS Orphan Nutrition Program based in the KwaZuluNatal province where more than 40% of the population are HIV positive. There are currently 1.5 million children orphaned by HIV and AIDS in South Africa and it is estimated that by 2015 there will be 5 million children orphaned by the virus. Oxfam’s program supports local community initiatives and helps provide nutrition (by way of drop in centres and training in planting vegetable patches), education and medications for the orphans as well as
providing skills training for the local community to encourage and maintain small businesses. The program is in its first 3 year phase and it is estimated that it will run for another 12 years. The Red Party will continue to support this worthwhile project in the years to come. With a team of 20 medical students on the committee and subcommittees we set about creating the party and publicity campaign of the year. The party was preceded by a large scale publicity campaign called Paint the Town Red, a series of bizarre Red events aimed at creating awareness of both HIV and the party on campus, there were red balloon trees, red fire engines, red frogs and red washing lines. Paint the Town Red’s climax was Red Day where we invited all medical students to come down dressed in red to help spread the word about the party. Despite torrential rain about 150 medical
Nepal - Male life expectancy: 62; Female life expectancy: 63; Under-5 mortality rate (per 1000): 59;
“The party was preceded by a large scale publicity campaign called Paint the Town Red, a series of bizarre Red events aimed at creating awareness of both HIV and the party on campus...”
students equipped with inflatable red Havaianas thongs ran around campus with AIDS ribbons, red frogs and pamphlets. We recruited 30 representatives from 12 different student societies, 3 different student guilds and 3 residential colleges who also helped publicise the party and sell tickets. Our 1800 tickets sold out within 5 days of the party. The night itself was a huge success. We had a Brazilian carnival band, African drummers, fire twirlers, trapeze artists and other circus acts as well as face painters, Safe Sex Sluts handing out free condoms and cheap drinks. As well as raising money, we
also aimed to raise awareness of HIV and AIDS. We achieved this with a lot of help from the WA AIDS Council who provided us with educational information to hand out with tickets, at our stall at UWA and at the party. We also had a screening of A Closer Walk, a documentary about HIV and AIDS narrated by Will Smith and Meryl Streep, featuring interviews with the Dalai Lama, Bono and with people living with HIV and AIDS across 4 continents. We raised $25,000 for Oxfam, $15,000 more than our $10,000 aim and were awarded the West Australian AIDS Council World AIDS Day Youth Award for 2007. More importantly the Red Party is now an annual event. It was so rewarding to see such over-
whelming support for the party; students, the UWA Vice Chancellor, the Faculty of Medicine, Dentistry and Health Sciences at UWA, the West Australian AIDS Council, Interhealth, WAMSS and our live acts were all really supportive. The Red Party is a simple and versatile concept, if you are interested in hosting a Red Party please do not hesitate to contact me and I will send you out a How to Run a Red Party information pack to get you started. It was SO much fun- it doesn’t get much better - you get to organise a huge party with a great bunch of people whilst raising awareness and funds for a great cause!
Global Health Experiences
The Mirrar People of Jabiru Rahul Barmanray University of Melbourne During January and February of 2008 I was fortunate enough to go on a John Flynn placement to the Northern Territory, though those familiar with the Territory’s weather patterns would say unfortunate and for a person who can hardly swim, essentially being drowned every wet season day for a month was something of a challenge. Following my experiences in Jabiru, I can wholeheartedly say I don’t regret it one iota. As a town, Jabiru is many things to many people. To tourists it’s the heart of Kakadu and a convenient base from which to conduct their holiday. To Australians, depending on your point of view, it embodies either our massive natural wealth or our environmental apathy, as the home of miners working at Ranger, Jabiluka and Koogarra, 3 uranium mines in our biggest National Park. To health
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workers it’s the biggest clinic for a few hundred kilometres and the gateway to Arnhem Land. To the traditional Mirrar owners of the land it is yet another story of lost indigenous self-determination and dignity. For those of you who thought that Communism was more or less forgotten in Australia after the 1951 referendum, a few bastions still exist, Jabiru being one of them. All land in Jabiru is owned by the government and one is only allowed to lease it if one is employed in and around the community, a dependent child or the spouse of a local employee. Most of the indigenous people of Jabiru can hardly afford to buy food for themselves let alone pay rent and so are forced to either stay in the euphemistically named ‘Town Camp’, the only place one may stay if one is unemployed, or live on an outstation, the closest of which being Mudginberri is 10km from Jabiru.
When mining giant ERA received approval for the Ranger mine, part of the conditions of the project were that they compensate the Mirrar, whose land they usurped. This compensation took the form of an ongoing percentage of their profits that goes to the Northern Land Council, as well as the establishing of a health clinic in the newly founded town of Jabiru, that would provide free health care to all indigenous patients. Naturally, the Mirrar who lived in surrounding areas congregated on Jabiru to take advantage of this free service, as well as the alcohol and food that could be bought there. But this led to Mirrar sleeping in the long grass of Jabiru and setting up makeshift humpies along the roads, sights hardly conducive to continued overseas tourism in the area. And so the Town Camp was born, a fenced-off ghetto at the outskirts of the township which is legally the only place in town one can live without employment.
Netherlands - Male life expectancy: 78; Female life expectancy: 81; Under-5 mortality rate (per 1000): 5;
Needless to say, the cramped conditions and sparse housing within the Camp do little to stop the spread of disease and sick children are a common sight amongst the 300 or so Mirrar who live there. In the week I spent at the clinic, two children younger than 10 came in with metal heart valves due to rheumatic fever, an entirely preventable complication of streptococcal infection. I doubt anyone living in the Camp would have a refrigerator but many don’t even have a dry place to store medications, a fact that probably artificially drives up any apparent non-compliance amongst indigenous patients. To compound the issue, the young males of the Camp are known for their violent behaviour and exhibit the sort of horizontal aggression Richard Trudgen talks about in, “Why Warriors Lie Down and Die”, apparently a symptom idiosyncratic of oppressed postcolonisation people everywhere. For this reason, health professionals are prohibited from even
being near the Camp whilst alone and must always check that the police station across the street is manned before entering.
rugated iron sheets and a few rusty utes. On a fuller inspection it became apparent that that was because there wasn’t much else.
For those who do not wish to suffer this modern-day segregation, the outstations are a popular option, but judging by my experiences of Mudginberri, are not much better. Before Kakadu became a National Park and all the remaining buffalo introduced by early European settlers were killed, Mudginberri was a small abattoir. Many will have heard of it as being the reason for the 1985 fining of the Australasian Meat Industry Employees Union $1.7 million, the highest ever fine against an Australian trade union. That fining came about due to poor conditions at Mudginberri and from what I saw, not much has changed. Driving into the station in the health clinic’s mobile unit jeep beneath the abandoned abattoir buildings looming large over the main road, I could see nothing but long grass, cor-
Outstations in Kakadu usually follow the general pattern of 1015 forty year-old prefabricated houses in a ring around a central generator with attached street lamp next to a toilet block. The Northern Land Council pays for fuel for the generator and maintains the septic toilets once every two months. Almost all outstation inhabitants are indigenous and when the health centre jeep pulled up next to the generator, their faces started appearing at windows. As was explained to me by the clinic staff, the Mirrar living on outstations have a bit of a love-hate relationship with the health clinic’s mobile unit. While they appreciate not having to walk the 10km to Jabiru, they tend to be the ones with more self-dignity and sense of tradition. The main reasons they are living on the outstations are
New Zealand - Male life expectancy: 78; Female life expectancy: 82; Under-5 mortality rate (per 1000): 6;
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“In the week I spent at the clinic, two children younger than 10 came in with metal heart valves due to rheumatic fever ...” with kidney failure must leave and so the thought that one may be snatched away to Darwin at any time weighs heavily on the minds of those with chronic disease, not to mention the stress it causes their family and friends.
Above: Public health poster at the Jabiru Clinic that they either wish to be closer to their land or refuse to live in Jabiru on their own land under the rule of, to them, a foreign power that claims their land and will not let them own it as they always have. As such, to be seen to be too eager to access the mobile unit’s help is to be seen as deferring to this foreign power’s authority. So they hang back and wait for the mobile team to approach them. Of all the indigenous adults in Jabiru and on outstations, the majority have type 2 diabetes, hypertension, are obese or have renal failure, with a significant proportion having all of the first three conditions. This unfortunate situation makes the clinic staff’s job rather predictable as
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most patient presentations consist of a doctor or remote area nurse dealing with the complications of these four illnesses. In not one of the consultations I sat in on was a patient’s medication dosage reduced and more often than not it was increased. The Territory Health Service pay for all PBS medication prescribed to indigenous people on Centrelink meaning that increased dosages never impact economically upon the Mirrar or the clinic. The situation does however cast light upon just how much of an effect chronic disease has upon the community. The Jabiru health clinic is not dialysis capable and so most renal failure patients are forced to leave for Darwin where they can receive dialysis. Many Mirrar don’t understand that only those
In fact, as with almost all Aboriginal communities, the Mirrar feel such a connection to their homeland that it is not unheard of for families to hide their dying elders from the clinic and police until they have passed away, to prevent them being taken away for palliative care. It is welldocumented amongst many indigenous people that they would rather die a few years earlier in their homeland amongst family and friends than be taken away and die in an alien place to which they felt no connection. This is thus a major challenge for western health professionals. In our culture it is considered deplorable to let someone die at home of septicaemia secondary to renal failure when they could be hospitalised and placed on dialysis for a pain-free death months later. To the Mirrar this is more than often than not a culturally-inappropriate response and if carried out could warrant payback by the patient’s relatives against the clinic and its staff. It is a sad irony that those who often cause indigenous Australians the greatest harm are in fact those health professionals who are trying to bring about the greatest good. For this reason, all those in the health field, professionals and students alike, must seek to have as great an understanding of Aboriginal Australia as possible, to be able to be the cause of change for the better.
Nicaragua - Male life expectancy: 68; Female life expectancy: 74; Under-5 mortality rate (per 1000): 36;
Global Health Experiences
Remote Medicine: Thai Style Evelyn Chan and Paul Leong Monash University Thailand. The word conjures images of elephants, temples, bustling markets and mouth-watering food; a tourist Mecca. In Northern Thailand live the enigmatic ‘hill-tribes’, whose seemingly peaceful anachronistic lifestyle belies a difficult existence. Around Christmas 2006, we travelled to Chiang Rai, the northernmost city in Thailand. There we were met by Dr. David Mar Naw, the founder of Where There Is No Doctor, a one-man non-governmental organisation with a vision to help the poorest and most needy hill tribes. From Chiang Rai, we journeyed further north through lush mountainous jungle deeper within the notorious Golden Triangle. Children ran to greet us as old women in traditional Akha dress smiled, affording us a glimpse of
betel-nut stained teeth. Above us, straw-roofed, bamboo houses on stilts stood terraced on the hilly banks of the Mae Kok river amongst dense tropical bamboo forest. Below us lay the detritus of humanity sans garbage collection: discarded plastic wrappers, crushed soft drink cans, cigarette butts and cardboard. Pigs, cows and chickens under houses, scavenging scraps and contributing their faeces to the squalor.
bamboo verandas that adorn each house. Our medical arsenal was the sum contents of two microwave-sized plastic boxes, supplemented by whatever we could carry on foot from village to village. With it, we attempted to deal with the damage done by smoking, tuberculosis, HIV/AIDS, helminthic infection, hypertension, skin problems, gastroenteritis, dehydration, dysentery and musculoskeletal ailments.
For a day of strenous manual labour, a hill tribe man can expect to earn 120 Baht (4 AUD); his wife 100 Baht a day (3.10 AUD). Survival is not an abstruse concept – here, life is an everyday struggle. Meals consist of what little rice can be grown in the rainy season, supplemented by home-grown chilli and salt. Meat and vegetables are only consumed at celebrations, leading to widespread malnutrition.
Yet despite myriad challenges, the hill tribe people are generous, kind and happy. They take pleasure in the small things: eating, singing and family. Children play simple games: wooden toys, swimming and mud balls. Many children can attend primary school through the sponsorship of Where There Is No Doctor – but there are many more who can not. Few complete secondary schooling due to the pressure to help provide for the family. Those who have completed secondary schooling face poor job oppor-
Most mornings, Dr. Mar Naw held a clinic on one of the small, shaky
Niger - Male life expectancy: 42; Female life expectancy: 43; Under-5 mortality rate (per 1000): 253;
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tunities in cities far away from home and firmly entrenched racial discrimination. One night, the children led us up a rickety bamboo ladder to one of their houses. Amongst them was Bi Soon, a clear-eyed 5 year old. She gestured to show us that this was her home. Clearly, this was a rich manâ&#x20AC;&#x2122;s house, for inside, a TV stood proudly, playing pirated Burmese VCDs. A smiling man emerged from another room, tanned weathered face and rough blackened hands testament to
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his hard life. With his hands, he gestured to us how he earned his living: sowing and reaping crops. The child ran to him and hugged him fiercely, her enthusiasm a counterpoint to his world-weary demeanour. After dinner, he sat with his arm around Bi Soon and pointed first at her, then to us and then pushed her towards us with an imploring look on his face. He gestured to us as if he wanted us to leave. Dr. Mar Naw translated from Akha: â&#x20AC;&#x153;He wants you to take her back to Australia with you so that she can have a
good lifeâ&#x20AC;?. So many tourists visit the hill tribes, yet so few bother to understand their plight, their struggle and their dreams. When you visit Thailand, please think of them. For more information: http:// www.wtinad.org
Nigeria - Male life expectancy: 48; Female life expectancy: 49; Under-5 mortality rate (per 1000): 191;
Global Health Experiences
“Welcome to South Africa, my friend ...” Jenny Jamieson University of Melbourne I had landed in the O.R. Tambo Airport and was en route to Cape Town when I found myself in a Johannesburg police station only one hour after landing, reporting the stolen mobile phone which had previously been in the back pocket of my jeans. The policeman just smiled at me, reclining behind his desk, hands folded behind his head. Then grinning his wide-toothed smile, he chuckled: “Welcome to South Africa, my friend!” This was an immediate shock to my previously-held credentials as a travel-savvy backpacker. So perhaps people hadn’t been lying when they’d warned me about the crime rate in South Africa? The evidence of this was soon seen on a daily basis in Cape Town as I would leave behind the wealthier suburbs complete with their barbed wire fencing, curiously high walls, alarm systems and private guards. I would travel only 10 minutes down the N2 every morning before being plunged into the “other” world of Cape Town, better known as the Cape Flats. Low-cost council
houses, shacks and informal settlements brutally lined the sides of the freeway, where this long stretch of tarmac demarcates the separate vicinities of privilege and deficit. Cape Town is one of South Africa’s most attractive destinations; and it is not difficult to see why. The staggeringly beautiful Table Mountain would rise up above the vibrant student suburb of Observatory, home to a hub of artists and musicians, with quirky bars and cafes nestled in the small side streets. For most people, this is a world which they do not have to leave, hence blissfully repressing any acknowledgement of the gaping inequalities that exist between here and the townships. Admittedly, it is a world I was fortunate to return to at the end of every day. But by turning off onto Dunefontein Road each morning and heading towards Manenberg, one can no longer deny the discrepancy. After passing Cape Town’s richest golf course, one is suddenly plunged into immense shanty towns that stretch for miles, often with barely any electricity and restricted access to water.
The extreme violence and crime are bred from displacement and poverty during apartheid where Manenberg was used as a type of “dumping ground” for black Africans, Indians and other migrants. Post-apartheid, there is still far to go to catch up with the rest of Cape Town. Today Manenberg remains a name deeply synonymous with criminal networks and underworld gang violence. It has been described as “the product and symbol of dispossession and extrusion from Cape Town’s heart.” Simply, Manenberg is an area which breeds brutality. No where can one see the end result of this better than the casualty department of the G. F Jooste hospital. Situated in the heart of Manenberg, the hospital has a catchment area of over 1 million people. The 24-bed emergency department is where I chose to spend my elective. Under-resourced and under-staffed, this is where a clash of political, social and economic determinants of health come to surface. The waiting room is seeming with patients waiting to be triaged, most of whom are
Niue - Male life expectancy: 64; Female life expectancy: 78; Under-5 mortality rate (per 1000): 42;
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sent away. The hospital only sees category red or orange and (if you’re lucky) yellow. Even then, the chances of a bed are slim to none - patients sit, lie or slump anywhere they can find room. The Emergency Department is a place where TB meningitis is like the common cold, where 80% of patients have HIV / AIDS and where gunshot wounds, stabbings and assaults are everyday practice. Chest drains and lumbar punctures are daily routines to South African physicians... yet the desolation of performing these never goes away. Horrifyingly I’ve discovered you’re not a doctor in South Africa until you’ve stepped in the “Big Five” in one night… blood, urine, faecal matter, pus and vomit! I was introduced to the Jooste’s policy of teaching within the first hour. “See one, do one, teach one,” Naashad said to me. “You’ve seen a lumbar puncture before? Well, jump to it…” Overcrowded and poor housing in the flats results in a disproportionate amount of TB, including multi-drug resistant types. This, in turn, leads to a disproportionate amount of TB meningitis and a corresponding number of lumbar punctures carried out in the emergency department. To my utmost astonishment, LPs became as routine as taking bloods… Every day we saw victims from the townships - the young girl who has been beaten & raped by her brother-in-law; the elderly man who was mugged & stabbed walking to buy groceries; the housewife who was beaten with a glass bottle by her husband; and the young “Tsotsis” involved in gang terrorism around the townships. Of course, the minute I pushed a chest drain into the mid-axillary line of these Tsotsis, they would scream for their mum! However, it never stopped them from walking out of the hospital and going to stab the Tsotsi who stabbed him - (we would often see his “friend” in the emergency department the next day). And on it went... until one finished
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the other. Every day patients would be wheeled into the hospital handcuffed to the trolley and escorted by 4 policemen carrying AK47s. In a country where there are over 10,000 road fatalities a year, it is inevitable that the hospital receives countless numbers of motor and pedestrian vehicle accidents. Often these are simply “hit-and-runs” where 2 year olds are hit by a vehicle and left at the side of the road until they are brought in to hospital by a bystander. Christmas Eve was a sombre and incredibly arduous night, as assault after assault was wheeled through the doors. One patient came in after having an axe brought down on his head, leaving the deepest cut I will ever witness. Yet he continued to insist to me that he had simply fallen down the stairs. Mid-way through the night, a group of carollers braved the hospital and stood amongst the gun-shot wounds and bloodshed singing “Silent Night.” The irony of this was not lost on anyone, yet dearly comforting to patients and staff alike. There is such a vast interplay of factors which affect health and no where was this more apparent to me than in Manenberg. The most challenging aspect was not learning the skills or acquiring the ini-
tiative necessary for procedural work. Instead it was the difficulties and struggles of seeing and treating the terrifying HIV statistics which remain so distant to us in Australia. It was the challenge of performing CPR on a TB patient. It was the difficulty of standing by the bedside of an AIDS patient as he passed away. When Abdullah Ibrahim famously sang “Manenberg, is where it’s happening,” he certainly wasn’t being facetious. Whilst the staff always had time to spend teaching, inevitably it was the stories heard from the bedsides of patients which taught me more about the realities of medicine and the manner in which politics, society and culture can shape health. An elective spent here could be considered by some as a “medical tourist” visit to enhance skills. Alternatively, an elective undertaken here can be viewed as an incentive to strive towards addressing the underlying reasons for inequalities and discrepancies in health, both in Australia and abroad. I truly believe this is the most important task at hand for us as future health professionals. With this task in mind now and for the future, I will never forget my time spent in Manenberg at the G.F. Jooste Hospital.
Kenya - Male life expectancy: 78; Female life expectancy: 83; Under-5 mortality rate (per 1000): 4;
Global Health Experiences
Cameroon ... and Aboriginal Australia Caitlin Keighley University of Melbourne Cameroon is a country of contrast. It is a place where beaches and forests blend Northward into sub-Saharan desert, where Christianity mingles with Islam, where French and English stand together as national languages, and where aid organisations supplement local medicine, and where I ventured for my elective. I went with a friend, unsure of what awaited us in this country largely untouched by Australians. Picture a blonde, white girl and a young South-East Asian background man, despite our best efforts to blend in, we were a novelty. We arrived on the day of the goat (Cameroon enjoys both Muslim and Christian holidays), which was rapidly followed by Christmas and New Year’s Eve. Arriving during this holiday pe-
riod, our elective in infectious diseases and haematology expanded to include emergency and obstetrics. (While wards might take holidays, there are always accidents and babies.) We also did a research project in HIV at the new institute run by our supervisor. Allow me to give you a tour of medicine in Cameroon. Like a novice swimmer that with mixed courage and naivety plunges into the deep end of the pool, we began with a New Year’s Eve shift in the Emergency Department of Yaounde’s General Hospital. This is a hospital where patients buy all of their own equipment, investigations and treatment in hospital, down to the pair of gloves the doctor will use to examine them and the notebook for the patient record, before they get treated. When it can be spared or afforded, analgesia is used ad hoc. Morphine was considered excessive for a
patient with a broken arm hanging at right angles; he got voltaren, after it was reduced! It need only be said that user-pays does not work in a healthcare system. On to obstetrics and gynaecology provided and ward rounds with an entourage of 40, led by the consultant, with the entire medical staff and student group in tow. Students were brought to the front of this group to present each patient, and be drilled in front of the group. This multilingual group learnt by intimidation and humiliation in the age-old, tried-and-true, tradition of medicine. Exchanges occurred fluently and interchangeably in French and English. The skill, both in medical theory and linguistics, of this group was impressive. And then after the detour over the holiday period, we moved to infectious diseases, led by a registrar who also ran the cardiology
Oman - Male life expectancy: 72; Female life expectancy: 77; Under-5 mortality rate (per 1000): 11;
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department in the hospital. Tuberculous disease was rampant, and HIV an endemic background. I have to admit some trepidation when I examined one young girl admitted after three months coughing, but lay my concerns about bacilli and returning to Australia aside. She presented with meningitic symptoms, along with a hepatitis and genital infection on a background of HIV. After two days and for better or worse, her mother took her home to try natural medicines. Infectious diseases ward rounds only occurred on 2 days of the week, and on other days we went to haematology. Amongst many large spleens and livers, were some that were obvious through the skin of patients as they breathed. Beyond the confines of blood, this ward treated sickle cell patients along with whatever their precipitating illness, giving a breadth of medicine foreign to haematology in Australia. The registrar in this ward was also a poet with a gift for philosophy, and we probably spent as much time talking to him about colonial French Africa as we did with the patients. Aside from the clinical experience
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(we were there for 2 months), we started a research project on HIV and cytokines. It may come as a surprise that this was possibleâ&#x20AC;Ś In contrast to the image of Cameroonian facilities I have painted to now, there was also a state-of-the-art research facility opened only two years before. This will see HIV burden reduced in the coming decades. Research, as our supervisor quickly pointed out, is almost as important as treatment (which is available for free from the World Health Organisation) because it gives a country ownership over a problem, and the capacity to examine and solve questions themselves. Despite sitting at number 149 on the UN human development index, Cameroon is establishing research capacity, and succeeds in providing a high standard of clinical training. Their main difficulty is in getting graduates to stay. Australia contributes to the brain drain not of this country, but of countries like this, that despite their best efforts remain poverty-stricken and floundering for leadership to support their bursting potential. So, why the title of this essay? My next rotation on return was
in an Aboriginal Medical Service. Strikingly, the blending of a colonial and an Indigenous culture of France in Cameroon has echoes of our context in Australia. Both Indigenous populations have had other cultures imposed, both have surprisingly similar health statistics, both suffer tropical diseases that are rare in Western societies, and both are underresourced. Whilst a poor state of health however is expected (whether rightly or not) in countries such as Cameroon, it comes as a surprise to Australians that it might be parallelled by Aboriginal people not just in remote and rural areas, but also in the midst of metropolitan Melbourne. In a year that began with the Australian Apology, the pride that many Australians feel is slowly gaining some legitimacy, and hopefully the compassion and attention received by overseas developing countries will increasingly be translated to our Australian Indigenous population. It was with much consternation that I had to confirm some of the prejudices that Cameroonians are well aware of, and with enormous relief that I tell them news of our recent moves for the better.
Pakistan - Male life expectancy: 62; Female life expectancy: 63; Under-5 mortality rate (per 1000): 97;
Global Health Experiences
Paiga Clinic: Health issues in a Papua New Guinean Highlands Village Bronwen Morrison The University of Sydney Papua New Guinean Highlanders are born gardeners. Agriculture started here 9,000 years ago and little has changed in methods of cultivation today - Highland soils are rich, rainfall plentiful and the climate mild.1 I was told about the spectacular landscape, its yield and the delicious local cuisine by a foodie friend, Paul van Reyk, who invited me to visit Paigatasa in the Eastern Highlands for the opening of the village’s new clinic on 30 January 2008. I’d attended Paul’s fundraising activities for the clinic and was very interested in seeing the results.2 I was also keen to have a preliminary taste of medicine in a developing world context, with the
view to working overseas with a non-government organisation when I qualify to practise. The invitation presented me with the opportunity to learn more about determining a community’s core health needs, obtaining medical training and supplies, and observing health promotion and tropical medicine in practice. My proposal was to assist in developing recommendations that the fundraising group could use to gain support from NGOs for further development of health services in the village. What I didn’t expect from the visit was the full extent of my immersion in the local cultural experience, or that I would return to Australia with new wantoks3 (or adopted family) and a strong commitment to the future of the
village after just 11 days in PNG. Paigatasa (or Paiga) is a large village consisting of several hamlets spaced along the sides of a deep valley, surrounded by vegetable gardens and secondary forest. The community speaks Fore South (one of PNG’s 800 languages); many people also speak Pidgin and English to varying degrees. The nearest navigable road is a four to six hour walk away, and the district capital of Okapa is a day’s walk. The people of the valley are subsistence farmers whose main source of cash income is from small coffee plantations. Coffee is sold as a raw harvested product to a coffee roaster in Goroka, and the average family plantation makes the equivalent of about AUD$100 per year.
Panama - Male life expectancy: 74; Female life expectancy: 79; Under-5 mortality rate (per 1000): 23;
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PNG’s average life expectancy is 60 years.4 There are just 750 doctors for a population of 6.1 million, most of these based in Port Moresby.5 (In contrast, Australia has 47,875 physicians for 20 million people. 6) In PNG, communicable diseases, including malaria, tuberculosis, HIVAIDS, pneumonia, diarrhoeal diseases, meningitis and vaccinepreventable childhood illnesses, still account for the greatest loss of life.7 Regionally, the neurodegenerative disease kuru has affected the Fore South population
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in epidemic proportions. Kuru, a spongiform encephalopathy caused by a single CreutzfeldtJakob-like prion mutation8 and transmitted via the traditional Fore practice of consuming part of a deceased relative’s body before burial, caused the early deaths of many local people until the ‘mortuary feasting’ practice ceased.9 Only 3% of PNG roads are paved,10 and I experienced the harsh reality of this when our hired 4WD became bogged just 2 kilometres down the road to Ka-
buye, the closest village to Paiga with questionable road access. The twenty men who’d ridden in the back of the truck worked for hours to free the tyres from the muddy embankment of a stream, but eventually we abandoned the truck and walked in, carrying our luggage with us. The walk into Paiga took us 6 hours, the last three hours after dark, in the rain, making the 45-degree slope of the mountainside path a slippery-slide. I felt a strong empathy for local people who become seriously
Papua New Guinea - Male life expectancy: 60; Female life expectancy: 64; Under-5 mortality rate (per 1000): 73;
when his house caught fire two weeks after we returned to Australia, and died on the long journey to a facility that could treat his injuries adequately. If a villager dies in hospital, relatives then carry the body in its coffin back to the village for burial – about two-thirds of Paigans are Seventh-day Adventists and whole-body burial is important to them.
ill and need to be carried out to the nearest hospital on stretchers, and the relatives who carry them. I was told that five village women had died on the way to hospital in the last few years because of obstructed labour, postpartum haemorrhage or other obstetric complications, and 15 neonates had also been lost. It is not surprising that PNG’s infant and maternal mortality rates are the worst in the western pacific region.11 The village’s remoteness also creates a horrendous situation for accident victims. An elderly man was severely burned
The Adventist faith also prohibits the consumption of pig meat;12 ironically, pigs are a crucial aspect of Highlander produce, and the Adventist families in the village, while they might not eat the meat, use their carefully raised pigs for ‘bride price’, to feed guests, and for ‘payback’ and trade. This removes one important source of protein from the diet of many Paigans, although chicken, eggs, goat, cuscus (possum), legumes and peanuts are also consumed to a greater or lesser extent. The gardens surrounding each house provide a wide variety of fresh vegetables and local fruits, including the most succulent pineapples I’ve ever tasted and sugar cane (carried for sustenance on journeys and also used to clean teeth – possibly a self-defeating practice13). The ubiquitous sweet potato, taro, yam, corn and green banana provide carbohydrates.14 Not surprisingly, given this dietician’s dream diet combined with a lifestyle of walking up and down mountains carrying heavy loads, there was no evidence of an obesity epidemic in the valley. While I had read about protein deficiency being common in the Highlands, neither local adults nor children appear to have significant problems caused by malnutrition, although Highlanders tend to have shorter statures than the population as a whole. It is hard to say whether this is a result of childhood nutritional deficits or genetic characteristics, as scales and growth charts are currently unavailable to local health workers to determine such basic statistics as increases in weight and height with growth.15
Paul had told me that I wouldn’t need to boil the village water before drinking it, but I was a little sceptical until I visited the two sources where water is collected in the valley. Both are pure springs that arise from the mountainside, having been filtered naturally through rock. Other streams abound, but are downstream of houses and gardens and unsuitable for drinking. Water porting is the main issue; it can be a long walk home with heavy water containers, depending on where a house is situated in the valley. As a consequence, people tend not to cart water to wash, instead walking down to bathe in streams. The practicality of maintaining hygiene around the home is limited by this factor. Most families have a pit toilet at a short distance from their house, but nothing to wash hands with afterwards, which contributes to the spread of diarrhoeal disease. More households would use water tanks, given the abundant rainfall, if it were not for the expense of purchase, the extreme difficulty of carrying a tank into the valley, and the fact that the roofs of most village homes are thatched with grass and unsuitable for rainwater collection. Two rainwater tanks have been installed for the new clinic, which has a tin roof, forestalling the water supply problem there. Village houses are traditionally built in the round with a pole frame, woven pandanus walls and a large single room with an earth floor, a central fireplace and an elevated woven platform extending back to the walls that is used for sleeping, food preparation, receiving guests and all other home activities. There is no chimney – smoke from the fire escapes through the thatch quite effectively – but it is a smoky indoor environment nonetheless, and I noticed on returning to Moresby that my luggage had a strong wood-smoke aroma. The traditional house is warm and cosy in the cool Highlands evenings, but nocturnal coughing, sneezing and wheezing in close
Paraguay - Male life expectancy: 72; Female life expectancy: 78; Under-5 mortality rate (per 1000): 22;
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confines facilitates the spread of respiratory diseases such as tuberculosis among family members (a young man in Amusi hamlet, on the other side of the valley from where we stayed, died of TB during our visit). I also wondered to what extent the constant inhalation of wood-smoke contributes to lung disease. Some Paigans smoke tobacco, bought in long rolls of dried leaf product from the market, but cigarettes, if smoked at all, are an occasional luxury because of the village’s isolation, as with all other manufactured products including alcohol – smoking and drinking are also discouraged by the Adventist faith. People enjoyed some sparking (Tok Pisin for beer-drinking) during the clinic opening celebrations, but the carted supply soon ran out. Buai or betel nut is the perennial stimulant of choice, and our friend, driver and village contact Josca16 chewed and spat constantly during our long drive between Goroka and the dropoff point in Okapa District where the road stops and the walk into Paiga begins. Betel-chewing increases an individual’s risk of oral cancers, and in PNG, where betel nut is widely available, oral cancers rival hepatic and cervical as the leading types of cancer – all three with largely preventable causes.17
form in Paiga, had carried their instruments, mikes and amps over the mountain. They played the Eagles’ song ‘Hotel California’ as we climbed onto the stage – a surreal moment.
The clinic opening was reportedly the biggest event in Paigatasa’s history. A big cultural performance had been arranged, with groups from Asaro, South Gimi and other areas in the district dancing, singing, drumming, brandishing wooden shields, bows and arrows, batons, billums (traditional woven bags), spears and banners, spectacular in traditional costume. 3,000 people attended the celebrations, including 50 special guests. Paul and I were asked to sit on the bamboo stage that had been purposebuilt for the occasion, and to give speeches along with the other guests. I was presented with a colourful billum dress to wear to the ceremony. A rock band from Goroka, the first one ever to per-
The Clinic Committee met the following day to discuss priorities for the next phase of clinic development. We met inside the
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The new local Member of Parliament for Okapa District, the Hon. Bonny Oveyara, made a favourable impression by walking into the valley with everyone else to attend the clinic opening, rather than commandeering a helicopter for the day. Bonny gave his speech after the local bigmen (village leaders) and clinic committee members, who had all used the opportunity to passionately emphasise how little the government had done for their community since Independence in 1975. Bonny, choosing to acknowledge but not to accept responsibility for his predecessors’ lack of action, made a pledge to supply tin for the roof of the community school, which is run by volunteer teachers and currently housed in leaky bamboo huts with dirt floors. The speeches were made in Tok Pisin and translated for us by Josca. He also interpreted our speeches for the crowd, who were very enthusiastic about our presence and satisfied by our undertakings to carry the clinic and school plans forward to their next stage.
impressive new building, seated on the floorboards of the room designated as the general ward. The clinic has two wards, a labour room and an outpatient clinic, a dispensary and two offices, but is currently just a shell and requires furnishings and equipment to be functional. Furniture and floor coverings were an immediately obvious need. The committee decided that a two-way radio and a generator were essential clinic items and the local MP has since agreed to fund this purchase. Flyscreens and curtains, plumbing for indoor sinks and solar lighting were also itemised. I later sought advice on the basic medical supplies and equipment needed to run the clinic, including a set of scales, a sphygmomanometer, birthing kits and suturing materials. We prepared a list with the local health worker’s input, and are now seeking donor support to purchase this equipment.18 The issue of an access road into the valley had been raised several times during the clinic opening speeches, and was raised again at the meeting. While a road is a major infrastructure item that donors are unlikely to be able to fund at this point, we hope to involve Engineers Without Borders in working on some aspects of accessibility, such as bridges over the three streams on the path into Paiga, currently spanned only by logs that require very good balance. After the committee meeting, we
Peru - Male life expectancy: 71; Female life expectancy: 75; Under-5 mortality rate (per 1000): 25;
visited the old village aid post and discussed the communityâ&#x20AC;&#x2122;s health situation. Profound health challenges exist in the Paiga community, largely associated with poor access to adequate health care and low levels of education. The village has one health worker, Denmark Oâ&#x20AC;&#x2122;oa, who completed three years of aid post orderly training in 1981. He has had no opportunity to attend any further professional training, and is not equipped to deal with situations such as pneumonia, severe malaria, TB, obstetric complications, childhood meningitis or major injuries. Together we saw a seventy-year-old patient who had walked two hours from her home with fever and myalgia, whom Denmark treated for malaria. Her elderly husband who accompanied her wore a bandage on one knee in an attempt to control some joint instability. Walking down the mountain must have been very difficult for both of them. There is no Flying Doctor service in PNG, and a helicopter has not been to the village since the last missionaries left in 1989.
Patients who need a higher level of care are carried for hours on stretchers by relatives to the district hospital. Denmark explained that he does the day-long walk to Okapa about once a month to restock the medicines in the aid post, and he pays village men from his own salary to help carry supplies back to Paiga, as the district health department does not arrange distribution to aid posts. Another local issue relates to the keeping of records. Many villagers, especially elderly people, do not know their date or even year of birth, and there is no local data on the incidence and prevalence of specific diseases and disorders, or births and deaths, in Paiga. Highlands culture is very maledominated, and men not only have better education and greater fluency in English, but are also accustomed to speaking on behalf of the women in all official matters, so I arranged a village womenâ&#x20AC;&#x2122;s meeting to discuss their own health concerns. I was par-
ticularly interested to hear about traditional birthing practices and the village women who assist with these, to assess the general level of knowledge about delivery and to identify individuals who may be interested and able to participate in further midwifery and other health-related training. Sixty women attended the meeting, and asked for access to more information on family planning, via health promotion pamphlets and information sessions, and on spacing babies, delivery, breastfeeding, contraceptives and their side effects, infertility and sexual health in general. Other chronic health problems included dysmenorrhoea, pelvic inflammatory disease, iron-deficiency anaemia, arthritis and back problems. The group also put forward their support of volunteer doctors visiting Paiga for periods of time, and encouraged me to return when I complete my medical training. In the meantime, there list of project tasks to wards. The Australian tion for the Peoples of
Philippines - Male life expectancy: 64; Female life expectancy: 71; Under-5 mortality rate (per 1000): 32;
is a long work toFoundaAsia and
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the Pacific19 has donated some clinic equipment and shipment to PNG, and I’m sourcing other clinic items that they don’t have in stock. Further training for the local health worker and his successors in midwifery, HIV-AIDs, record keeping and clinic administration, community health promotion, use of new clinic equipment, and other clinical skills (e.g. plastering, basic dental) is also on the community’s priority list. Paul has pledged assistance for the community school, including new classroom buildings, funds to pay local volunteer teachers and sponsorship for one teacher’s enrolment in Lae Teachers College from 2009. An organisation named One Laptop Per Child20 is interested in testing their equipment in the Highlands setting, which means a number of solar- or crank-powered, dustproof laptops for the school. The community now has two orchid gardens from which they would like to start exporting orchids, and they are very keen to develop eco-tourism in the area. We are also selling billums (traditional string bags) at Sydney markets and via the Paiga website, and plan to supply a pedal-powered sewing machine for village women to set up a small business venture. And we are seeking official recognition as a charitable organisation, a two-step process that requires incorporation, and then registration as a project partner with another charity that has ATO tax-deductible gift
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status. We can then broaden our fundraising activities in Australia to include corporations as well as friends and acquaintances. In all this, I feel I have learnt something useful about making little things grow from the best gardeners in the world. (If you are interested in contributing to the project or finding out more about Paiga, visit the village website at www.paiga.com. au or contact me at bmor7768@ gmp.usyd.edu.au.)
Endnotes
1. Lonely Planet Guide: Papua New Guinea & Solomon Islands, Lonely Planet Publications Pty Ltd, 2005, 111-112. 2. See www.paiga.com.au for more information on Paul’s first visit to Paigatasa and his instigation of the fundraising project for the village. 3. Tok Pisin, or Pidgin, is the most widely spoken of PNG’s approximately 800 languages, and is taught in schools along with English. The literal translation of wantok is ‘one talk’, meaning you and your kin share a local language or tok ples and have obligations towards each other. Everything your wantoks have is yours, and vice versa - essentially a village-based social security system. 4. WHO Mortality Country Fact Sheet 2006 – Papua New Guinea. 5. WHO Country Health Information Profiles – Papua New Guinea, (2005 data). 6. http://www.who.int/countries/aus/ en/; as at 2005. 7. WHO – PNG Health Situation and Trend. http://www.wpro.who.int/ countries/png/. 8. Robbins and Cotran, Pathological Basis of Disease 7th edition, Saunders
2005, 346 & 1380-82. 9. Michael P Alpers for the Kuru Surveillance Team. “The epidemiology of kuru in the period 1987 to 1995.” Communicable Diseases Intelligence 29, 4: Dec 2005. See also Donald Denoon’s monograph, Public Health in Papua New Guinea: Medical Possibility and Social Constraint, 1884-1984, Cambridge University Press 1989, for the social history of the disease. http://www.health.gov.au/internet/ wcms/publishing.nsf/Content/cdacdi2904i.htm. 10. WHO – PNG Country Context. http://www.wpro.who.int/countries/ png/. 11. WHO Country Cooperation Strategy: Papua New Guinea 2005-2009, 11. 12. ABC Radio National, “Seventh-day Adventists”, on The Spirit of Things, 21 October 2007. Transcript available at: http://www.abc.net.au/rn/spiritofthings/stories/2007/2059943.htm. 13. See Paul L Newell, “Huli Oral Health.” PNG Medical Journal 2002 Mar-Jun: 45(1-2), 63-79, for his study of a comparable rural population in the Tari Basin of the Southern Highlands. 14. For more on the Eastern Highlands diet, and some traditional recipes, see http://www.paiga.com.au/index. php?pageid=1179. 15. See Joy E Gillett’s monograph, The Health of Women in Papua New Guinea, PNG Institute of Medical Research 1990, Chapter 3.2, for further discussion of nutrition and children’s growth in rural areas. 16. Josca Ariva works as a driver for the UNICEF office in Goroka. He plays a significant role as intermediary between the Paiga community and overseas donors, being well-educated, fluent in Fore, Pidgin and English, and having access to email, telephone, postal services and other town resources. 17. WHO Country Cooperation Strategy: Papua New Guinea 2005-2009, 12. 18. See Paiga website for equipment list: www.paiga.com.au. 19. See http://www.afap.org/ 20. See http://laptopfoundation.org/ index.shtml
Poland - Male life expectancy: 71; Female life expectancy: 80; Under-5 mortality rate (per 1000): 7;
Global Health Experiences
Mwandi Jasmine Pillai University of Melbourne It is about nine o’clock at night and I am staring straight into the depths of a giant African vagina. The power is down and the delivery suite around me is dark, illuminated only by the dim flicker of a fluorescent lamp. The air is musty and has a uniquely fetid smell which can best be described as a mixture of sweat, vaginal fluids, urine and faeces.
The owner of the vagina is Marjorie, she is my age (19 years) and she is attempting to give birth to her second child. The operating table on which she is lying is covered in blue tarpaulin-like material and Marjorie’s bottom is positioned over a large black garbage bag, which is designed to catch blood and afterbirth. There are no smiling doctors nor reassuring midwives, no vases of fresh flowers, no husband for support, no epidural for pain relief and no fan to cool her down. The only other people in the room are my friend Nicky (a University of Melbourne Arts student) and the grandmother-to-be, who is kneeling on the hospital floor muttering fervent and wailing prayers to Jesus. I have just completed my second year of medical studies and I have absolutely no idea what on earth I’m supposed to be doing. Luckily a midwife eventually returns, the power flicks back on and despite Marjorie’s “lack of maternal effort”, I assist in delivering a healthy baby boy. This account may sound sensationalistic; but in Mwandi, Zambia, this haphazard process of bringing life
into the world is all very routine. The Mwandi Village is situated on the Zambezi River in the Western Province of Zambia and is about 70 km away from the Caprivi Strip of Namibia. It is impossible to reflect upon my experiences in Mwandi without being flooded by the faces of children. Being in Mwandi is like being swallowed by a World Vision advertisement from TV. This is unsurprising, considering the life expectancy is a mere 32 in men and 37 in women and the under 15’s population bracket forms 42.6% of the village’s total 13,000 inhabitants. Of this, there are approximately 3,000 orphans. The Mwandi Mission Hospital (run by the United Church of Zambia), subserves in the order of 22,0000 people and although it is staffed with nurses and nurse assistants there is only one qualified doctor. I was lucky enough to spend two weeks volunteering in the mission hospital over summer and it is an experience that has greatly shaped the way I think about international health.
Portugal - Male life expectancy: 75; Female life expectancy: 82; Under-5 mortality rate (per 1000): 7;
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“Having never met a patient with HIV/ AIDS, it was a surreal experience to be thrust into a third world environment where the pandemic affects close to a third of the population ...”
The hospital conditions contrasted greatly to the clean, resourceplenty hospitals I was used to seeing in Australia. The wards were overcrowded, with some patients on mattresses on the floor and there were often no pillows on the hospital beds. The hospital ceilings (which also housed a small bat population) were leaking and the floors seemed permanently dirty. Cockroaches scurried to and fro and neighbourhood dogs wondered casually in and out of the hospital. This was coupled with a severe lack of medical equipment. The hospital had an X-ray machine, but there were no CT, US or MRI machines and the ECG machine dated from the 70’s. There was also a shortage of medications; drugs which were ideally administered IV had to be given orally or were quite simply unavailable. To further complicate the situation, the Doctor was Western Cogonese and spoke a limited amount of Lozi (the local language). This provided a significant communication barrier, with family members often translating patient’s ailments back to the Doctor in broken English. Having never met a patient with HIV/AIDS it was a surreal experience to be thrust into a third world environment where the pandemic affects close to a third
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of the population and is the single most important factor in determining a patient’s prognosis. I soon learnt that the first question to ask when dealing with a patient was whether they had antiretroviral disease or ARD (a blanket term used to cover the spectrum of disease from HIV to AIDS) and the first test to order was a CD4 cell count. Most patients (suffering from a variety of tropical ailments such as malaria, spinal and peritoneal tuberculosis as well as pneumonia and UTI) were treated with Septrin (co-trimoxazole), a combination of antibiotics commonly used in ARD patients. Luckily, most were also on antiretroviral therapy (ARVs) and those who were not were rapidly commenced on treatment. ARVs seemed to be the only resource not lacking in the hospital; they continue to be donated by overseas companies in exchange for important data on their effectiveness. Despite this the hospital still lost an average of two patients a week to ARD. Unfortunately, due to the powerful influence of the Church, safe sex practices were only encouraged after marriage. Abstinence was pushed and condoms not made readily available to the younger population. The sad reality in Mwandi is that ARD is not
just restricted to a sector of the population engaging in unsafe sex or drug-taking practices, but is heavily prevalent in the child population. Mother-to-child transmission can occur during birth, but more commonly through the breast milk of women who are not on ARV therapy. The burden of the ARD pandemic was not just apparent in the hospital, with the social burden of the disease hitting the children the hardest. With parents either dead or too sick to provide for their children; the kids in Mwandi spent most of their time doing chores at home or looking after their younger siblings (it was common to see five year old girls carrying babies on their backs) and often did not have enough money to go to school. Having returned to Australia it is almost impossible to comprehend how the term “international health” when applied to Zambia could encapsulate such a dangerously under resourced healthcare system and could be used to describe such a crippling burden of disease (both medically and socially). I am still waiting for the shock of returning to a Western ward where the patients are predominantly elderly and the illnesses age-related.
Republic of Korea - Male life expectancy: 75; Female life expectancy: 82; Under-5 mortality rate (per 1000): 5;
Global Health Experiences
Cambodia Calling Phoebe Star and Eva Sudbury University of Melbourne We were determined not to fritter away our entire summer holidays at yet another mindless waitressing job, or perhaps we just wanted something more impressive to report at the first PBL tute for the year, when everyone gets asked the obligatory question ‘‘How did you spend your holidays?” Whatever our motivation, our quest to be constructive with our time-off led us on a trip to Cambodia, a
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country where immense wealth is juxtaposed with absolute poverty; where the divide between upper and lower class is a veritable chasm; and where one portion of the population is desperately trying to rebuild the country after the devastation of the Khmer Rouge, while another portion is throwing a spanner in the works with the corruption that is seemingly rife amongst officials at every level. Although we were keen to participate in a volunteer program that was medically-related, we were
only two years into our medical degrees and felt that we would be more useful teaching conversational English - in Cambodia, to speak fluent English is to escape a life of poverty. However, our thirst for an insight into the Khmer healthcare system needed to be quenched, and so we found ourselves on the doorstep of an expat doctor whose credentials of ‘being involved with the UN’ made him sound like the perfect candidate to inform us on ‘Third World’ medicine. The meeting that followed could not have gone more differently to what we had expected – in fact we both left his surgery doubting that we would ever want work in a developing country. We had intended to find out fun facts such as which exotic diseases he commonly treats, what it had been like working for the UN, whether he could get us a job at the UN etc etc, but all we managed to get out of him was a tale of woe spanning everything from the corruption of the healthcare system over there, to the fact that his patients don’t like him because he’s not female, to how female doctors can get away with murder. As the only two females in the building at that point we were getting a little antsy, and needless to say
we were not overly keen to take him up on his offer of working at his practice in the future. Thanks but no thanks! It’s fair to say, many of our thoughts about Cambodia leading up to our departure centered on those things that sting and bite. The prevalence of mosquito-borne diseases in Cambodia is high and led us to devote a sizable portion of our backpacks to 80% DEET gel, an insect repellent so toxic that it can’t be thrown out in the normal rubbish. Yet, a sign outside a children’s hospital in Siem Reap, warning of a “hemorrhagic dengue fever outbreak”, had us reaching for our fifth application of this substance for the day. Other animals filled us with trepidation; being chased by a dog became a rabies-avoidance exercise, a foray into a village with pigs and wading birds had us expecting Japanese Encephalitis, and don’t open your eyes in the shower, a worm in the contaminated water could burrow through your eyeball! A little paranoid you may say? Well probably, but we arrived home unsullied in this regard.
Cambodia is now thankfully emerging from decades of war and military occupation. However, the large number of people with amputations and crippling deformations bear witness to the ever-present threat of landmines, a lasting legacy of the Khmer Rouge and successive military rebels. Despite, extensive landmine deactivation programs, there are still new victims weekly. It was hard to believe that amongst the lush greenery of the landscape, in the darkness of the jungle, and in the cool waters of the rice paddy fields, these instruments of destruction lurked. However, warnings not to wander too far from the bus reminded us of their sinister presence. As you would expect, there is high demand for physiotherapists, occupational therapists and disability services to support landmine victims, not to mention a call for professionals to help the victims deal with the psychological scars of such trauma. Unfortunately, Cambodia cannot easily progress forwards in terms of agriculture, transport, resettlement and tour-
ism until its landscape is cleared of this scourge. On a more positive note, in our eagerness to look into public health campaigns, we encountered a truly inspirational program, which has drastically reduced the incidence of the curable, yet highly infective disease of leprosy. The Order of Malta, a humanitarian aid organisation, runs a leprosy rehabilitation clinic in Phnom Penh, which provides surgical and physiotherapy intervention, treatment for ulcers, specialised assistive devices and social activities to encourage reintegration of patients into society. The program extends to the provinces where self-care and vocational training courses are run. Working in conjunction with the Cambodian Ministry for Health since 1993, the Order of Malta Leprosy Program has not only dealt with the physical manifestations of the disease but also addressed the social stigma associated with the it. The stigma surrounding leprosy is pervasive and had previously seen suffer-
Russia - Male life expectancy: 60; Female life expectancy: 63; Under-5 mortality rate (per 1000): 13;
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ers cast out of their communities, losing their friends, livelihood and self confidence - dying alone with the ulcers and infection that come with untreated nerve damage. Now, however, Cambodian soap opera stars participate in advertising campaigns to dispel the stigma of leprosy and encourage early detection. It was at this clinic that we came across a group of Cambodian medical students, who had spent a month at the leprosy clinic, a testament to the importance of this disease in Cambodia. After quizzing us about our knowledge of leprosy, about which we knew very little,
and after taking a specimen from a lesion, they rushed off to study for an impending exam - sound familiar? The success of the treatment of leprosy is just one of several reasons to be optimistic about the future of healthcare in Cambodia. HIV is relatively well-controlled, compared with other developing countries, although this intervention certainly met its share of road blocks. When health workers rallied for the distribution of condoms to all sex workers, this contradicted the government’s official stance that all brothels in
Cambodia had been shut down. Thus, in order to both prevent the spread of HIV and save face, the condoms were officially distributed to ‘restaurants’ instead. So, overall, what is the healthcare system like in Cambodia? It’s bad. Of course it is – almost every educated person in the country, doctors included, was killed by the Khmer Rouge only 30 years ago. Imagine what it would be like to rebuild a country where most of the population are uneducated and illiterate. Needless to say, there is still a huge doctor shortage, and the state
“It was hard to believe that amongst the lush greenery of the landscape, in the darkness of the jungle, and in the cool waters of the rice paddy fields, these instruments of destruction lurked.”
of the hospitals is substandard to say the least. Indeed, a Cambodian friend who was admitted to hospital with a severe calcium deficiency was told his ongoing treatment was to eat more dessert. Fortunately, there are now several Cambodian universities offering medical courses (taught completely in French!), and so slowly but surely the number of local doctors is increasing. Thus, the picture over there is not all doom and gloom, and we cer-
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tainly did not want to write a piece about Cambodia that sounded too grim because there were so many aspects of the country that we fell in love with. The cheap and tasty food; the lush tropical landscape; the incredibly friendly locals; and, of course, Angkor Wat, were just some of the things that made Cambodia an amazing place to visit, and one that we will definitely return to again and again. And despite his best efforts to deter us from working as doctors in Cambodia, even the
‘UN doctor’ won’t be able to keep us away.
Resources Cambodian Volunteers for Community Development www.cvcd.org.kh The Order of Malta www.orderofmalta.org
Singapore - Male life expectancy: 78; Female life expectancy: 83; Under-5 mortality rate (per 1000): 3;
Global health events The Asian Collaborative Training on Infectious disease, Outbreak and Refugee management, Patong Beach, Phuket, Thailand 13-19 August 2007 Geordan Shannon, University of Newcastle
39 medical students from 8 countries converged in Phuket for one week of intensive seminars, workshops and skill building activities that focused on training future doctors in the area of natural disaster response and subsequent refugee management and infectious disease control. Using the example of the Boxing Day Tsunami 2004, we learnt about the myriad of issues to consider in a disaster, from initial medical aid and dead body management, to basic needs such as food, shelter, and water sanitisation, and the long term needs of a community such as psychological rehabilitation and support. Natural and humanitarian disasters leave a huge impact on countries worldwide every year. Such events come in many forms: from civil unrest in countries such as Sudan to the Andaman Basin Tsunami affecting costal regions in Asia, from an earthquake in Peru to local flooding in Newcastle. A spectrum of different aspects of human existence and fundamental human rights are thrown into disarray through the event of a disaster. In the worst case, infrastructure within a community is destroyed, lives are lost, economic burden is huge, political relationships may be disturbed, local employment strategies are ruined, and people are displaced from their original community, placing a huge burden on other countries who will accept them as refugees. Medically speaking, there are initial injuries, trauma, and dead body management, and subsequent opportunity for the spread of infectious diseases through poor water hygiene, waste management, vector control and overcrowding of shelters. Although many medical aid projects often focus on the immediate situation, there are huge long term ramifications of a disaster for communities and countries, such as psychological trauma, physical rehabilitation, management of refugees or internally displaced persons, and, disturbingly, the exploitation of vulnerable groups of people through rape, abduction of children and forced prostitution. The Council of Australian Governments, in their 2003 report on Natural
disasters in Australia, defines a natural disaster as: A natural disaster is a serious disruption to a community or region caused by the impact of a naturally occurring rapid onset event that threatens or causes death, injury or damage to property or the environment and which requires significant and coordinated multi-agency and community response. Such serious disruption can be caused by any one, or a combination, of the following natural hazards: bushfire; earthquake; flood; storm; cyclone; storm surge; landslide; tsunami; meteorite strike; or tornado Whereas the International Federation of Red Cross and Red Crescent Societiesâ&#x20AC;&#x2122; definition of a humanitarian disaster is: Long-term man made disasters tend to refer to civil strife, civil war and international war. On a national level this involves warlike encounters between armed groups from the same country which take place within the boarders. Such outbreaks of war may pose large-scale medical problems such as epidemics, lack of water, accumulation of rubbish, displaced persons, refugees, food shortage, hunger etc.Internationally, war may break out between two or more armies from different countries. Similarly such conflict may cause large scale mass movements of refugees and displaced persons. THE SITUATION IN AUSTRALIA In order to appreciate the effect of a natural or humanitarian disaster on communities worldwide, one must first deconstruct the situation of disasters in Australia: how this has shaped our country and how we have responded to each disaster. Natural disasters such as floods, bushfires and tropical cyclones occur regularly across the Australian continent. $1.14 billion damage is caused each year to homes, businesses and the nationâ&#x20AC;&#x2122;s infrastructure, along with serious disruption to communities. Fortunately in contemporary Australia there is no civil unrest or military rule, however we must not forget the genocide and displacement of our Indigenous people that has occurred over previous centuries. As Dorothea McKellar summed-up so eloquently in her poem, My Country, Australia has been shaped by our environment and its extremes: I love a sunburnt country, a land of sweeping plains,
Of ragged mountain ranges, of droughts and flooding rains. I love her far horizons, I love her jewel-sea, Her beauty and her terror - the wide brown land for me! Many socio-geographical aspects of Australia are unique, such as a large surface area to population ratio, an increasingly multicultural society, a variety of climates and fauna, a dense (particularly eastern) coastline population, landmarks such as the great barrier reef, unique indigenous practices and knowledge of the land, and a strong agricultural industry and culture. Most notable of the natural disasters to affect Australia are droughts, bushfires, heatwaves, floods and cyclones. Although historically lives have been lost during these disasters, it is the economical burden that is quite pronounced. Interestingly, events such as droughts have altered much more than our geographical history, from re-directing stock routes through the bush, to the rabbit plague and the event of salinity. Aboriginal people have employed methods to alter certain harsh aspects of our land, such as employing controlled burning to avoid bushfires and being a nomadic race and relocating in the event of a flood. Scientific research indicates that more extreme weather events, and largescale single events with more severe cyclones, storms and floods, are expected in the future. The importance of having a directed and effective response to natural disasters, refugee management, infectious disease control, and financial relief is becoming increasingly apparent. Moreover, our proximity to many countries in the Asia pacific mandates a good reciprocal relationship in the area of aid in the event of a natural or humanitarian diaster. ACTION TRAINING PROGRAM 2007 The academic program for the ACTION conference was extremely busy. The first 3days of the program were dedicated to discussing various aspects of natural disasters. Over the 25 sessions in the first 3 days, including workshops, seminars and debates, we met with many experts who work in the field of natural and humanitarian disaster management. We learnt from local paediatricians, psychiatrists and pathologists, international World Health Organisation representatives, geologists, and health care system
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philosophers. It was very interesting to hear not only about the immediate and long term medical concerns and needs of a community after a natural disaster, but also to hear from professionals in other fields such as health infrastructure and climatology. The second half of the week saw us becoming more hands-on, and performing a lot more group work and problem solving activities. For example, we were given a scenario in a small group, and would have to assess the needs of a community and the resources needed for an effective disaster response and prevention. We also were fortunate enough to partake in two excursions to the surrounding mainland regions and look at the way the Tsunami affected individual
Medical Students unite in Pakistan to India Peace March Marcus Yip, Flinders University
Seventy-four international student delegates from 10 different countries participated in the International Physicians for the Prevention of Nuclear War (IPPNW) Peace March from the 2nd to 5th March 2008, from the Wagah Border (border between Pakistan and India) to Delhi. I went as a representative of IPPNW’s Australian affiliate, the Medical Association for Prevention of War, or MAPW. The journey really started on the night of the 1st, with the student delegates bonding after a 14-hour backbreaking overnight bus ride from Delhi straight to Amritsar. The morning of the 2nd, we made our way to the Wagah border in hopes of welcoming the Pakistani delegates, but due to political complications, they were not able to join us. The march went on though, with students from Sweden, Germany, Nigeria, Netherlands, Nepal, Bangladesh, Ecuador, Nicaragua and India. Taking 4 days and 3 nights, we made our way back to Delhi, visiting Amritsar, Ludhiana, Jalandar and Am-
MAPW seeks new student representatives at the GHC Angela Wilson University of Melbourne
Student members of the Medical Association for Prevention of War (MAPW) are hoping to expand MAPW’s involvement in Australia’s medical schools, and are looking for expressions of interest from enthusiastic medical
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communities. We were visitors to a morgue, a regional hospital involved in triage after the tsunami, a temple used for dead body management, a small fishing village recovering its main income, and a memorial centre for victims of the tsunami. It was enlightening to speak to people who had worked through the initial relief phase and into the recovery and rehabilitation phase of the natural disaster. Apart from the academic schedule, the ACTION project was designed to allow delegates to network with other medical students from other nationalities. Medical students from 8 countries were present at this event, and it was particularly interesting to hear about the situation of natural and humanitarian disasters in countries like bala, stopping frequently at various medical collages, talking to medical students, factory workers, the general public and lots of media – radio stations, local television stations and newspapers, trying to increase awareness amongst the general population on the topic of nuclear weapons, how much they cost their country to develop and maintain and the cost that is having in drawing funds away from more essential issues – like the hunger and atrocious poverty in a developing country such as India. Highlights of the Tour included the Golden Temple in Amritsar. It is largest Sikh place of worship, welcoming people of all religions, and also providing dinner, with hundreds in a huge hall every half and hour (with the most delicious rice pudding), FREE FOR ALL. It was heartening, knowing that no one in a whole city of Amritsar went hungry. Talk about the first step toward universal healthcare! The other main highlight was visiting Mahatma Gandhi’s Shrine, where the peace march ended, welcomed by delegates of the World Congress, in Rajghat. This poignant end, in line with what Mahatma Gandhi stood for, encapsulated our whole march – students attending the GHC to help us run advocacy campaigns with our partner affiliates at medical schools around the world. MAPW is a member of International Physicians for Prevention of Nuclear War (IPPNW), which was founded during the 1980s by a handful of doctors in the United States and the USSR to work for peace during the Cold War. IPPNW was awarded the 1985 Nobel
Sudan, Germany, Slovenia, Indonesia, and Japan. This conference was an amazing learning experience and has contributed hugely to further ignite my interest in natural and humanitarian disasters and refugee health. After spending two months in post-Tsunami Sri Lanka in 2005 and seeing the effects of the Tsunami on local people and communities, it was particularly useful to visit Thailand and gain another perspective on the situation. This conference has helped me to learn about the considerations of a community in the face of disaster, network with other students and prepare and for future work in the field of relief medicine and refugee health.
a peaceful demonstration, through talking and hopefully raising awareness, to promote peace. Memorable moments were the numerous flower flights while on the bus (from the garlands we received wherever we went), the marching through the streets of Ludhiana, the interactive discussions with the Indian medical students, and of course getting to know so many wonderful people from all over the world, inspirationally uniting for such an important international cause. The peace march was a great prequel to the IPPNW World Congress that was to be held in the week following the march, where it was reinforced, that together, we can make a difference in the world for the better. Aman Shanti! Visit IPPNW’s Blog of the Peace March at http://ippnweupdate.wordpress. com/2008/03/03/ippnw-wagahborder-to-delhi-peace-march/ To learn more about IPPNW’s Australian affiliate, the Medical Association for Prevention of War, visit our website at www.mapw.org.au.
Peace Prize and now has 59 national affiliates around the world. Today it works on a diverse range of issues, including small arms violence, cluster munitions, nuclear safety and the impact of conflict on civilian health. Some of IPPNW’s major international projects include ‘ICAN’, or the International Campaign for the Abolition of Nuclear Weapons, and ‘Aiming For Prevention’.
Thailand - Male life expectancy: 69; Female life expectancy: 75; Under-5 mortality rate (per 1000): 4;
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* Please refer to Health Super’s current Product Disclosure Statement (PDS) for full disclosure of fees, charges and past returns. Past performance is not indicative of future performance. Issued by Health Super Pty Ltd (ABN 97 084 162 489, RSE Licence No. L0000482, AFSL No. 246492) as Trustee of Health Super (ABN 88 293 440 675, RSE Registration No. R1004113). May 2008. This advice has been prepared without taking into account your objectives, financial situation or needs. Before acting on this advice, you should consider the appropriateness of the advice having regard to your objectives, financial situation and needs. If the advice relates to Health Super or its products you should obtain and consider a current Product Disclosure Statement (PDS) relating to these products. The Trustee recommends that you speak to a licensed or authorised financial adviser before investing or making any other financial decisions in relation to Health Super.
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1800 331 719
or visit MIPs AMSA Ad:Layout 1
22/5/08
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www.healthsuper.com.au
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Join MIPS for FREE Student Medical Indemnity Cover and More Why Join MIPS?
• approved supervised activities during your electives period (except in the USA or where USA law prevails); • Good Samaritan acts. MIPS membership also provides: • Access to medico-legal advice – with urgent advice being available 24 hours a day, 7 days a week; • The MIPS Review and MIPS Review Student newsletters, issued quarterly, covering current medico-legal issues; • MIPS Protections, providing members with the ability to request assistance for non-medical indemnity risks associated with educational activities. Membership of the Medical Indemnity Protection Society Limited (MIPS) and the risk protections available to members of MIPS (MDO protections) is issued by MIPS, AFS Licence No 301912. MIPS has binding authority from MIPS Insurance Pty Ltd (MIPS Insurance), AFS Licence No 247301 to issue the MIPS Insurance medical indemnity policy. To make sure the MDO protections and the MIPS Insurance medical indemnity policy are right for you, you should read the Product Disclosure Statements available at www.mips.com.au or by calling 1800 061 113. ABN 64 007 067 281
Freecall: 1800 061 113
• clinical activities during the term of your studies;
Medical Indemnity Protection Society Ltd
Join MIPS
As a Student Member of MIPS, you will be covered under the MIPS Student Member Policy, underwritten by MIPS Insurance Pty Ltd for medical indemnity claims arising from:
Health information you can trust in their hands
HS903_bhc_ad.indd 1
Better Health Channel is Australiaâ&#x20AC;&#x2122;s leading health and medical information website â&#x20AC;&#x201C; designed for the health consumer and quality assured by the Victorian Government.
6/6/08 12:34:06 PM
Australian College of Rural & Remote Medicine The Australian College of Rural & Remote Medicine (ACRRM) is the national peak professional body for rural medical education and training in Australia. Following accreditation by the Australian Medical Council and inclusion in Medicare, ACRRM is now a second college of General Practice and provides the opportunity for medical students to train for a career specifically in Rural and Remote Medicine. ACRRM manages a range of exciting student support programs including the popular John Flynn Placement Program, MRB and BMP Support Schemes, and the Prevocational GP Placements Program. For more information on student support, or training as a rural doctor, visit our booth or go to the ACRRM website at www.acrrm.org.au
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We Want to help you so you can help others The Doctorsâ&#x20AC;&#x2122; Health Fund is a not-for-profit health insurance fund serving the medical community. We provide our members with financial protection from the cost of healthcare events in their lives. We can also help you with the financial challenge of studying medicine.
the Doctorsâ&#x20AC;&#x2122; health Fund and aMsa Medical student Bursary scheme With the assistance of AMSA we have established a medical student bursary scheme to help you achieve your education goals. The bursaries are granted to help with the cost of texts and equipment, or the cost of professional development. This includes activities such as the electives many of you will be considering during the AMSA Global Health Conference. For information and to apply for a bursary visit www.doctorshealthfund.com.au/bursaries. Further enquiries can be made to us at 1800 226 126 or email bursaries@doctorshealthfund.com.au.
www.doctorshealthfund.com.au
STU205 Mar 08
MDA National is a registered business name of the Medical Defence Association of Western Australia (Incorporated) ARBN 055 801 771 incorporated in Western Australia. The liability of members is limited.
Support. Protect. Promote. Support. Protect. Promote. Support. Protect. Promote.
Freecall: 1800 011 255 | Email: peaceofmind@mdanational.com.au
Yesterday.
Today.
MDA National, supporting medical students across Australia.
As Committed as You are.
MDA National
Global Health Conference
Convenors: Daniel Yore and David Humphreys
Social Convenor: Emma Lightbody
Logistics Coordinator: Prashanti Manchikanti Promotions Co
IT Officer: Romi Goldschlager
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Secretary: Aspasia Pefanis
Conference Book Editor: Anny Huang
United States of America - Male life expectancy: 75; Female life expectancy: 80; Under-5 mortality rate (per 1000): 8;
Organising Committee â&#x20AC;&#x2DC;08
Treasurer: Adam Flavell
Academic Convenor: Jenny Jamieson
ns Coordinators: Rasha Rahman and Madeleine Finney-Brown Partnerships Coordinator: Caitlin Keighley Academic subcommittee: David Anderson Melanie Archer Evelyn Chan Susan Harch David Humphreys Jonathan Kam Caitlin Keighley Mikhaila Lazanyi Anthea Lindquist Jenna Mahony Catherine Pendrey Sowmya Prabhakaran Justin Sherwin Hollie Spence Zoe Stewart Kevin Tan Tamara Vu Angela Wilson Heidi Woolford Natalie Wright Hong Wu
Conference Book subcommittee:
Sarah Heynemann Khai Lin Kong Emma Leitinger Vivien Li Raymond Wen Aaron Wong Special thanks to Tim Fazio
Logistics subcommittee: Yara Abo Cara Fox Matthew Harvey Preethi Mathew Catherine Taylor Ai Li Yeo
Partnerships subcommittee: Tim Fazio
Adam Flavell David Humphreys Nelu Jayawardena Mabel Leung Tim Lindsay Hollie Spence Daniel Yore Jasmine Zhu
Social subcommittee:
Christine Mandrawa Aspasia Pefanis Special thanks to Eloise Williams
Logo Design:
Tim Fazio Madeleine Finney-Brown David Humphreys Rasha Rahman Kevin Tan Daniel Yore
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