Vector Volume 11 Issue 2 - 2017

Create successful ePaper yourself

Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.


Advisory Board<br />

The Advisory Board, established in <strong>2017</strong>, consists of academic mentors who provide guidance for the present and future<br />

direction of <strong>Vector</strong>.<br />

Dr Claudia Turner<br />

Consultant paediatrician and clinician scientist with the University of Oxford & Chief Executive Officer of Angkor Hospital for<br />

Children.<br />

Professor David Hilmers<br />

Professor in the Departments of Internal Medicine and Pediatrics, the Center for Global Initiatives, and the Center for Space<br />

Medicine at the Baylor College of Medicine<br />

Associate Professor Nicodemus Tedla<br />

Associate Professor at the University of New South Wales School of Medical Sciences<br />

Dr Nick Walsh<br />

Medical Doctor (RACP) & Regional Advisor for Viral Hepatitis at the Pan American Health Organization / World Health<br />

Organization Regional Office for the Americas<br />

Thank you to the <strong>Vector</strong> Journal peer reviewers for <strong>2017</strong>:<br />

Dr Phil Baker<br />

Dr Denton Callander<br />

Professor Nicholas Crofts<br />

Dr Greg Fox<br />

Dr Alexandra Gibson<br />

Dr Max Hopwood<br />

Ms Alexandra Jones<br />

Dr Erik Martin<br />

Dr Bridianne O’Dea<br />

Dr Dominique Martin<br />

Professor Geetha Ranmuthugala<br />

Dr Mitchell Smith<br />

Dr Adrienne Torda<br />

Dr Leonie Watterson<br />

Professor Bridget Wills<br />

<strong>2017</strong> <strong>Vector</strong> Committee<br />

Editor-in-chief<br />

Carrie Lee carrie.lee@amsa.org.au<br />

Associate Editors<br />

Kryollos Hanna Sophie Lim Koshy Matthew Nic Mattock Aidan Tan<br />

Ash Wilson-Smith Sophie Worsfold Danica Xie<br />

Publication Designer<br />

Lucy Yang<br />

Design and layout<br />

© <strong>2017</strong>, <strong>Vector</strong><br />

Australian Medical Students’ Association Ltd, 42 Macquarie Street, Barton ACT 2600<br />

vector@globalhealth.amsa.org.au<br />

vector.amsa.org.au<br />

Content<br />

© <strong>2017</strong>, The Authors<br />

Cover design image accessed from https://pixabay.com/p-2349893/?no_redirect<br />

<strong>Vector</strong> Journal is the official student-run journal of AMSA Global Health.<br />

Responsibility for article content rests with the respective authors. Any views contained within articles are those of the authors and do not necessarily<br />

reflect the views of the <strong>Vector</strong> Journal or the Australian Medical Students’ Association.<br />


Contents<br />

Editor’s Note: Turning Up the Heat 1<br />

Features<br />

Non-Health for Non-Persons: Rohingya Muslims in Crisis 2<br />

Jumaana Abdu<br />

LGBTIQ people’s experiences of and barriers to healthcare 5<br />

Salwa Barmaky and Alex Lee<br />

Commercial surrogacy in Australia: the benefits of harm minimisation through legalisation 10<br />

Keyur Doolabh and Emily Feng-Gu<br />

Polio vs Politics: The Case of Pakistan 15<br />

Jeanine Hourani<br />

Turning up the heat 17<br />

Tara Kannan<br />

Coal mining, climate change and the global impacts on health: examining Adani’s proposed Carmichael coal mine 21<br />

John E Morgan<br />

Paddling upstream: Experiences from a medical placement in rural Papua New Guinea 26<br />

Nicholas Snels<br />

Reviews<br />

Sugar tax: a sweet solution for obesity? 29<br />

Saiuj Bhat<br />

Drug control in Australia: where to next? 34<br />

Raquel Maggacis<br />

Dengue in the Pacific Islands 38<br />

Madeleine Marsland and Dunya Tomic<br />

Conference reports<br />

AIDA <strong>2017</strong> - Family, Unity and Success 44<br />

Narawi Foley Boscott<br />

World Congress on Public Health 47<br />

Michael Au, Ka Man Li, Helena Qian, Michael Wu<br />

Commentary<br />

Welfare cuts to refugees 50<br />

AMSA Global Health Crossing Borders National Managers Sibella Breidahl, Jasmine Sekhon<br />

GHC <strong>2017</strong><br />

Start where you are, use what you have, do what you can - Adelaide Global Health Conference <strong>2017</strong> Closing<br />

Address 52<br />

Liz Bennett, AMSA Global Health Chair <strong>2017</strong><br />

GHC Competition Winner: “Where to now?” 54<br />

Helena Qian<br />

Book review<br />

A walk to remember 55<br />

Anna Marie Plant<br />


Editor’s Note- Turning up the heat<br />

Global health is intrinsically linked to the changing social,<br />

economic, cultural and political environment. Political leaders<br />

powerfully shape responses to global health, whether in a<br />

positive or negative way. Historically, when health issues<br />

have risen on the political agenda, they received greater<br />

media attention, and importantly, funding – the HIV/AIDS<br />

epidemic exemplifies this. The change in leadership in the<br />

World Health Organization under the new Director-General Dr<br />

Tedros offers new opportunities to advocate for issues such<br />

as universal health coverage, women’s health and rights, and<br />

climate health.<br />

However, like many others, I find myself disappointed<br />

by the lack of political will to assist refugees and people<br />

seeking asylum. This is an ongoing problem, in Australia with<br />

the recent welfare cuts to refugees, described by Sibella<br />

Briedahl and Jasmine Sekhon (pg 2) , and internationally,<br />

with the plight of the stateless Rohingya people fleeing<br />

persecution in Myanmar, in a feature article by Jumaana Abdu<br />

(pg 50).<br />

Over the past year, controversial policies have dominated<br />

public health discourse on both a national and international<br />

scale. Non-communicable diseases continues to rise on<br />

the agenda. A tax set to cut sugar-sweetened beverage<br />

consumption takes a step towards tackling Big Sugar in the<br />

footsteps of movements against Big Tobacco, as covered in<br />

a review by Saiuj Bhat (pg 29).<br />

In Australia, we have also seen pushes for safe injecting<br />

rooms and pill testing at festivals. Does this reflect the<br />

global shift in attitudes from criminalisation towards harm<br />

minimisation, with decriminalisation in Portugal providing<br />

successful proof-of-concept? Raquel Maggacis overviews<br />

drug control approaches worldwide, arguing that Australia<br />

should adopt a harm minimisation approach (pg 34).<br />

Global health does not obey borders, and health policies<br />

have far-reaching effects. Infectious diseases certainly<br />

require no passport to spread from country to country,<br />

and Madeleine Marsland and Dunya Tomic highlight the<br />

importance of strong regional surveillance systems and<br />

prevention strategies (pg 38) Moreover, so long as one child<br />

has polio, all countries remain at risk, as described by Jeanine<br />

Hourani (pg 19). However, polio eradication in Pakistan, one<br />

of the last remaining polio-endemic countries, is incredibly<br />

complex due to political instability and competing agendas.<br />

Local policies certainly have broader international<br />

consequences, and Keyur Doolabh and Emily Feng-Gu<br />

explore issues around commercial surrogacy such as<br />

exploitation in countries where surrogacy is cheaper or<br />

poorly regulated (pg 10). Similar to drug control approaches,<br />

a harm minimisation approach may offer a better alternative<br />

to regulate processes and protect the rights of parents and<br />

children.<br />

Other contentious topics in Australia include the Adani<br />

coal mine and the postal vote for same sex marriage. These<br />

will have significant implications both now and in the future.<br />

With the recent postal vote, the mental health and wellbeing<br />

of LGBTIQA+ people could not be of more relevance.<br />

However, as Salwa Barmaky and Alex Lee write, LGBTIQA+<br />

people also face barriers in access to healthcare, including<br />

discrimination from the medical profession itself (pg 5).<br />

Aboriginal and Torres Strait Islander people also<br />

experience discrimination within the health care system,<br />

as Narawi Foley-Boscott explains (pg 44). So what then is<br />

the way forward for such issues? Both authors emphasise<br />

the importance of educating medical professionals to be<br />

culturally sensitive, to be open to learning, and to be aware of<br />

the structural factors that contribute to discrimination.<br />

Evan Morgan (pg 21) argues that the Adani coal mine<br />

endangers our health and the environment and is a poor<br />

investment for tax-payers. It hinders Australia’s ability to fulfil<br />

its global commitments under the Paris Agreement to reduce<br />

carbon emissions and temperature rises.<br />

Divestment offers a solution to climate change: take money<br />

away from the fossil fuel industry. We, as medical societies<br />

and the future medical profession, have an important role to<br />

add to this social movement, as thoughtfully argued by Tara<br />

Kannan (pg 17) The title of her article, “Turning up the heat”,<br />

captures the energy that connects the articles in this issue, a<br />

panoramic range of contemporary and controversial issues.<br />

It calls on us to take action and to challenge the paradigm of<br />

seeing health as purely a biomedical issue, but one inherently<br />

connected to regional and international social and political<br />

forces.<br />

As medical students, we are well-placed to educate<br />

and upskill ourselves to contribute to global health in the<br />

future. Attend conferences (Australian Indigenous Doctors’<br />

Association, pg 44 World Congress of Public Health, pg<br />

47. Take elective placements in developing countries, and<br />

prepare yourself with pre-departure training (Nicholas Snels,<br />

pg 26 ). As yourself, what can we do about these global health<br />

issues? (Helena Qian, pg 54)<br />

One of the statements that left a lasting impression on<br />

me from this year’s Global Health Conference was from the<br />

AMSA Global Health Chair, Liz Bennett: “It is not enough to be<br />

inspired... We do not have the luxury of apathy and you cannot<br />

afford to waste time thinking that you are too small to make<br />

a difference.” (pg 52).<br />

I am continually amazed and grateful to the incredible<br />

work of the authors, editorial team, peer reviewers and<br />

Advisory Board. It has been a privilege and a half to lead<br />

<strong>Vector</strong> Journal this year and hope that this issue inspires you<br />

and challenges you to take action.<br />

Carrie Lee<br />

Editor-in-chief, <strong>2017</strong><br />


Non-Health for Non-Persons:<br />

Rohingya Muslims in Crisis<br />

[Feature article]<br />

Jumaana Abdu<br />

Jumaana is currently finishing her first year of medicine at the University of New South Wales.<br />

She aims to find a career path which combines her passion for medicine and human rights.<br />

She also hopes her future involves as a side-profession of writing, fiction or otherwise.<br />

In a tightening spiral of human suffering that winds<br />

back five decades, the Rohingya have come to be<br />

mentioned as a customary precursor to the phrase “most<br />

persecuted minority in the world”. The long-disowned<br />

nationals of Myanmar are estimated at a population<br />

of 1.2 million,[1] stateless victims of humanitarian<br />

violations so comprehensive and extensive that the<br />

world’s empathy can only be directed towards a vague<br />

fog of injustice. However, as flagbearers of the right to<br />

health and human dignity, healthcare professionals must<br />

be able to shine a torch into the fog and discern the<br />

faces within.<br />

Current Situation<br />

While systematic persecution of the Rohingya Muslims<br />

has been noted since the stripping of voting rights and<br />

the military “purges” of the 1970s, events within the past<br />

year have seen violence escalate dramatically. A border<br />

attack by a group of radicalised Rohingya Muslims on<br />

Myanmar’s police last October resulted in an estimated<br />

10 casualties. Extremist violence is unacceptable and<br />

unhelpful, though one can see the desperation, injustice<br />

and generations-worth of marginalisation from which<br />

this radicalisation was inevitably born. Since the attack,<br />

disproportionate and indiscriminate military retaliation<br />

has resulted in hundreds of deaths and torrents of<br />

Rohingya fleeing Myanmar’s northern Rakhine state,<br />

where the situation is worst. The United Nations (UN)<br />

reports that from the last week of October <strong>2017</strong> to the<br />

first week of September <strong>2017</strong> alone – just two weeks –<br />

270,000 people fled to Bangladesh for safety.[2]<br />

The humanitarian crisis in which the Rohingya find<br />

themselves is undeniable. Officially stateless, access<br />

to basics such as healthcare, education, employment,<br />

security and freedom is often impossible. Tragically,<br />

these deprivations are far less confronting than other<br />

reasons for which the Rohingya have been forced to flee.<br />

With UNHCR reports documenting common experiences<br />


of “mass gang-rape, killings, including of babies and<br />

young children, brutal beatings, disappearances and<br />

other serious human rights violations by the country’s<br />

security forces”, returning to Myanmar is not an option.[3]<br />

UNHCR interviews with<br />

Rohingya refugees detail random<br />

shooting at crowds who were<br />

fleeing houses, schools, mosques<br />

and markets that had been set<br />

alight by Myanmar’s army, police<br />

and occasionally civilian mobs.[4]<br />

Destruction of food, livestock and<br />

food sources; cases where the army or Rakhine civilians<br />

have trapped an entire family, including the elderly and<br />

disabled, inside a house and set it on fire “killing them all”;<br />

mothers assaulted by “security” forces while being forced<br />

to watch their babies stabbed and killed – words cannot<br />

do it justice.[4]<br />

Recent news reveals that Burmese officials have<br />

planted landmines along the Bangladesh border, posing<br />

a lethal threat to Rohingya peoples fleeing atrocities.<br />

Deemed unlawful for their inability to distinguish between<br />

civilians and militants, children and adults, landmines have<br />

been banned in many countries under the 1997 Mine Ban<br />

Treaty. Not a signatory to this, Myanmar officials continue<br />

to use them against Rohingya civilians, protected by the<br />

unsurprising denial by the Burmese government that such<br />

landmine plantings have taken place.<br />

An assortment of condemnations have been offered<br />

by the UN; crimes against humanity,[3] genocide, ethnic<br />

cleansing. The UN High Commissioner for Human<br />

Rights Zeid Ra’ad Al Hussein, concludes his report on<br />

the Myanmar atrocities by despairing, “What kind of<br />

‘clearance operation’ is this? What national security<br />

goals could possibly be served by this?”.[3] As Hussein<br />

seems painfully aware, these words fall on deaf ears.<br />

Medical Crisis<br />

Humanitarian agencies are floundering, desperately<br />

attempting to provide emergency care for the monsoonal<br />

influx of Rohingya refugees, most of whom have a variety<br />

of physical and psychological conditions. Studies of the<br />

health conditions within Bangladesh’s two main registered<br />

refugee camps present unsurprisingly dire findings.<br />

One psychiatric study surveyed a group of registered<br />

Rohingya refugees and reported experiences of torture<br />

(39.9%), sexual abuse (12.8%), rape (8%), forced<br />

abortions (2.4%), PTSD (36%), depressive symptoms<br />

(89%), suicidal ideations (19%) and deaths of friends or<br />

family due to illness or starvation while fleeing (22.4%).<br />

[5] Hopelessness was the common theme, with one<br />

Rohingyan interviewee asking, “Our future has been<br />

spoiled, but what will happen to the future of our children?”<br />

Hopelessness was the common theme,<br />

with one Rohingyan interviewee asking,<br />

“Our future has been spoiled, but what<br />

will happen to the future of our children?”<br />

In 2015, another study investigated the general health<br />

conditions of Bangladesh’s largest Rohingya refugee<br />

camp, Nayapara.[1] With a population of 18,777, the camp<br />

was attended by only four trained doctors and six nurses.<br />

The infant mortality rate was 45.4 per 1000 livebirths and<br />

one quarter of the population was<br />

children, most of whom were born<br />

in a camp. Additionally, the study<br />

reported widespread stunting due<br />

to malnutrition (57%), anaemia<br />

(49%), and a high prevalence of<br />

respiratory (46.9%), endocrine<br />

(21.9%) and cardiovascular<br />

disorders (14.8%). Mental health<br />

conditions were ubiquitously poor; 18.7% of camp<br />

injuries were caused by self-harm, and in Bangladesh’s<br />

other major camp, 43.3% of Rohingya refugees were<br />

diagnosed with a psychotic disorder.<br />

Importantly, health conditions in registered refugee<br />

camps far surpass those of the many unregistered camps<br />

in countries neighbouring Myanmar. These makeshift<br />

shelters, which house twice as many Rohingya as the<br />

registered camps, are conferred no security or support<br />

from the already-drowning NGOs servicing the area.<br />

This, however, is still favourable to staying in the northern<br />

Rakhine state of Myanmar where health conditions are<br />

so abysmal that, for example, mortality in children under 5<br />

has reached 224 per 1000 livebirths.[6]<br />

Role of Health Professionals in Social Justice<br />

In situations where political and military injustice<br />

seem impenetrable, often the most basic human<br />

right affordable is emergency medical care, but is the<br />

assumption that medical aids are exempt from political<br />

and military violence still applicable today? As seen<br />

in reports of hospitals targeted in Syria by Western<br />

military, it seems that medical neutrality is no longer a<br />

guarantee. Combined with the Myanmar government’s<br />

notoriously uncooperative relationship with humanitarian<br />

organisations, one must ask what responsibility<br />

healthcare professionals are expected to bear in the<br />

realm of human rights.<br />

In 2014, Médecins Sans Frontières was banned<br />

in Rakhine, and a month later, when humanitarian aid<br />

agencies were attacked by Buddhist anti-Rohingya<br />

radicals, Myanmar’s government only further restricted<br />

humanitarian aid.[6] This ban has since been lifted<br />

but access is now parlous again due to the Myanmar<br />

government’s “formulated and disseminated accusations<br />

against the UN and international NGOs, denial of required<br />

travel and activity authorisations, and threatening<br />

statements and actions by hardline groups”.[7] Also<br />

recently, the UNHCR High Commissioner Hussein has<br />

struggled with repeated government restrictions on<br />

humanitarian access to the worst affected regions of<br />

Rakhine, and bans on UN investigative officials entering<br />


Rohingyan regions of Myanmar. Forced to work within the<br />

law, the UN can only deploy officers to the Bangladeshi<br />

border.[2]<br />

These tensions between humanitarian aid and the<br />

state beg the question: in health emergencies and human<br />

rights violations as staggering as those experienced by<br />

the Rohingya Muslims, should human rights and healthcare<br />

organisations bend to the will of unjust – even criminal –<br />

governments? It is a problem the UN and its subcommittee,<br />

the World Health Organization, still grapple with. Do they<br />

obey their mandate to respect the sovereignty of their<br />

member states? Or do they perform their constitutional<br />

role of helping member states “respond to... emergencies<br />

with public health consequences”?[8] How can they, when<br />

the member state itself is perpetuating the emergency?<br />

Additionally, the aforementioned lack of confidence in<br />

medical neutrality makes it unsafe for health workers to<br />

stand against government and military opposition.<br />

The only solution where a full response to this<br />

... should human rights and healthcare<br />

organisations bend to the will of unjust –<br />

even criminal – governments?<br />

humanitarian crisis can be appropriated lies in either<br />

cooperation with Myanmar’s government – which seems<br />

unlikely – or direct actions against the government by<br />

UN member states. Ideally, the Burmese government<br />

would grant the Rohingya some form of internationally<br />

recognised citizenship, allowing for better organisation<br />

of refugee status and resettlement programs for the<br />

Rohingya in neighbouring countries. Sanctions intended<br />

to force the Burmese government’s hand have failed in<br />

the past,[6] but if the global community can unite with<br />

harsher repercussions for the continued persecution of<br />

Rohingya Muslims, surely the situation can only improve.<br />

Conclusion<br />

The Rohingya peoples are born into a cycle of<br />

poor health outcomes that begin with low birthweight<br />

and continue with dismal access to healthcare. Timid<br />

international responses to the systematic abuse, torture<br />

and dehumanisation of this minority have allowed for the<br />

continuation of historical persecution. The 2015 election<br />

of Nobel Prize laurate Aung San Suu Kyi as Myanmar’s<br />

Prime Minister presented an opportunity for a Myanmar<br />

government to end their denial and dismissal of decades<br />

of Rohingyan suffering. However, as stated by her aide,<br />

it seems she has “other priorities”,[6] which probably<br />

includes avoiding conflict with her majority-Buddhist<br />

supporters and the hugely politically influential Burmese<br />

military. For now, Rohingya Muslims will have to continue<br />

to relying on NGOs who are drowning under resource<br />

insufficiencies and legal restrictions, attempting to deal<br />

with the desperate masses in any way possible.<br />

History paints a picture of peaceful generations<br />

of Rohingya living in Myanmar. Their future seems<br />

increasingly uncertain, although ideally it involves them<br />

returning safely home. One and a half million people await<br />

a saving grace, security for their children, medicine, clean<br />

water. If international global health organisations cannot<br />

work within Myanmar’s policies, then they must find a<br />

conclusive alternative. It is unacceptable that there is still<br />

not a light at the end of this half-a-century long tunnel.<br />

Photo credit<br />

EU/ECHO/Pierre Prakash<br />

Accessed from https://www.flickr.com/photos/eu_<br />

echo/17337141093/in/photostream/<br />

Conflicts of interest<br />

None declared<br />

Correspondance<br />

jumaana.a6000@gmail.com<br />

References<br />

1. Milton, A. H., Rahman, M., Hussain, S., Jindal, C., Choudhury,<br />

S., Akter, S., ... & Efird, J. T. (<strong>2017</strong>). Trapped in Statelessness:<br />

Rohingya Refugees in Bangladesh. International Journal of<br />

Environmental Research and Public Health, 14(8).<br />

2. United Nations (<strong>2017</strong>). UN scales up response as<br />

270,000 flee Myanmar into Bangladesh in two weeks. Retrieved<br />

from http://www.un.org/apps/news/story.asp?NewsID=57480#.<br />

WbZ6eK2B3Vo<br />

3. United Nations (<strong>2017</strong>). UN report details ‘devastating<br />

cruelty’ against Rohingya population in Myanmar’s Rakhine<br />

province. Retrieved from http://www.un.org/apps/news/story.<br />

asp?NewsID=56103#.WbZ4w62B3Vp<br />

4. OHCHR Zeid Ra’ad Al Hussein (<strong>2017</strong>). Interviews with<br />

Rohingyas fleeing from Myanmar since 9 October 2016.<br />

Retrieved from http://www.ohchr.org/Documents/Countries/MM/<br />

FlashReport3Feb<strong>2017</strong>.pdf<br />

5. Riley, A., Varner, A., Ventevogel, P., Taimur Hasan, M. M.,<br />

& Welton-Mitchell, C. (<strong>2017</strong>). Daily stressors, trauma exposure,<br />

and mental health among stateless Rohingya refugees in<br />

Bangladesh. Transcultural Psychiatry, 54(3), 304-331.<br />

6. Mahmood, S. S., Wroe, E., Fuller, A., & Leaning, J. (<strong>2017</strong>).<br />

The Rohingya people of Myanmar: health, human rights, and<br />

identity. The Lancet, 389(10081), 1841-1850.<br />

7. Médecins Sans Frontières (<strong>2017</strong>). Myanmar:<br />

International humanitarian access to Rakhine State must<br />

urgently be permitted. Retrieved from http://www.msf.org/en/<br />

article/myanmar-international-humanitarian-access-rakhinestate-must-urgently-be-permitted<br />

8. Kennedy, J., & McCoy, D. (<strong>2017</strong>). WHO and the health<br />

crisis among the Rohingya people of Myanmar. The Lancet,<br />

389(10071), 802-803.<br />


LGBTIQ people’s experiences of and<br />

barriers to healthcare<br />

[Feature Article]<br />

Salwa Barmaky and Alexander Lee<br />

Salwa is a fourth year medical student at the University of New South Wales. and a public<br />

health enthusiast, especially interested in health disparities and programme interventions.<br />

Alexander is an undergraduate medical student currently studying at the University of New<br />

South Wales. His interests include improving healthcare access for marginalised populations<br />

including gender and sexuality diverse groups and reproductive health.<br />

Introduction<br />

Increasing data on sexual orientation and gender<br />

identities in large scale social studies has revealed<br />

that significant portions of the Australian community<br />

are sexuality and/or gender diverse. In the 2014 ABS<br />

General Social Survey, 3% of the Australian population<br />

identified as not heterosexual,[1] and whilst Australian<br />

data is unavailable, a study of 8500 New Zealand<br />

secondary school students revealed that 1.2% identified<br />

as transgender.[2]<br />

LGBTQIA+ refers to lesbian, gay, bisexual,<br />

transgender, queer and questioning, intersex, asexual<br />

and aromantic individuals, with the ‘+’ connoting other<br />

diverse sexualities, sexes and genders. LGBTQIA+<br />

Australians continue to face significant barriers to care<br />

which in turn impact individuals’ help seeking behaviours.<br />

[3, 4]<br />

Until 1973, homosexuality was considered a mental<br />

disorder. Similarly, transgender and gender diverse (TGD)<br />

identities were classified as ‘gender identity disorder’<br />

until the 2013 edition of the Diagnostic & Statistical<br />

Manual (DSM-5) [4] and continues to<br />

be listed as such by the World Health<br />

Organization’s International Statistical<br />

Classification of Diseases and<br />

Related Health Problems (ICD-10).[5]<br />

Furthermore, access to hormonal and/<br />

or surgical intervention largely remains<br />

tied to gatekeeper models requiring<br />

TGD individuals to be ‘diagnosed’.[6, 7]<br />

Despite having been widely condemned as ineffective<br />

and causing significant psychological harm,[8, 9]<br />

pseudoscientific ‘gay conversion therapy’ continues to<br />

persist. Most recently, a New South Wales GP appearing<br />

in a ‘Vote No’ television campaign against same-sex<br />

marriage was identified as a founder of a ‘family values’<br />

Whilst questions such as<br />

“do you have a boyfriend/<br />

girlfriend?” seem innocent, they<br />

carry value judgements on what<br />

is considered ‘normal’.<br />

group advocating this practice. Many intersex individuals<br />

have also been subjected to risky, non-consensual<br />

genital mutilation surgery as infants in a bid to ‘normalise’<br />

them.[10] Furthermore, some clinicians expressly feel<br />

awkward treating LGBTQIA+ individuals.[<strong>11</strong>] Hence, to<br />

effectively advocate for greater inclusivity and equity, it<br />

is paramount that health professionals understand both<br />

current and historical healthcare barriers as well as the<br />

specific health concerns of LGBTQIA+ communities<br />

As such, this article will outline:<br />

1) Effects of individual, interpersonal and structural<br />

social determinants of health on healthcare access for<br />

LGBTQIA+ individuals;<br />

2) Key health issues affecting LGBTQIA+ individuals;<br />

and<br />

3) Recommendations for improving access.<br />

Social determinants of healthcare access for<br />

LGBTQIA+ individuals<br />

Despite the acronym LGBTQIA+ construing<br />

homogeneity, LGBTQIA+ communities are distinctly<br />

heterogeneous. Individuals may have different<br />

experiences of their identity and come from different<br />

social contexts such as ethnic<br />

background or socioeconomic<br />

class.[12] However, they do share a<br />

continued exposure to societal stigma<br />

associated with their diverse identities.<br />

This stigma plays into all levels of the<br />

social determinants of health which in<br />

turn impact both individuals’ health and<br />

healthcare access. These include individual internalised<br />

shame, interpersonal discrimination and ignorance and<br />

structural legal, administrative and systemic challenges.<br />

These determinants limit LGBTQIA+ Australians’<br />

confidence in our healthcare system.<br />


Individual and interpersonal<br />

While accessing healthcare, LGBTQIA+ individuals<br />

face interpersonal barriers in the form of clinicians’ lack<br />

of knowledge and discrimination as well as their own<br />

individual internalised homophobia.<br />

DSM-5 now allows for self-identification as asexual as<br />

an alternative to diagnosis with ‘hypoactive sexual desire<br />

disorder’ or ‘female sexual arousal/interest disorder’ [25],<br />

historically, a lack of interest in sex has been pathologised<br />

by Western medicine.[26]<br />

Many practitioners have limited training and<br />

awareness around the importance of comprehensive,<br />

non-judgmental sexual history taking. Clinicians’<br />

unconscious biases often result in LGBTQIA+ clients<br />

being forced to ‘out’ themselves in response to questions<br />

that assume heterosexuality and do not recognise<br />

gender diverse or intersex experiences (e.g. asking a<br />

trans woman about birth control). This exacerbates<br />

existing awkwardness around sexual and mental health<br />

and is associated with significant discomfort, which<br />

may contribute to patients’ decisions<br />

not to disclose their sexuality or gender<br />

identity.[13] Additionally, some GPs did not<br />

understand different sexual practices and<br />

felt uncomfortable broaching the topic.<br />

[14] One third of LGBTQ* Australians<br />

still hide their sexuality or gender identity<br />

when accessing healthcare.[15] In youths, half did not<br />

disclose.[16] This not only impacts individuals’ ability to<br />

build trust with healthcare providers but also undermines<br />

the provision of targeted health services such as human<br />

immunodeficiency virus (HIV) testing in men who have sex<br />

with men (MSM).<br />

Healthcare providers’ lack of knowledge regarding<br />

TGD identities and unique health needs is a common<br />

theme.[17-20] Having to educate healthcare providers<br />

was found to be a key contributor to negative GP<br />

encounters in Australia.[17] A lack of sensitivity [19, 20]<br />

with practitioners asking invasive or offensive questions<br />

[17] and misgendering clients through the use of incorrect<br />

pronouns or old names [15, 21] contributes to these<br />

barriers. Clinicians not working in TGD-specific fields<br />

often have little knowledge on the issue, resulting in<br />

these clients’ exclusion from mainstream health services.<br />

[2, 15, 21] Even clinicians regularly engaged with TGD<br />

clients enlist gatekeeping behaviours which restricts<br />

access to hormonal and surgical intervention.[17, 22] This<br />

discourages TGD individuals from raising mental health<br />

concerns and many find this process of “assessment”<br />

to be degrading and pathologising.[21] Moreover, rigid,<br />

binary views of gender results in non-binary individuals<br />

feeling invisible and unwelcome to services.[23]<br />

LGBTI people in Australia<br />

are five times more likely to<br />

attempt suicide in their lifetimes<br />

Internalised homophobia may manifest as a further<br />

barrier to seeking healthcare services. Consequently,<br />

during periods of illness, individuals turn to pharmacies<br />

and only seek health services when self-medication has<br />

been unsuccessful.[27]<br />

Structural<br />

LGBTQIA+ communities also face a myriad of<br />

structural barriers to quality healthcare.<br />

Australia is currently the only<br />

Western country which requires TGD<br />

adolescents to gain Family Court<br />

‘approval’ to access hormones.<br />

Despite the time-sensitive nature of<br />

hormone therapy, the legal process<br />

can take up to 10 months, and cost<br />

tens of thousands of dollars.[28] However, this is currently<br />

under review by the Family Court.[29]<br />

TGD communities, especially non-binary individuals,<br />

also face inaccurate medical record keeping that do<br />

not reflect individual’s chosen names, genders and/or<br />

pronouns and a lack of gender-neutral bathroom access.<br />

[18, 23] Moreover, TGD individuals experience discomfort<br />

in gendered spaces such as gynaecologists’ clinics [23]<br />

and heightened discomfort surrounding pap smears and<br />

breast checks.[18, 22] The relegation of TGD services to<br />

the realm of expensive private healthcare[15] is at heads<br />

with their increased risk of poverty, underemployment and<br />

housing instability.[18, 19, 23]<br />

Additionally, the view of LGBTQIA+ identities as<br />

inherently pathological by some providers is discriminatory.<br />

[13, 21, 24] TGD individuals may face clinician discomfort,<br />

disgust, ridicule, contempt and even refusal of treatment.<br />

[19, 21-23] One participant of the Australian and New<br />

Zealand TranZnation report was told by their doctor<br />

that she was ‘the filthiest, most perverted thing on earth’<br />

while another was informed they ‘needed to find god not<br />

hormones’.[21] Asexuality is also pathologised. While<br />

Furthermore, unconscious bias can also manifest<br />

in the distribution of research funding and practitioner<br />

training. Compared to the relative visibility of gay men’s<br />

health around the HIV/AIDS epidemic, TGD health as well<br />

as queer women’s health have largely been ignored.[13]<br />


Sexual health<br />

LGBTQIA+ individuals may also experience poorer<br />

sexual health. There is evidence to suggest that women<br />

who have sex with women (WSW) are at higher risk for<br />

cervical cancer.[32] Both patients and clinicians lack<br />

awareness around sexually transmitted infection (STI),<br />

specifically human papilloma virus (HPV), transmission<br />

during cisgender woman to woman sexual contact.<br />

Consequently, WSW are less likely to have Pap or other<br />

cervical smears.[33]<br />

Key LGBTQIA+ health issues<br />

Besides issues of access, LGBTQIA+ individuals have<br />

specific healthcare risks, needs and concerns. Pertinently,<br />

LGBTQIA+ individuals have significantly poorer mental<br />

and sexual health. They also have higher incidence of<br />

certain chronic diseases such as cardiovascular disease,<br />

asthma and diabetes.[30]<br />

Mental health<br />

Poorer mental health is one of the ways that stigma<br />

affects LGBTQIA+ individuals’ wellbeing. Compared to<br />

the general population, LGBTI people in Australia are<br />

five times more likely to attempt suicide in their lifetimes<br />

and more specifically, TGD-identifying individuals are<br />

eleven times more likely.[31] LGBT people are also twice<br />

as likely to be diagnosed and treated for mental health<br />

disorders, and 24.4% of LGBT people aged 16 and over<br />

currently meet the full criteria for a major depressive<br />

episode.[31]<br />

Reasons for poorer mental health are also based in<br />

internalised, inter-personal, organisational and structural<br />

stigma and discrimination.[31] These include: bullying at<br />

schools, lack of bullying laws, ostracism from families<br />

and faith communities, fear of employment and economic<br />

stability, and inner conflict and internalised phobia<br />

about their respective identities. LGBTQIA+ individuals<br />

also have higher risk for poor coping mechanisms and<br />

substance abuse.[32]<br />

In addition, MSM have greater incidence of HIV. In<br />

Australia, HIV transmission occurs primarily through<br />

male-to-male sex with 68% of new HIV diagnoses in 2015<br />

having been attributed to male-to-male sex.[34] Besides<br />

the greater susceptibility of anal mucosa, this increased<br />

incidence arises from the concentration of HIV within<br />

MSM sexual networks in Western nations.[35] Receptive<br />

anal intercourse in male-to-male sex may also increase<br />

risk of hepatitis B, HPV and herpes.[32] In NSW, MSM<br />

are also more likely to report ever having had an STI,<br />

particularly chlamydia, pubic lice, genital herpes, syphilis,<br />

anal warts and gonorrhoea.[36] As some of these STIs<br />

are risk factors for anal cancer, MSM are also at greater<br />

risk for anal cancer.[32] However, MSM are also more<br />

likely than any non-MSM to be tested for STIs.[36]<br />

Furthermore, poor data collection means that the<br />

sexual health of TGD populations in Australia remain<br />

poorly understood. The tendency to collapse TGD<br />

experiences into a single ‘third gender’ category ignores<br />

the vast differences in risk associated with different<br />

gender identities, sexual orientations and partners. For<br />

example, the Kirby Institutes’ 2016 annual report on<br />

STIs recorded sex as ‘male’, ‘female’ and ‘transgender/<br />

missing’.[37] This is particularly disappointing in the<br />

context of trans women in particular being significantly<br />

overrepresented in global HIV prevalence.[38]<br />

Aging<br />

Owing to Australia’s aging population, the issue of older<br />

Key messages<br />

• LGBTIQA+ people face barriers to healthcare access,<br />

historically influenced by discrimination from the medical profession<br />

• Health disparities exist between LGBTIQA+ individuals and<br />

the general population, particularly in the areas of mental health,<br />

sexual health and chronic disease<br />

• Further research and education, a collective effort to treat<br />

LGBTIQA+ people with individual respect, and a willingness to learn,<br />

will help to reduce health inequalities<br />

*In certain parts of this article, terms to refer to the sex, sexuality and gender diverse individuals may change dependent<br />

on the groups of people being researched in the various research articles cited.<br />


LGBTQIA+ individuals is topical. LGBTQIA+ individuals in<br />

aged care have specific care needs such as ongoing<br />

HIV/AIDS treatment and hormone therapy. Having lived<br />

through the criminalisation of homosexuality, many may<br />

be impacted by an internalised need to go ‘back into the<br />

closet’ for fear of discrimination.[39]<br />

Improving access<br />

To reduce the aforementioned barriers and risks,<br />

various areas can be improved. Institutionally, education<br />

around LGBTQIA+ issues of sexuality, gender diversity,<br />

access and risk should be integrated into the medical<br />

curriculum. Trainees should be taught to adopt<br />

non-judgmental approaches to history taking and<br />

communication.[16, 40] Whilst questions such as “do you<br />

have a boyfriend/girlfriend?” seem innocent, they carry<br />

value judgements on what is considered ‘normal’. Instead,<br />

more inclusive terminology should be encouraged to<br />

enable clinicians to invite discussion around sexual health<br />

without assuming heterosexuality or gender binaries.<br />

Encouragingly, previous efforts in introducing LGBTQIA+<br />

content through lectures and clinical simulations have<br />

been effective in decreasing at least clinician discomfort<br />

in providing LGBTQIA+ related care.[41-44]<br />

Clinicians should also create environments of<br />

inclusiveness. This includes respecting patients’ chosen<br />

pronouns and names, and keeping open minds about<br />

their relationships. This is imperative to building trust.<br />

Introducing intake forms that include diverse gender<br />

identities and LGBTQIA+ specific signage or educational<br />

brochures also increase patient comfort.[40] Additionally,<br />

revision of current data collection systems would enable<br />

more targeted healthcare delivery for TGD populations.<br />

This could be aided through mandatory recording of<br />

both sex assigned at birth and current gender identity<br />

which would enable the disaggregation of different TGD<br />

experiences.[45]<br />

Conclusion<br />

LGBTQIA+ people face on-going barriers to healthcare<br />

on individual, interpersonal and structural levels and have<br />

an increased risk of mental, sexual and chronic illnesses.<br />

Thus, in order to improve health outcomes, barriers to<br />

access should be targeted on both interpersonal and<br />

structural levels. Ultimately, treating LGBTQIA+ people<br />

with individual respect and a willingness to learn will go a<br />

long way in in reducing these inequities.<br />

Acknowledgements<br />

The authors acknowledge and thank Gale Chan for<br />

their contributions to the drafting and revising of this<br />

article.<br />

Photo credit<br />

©2008 laverrue, accessed from https://www.flickr.<br />

com/photos/23912576@N05/2942525739<br />

Ryan melaugh, accessed from https://www.flickr.com/<br />

photos/120632374@N07/13974181800<br />

Conflicts of interest<br />

None declared<br />

Correspondance<br />

salwasayeed70@hotmail.com<br />

alexanderlee193@gmail.com<br />

References<br />

1. Australian Bureau of Statistics. General Social Survey:<br />

Summary Results, Australia, 2014 2014 [cited <strong>2017</strong> September<br />

9]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/<br />

mf/4159.0.<br />

2. Clark TC, Lucassen MFG, Bullen P, Denny SJ, Fleming<br />

TM, Robinson EM, et al. The health and well-being of transgender<br />

high school students: Results from the New Zealand Adolescent<br />

Health Survey. Journal of Adolescent Health. 2014;55:93-9.<br />

3. Mulé NJ, Ross LE, Deeprose B, Jackson BE, Daley A,<br />

Travers A, et al. Promoting LGBT health and wellbeing through<br />

inclusive policy development. International Journal for Equity in<br />

Health. 2009;8(18).<br />

4. Potter J, Goldhammer H, Makadon M. Clinicians and the<br />

care of sexual minorities Potter J, Goldhammer H, Makadon M,<br />

Mayer K, editors. Philadelphia: American College of Physicians;<br />

2008.<br />

5. World Health Organisation. International Statistical<br />

Classification of Diseases and Related Health Problems 10th<br />

Revision 1992 [updated 2016. 10:[Available from: http://apps.<br />

who.int/classifications/icd10/browse/2016/en#/F60-F69.<br />

6. Australian and New Zealand Professional Association<br />

for Transgender Health. Standards of Care [Available from:<br />

http://www.anzpath.org/about/standards-of-care/.<br />

7. World Professional Association for Transgender Health.<br />

Standards of care for the health of transsexual, transgender<br />

and gender nonconforming people 20<strong>11</strong> [Available from: http://<br />

www.wpath.org/site_page.cfm?pk_association_webpage_<br />

menu=1351&pk_association_webpage=3926.<br />

8. Mayers L, Chow K. Same-sex marriage survey: Petition<br />

to deregister Pansy Lai, doctor in No campaign ad, taken down.<br />

ABC News. <strong>2017</strong>.<br />

9. Daniel H, Butkus R. Lesbian, Gay, Bisexual, and<br />

Transgender Health Disparities: Executive Summary of a Policy<br />

Position Paper From the American College of Physicians.<br />

Annals of Internal Medicine. 215(163):135 — 7.<br />

10. Minto CL, Liao L-M, Creighton SM, Woodhouse CRJ,<br />

Ransley PG. The effect of clitoral surgery on sexual outcome<br />

in individuals who have intersex conditions with ambiguous<br />

genitalia: A cross-sectional study. Lancet. 2003;361(9365):1252<br />

— 7.<br />

<strong>11</strong>. Smith D, Mattews W. Physicians’ attitudes toward<br />

homosexuality and HIV: a survey of a California medical Societyal<br />

of Homosexuality. Journal of Homosexuality. 2007;52(3/4):1 — 9<br />

12. Ard KL, Makadon HJ. Improving the health care of<br />

lesbian, gay, bisexual an transgender people: understanding<br />

and eliminating health disparities. Boston, Massachusetts: The<br />

Fenway Institutee; 2012.<br />

13. Australian Human Rights Commission. Resilient<br />

Individuals: Sexual Orientation, Gender Identity & Intersex<br />

Rights 2015.<br />

14. Hinchliff S, Gott M, Galena E. ‘I daresay I might find<br />

it embarrassing’: general practitioners’ perspectives on<br />

discussing sexual health issues with lesbian and gay patients.<br />

Health & Social Care in the Community. 2005;13(4):345.<br />


15. Leonard W, Pitts M, Mitchell A, Lyons A, Smith A, Patel S,<br />

et al. Private Lives 2: The second national survey of the health<br />

and wellbeing of gay, lesbian, bisexual and transgender (GLBT)<br />

Australians. Melbourne: The Australian Research Centre in Sex,<br />

Health & Society, La Trobe University; 2012.<br />

16. Robinson KH, Bansel P, Denson N, Ovenden G, Davies<br />

C. Growing Up Queer: <strong>Issue</strong>s Facing Young Australians Who Are<br />

Gender Variant and Sexuality Diverse. Melbourne Young and<br />

Well, Cooperative Research Centre 2014.<br />

17. Riggs DW, Coleman K, Due C. Healthcare experiences<br />

of gender diverse Australians: a mixed-methods, self-report<br />

survey. BMC Public Health. 2014;14(1):230.<br />

18. Roberts TK, Fantz CR. Barriers to quality health care for<br />

the transgender population. Clinical biochemistry. 2014;47(10-<br />

<strong>11</strong>):983-7.<br />

19. Safer JD, Coleman E, Feldman J, Garofalo R, Hembree<br />

W, Radix A, et al. Barriers to healthcare for transgender<br />

individuals. Current opinion in endocrinology, diabetes, and<br />

obesity. 2016;23(2):168-71.<br />

20. Snelgrove JW, Jasudavisius AM, Rowe BW, Head EM,<br />

Bauer GR. “Completely out-at-sea” with “two-gender medicine”:<br />

A qualitative analysis of physician-side barriers to providing<br />

healthcare for transgender patients. BMC Health Services<br />

Research. 2012;12(1):<strong>11</strong>0.<br />

21. Couch M, Pitts M, Mulcare H, Croy S, Mitchell A, Patel<br />

S. TranZnation: A report on the health and wellbeing of<br />

transgendered people in Australia and New Zealand Melbourne<br />

Australain Research Centre in Sex, Health & Society, La Trobe<br />

University 2007.<br />

22. Pitts M, Couch M, Croy S, Mitchell A, Hunter M. Health<br />

service use and experiences of transgender people: Australian<br />

and New Zealand Perspectives Gay & Lesbian <strong>Issue</strong>s and<br />

Psychology. 2009;5(3):167-76.<br />

23. Mogul-Adlin H. Unanticipated: Healthcare Experiences of<br />

Gender Nonbinary Patients and Suggestions for Inclusive Care.<br />

United States, Connecticu: Yale University; 2015.<br />

24. Transgender and Gender Diverse Health and Wellbeing:<br />

Background paper. Victoria Gay, Lesbian, Bisexual, Transgender<br />

and Intersex Health and Wellbeing Ministerial Advisory<br />

Committee, ; 2014.<br />

25. Bogaert A. Asexuality: What It Is and Why It Matters. The<br />

Journal of Sex Research. 2015;52(4):362-79.<br />

26. Gupta K. “And Now I’m Just Different, but There’s<br />

Nothing Actually Wrong With Me”: Asexual Marginalization and<br />

Resistance. Journal of Homosexuality. <strong>2017</strong>;64(8):991-1013.<br />

27. Alencar Albuquerque G, De Lima Garcia C, Da Silva<br />

Quirino G, Alves MJH, Belém JM, Dos Santos Figueiredo FW,<br />

et al. Access to health services by lesbian, gay, bisexual,<br />

and transgender persons: systematic literature review. BMC<br />

international health and human rights. 2016;16(2):22.<br />

28. Taylor J. Chief Justice vows change to ‘traumatic’ court<br />

process for transgender children. ABC News. 2016.<br />

29. Ryan E. Access to justice for young transgender<br />

Australians: Laywers Weekly <strong>2017</strong> [Available from: https://www.<br />

lawyersweekly.com.au/opinion/2<strong>11</strong>01-access-to-justice-foryoung-transgender-australians.<br />

30. Bolderston A, Ralph S. Improving the health care<br />

experiences of lesbian, gay, bisexual and transgender patients.<br />

Radiography. 2016;22:207 — <strong>11</strong>.<br />

31. Alliance NLH. Snapshot of mental health and suicide<br />

prevention statistics for LGBTI people. National LGBTI Health<br />

Alliance; 2016.<br />

32. Lee R. Health care problems of lesbian, gay, bisexual,<br />

and transgender patients. The Western Journal of Medicine.<br />

2000;172(6):403 — 8.<br />

33. Curmi C, Peters K, Salamonson Y. Lesbians’ attitudes<br />

and practices of cervical cancer screening: a qualitative study.<br />

BMC Women’s Health. 2014;14(153).<br />

34. The Kirby Institute. HIV, viral hepatitis and sexually<br />

transmissible infections in Australia. The Kirby Institute; 2016.<br />

35. Amirkhanian YA. Social Networks, Sexual Networks and<br />

HIV Risk in Men Who Have Sex with Men. Current HIV/AIDS<br />

reports. 2014;<strong>11</strong>(1):81-92.<br />

36. Richters J, Zou H, Yeung A, Caruana T, O de Visser R,<br />

Rissel C, et al. Sexual health and behaviour of men in New South<br />

Wales 2013–2014. School of Public Health and Community<br />

medicine 2015.<br />

37. The Kirby Institute. HIV, viral hepatitis and sexually<br />

transmissible infections in Australia Annual Surveillance Report<br />

2016. Sydney, Sydney NSW 2052: The Kirby Institute<br />

38. Groves A. Transgender women and HIV: A footnote to the<br />

epidemic. HIV Australia. 2012;9(4):30-2.<br />

39. Australian Department of Health and Aging. National<br />

Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI):<br />

Ageing and Aged Care Strategy. 2012.<br />

40. Ard KL, Makadon HJ. Improving the Health Care of<br />

Lesbian, Gay, Bisexual and Transgender People: Understanding<br />

and Eliminating Health Disparities Boston, MA: The National<br />

LGBT Health Education Center; 2012.<br />

41. Arora M, Walker K, Duvivier RJ, Wynne K. Transgender<br />

health delivery and education in the Hunter New England local<br />

health district. ANZPATH <strong>2017</strong> Biennial Conference; Sydney,<br />

Australia<strong>2017</strong>.<br />

42. Canty J, Gray L. The last taboo? Teaching skills for<br />

clinical consultations with sex/gender diverse people in medical<br />

education. . ANZPATH <strong>2017</strong> Biennial Conference; Sydney,<br />

Australia<strong>2017</strong>.<br />

43. Grosz AM, Gutierrez D, Lui AA, Chang JJ, Cole-Kelly K,<br />

Ng H. A Student-Led Introduction to Lesbian, Gay, Bisexual, and<br />

Transgender Health for First-Year Medical Students. Family<br />

Medicine. <strong>2017</strong>;49(1):52-6.<br />

44. Safer JD, Pearce E. A simple curriculum content change<br />

increased medical student comfort with transgender medicine.<br />

Endocrine Practice. 2013;19(4):633-7.<br />

45. Sizemore LA, Rebeiro PF, Mcgoy SL. Improving HIV<br />

Surveillance Among Transgender Populations in Tennessee.<br />

LGBT Health. 2016;3(3):208-13.<br />


Commercial surrogacy in Australia:<br />

the benefits of harm minimization<br />

through legalisation<br />

[Feature Article]<br />

Emily Feng-Gu and Keyur Doolabh<br />

Emily is an enthusiastic fourth year medical student at Monash University. She is completing<br />

a Diploma of Liberal Arts (Philosophy), and hopes to complete a Bachelor of Medical<br />

Science next year in her area of interest: bioethics. In her spare moments, she can be found<br />

with a coffee in one hand and a book in the other.<br />

Keyur is a medical student with an interest in philosophy. He enjoys writing, and is particularly<br />

interested in poverty, climate change and animal welfare.<br />

Surrogate /sʌrəɡət/<br />

A substitute, or someone or something that<br />

represents another person or thing in their<br />

stead.[1]<br />

The status quo<br />

There is much controversy around surrogacy<br />

in Australia. We have what is known as ‘altruistic<br />

surrogacy,’ whereby a woman cannot be compensated<br />

beyond reasonable expenses for gestating a baby<br />

intended for someone else. Even the name puts our<br />

moral intuitions at ease. Altruistic. Contrast this with<br />

the term ‘commercial surrogacy’, which makes many<br />

of us instinctively recoil. So what is it about commercial<br />

surrogacy, where a woman is paid to gestate a baby, that<br />

we take issue with?<br />

The most common type of surrogacy is gestational<br />

surrogacy, wherein the commissioning parent(s)<br />

uses IVF to create an embryo from their own or donor<br />

gametes and transfer it into the uterus of the gestational<br />

surrogate. With this method, the surrogate mother does<br />

not provide any genetic material. People that seek out<br />

surrogacy commonly include infertile heterosexual<br />

couples and homosexual couples desiring children of<br />

their own. The demand for surrogacy has heightened in<br />

recent years following changes to child protection policy,<br />

which lead to drastic falls in the number of children for<br />

adoption and stricter criteria implemented by overseas<br />

countries regarding the age and family types who<br />

can adopt. For example, none of Australia’s current<br />

international adoption agreements allow same-sex<br />

couples to adopt.[2] The status quo in Australia (except<br />

the Northern Territory) only allows altruistic surrogacy,<br />

where one must not compensate the surrogate mother<br />

beyond out-of-pocket expenses like medical cost, travel,<br />

and time off work. The options are further limited by the<br />

fact that surrogacy is illegal for single people and samesex<br />

couples in certain states like Western Australia and<br />

South Australia. The increasing number of roadblocks<br />

to accessing surrogacy has left many desperate<br />

couples resorting to offshore commercial surrogacy.<br />

But even this option is becoming more restricted now<br />

that Thailand, Cambodia, India, and Nepal have banned<br />

foreigners from commercial surrogacy following the<br />

notorious “Gammy scandal” in 2014.[3]<br />

Objections to commercial surrogacy<br />

Commercial surrogacy commonly encounters several<br />

types of objections. Some think it is inescapably a form<br />

of exploitation of women, reducing the surrogate to her<br />

base reproductive capability, and effectively turning her<br />

into a walking incubator. Certainly, the idea of a class<br />

of ‘breeders’ is eerily reminiscent of Margaret Atwood’s<br />

classic novel The Handmaid’s Tale, which could be<br />

interpreted as a cautionary tale warning against the<br />

harms of surrogacy. In a similar vein, some argue that<br />

pregnancy belongs in a special moral realm, and that by<br />

bringing market forces into the arena we degrade the<br />

intrinsic value of creating life. Maybe there are some<br />

things in life which simply should not come with a price<br />

tag.<br />

Certainly, the idea of a class<br />

of ‘breeders’ is eerily reminiscent<br />

of Margaret Atwood’s classic<br />

novel The Handmaid’s Tale<br />


Commercial surrogacy also raises objections that<br />

intersect with other ethical and societal issues. Some<br />

assume that a child is best raised with both a father<br />

and a mother figure, and therefore believe that enabling<br />

same-sex couples to access surrogacy would be harmful<br />

for children. However, existing Australian law allows<br />

same-sex couples to adopt, and it is difficult to see why,<br />

on the grounds of concern for the child, surrogacy would<br />

be different. Furthermore, the assumption that samesex<br />

parenting is harmful to children is not borne-out in<br />

the evidence,[4] and so we do not see this as a relevant<br />

argument against commercial surrogacy.<br />

Another objection to commercial<br />

surrogacy is that it would change the<br />

nature of the family unit by involving the<br />

surrogate as a third parent figure. But<br />

these changes to the more ‘traditional’<br />

family unit are already common in<br />

society. Take for example adoption,<br />

where both biological and adoptive<br />

parents may be involved in the child’s<br />

life. It is also possible for women to<br />

become single parents through the help<br />

of donor sperm and IVF. In neither case has disruption<br />

of the ‘traditional’ family unit been viewed as reason for<br />

prohibition, and it would be inconsistent ban commercial<br />

surrogacy on these grounds.<br />

These ethical objections may be why Australia has<br />

made commercial surrogacy illegal. But given that no one<br />

has ever been prosecuted on these grounds,[5] the legal<br />

threat is a poor deterrence.[6] For people desperate to<br />

have a baby of their own, but who are otherwise unable<br />

to, the risks of commissioning illegal surrogacy can pale<br />

in comparison to the intoxicating notion of holding a fleshand-blood<br />

child.<br />

Banning commercial surrogacy<br />

domestically has created a<br />

transnational black market of<br />

commercial surrogacy that does<br />

not protect the best interests of<br />

the surrogate, the child, or the<br />

intended parents<br />

Undesirable consequences<br />

The supply of altruistic surrogates in Australia falls<br />

well short of demand, driving Australian couples to search<br />

for surrogates overseas. Most are travelling to countries<br />

like India or Thailand where the process was until recently<br />

legal, cheaper, and poorly regulated. It is this scene that<br />

has become inextricably associated with commercial<br />

surrogacy. The transnational surrogacy market operating<br />

out of developing countries has been widely criticised in<br />

popular media,[7,8] and rightly so. Women who become<br />

surrogates in these countries tend to be poorly educated,<br />

have low incomes, and may even<br />

be coerced into surrogacy by family<br />

members or intermediaries seeking to<br />

turn a profit.[9] Often, very little of the<br />

money actually reaches the surrogate<br />

herself. There are some surrogacy<br />

agencies which effectively imprison<br />

surrogates, controlling their diet, sleep,<br />

sexual activity, and contact with the<br />

outside world. All this is done under the<br />

guise of antenatal care, which is in truth<br />

scant and inadequate.[9] It is difficult to<br />

see how informed consent could truly be said to exist in<br />

this environment.[10]<br />

Even if the surrogacy results in a liveborn child, the<br />

challenges do not necessarily resolve. The lack of<br />

enforceable contracts between commissioning parents<br />

and surrogates, combined with issues of legal citizenship<br />

and parentage, can create a veritable labyrinth if<br />

conflict arises or if commissioning parents change their<br />

minds and no longer want the child. Case examples of<br />

transnational surrogacy debacles abound in the media.<br />

For example, commissioning parents have divorced<br />

before the surrogacy was complete, leaving the child<br />


with an uncertain future.[<strong>11</strong>] Another case saw a baby left<br />

stranded with no identity or legal papers for as long as two<br />

years.[<strong>11</strong>] Fortunately, Australian laws allow a child born<br />

from an international surrogacy arrangement to be given<br />

Australian citizenship, provided that at least one parent<br />

is an Australia citizen and a parent-child relationship is<br />

proven with DNA testing, although other measures of<br />

‘parent’ can be used. If ineligible, commissioning parents<br />

may be required to apply for a permanent visa or an<br />

adoption visa. Despite being lengthy and difficult for<br />

parents to navigate, these processes and laws minimise<br />

the risk of children born internationally via surrogacy<br />

being left stateless.[12,13]<br />

Australia’s current approach is to prohibit commercial<br />

surrogacy because it is regarded as immoral, but is this<br />

policy helping the situation or making it worse? At present,<br />

Australians for whom altruistic surrogacy is simply not<br />

feasible appear to be turning to transnational surrogacy.<br />

In 20<strong>11</strong>, only 21 births by altruistic surgery were recorded<br />

in Australia.[14] In the same year, it is estimated over 270<br />

babies were born via transnational commercial surrogacy<br />

arrangements.[6] Banning commercial surrogacy<br />

domestically has created a transnational black market<br />

of commercial surrogacy that does not protect the best<br />

interests of the surrogate, the child, or the intended<br />

parents; the process is expensive, risky, poorly regulated,<br />

and is largely a profit-making exercise for overseas<br />

surrogacy agencies. Despite being designed to prevent<br />

exploitation, our current system might in fact ironically be<br />

encouraging it.<br />

Harm minimisation<br />

Simply prohibiting a behaviour on the basis of its<br />

supposed immorality is not necessarily an effective<br />

strategy. Data shows that in Australia and overseas,<br />

drug use and morbidity increased under policies of<br />

prohibition, and decreased with decriminalization and<br />

regulation.[15] Harm minimisation is a principle we see<br />

being used more often in Australia’s approach to illicit<br />

drug use and prostitution. It recognises that prohibition<br />

can be counterproductive in achieving its overarching<br />

goal of improving the lives of Australian citizens. Instead,<br />

our laws regulate the potentially damaging behaviour or<br />

substance in a way that realistically protects the people<br />

involved. So why not apply a similar harm-minimization<br />

approach to surrogacy? Given that our prohibitive model<br />

is failing to protect Australian couples seeking surrogacy,<br />

and instead funnelling business into exploitative<br />

transnational surrogacy agencies, we should instead look<br />

to harm minimisation to guide how we approach the issue<br />

at hand. This could be best accomplished through the<br />

decriminalisation of commercial surrogacy in Australia.<br />

Decriminalisation and the establishment of a strictly<br />

regulated system would better enable us to protect the<br />

interests and rights of the intending parents, surrogates,<br />

and children. But what should these regulations actually<br />

look like?<br />

A suggested solution<br />

Ideally, a reformed system in Australia would be<br />

carried out by a centralised institution that could oversee<br />

the entire process, from psychological screening and<br />

matching, to counselling, and support services. This<br />

centralised institution could be national, state-run or notfor-profit.<br />

Strict criteria of eligibility could then more easily<br />

be applied, screening out individuals who are unsuitable<br />

for surrogacy arrangements due to medical, social, or<br />

psychological reasons. This assessment could draw on<br />

existing assessment processes for adoption.[16]<br />

The relationship between the surrogate and intending<br />

couple appears to be the most crucial factor affecting<br />

satisfaction with the experience and the likelihood of<br />

conflict regarding parentage of the baby.[17] In fact,<br />

some studies suggest the most common reason for a<br />

surrogate to want to keep the baby is being unsure of the<br />

commissioning couples ability to provide adequate care.<br />

[17] With this in mind, matching surrogates and intended<br />

parents with similar values and desired levels of contact,<br />


as well as facilitating educated discussion about the<br />

possibilities of chromosomal abnormalities or multifetal<br />

gestation, would also mitigate conflict. Antenatal and<br />

postnatal support, including mental health checks, could<br />

also be provided through this system.<br />

The exclusion of profiting intermediaries increases the<br />

likelihood that the interests of all parties would be equally<br />

considered, rather than sacrificing the surrogate’s health<br />

and experience in favour of maximising profits. Moreover,<br />

any surrogacy arrangements would still be constrained<br />

by Australia’s existing common law and family law. This<br />

ensures that the surrogate maintains all the decisionmaking<br />

powers throughout the pregnancy, including her<br />

rights to access termination of pregnancy and to bodily<br />

autonomy.<br />

In terms of the appropriate compensation, it seems<br />

prudent to set both a minimum and a maximum limit.<br />

Pregnancy is unavoidably risky for a woman, and gestating<br />

a growing fetus is no easy task. Why should it not, like<br />

many other jobs, receive recompense proportionate to<br />

the task? Moreover, pregnancy is intrinsically care-based<br />

‘women’s work’, which is still insidiously undervalued<br />

even in modern times. Conversely, to titrate the price of<br />

surrogacy to the intensity of a commissioning couple’s<br />

desire for a child is hardly ethical. The US can shed light<br />

on what prices may look like in an uncapped surrogacy<br />

market; the estimated reimbursement for surrogates<br />

advertised by leading US agency Circle Surrogacy, not<br />

including medical or otherwise associated expenses,<br />

is US$30,000.[18] Most couples experiencing infertility<br />

would struggle to pay this price, which does not include<br />

medical and legal costs. The aim of setting both minimum<br />

and maximum limits on a surrogate’s compensation is to<br />

strike a balance between the interests of the surrogate<br />

and the commissioning parents - or more simply put,<br />

ensuring fair pay for fair work.<br />

Furthermore, a centralised agency would also offer<br />

benefits for children born from surrogacy arrangements.<br />

There would exist a database through which children<br />

could later in life track down their surrogates should<br />

they choose to, just as adopted children can request<br />

information regarding their birth origins after turning 18.<br />

The laws regarding surrogacy should be standardised<br />

across all Australian states and territories. At present, the<br />

laws are fractured and discordant, diverging on points<br />

including whether same-sex couples should be eligible<br />

to be intended parents, the legality of advertisement for<br />

surrogacy, as well as that of seeking overseas surrogates.<br />

The murky legalities of surrogacy make it confusing for<br />

surrogates without deterring commissioning parents; if<br />

they are willing to pay tens of thousands of dollars for<br />

surrogacy, they would probably be happy to travel to<br />

states with more favourable laws.[6]<br />

Challenges of decriminalisation of commercial<br />

surrogacy<br />

One might argue that by decriminalising commercial<br />

surrogacy in Australia, we simply shift the burden of<br />

exploitation from overseas to our own shores. The<br />

concern is that commercial surrogates will be uneducated<br />

and disempowered, and have little informed choice in<br />

the matter. If we assume that the demographic of paid<br />

surrogates in Australia would resemble that of the US,<br />

then this concern does not appear to be relevant.[17, 19]<br />

Small studies of commercial surrogates in the US have<br />

suggested the while surrogates do tend to have lower<br />

incomes and less education than commissioning parents,<br />

they are generally not of a vulnerable population. In one<br />

study, most had gone to college, or at least finished high<br />


school, were from middle income earning families, and<br />

were in long-term relationships.[17,20] Furthermore, their<br />

primary motivation was not the money, but rather to help<br />

a couple start their families. While self-report studies<br />

do have limitations, perhaps we are too quick to assign<br />

altruistic and commercial surrogates into two camps:<br />

those who are doing it purely for selfless reasons and<br />

those who are doing it for money.<br />

The move may also be politically unpopular, with<br />

possible public resistance making the implementation<br />

slow and difficult. Moreover, creating a system which<br />

successfully protects commissioning parents, surrogates,<br />

and children born from surrogate arrangements would<br />

be a time-consuming and expensive exercise, fraught<br />

with pitfalls. Unless it is well-designed, decriminalising<br />

commercial surrogacy could perpetuate the very<br />

consequences it was designed to mitigate.<br />

Why should it not, like many<br />

other jobs, receive recompense<br />

proportionate to the task?<br />

Conclusion<br />

Our approach is not to judge the morality of<br />

surrogacy, neither promoting or undermining its value<br />

as a reproductive option relative to other methods<br />

such as adoption. The problem is a thorny and possibly<br />

intractable one, and requires careful consideration of<br />

racial politics, gender and income inequality, and human<br />

rights. Even in a moral grey zone, however, there are<br />

things which are arguably more morally reprehensible<br />

than others. Australian couples are resorting to the<br />

unregulated and deeply unethical commercial surrogacy<br />

market in developing countries, as a result of the failure<br />

of our current system. Working towards a safer, more<br />

regulated model of surrogacy should be on the Australian<br />

and international agenda.<br />

Acknowledgements<br />

The authors would like to acknowledge the contribution<br />

of ideas and research from their fellow medical students,<br />

Su Ern Poh and Eli Ivey.<br />

Photo credit<br />

http://maxpixel.freegreatpicture.com/Pregnant-<br />

Pregnancy-Pregnant-Woman-M-Mother-2640994<br />

https://www.pexels.com/photo/pregnancy-pregnantmotherboard-parenthoof-57529/<br />

http://www.publicdomainpictures.net/view-image.<br />

php?image=54223&picture=man-holding-newborn<br />

Conflicts of interest:<br />

None declared<br />

Correspondance<br />

keyurd12@gmail.com<br />

References<br />

1. Company H. The American Heritage Dictionary entry:<br />

surrogate [Internet]. Ahdictionary.com. <strong>2017</strong>. Available from:<br />

https://www.ahdictionary.com/word/search.html?q=surrogate<br />

2. Australian Institute of Health and Welfare. Adoptions<br />

Australia 20<strong>11</strong>-12. Canberra: AIHW; 2012. Contract No.: CWS<br />

42.<br />

3. Baby Gammy case reveals murky side of commercial<br />

surrogacy [Internet]. The Conversation. 2014 [cited 1<br />

October <strong>2017</strong>]. Available from: https://theconversation.com/<br />

baby-gammy-case-reveals-murky-side-of-commercialsurrogacy-30081<br />

4. Crouch S, Waters E, McNair R, Power J, Davis E. Parentreported<br />

measures of child health and wellbeing in same-sex<br />

parent families: a cross-sectional survey. BMC Public Health.<br />

2014;14(1).<br />

5. Stuhmcke A. The regulation of commercial surrogacy:<br />

The wrong answers to the wrong questions. Journal of Law and<br />

Medicine. 2015;23:333.<br />

6. Everingham SG, Stafford-Bell MA, Hammarberg K.<br />

Australians’ use of surrogacy. The Medical Journal of Australia.<br />

2014;201(5):270-3.<br />

7. Alford P. Surrogacy Scandal Widens with Southeast Asia<br />

Infant Trafficking Operation Exposed. The Australian. 2014 9<br />

August 2014.<br />

8. Murdoch L. Australian couples’ baby plans in limbo as<br />

Cambodia bans commercial surrogacy. The Sydney Morning<br />

Herald. 2016 4 November 2016.<br />

9. Saxena P, Mishra A, Malik S. Surrogacy: ethical and legal<br />

issues. Indian Journal of Community Medicine. 2012;37(4):2<strong>11</strong>.<br />

10. Deonandan R, Green S, van Beinum A. Ethical concerns<br />

for maternal surrogacy and reproductive tourism. Journal of<br />

Medical Ethics. 2012;38(12):742-5.<br />

<strong>11</strong>. Trimmings K, Beaumont P. International surrogacy<br />

arrangements: legal regulation at the international level:<br />

Bloomsbury Publishing; 2013.<br />

12. Fact sheet - International surrogacy arrangements<br />

[Internet]. Border.gov.au. [cited 1 October <strong>2017</strong>]. Available from:<br />

http://www.border.gov.au/about/corporate/information/factsheets/36a-surrogacy#offshore<br />

13. Birth, adoption and surrogacy [Internet]. Smartraveller.gov.<br />

au. [cited 1 October <strong>2017</strong>]. Available from: http://smartraveller.<br />

gov.au/guide/all-travellers/birth-death-marriage/pages/birthadoption-and-surrogacy.aspx<br />

14. Macaldowie A, Wang YA, Chambers GM, Sullivan EA.<br />

Assisted reproductive technology in Australia and New Zealand<br />

2010: AIHW; 2012.<br />

15. Wodak A. The failure of drug prohibition and the<br />

future of drug law reform in Australia. Australian Prescriber.<br />

2015;38(5):148-9.<br />

16. Review of the Adoption Act 1984. Melbourne: Victorian<br />

Law Reform Commission; 2015.<br />

17. Busby K, Vun D. Revisiting The Handmaid’s Tale: Feminist<br />

theory meets empirical research on surrogate mothers. Can J<br />

Fam L. 2010;26:13.<br />

18. Circle Surrogacy. Anticipated Costs for Gestational<br />

Surrogacy [Available from: http://www.circlesurrogacy.com/<br />

costs.<br />

19. Jadva V, Murray C, Lycett E, MacCallum F, Golombok<br />

S. Surrogacy: the experiences of surrogate mothers. Human<br />

Reproduction. 2003;18(10):2196-204.<br />

20. Ciccarelli J, Beckman L. Navigating Rough Waters:<br />

An Overview of Psychological Aspects of Surrogacy. Journal of<br />

Social <strong>Issue</strong>s. 2005;61(21):21-43.<br />


Polio vs Politics: The Case of Pakistan<br />

[Feature Article]<br />

Jeanine Hourani<br />

Jeanine has just completed her first year of the Master of Public Health at the University of<br />

Melbourne, having come from an Immunology & Microbiology background. She is particularly<br />

interested in refugee and migrant health as well as the effect of warfare on Public Health.<br />

Her previous work includes ‘As Syria Bleeds’ which explores the effect of the Syrian Crisis on<br />

the health system.<br />

Polio is a highly infectious disease caused by<br />

poliovirus which predominantly infects young children by<br />

invading the nervous system and can result in paralysis.<br />

[1] Polio reached epidemic proportions in the early 1900s<br />

but was brought under control after the introduction of<br />

effective vaccines in the 1950s and 1960s.[1] Despite<br />

the progress that has been made, as long as a single<br />

child remains infected with poliovirus, children in all<br />

countries are at risk of contracting the disease.[2] This<br />

is because poliovirus can easily be imported into poliofree<br />

countries and subsequently spread, potentially<br />

resulting in as many as 200,000 new cases every year.<br />

There is no cure for polio, it can only be prevented by<br />

the polio vaccine which, if administered correctly, can<br />

protect a child for life.[2] As such, vaccination programs<br />

are key to achieving global polio eradication.<br />

War and civil unrest have a destructive effect on<br />

population health. In particular, conflict increases<br />

the prevalence of vaccine preventable diseases and<br />

decreases the success of vaccination programs.[3] For<br />

instance, Pakistan is one of the few countries in the world<br />

where polio is still endemic [1, 4, 5] and this is largely<br />

due to its geopolitical and socioeconomic challenges.<br />

[6] In 2006, Taliban insurgency intensified in Pakistan<br />

and the resulting political insecurity has been directly<br />

associated with the rise in polio transmission.[7] Failure<br />

to achieve polio eradication in Pakistan demonstrates<br />

the importance of non-health sector issues, such as<br />

barriers to access in war and conflict zones [6].<br />

Conflict and insecurity in Pakistan is clustered in<br />

Khyber Pakhtunkhwa (KP) and Federally Administered<br />

Tribal Areas (FATA) which are home base to the Taliban<br />

and al-Qaeda.[5, 7, 8] The conflict and insecurity in KP<br />

and FATA has led to a dramatic rise of reported paralytic<br />

polio cases in Pakistan with more than 85% of the<br />

global polio cases coming from these regions.[7, 9] The<br />

establishment of KP and FATA as major polio reservoirs<br />

is undeniably linked to active conflict and insecurity in<br />

these regions.[7-10]<br />

It is clear that global health<br />

programs can no longer isolate<br />

themselves from economic,<br />

security, and political interests.<br />

Polio eradication in Pakistan jeopardises worldwide<br />

efforts aimed at eradicating polio.[6] In 2013, polio<br />

strains originating in Pakistan were detected in sewage<br />

samples in Egypt, Israel, the West Bank, the Gaza Strip,<br />

Syria, and Iraq.[1, 7] The first subsequent polio case<br />

occurred in Syria in October 2013, resulting in 35 children<br />

being paralysed by November.[1] The first Iraqi polio<br />

case was confirmed in March 2014.[1] Polio has spread<br />

from Pakistan in South Asia to countries in the Middle<br />

East that have been polio-free for decades, unraveling<br />

progress that has been made on a global scale [1, 7]<br />

and confirming that polio eradication is no longer solely<br />

Pakistan’s problem, but a global one.<br />

Fueling this problem is the United States’ involvement<br />

in Pakistan. In 20<strong>11</strong>, the CIA attempted to obtain DNA<br />

samples from the children in KP as part of the search for<br />

Osama bin Laden. In order to do this, the CIA conducted<br />

a fake vaccination program against hepatitis B, leading<br />

to an erosion of public trust in immunisation.[1, 7-9]<br />

The use of aid workers for intelligence purposes and<br />

the use of health initiatives to advance security and<br />


foreign policy motives has undermined global healthcare<br />

initiatives aimed at polio eradication, jeopardising longterm<br />

global health goals.[7]<br />

Recent fatal attacks on polio vaccination workers in<br />

politically fragile parts of Pakistan pose a further threat<br />

to the global eradication of polio.[<strong>11</strong>] It is believed that<br />

the international attention paid to polio eradication may<br />

have led terrorist groups to believe that they can achieve<br />

some of their aims by interfering with its eradication.<br />

[<strong>11</strong>] As such, the Pakistani Taliban announced in June<br />

2012 that it would place a ban on all vaccinations until<br />

the United States ended drone strikes.[9] Since then,<br />

the Taliban have orchestrated targeted attacks on<br />

immunisation teams that have tragically killed over 40<br />

vaccinators.[1, 7] This includes the killing of Abdul Ghani<br />

(who was the head of the government’s vaccination<br />

campaign) by a road-side bomb after upon his return<br />

from a meeting with tribal elders to dispel rumours that<br />

vaccination is a U.S. conspiracy to sterilize their children.<br />

[5] To this day, vaccination program staff remain under<br />

threat of kidnappings, beatings, harassment, and even<br />

assassinations in conflict zones.[9]<br />

It is believed that the actions against polio workers may<br />

be driven by two objectives; to terrorise local populations<br />

and government workers, or to stop the house-to-house<br />

movement of polio workers who some terrorist groups<br />

suspect of carrying out US surveillance activity (brought<br />

about by the fake hepatitis B campaign).[<strong>11</strong>] Regardless<br />

of the reason, it is clear that polio eradication has evolved<br />

into a war tactic resulting in an environment of fear and<br />

anarchy.<br />

Global health initiatives are becoming increasingly<br />

intertwined with diplomatic, foreign policy, and security<br />

interests.[7] This is not limited to Pakistan: earlier this<br />

year, six Red Cross Aid workers were killed in Afghanistan<br />

[12], and healthcare in Syria has been transformed into a<br />

target of war.[13] It is clear that global health programs<br />

can no longer isolate themselves from economic,<br />

security, and political interests.[7] The recent portrayal of<br />

polio as the new battleground between Western forces<br />

and terrorist groups illustrates the importance of efforts<br />

to depoliticise polio activities.[<strong>11</strong>] We can no longer allow<br />

security or foreign policy motives to undermine polio<br />

eradication and thus compromise the wellbeing of the 7.5<br />

billion people living on earth.<br />

Photo credit<br />

Sanofi Pasteur / Almeena Ahmed / Sanaullah Afridi,<br />

accessed from https://www.flickr.com/photos/sanofipasteur/29837040256/in/album-72157673062558422/<br />

Conflicts of interest<br />

None declared<br />

Correspondance<br />

jeaninehourania@live.com.au<br />

References<br />

1. Akil L, Ahmad HA. The recent outbreaks and reemergence<br />

of poliovirus in war and conflict-affected areas. Int J Infect Dis.<br />

2016;49:40-6.<br />

2. WHO. Does polio still exist? Is it curable? <strong>2017</strong> [Available<br />

from: http://www.who.int/features/qa/07/en/.<br />

3. Glatman-Freedman A, Nichols K. The effect of<br />

social determinants on immunization programs. Hum Vaccin<br />

Immunother. 2012;8(3):293-301.<br />

4. Afzal O, Rai MA. Battling polio in Pakistan: breaking new<br />

ground. Vaccine. 2009;27(40):5431.<br />

5. Ahmad K. Pakistan struggles to eradicate polio. The<br />

Lancet Infectious Diseases. 2007;7(4):247.<br />

6. Nishtar S. Pakistan, politics and polio. Bull World Health<br />

Organ. 2010;88(2):159-60.<br />

7. Hussain SF, Boyle P, Patel P, Sullivan R. Eradicating polio<br />

in Pakistan: an analysis of the challenges and solutions to this<br />

security and health issue. Global Health. 2016;12(1):63.<br />

8. Roberts L. Fighting Polio in Pakistan. Science. 2012;337.<br />

9. Chang A, Chavez E, Hameed S, Lamb RD, Mixon K.<br />

Eradicating Polio in Afghanistan and Pakistan. A Report of the<br />

CSIS Global Health Policy Center. 2012.<br />

10. Shah M, Khan MK, Shakeel S, Mahmood F, Sher Z, Sarwar<br />

MB, et al. Resistance of polio to its eradication in Pakistan. Virol<br />

J. 20<strong>11</strong>;8:457.<br />

<strong>11</strong>. Abimbola S, Malik AU, Mansoor GF. The Final Push for<br />

Polio Eradication: Addressing the Challenge of Violence in<br />

Afghanistan, Pakistan, and Nigeria. PloS Med. 2013;10(10):1-4.<br />

12. SBS. Opinion: Aid workers are not a target, and never<br />

should be <strong>2017</strong> [Available from: http://www.sbs.com.au/news/<br />

article/<strong>2017</strong>/02/17/opinion-aid-workers-are-not-target-andnever-should-be.<br />

13. The Guardian. Syria ‘the most dangerous place on<br />

earth for healthcare providers’ <strong>2017</strong> [Available from: https://<br />

www.theguardian.com/world/<strong>2017</strong>/mar/15/syria-conflict-studycondemns-weaponisation-of-healthcare.<br />

Key Messages<br />

• The persistence of polio in Pakistan jeopardises worldwide<br />

efforts aimed at eradicating the disease.<br />

• Global health initiatives are becoming increasingly<br />

intertwined with the diplomatic, foreign policy, and security interests<br />

• With the portrayal of polio as a battleground between<br />

Western forces and terrorist groups, greater effort should be made<br />

to depoliticise polio activities<br />


turning up the heat<br />

[Feature Article]<br />

Tara Kannan<br />

Tara Kannan is a first-year MD student at the University of Newcastle. Passionate about<br />

global health, she represents AMSA’s <strong>2017</strong> Code Green portfolio within her university’s<br />

global heath group. She believes that a major way forward in advancing medicine on the<br />

world stage is through nursing our environment back to good health. Aside from that, when<br />

she’s not busy dissecting Guyton’s diagrams, she enjoys perusing news articles online and<br />

loves her Cadbury.<br />

American environmentalist and journalist, Bill<br />

McKibben, offers a simple yet revolutionary proposition<br />

in the climate debate: “Leave oil in the soil, coal in the<br />

hole and gas under the grass”.<br />

The birth of an idea<br />

Divestment is a very simple idea. You just remove your<br />

money from companies that are involved in extracting<br />

fossil fuels. It’s a novel movement in the climate debate<br />

that is different from your traditional change-yourlightbulb<br />

kind of ideas.<br />

Its underlying basis is that to avoid catastrophic<br />

global warming, we will need to reduce our carbon dioxide<br />

emissions. There are three key numbers that explain<br />

this. First, 2˚C is the maximum global temperature rise<br />

this century that is aspired to in the Paris Agreement.[1]<br />

Secondly, we have a ‘carbon budget’ of 565 gigatons<br />

which is essentially the amount of carbon dioxide that<br />

can safely be released into the atmosphere while still<br />

complying to our 2˚C rule.[2] Most importantly, the third<br />

number to know is 2795 gigatons. This is the amount<br />

of carbon dioxide that will be released if all of the<br />

documented fossil fuel reserves<br />

were burned.[2]<br />

Addressing a sixfold rise<br />

in energy demand in the last<br />

50 years, fossil fuels provide<br />

roughly 80% of the energy we<br />

need through coal, gas and oil.[3]<br />

Yet, the money-making industry<br />

releases greenhouse gases into<br />

the atmosphere and thickens Earth’s blanket of air<br />

pollution which led to 3.7 million deaths in 2012 due to<br />

pneumonia, asthma, heart disease, stroke and cancer.<br />

[3] Needless to say, carbon dioxide is a tiny molecule with<br />

a big bite.<br />

So, while as individuals we could make some<br />

adjustments such as changing our lightbulbs and<br />

switching from car use to public transport, if companies<br />

continue to dig up and burn their reserves, these<br />

measures will prove rather insignificant. This is where<br />

divestment comes in - a movement about shifting your<br />

money away from the problem and towards the solution.<br />

Turning back time<br />

So, while as individuals we could make<br />

some adjustments such as changing our<br />

lightbulbs and switching from car use to<br />

public transport, if companies continue<br />

to dig up and burn their reserves, these<br />

measures will prove rather insignificant.<br />

In history, divestment has been shown to be a powerful<br />

political tool in several major movements.<br />

In the latter half of the 20th century, a time when South<br />

Africa’s Apartheid was our world’s largest moral issue,<br />

two prominent figures created massive change. Nelson<br />

Mandela and Desmond Tutu suggested a revolutionary<br />

tactic to help counter institutionalised racial segregation<br />

and white supremacy, imploring Western institutions<br />

to cut their economic ties with companies backing<br />

the Apartheid regime. Experts often deem this as the<br />

model of symbolic pressure as it raised awareness and<br />

embarrassed many American businesses.[4]<br />

Then, through the 1990s, a<br />

movement against the tobacco<br />

industry took place to shun the<br />

industry’s negative impacts on<br />

health. Along with regulation and<br />

taxation, tobacco divestment had<br />

a sizeable impact on society,<br />

shrinking the industry and<br />

smoking rates.[4]<br />

Most recently, divestment has had a role in the<br />

Darfur genocide - the first genocide of the 21st century.<br />

Darfur divestment involves removing money away from<br />

companies with ties to the Sudanese government. Some<br />


Western institutions including Brown University divested;<br />

however, other investors interested in the nation’s<br />

valuable resources simply filled their place. Drawing from<br />

this rather unsuccessful campaign, fossil free activists<br />

are encouraged to consider how their actions could lead<br />

to the success or failure of the divestment movement.<br />

More specifically, it is important to weigh the impact of<br />

divesting from a company relative to giving up your voice<br />

as a shareholder.<br />

Fuelling a movement<br />

Nevertheless, the balance scales show that<br />

divestment is well worth the bet. Major goals of the<br />

fossil fuel divestment campaign can be captured in the<br />

following:[4]<br />

a) leverage the power of investors and institutions to<br />

make strong political statements and influence policy<br />

change<br />

b) raise awareness of the impact of the fossil fuel<br />

industry in our society<br />

c) lead the market to consider the effects of climate<br />

change when evaluating any investments<br />

d) drive capital investment into clean energy and<br />

other climate mitigation strategies<br />

Above all else, divestment stigmatises the fossil fuel<br />

industry, eroding its social license to operate and posing<br />

the largest threat to these companies.<br />

Back home, Australian universities are making<br />

bold statements with the help of several fossil free<br />

organisations on campus. La Trobe University, Swinburne<br />

University and the Queensland University of Technology<br />

pledged to divest their A$40 million, A$150 million and<br />

A$300 million portfolios from fossil fuels respectively.<br />

[7] Recently, both Monash University and the Australian<br />

National University have partially divested.[8] But sadly,<br />

Westpac, ANZ, NAB and the Commonwealth Bank –<br />

which make up the ‘big four’ banks of Australia — have<br />

failed to divest, instead funding the industry to the tune of<br />

A$5.5 billion in 2015.[7]<br />

the ‘carbon bubble’ has its<br />

underlying roots in the fact that<br />

our financial markets maintain<br />

an extraordinary overvaluation<br />

of fossil fuel reserves that has<br />

the potential to burst.<br />

Pop goes the bubble<br />

From an economic point of view, fossil fuel divestment<br />

is falsely thought to come with financial uncertainty and<br />

major repercussions. Addressing this, a key argument<br />

in the fossil fuel divestment campaign is that returns<br />

will, in fact, improve once investors have divested – an<br />

And, if you have not figured it out yet, the fossil fuel<br />

divestment campaign is not a normal movement. There<br />

are no great leaders. There is no Gandhi or Martin Luther<br />

King Jr. of the climate movement. But, establishing firm<br />

roots in society, the fossil fuel movement is set to be<br />

colossal with or without a figurehead.<br />

...divestment stigmatises the<br />

fossil fuel industry, eroding its<br />

social license to operate and<br />

posing the largest threat to<br />

these companies.<br />

Blossoming ideas<br />

Since its initial conception in 2010, the idea of fossil<br />

fuel divestment has been spreading like wildfire. The<br />

campaign celebrated its first major victory in mid-2014<br />

when Stanford University committed to divesting its<br />

US$18.7 billion endowment from the industry.[5] Later that<br />

year, the campaign inspired the People’s Climate March<br />

where a 400,000-strong crowd flooded Manhattan’s<br />

streets, demanding U.N. action on global warming.[4] By<br />

2015, around 2500 investors representing US$2.6 trillion<br />

in assets had divested, including major organisations<br />

such as the Rockefeller Brothers Fund and the Canadian<br />

Medical Association.[6]<br />

Figure 1: Global health groups are leading the fossil fuel divestment game<br />

with eight societies having divested; while, only three medical societies have<br />

divested so far.<br />


argument based on a concept called the ‘carbon bubble’<br />

– named by the Carbon Tracker Initiative. Much like the<br />

US housing bubble of 2009, the ‘carbon bubble’ has its<br />

underlying roots in the fact that our financial markets<br />

maintain an extraordinary overvaluation of fossil fuel<br />

reserves that has the potential to burst.[4, 8] The problem<br />

here is that all reserves simply cannot be burned if we<br />

intend to comply with the ‘carbon budget’, or else, there’s<br />

no doubt that we will find ourselves amidst catastrophic<br />

climate change.<br />

More importantly, with increasing pressure from<br />

pollution regulations, competition from renewables<br />

and one of history’s fastest growing stigmatisation<br />

...the fossil fuel divestment<br />

campaign is not a normal<br />

movement. There are no great<br />

leaders. There is no Gandhi<br />

or Martin Luther King Jr. of the<br />

climate movement.<br />

campaigns, the value of fossil fuels is already diminishing.<br />

[4,8] Last year, energy use emissions grew less than<br />

1% for the third consecutive year.[9] Oxford University<br />

researchers and commercial analysts are predicting that<br />

fossil fuels are likely to become ‘stranded assets’ which<br />

cannot be used, rendering them worthless to investors.<br />

[8, 9] It follows that investors should prepare for such a<br />

scenario by selling their assets now rather than after the<br />

‘carbon bubble’ bursts when investors are likely to lose<br />

money.<br />

Preparing accordingly, investors in Wall Street banks,<br />

such as HSBC and Chase, have demanded that fossil<br />

fuel companies discuss the risks of the bubble; while,<br />

oil companies, including Shell, are now committed to<br />

disclosing their asset portfolios and discussing the<br />

bubble.[4] Similarly, with major financial news venues such<br />

as Bloomberg and the Financial Times now backing the<br />

movement, we are beginning to achieve one of our primary<br />

aims: influencing the economy’s thinking on climate<br />

change.[4] In fact, as of September <strong>2017</strong>, US$5.53 trillion<br />

has been divested by almost 800 institutions.[7]<br />

Renewable energy: a brave new world of investment<br />

So, you move your money away from the fossil fuel<br />

industry and then what? Many experts have shown that<br />

investing in ethical funds such as the renewable energy<br />

industry will have financial returns similar to, if not better<br />

than, the fossil fuel industry.[10]<br />

Renewable energy has made ambitious headlines<br />

around the world. For instance, China recently became<br />

home to the world’s largest solar farm at 27-squarekilometres<br />

which can produce 850 mega-watts of power<br />

- enough to supply around 200,000 households.[<strong>11</strong>]<br />

However, even though renewable technology needs to be<br />

used by all, it’s only accessible to those who can afford<br />

it. Addressing this gap, many grassroots movements are<br />

committed to providing renewable energy to developing<br />

nations. For instance, one such foundation, Liter of Light,<br />

teaches communities to recycle plastic bottles and use<br />

locally sourced materials with the aim of illuminating their<br />

homes – a strategy which has received much recognition<br />

and is often adopted for use in UNHCR camps.[12]<br />

Figure 2: the committee of the University of Newcastle’s global health group, Wake Up!, proudly put their W’s up to<br />

celebrate their divestment win. Congrats Wake Up!<br />


Key messages<br />

• Fossil fuel divestment is a very simple idea: a global movement<br />

focussed on shifting money away from a problem and towards a solution.<br />

• Divestment has been shown to be historically successful<br />

• Establishing firm and expansive roots in our society, divestment now<br />

sets out to radically influence the world’s thinking on climate change<br />

The power of smaller players<br />

Speaking of smaller players making big waves,<br />

medical societies and faculties, are major targets of<br />

the fossil fuel divestment campaign. As highly regarded<br />

entities within universities, they are large enough to<br />

matter but small enough to have an influence on. Now,<br />

more than ever, we are seeing Australian medical<br />

university groups divesting (Figure 1). Most recently, the<br />

University of Newcastle’s global health group, Wake Up!,<br />

switched from the Commonwealth Bank to Newcastle<br />

Permanent – a major win in our medical scene (Figure 2).<br />

Although divestment will not cripple the fossil fuel industry<br />

overnight, this strategy can still operate effectively,<br />

conveying a loud and clear message of disapproval – an<br />

objective we are closer to achieving thanks to societies<br />

like Wake Up!<br />

One of divestment’s main jobs is to draw attention<br />

and challenge the status quo – a powerful opportunity to<br />

be noticed, and be remembered, in times of tragedy and<br />

turbulence. It’s a movement that inspires students, banks<br />

and universities alike to make ethical commitments<br />

and invest in a sustainable future. With global warming<br />

looming large, now is the time to blaze trails and boldly<br />

transform the climate debate.<br />

2015; 82:913-37.<br />

5. Carroll R. Major University Divests $18 Billion Endowment<br />

From Coal Companies [Internet]. HuffPost. <strong>2017</strong> [cited 15<br />

September <strong>2017</strong>]. Available from: http://www.huffingtonpost.<br />

com/2014/05/07/stanford-university-divesting_n_5276899.<br />

html<br />

6. Rowe JK, Dempsey J, Gibbs P. The Power of Fossil<br />

Fuel Divestment (And its Secret). The University of California<br />

eScholarship. 2016.<br />

7. Go Fossil Free. Divestment Commitment [Internet]. Go<br />

Fossil Free. <strong>2017</strong> [cited 15 September <strong>2017</strong>]. Available from:<br />

http://gofossilfree.org/commitments<br />

8. Ansar A, Caldecott B, Tilbury J. Stranded assets and<br />

the fossil fuel divestment campaign: what does divestment<br />

mean for the valuation of fossil fuel assets?. Smith School of<br />

Enterprise and the Environment. 2013.<br />

9. Brahic C. Living with climate change: Have we reached<br />

peak emissions? New Scientist. <strong>2017</strong>; 234: 32-4.<br />

10. De George R. Ethics, corruption, and doing business in<br />

Asia. Asia Pacific Journal of Economics and Business. 1997; 1:<br />

39–52.<br />

<strong>11</strong>. Phillips T. China builds world’s biggest solar farm in<br />

journey to become green superpower #GlobalWarning [Internet].<br />

The Guardian. <strong>2017</strong> [cited 15 September <strong>2017</strong>]. Available from:<br />

https://www.theguardian.com/environment/<strong>2017</strong>/jan/19/chinabuilds-worlds-biggest-solar-farm-in-journey-to-become-greensuperpower<br />

12. Liter of Light. Liter of Light - About Us [Internet]. Liter of<br />

Light. <strong>2017</strong> [cited 15 September <strong>2017</strong>]. Available from: http://<br />

literoflight.org/about-us/<br />

Conflicts of interest<br />

None declared<br />

Correspondance<br />

taranikita@hotmail.com<br />

References<br />

1. United Nations Framework Convention on Climate<br />

Change: Adoption of the Paris Agreement. 21st Conference of<br />

the Parties, 2015: Paris, France: United Nations.<br />

2. 350.org. Do the Math [Internet]. Math.350.org. <strong>2017</strong> [cited<br />

15 September <strong>2017</strong>]. Available from: http://math.350.org/<br />

3. Perera F. Multiple Threats to Child Health from Fossil<br />

Fuel Combustion: Impacts of Air Pollution and Climate<br />

Change. Environmental Health Perspectives. <strong>2017</strong>; 125: 141-8.<br />

Doi:10.1289/EHP299<br />

4. Apfel DC. Exploring Divestment as a Strategy for<br />

Change: An Evaluation of the History, Success, and Challenges<br />

of Fossil Fuel Divestment. New School for Social Research.<br />


Coal mining, climate change and the<br />

global impacts on health: examining<br />

Adani’s proposed Carmichael coal mine<br />

Introduction<br />

The proposed Adani-owned Carmichael coal mine<br />

in central Queensland is currently in the final stages of<br />

planning with the support of both the Queensland and<br />

Australian governments. It is in the interest of human<br />

health, locally and abroad, for the medical profession<br />

to advocate on behalf of the community and lobby our<br />

legislators to reject this project.<br />

The Carmichael site will be the world’s largest export<br />

coal venture and the biggest mining site in Australia,<br />

consisting of six open cut pits and five underground<br />

mines. Mined in the Galilee Basin, 160km north-west<br />

of Clermont, coal will then be transported on a new<br />

railway network before connecting to shipping terminals<br />

bound for India via the Great Barrier Reef Marine Park.[1]<br />

Adani has stated that it plans to mine 60 million tonnes<br />

of coal every year over the expected 60 year lifespan<br />

of the Carmichael mine site.[2] The estimated annual<br />

average emissions of the proposed Adani coal mine are<br />

equivalent to the annual emissions of Malaysia, Vietnam<br />

or Sri Lanka.[3]<br />

The Carmichael mine is<br />

a highly politicised topic with<br />

widespread implications. This<br />

article considers some of the<br />

impacts on Australia’s economy,<br />

our natural environment (and that<br />

of our regional neighbours), and<br />

crucially; the seriousness of the<br />

Carmichael mine’s contribution to climate change and<br />

its effect on human health.<br />

Health Implications on a Global Scale<br />

The World Health Organization (WHO) has said that<br />

climate change is the greatest threat to human health<br />

this century.[4] This gigantic coal mine is set to contribute<br />

significantly to climate change. It will adversely affect<br />

[Feature Article]<br />

John E Morgan<br />

John Morgan is a fourth year medical student at James Cook University. He is<br />

passionate about advocacy, climate change and issues facing the developing<br />

countries within our region. He is a member of Doctors for the Environment and<br />

AMSA’s Mental Health Campaign. Based in Cairns, he loves bushwalking and<br />

camping (and so far hasn’t had any crocodiles up close).<br />

A report recently published in The<br />

Lancet has condemned the planned<br />

Adani Carmichael project as a “public<br />

health disaster”<br />

population health through greenhouse gas emissions,<br />

waterway damage and land clearing. A report recently<br />

published in The Lancet has condemned the planned<br />

Adani Carmichael project as a “public health disaster”,<br />

arguing that the health impacts and environmental<br />

damage will be significant for Australia and its regional<br />

neighbours.[5]<br />

The net effect of obtaining and using coal from the<br />

Carmichael site is estimated to release 4.7 billion tonnes<br />

of greenhouse gas emissions,[6] which will contribute<br />

to climate change. This will result in increased human<br />

exposure to pollen, moulds and air pollution, reducing<br />

air quality and increase the incidence of respiratory<br />

diseases.[7] Ambient pollution in Australia is primarily<br />

derived from fossil fuel powered electricity generation,<br />

heavy industry and wood or coal based home heating.[8]<br />

Annually, 3000 Australians die due to urban air pollution,<br />

more than the national road toll.[9] In its current state,<br />

the air pollution problem is already being insufficiently<br />

addressed. Additionally, exposure to ozone is linked with<br />

increased hospital admissions for respiratory diseases<br />

amongst both children and the elderly.[10] Our legislators<br />

must act decisively and commit meaningful action to<br />

reduce the impact of climate change as it will affect the<br />

health of future generations and<br />

our present vulnerable elderly<br />

population.<br />

Currently, 5% of the<br />

population will experience an<br />

allergic respiratory response to<br />

airborne moulds during their lifetime.[<strong>11</strong>] Changes in<br />

global precipitation are likely to increase the prevalence<br />

of airborne moulds.[7] Additionally, ambient air pollutants<br />

and allergens are most likely to exacerbate respiratory<br />

disease in individuals with pre-existing respiratory<br />

conditions.[12] Climate change associated air pollution<br />

will undoubtedly worsen the quality of life of patients<br />

living with chronic airway diseases.<br />


Coal combustion affects the water as well as the air.<br />

Rising water temperatures linked to climate change will<br />

cause further aerosolisation of marine toxins, thereby<br />

increasing respiratory disease prevalence globally.[7]<br />

Asthmatics exposed to the harmful algal bloom Karenia<br />

brevis’ marine aerosols on the south east coast of the<br />

United States of America (USA) experienced respiratory<br />

symptoms after just one hour of exposure. Inland<br />

residents experienced an average of 3.49 symptoms,<br />

more than coastal residents, who experienced an<br />

average of 2.24 symptoms.[13] This suggests that<br />

aerosolisation of marine toxins will increase respiratory<br />

morbidity as climate change related aerosols proliferate<br />

and distribute further afield.<br />

The cardiovascular burden of disease will worsen<br />

in the future if action is not taken now to reduce the<br />

impacts of climate change.[7] Airborne particulate<br />

matter is associated with compromised heart function,<br />

atherosclerotic disease, deep vein thrombosis,[14] and<br />

pulmonary embolism.[15] The particulates contributing<br />

to air pollution include black carbon, sulphates, nitrates,<br />

a complex mixture of metals and other byproducts<br />

from the incomplete combustion<br />

of fossil fuels.[16] In areas with long term<br />

exposure to high levels of particulate matter<br />

air pollution, it was found that an increase<br />

of just 10 ug/m3 is associated with a 70%<br />

increase in DVT risk.[15] Ozone is another<br />

key pollutant - exposure to a 10g/m3<br />

increment has demonstrated an increase<br />

in the risk of cardiopulmonary mortality by 1.014 times.<br />

[14] Both particulate matter and ozone type air pollution<br />

cause adverse cardiovascular outcomes.<br />

Increased global temperatures will exacerbate heat<br />

related deaths due to an increased frequency of heat<br />

stress events.[7] Untreated heat exhaustion can progress<br />

to heat stroke,[17] of which 15% of cases are fatal.[18]<br />

Heat related health events typically occur on the same<br />

day as initial exposure.[19] Emergency departments (ED)<br />

in Brisbane have demonstrated that during days ≥35°C,<br />

elderly patients were 1.9 times as likely to present<br />

to the ED and 3.75 times as likely to present due to<br />

heat-related complications specifically.[20] Based on<br />

current modelling of Brisbane’s population growth, ED<br />

presentations on days ≥35°C and the projected climate<br />

change related temperature increases, it is predicted to<br />

cause a 125-2065% increase in excess visits by 2060.<br />

[20] Consequently, political inaction now will continue to<br />

worsen the burden on public ED services.<br />

In areas with long term<br />

exposure to high levels of<br />

particulate matter air pollution,<br />

it was found that an increase of<br />

just 10 ug/m3 is associated with<br />

a 70% increase in DVT risk.<br />

[22] This emerging group of environmentally displaced<br />

people will need support to cope.[23] Climate change<br />

has the potential to create disasters beyond the capacity<br />

of developing nations’ public health systems.[24] Action<br />

must be taken to reduce the impact of climate change<br />

for the sake of public health. The global community is<br />

interconnected and each nation has the responsibility to<br />

reduce its contributions to climate change. Consequently,<br />

the impact of the planned Carmichael mine site and its<br />

extensive environmental damage will have substantial<br />

impact on human health into the future.<br />

Locally, coal worker’s pneumoconiosis has reemerged<br />

in Queensland with at least 20 cases recently<br />

diagnosed, highlighting the lack of appropriate health<br />

protection within the Queensland coal industry.[25] If the<br />

Queensland and Australian governments can’t manage<br />

these Occupational Health and Safety issues at home,<br />

how can they contribute to the ‘safe’ delivery and burning<br />

of this coal in Adani’s power stations in India – a country<br />

where air pollution already kills an estimated 1.1 million<br />

people annually.[26] If the mine proceeds, the flow on<br />

effects of poor governing locally will<br />

have detrimental health impacts on a<br />

global scale.<br />

Environmental Implications<br />

The establishment of the<br />

proposed Carmichael coal mine<br />

and its shipping impact will damage<br />

vital ecosystems and reshape the lives and health of the<br />

people reliant on waterways and reefs. More than 500<br />

million people around the planet rely on coral reefs for<br />

food, income and storm protection.[29] Climate related<br />

changes in waves, ocean circulation, cyclone frequency,<br />

temperature and precipitation will impact fisheries in<br />

tropical Queensland and further north.[30] Additionally,<br />

fisheries in our region may be contaminated by chemicals<br />

released into seawater by the mine and from increased<br />

shipping traffic. This will have economic, social and<br />

health implications and affect the productivity of the<br />

seafood industry in Australia and surrounding nations,<br />

especially those that rely on it as a major industry and<br />

cultural cornerstone.[30] Climate change associated<br />

contamination of food staples is also likely to impact on<br />

nutrition and human development.[7] In parallel, the social<br />

aspects of recreational fishing are also highly sensitive<br />

to climate change.[30] Thus, along with the state of the<br />

environment, multiple social determinants of health are<br />

at risk of declining for our coastal communities.<br />

The psychological impacts of climate change are<br />

generally indirect and have only recently been considered<br />

as part of the widespread impacts of climate change on<br />

health. Extreme weather events can lead to mental health<br />

disorders associated with loss, displacement and social<br />

disruption. This can increase anxiety about the future, with<br />

already-disadvantaged communities most likely to suffer<br />

the most severe consequences.[21] Two hundred million<br />

people will be displaced by climate change by 2050.<br />

Implications for Australia<br />

In Central Queensland, the proposed Adani mine<br />

will see more than 10,000 hectares of native bushland<br />

cleared from around the Galilee Basin. Combined<br />

with the Carmichael mine’s generous water licence<br />

enabling unlimited groundwater use from the Great<br />

Artesian Basin,[31] this has huge potential for irreversible<br />

environmental damage.<br />


The Great Artesian Basin is a drought-prone area that<br />

is critically responsible for supplying an estimated 200<br />

towns and settlements with irrigation and drinking water.<br />

[31] The construction of the world’s largest coal mine at<br />

this site could risk the livelihoods and lives of Australian<br />

primary producers in this region. The importance of<br />

water security in drought-prone areas is tantamount and<br />

supporting this mine renders these remote Australians<br />

even more vulnerable. Australians living in rural and<br />

remote settings already have a lower standard of health<br />

service provision and are more likely to suffer worse<br />

health outcomes as a consequence of their social<br />

determinants.[32] The health impacts from the proposed<br />

mine are likely to impact rural Australians to an even<br />

greater magnitude.<br />

Massive quantities of coal will be shipped overseas<br />

through the Great Barrier Reef.[3] It is feared that this will<br />

exacerbate the already extensive coral bleaching. This<br />

will impact Australian coastal communities as the Great<br />

Barrier Reef and other coral reefs provide protection<br />

from wave and storm damage.[33]<br />

Implications for Australia’s regional neighbours<br />

Climate change is projected to slow economic growth,<br />

erode food security and hinder poverty reduction. The<br />

negative effects will be most felt by those who are already<br />

disadvantaged.[34] This is especially pertinent for our<br />

regional neighbours, predominately developing countries.<br />

prevent the temperature associated rises in sea levels<br />

in order to prevent their nations going underwater. A 2°C<br />

goal requires a 40-70% reduction in greenhouse gas<br />

emissions compared with 2010 levels, whereas a 1.5°C<br />

increase will require a 70-95% reduction.[28] As one of<br />

the most influential developed countries in our region,<br />

Australia has a responsibility to support the continuing<br />

development of our regional peers. This begins with<br />

supporting their call for action to reduce the global<br />

temperature rise to 1.5°C. There is simply no room for<br />

the proposed Carmichael coal mine and its extensive<br />

pollution in a sustainable future – a future that needs<br />

action now.<br />

Economic and Political implications<br />

The proposed Carmichael mine project has struggled<br />

to achieve financing. Nineteen banks (including<br />

Australia’s ‘Big Four’) have refused to fund the venture<br />

due to ethical concerns, environmental policies, or the<br />

likelihood that renewable energy will outprice fossil fuels<br />

over the proposed life of the mine. The use of Australian<br />

mined coal in Indian power plants will also inevitably<br />

become economically foolhardy.[37] Both the Australian<br />

and Queensland governments should not continue to<br />

support this proposal as it will create few lasting jobs and<br />

crucially it will increase the loss of human life and burden<br />

of disease locally and abroad.<br />

Many of our regional neighbours are already suffering<br />

from the effects of climate change. Bangladesh has<br />

experienced increased temperatures, swollen rivers and<br />

sea level rises; all which threaten infrastructure, livelihoods<br />

and homes and undermining the region’s development.<br />

[35] Climate change is now making cyclones on many<br />

of our neighbouring Pacific Islands even more powerful<br />

and destructive. In 2016, Tropical Cyclone Winston hit Fiji,<br />

affecting more than half a million people and decreasing<br />

its national GDP by one-fifth.[36] As a developed nation,<br />

our government has a responsibility to contribute to the<br />

prosperity, safety and health of our region by supporting<br />

these developing nations. This begins with reducing our<br />

carbon footprint by stopping the expansion of our fossil<br />

fuel industry, including the proposed Carmichael coal<br />

mine.<br />

The climate impacts of the proposed Carmichael coal<br />

mine go against Australia’s international commitment<br />

to promote a sustainable future by limiting increases in<br />

global temperatures. The United Nations Framework<br />

Convention on Climate Change (UNFCCC) promotes the<br />

work of the Paris Agreement to limit a global temperature<br />

rise this century to below 2°C above pre-industrial levels.<br />

[27] Many of our regional neighbours do not believe this<br />

goes far enough. The “1point5toStayAlive” movement<br />

by the Caribbean and their partner states is fighting to<br />

The continued approval of Adani’s Carmichael<br />

mine by the Australian and Queensland governments is<br />

unwise as the economic return on taxpayer investment<br />


is questionable. The Northern Australia Infrastructure<br />

Facility (NAIF) has proposed a $1 billion AUD loan to<br />

Adani for the North Galilee Basin Rail Project – a 310km<br />

rail link from the mine site to the Abbot Point export<br />

terminal. Despite widespread coverage, little information<br />

was publicly available at the time of writing; only four<br />

documents were published on NAIF’s website, with none<br />

focussing explicitly on coal mining in the Galilee Basin.<br />

[38-41] Both Adani and the former Minister for Resources<br />

and Northern Development have suggested that the<br />

loan is “not critical” and consequently the mine should<br />

be ineligible for NAIF funding.[42] Other requirements<br />

for NAIF funding include public benefit and commercial<br />

viability, both of which are questionable.[42]<br />

Adani continues to claim that the Carmichael mine<br />

will create 10,000 direct and indirect jobs. However, reef<br />

industries threatened by the mine provide approximately<br />

69,000 jobs.[43] The proposed “10,000 jobs” is even more<br />

questionable because Adani has, under oath, stated only<br />

1,464 jobs will be created.[42] A loan of this magnitude<br />

seems wasteful for taxpayers. In September 2016, the<br />

Minister for Resources and Northern Australia Matthew<br />

Canavan stated that opening the Galilee Basin for coal<br />

mining would “not damage the environment”.[38] The<br />

political mismanagement and fabrications surrounding<br />

the Carmichael mine site are a disservice to Australian<br />

taxpayers.<br />

The lifespan of the proposed Carmichael coal mine<br />

is 60 years.[2] Australian coal is expected to be burnt in<br />

India, a country where the Power Minister plans to ban<br />

coal imports. India’s draft National Electricity plan states<br />

that until 2022, India will not require an increase of coal<br />

from its current rate of supply.[44] India is also a signatory<br />

to the Paris Agreement and has declared commitment<br />

to utilising emerging “cleaner sources of energy” as<br />

they become feasible.[45] The long term profitability of<br />

Adani’s Carmichael coal mine is even more questionable<br />

as there is growing public discontent in India with coalbased<br />

power sources and its resulting air pollution. Whilst<br />

there was an absolute increase in the use of coal in India,<br />

renewable generation grew at over six times the rate<br />

of conventional sources. Between April-October 2016,<br />

28% of Indian energy production came from renewable<br />

resources.[44] This demonstrates that the global trend<br />

towards increasing utilisation of renewable energy<br />

sources is extending to India and the coal industry is<br />

declining.<br />

The United Nations (UN) recognises that climate<br />

change is a threat to human health and rights.[4] In 2016,<br />

Australia ratified the Paris Agreement with a declaration<br />

to work towards combatting climate change. Yet due to<br />

the export nature of the proposed Adani Carmichael coal<br />

mine, these Australian sourced emissions will not count as<br />

part of our Intended Nationally Determined Contributions.<br />

The UN’s Committee on Economic, Social and Cultural<br />

Rights (CESCR) stated that Australia’s increasing carbon<br />

footprint is “at risk of worsening in the coming years”[46]<br />

which would undermine the vision of the Paris Agreement<br />

and its predecessor, the Kyoto Protocol, both of which we<br />

are signatories to. The CESCR’s panel of international<br />

human rights experts has recommended Australian<br />

politicians “review (their) position in support of coal<br />

mines and coal export”.[46] In light of the USA’s recent<br />

withdrawal from the Paris Agreement, it is of increased<br />

importance for Australia and other developed countries<br />

to consider the impact of our carbon footprint beyond our<br />

national border.<br />

Conclusion<br />

The real cost of Australia enabling the continuing<br />

burning of coal will be measured in health impacts, hunger<br />

and humanitarian disasters. Therefore, the Australian and<br />

Queensland governments must act now to preserve the<br />

health of Australian and global citizens into the future.<br />

The medical profession has a long and proud history of<br />

protecting public health. We must add our voices to the<br />

wave of protest to stop the construction of the world’s<br />

largest coal mine, and for the sake of our patients’ health,<br />

to make coal history.<br />

Acknowledgements<br />

Doctors for the Environment Australia<br />

Photo credit<br />

Julian Meehan, accessed from https://www.flickr.com/<br />

photos/takver/31283359832<br />

Conflict of Interest<br />

None declared<br />

Correspondance<br />

evan.morgan@my.jcu.edu.au<br />

References<br />

1. Queensland Government. Carmichael coal mine and rail project [Internet].<br />

Brisbane QLD: Department of State Development; 2010 Oct 22 [updated <strong>2017</strong><br />

June 19; cited <strong>2017</strong> Aug 28]. Available from: https://www.statedevelopment.qld.<br />

gov.au/assessments-and-approvals/carmichael-coal-mine-and-rail-project.html<br />

2. Australian Government. Carmichael coal and rail infrastructure factsheet<br />

[Internet]. Canberra ACT: Minister for the Environment’s office; 2014 [cited <strong>2017</strong><br />

Aug 28]. Available from: https://www.environment.gov.au/minister/hunt/2014/pubs/<br />

mr20140728-factsheet.pdf<br />

3. Amos, C. Carmichael in context [Internet]. Canberra ACT: The Australia<br />

Institute; 2015 [cited <strong>2017</strong> Aug 28]. Available from: http://www.tai.org.au/content/<br />

carmichael-context<br />

4. World Health Organisation. WHO calls for urgent action to protect health<br />

from climate change [Internet]. Geneva Switzerland: World Health Organisation;<br />

2015 [cited <strong>2017</strong> Aug 28]. Available from: http://www.who.int/globalchange/globalcampaign/cop21/en/<br />

5. McCall, C. Australia’s new coal mine plan: a “public health disaster”.<br />

Lancet [Internet]. <strong>2017</strong> Feb <strong>11</strong>[cited <strong>2017</strong> Aug 28];389(10069):p588.<br />

Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-<br />

6736(17)30329-X/fulltext<br />

6. McGrath, C. Carmichael coal mine cases in the Land Court and Supreme<br />

Court of Qld [Internet]. Brisbane QLD: Environmental Law Australia; 2010 [updated<br />

<strong>2017</strong> Aug 25; cited <strong>2017</strong> Aug 28]. Available from: http://envlaw.com.au/carmichaelcoal-mine-case/<br />

7. Portier C, Thigpen Tart K. A human health perspective on climate<br />

change [Internet]. North Carolina, USA: National Institute of Environmental Health<br />

Sciences; 2010 Apr 22 [cited <strong>2017</strong> Oct 15]. 80p. Available from: https://www.niehs.<br />

nih.gov/health/materials/a_human_health_perspective_on_climate_change_<br />

full_report_508.pdf<br />

8. Dennekamp M, Carey M. Air quality and chronic disease: why action on<br />

climate change is also good for health. NSW Public Health Bulletin. 2010 July 16<br />

[cited <strong>2017</strong> Oct 20]; 21(6): <strong>11</strong>5-121. Available from: http://www.publish.csiro.au/<br />

NB/NB10026<br />

9. State of the Environment 20<strong>11</strong> Committee. Australia State of the<br />

environment 20<strong>11</strong> [Internet]. Canberra, ACT: Department of Sustainability,<br />

Environment, Water, Population and Communities; 20<strong>11</strong> [cited <strong>2017</strong> Oct 20]. 940p.<br />

Available from: https://soe.environment.gov.au/sites/g/files/net806/f/soe20<strong>11</strong>-<br />

report-complete.pdf?v=1488164460<br />

10. Yang Q, Chen Y, Shi Y, Burnett R, McGrail K, Krewski D. Association<br />

between ozone and respiratory admissions among children and the elderly in<br />

Vancouver, Canada. Inhal Toxicol [Internet]. 2003 Nov [cited <strong>2017</strong> Oct 20]; 15(13):<br />


1297-308. Available from: https://www.ncbi.nlm.nih.gov/<br />

<strong>11</strong>. Hardin B, Kelman B, Saxon A. Adverse human health effects associated<br />

with molds in the indoor environment. J Occup Environ Med [Internet]. 2003 May<br />

[cited <strong>2017</strong> Oct 20]; 45(5): 470-478. Available from: https://www.ncbi.nlm.nih.gov/<br />

pubmed/12762072<br />

12. D’Amato G, Cecchi L. Effects of climate change on environmental factors<br />

in respiratory allergic diseases. Clin Exp Allergy. 2008 Aug [cited <strong>2017</strong> Oct 20];<br />

38(8): 1264-1274. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18537982<br />

13. Kirkpatrick B, Fleming L, Bean J, Nierenberg K. Aerosolized red tide toxins<br />

(Brevetoxins) and asthma: Continued health effects after 1 hour beach exposure.<br />

Harmful Algae [Internet]. 20<strong>11</strong> Jan 1 [cited <strong>2017</strong> Oct 20]; 10(2): 138-143. Available<br />

from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076944/<br />

14. Bacarelli A, Martinelli I, Zanobetti A. Exposure to particulate air pollution<br />

and risk of deep vein thrombosis. Arch Intern Med [Internet]. 2008 [cited <strong>2017</strong><br />

Oct 20]; 168(9): 920-927. Available from: https://jamanetwork.com/journals/<br />

jamainternalmedicine/fullarticle/414214<br />

15. Brook R. Cardiovascular effects of air pollution. Clin Sci (Lond) [Internet].<br />

2008 Sep [cited <strong>2017</strong> Oct 20]; <strong>11</strong>5(6): 175-187. Available from: https://www.ncbi.<br />

nlm.nih.gov/pubmed/1869<strong>11</strong>54<br />

16. Jerret M, Burnett R, Pope C, Kazuhiko I. Long-term ozone exposure and<br />

mortality. N Engl J Med [Internet]. 2009 Mar 12 [cited <strong>2017</strong> Oct 20]; 360: 1085-1095.<br />

Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa0803894#t=article<br />

17. Donoghue E, Graham M, Jentzen J, Liftschulz B, Luke J, Mirchandani H.<br />

Criteria for the diagnosis of heat-related deaths: National Association of Medical<br />

Examiners. Position Paper. National Association of Medical Examiners Ad Hoc<br />

Committee on the Definition of Heat-Related Fatalities. Am J Forensic Med Pathol<br />

[Internet]. 1997 Mar [cited <strong>2017</strong> Oct 20]; 18(1): <strong>11</strong>-14. Available from: https://www.<br />

ncbi.nlm.nih.gov/pubmed/9095294?dopt=Abstract<br />

18. Kilbourne E. Heat waves and hot environments. In: Noji E, editor. The<br />

public health consequences of disasters. New York, USA; Oxford University Press;<br />

1997. p245-269.<br />

19. Basu R, Samet J. Relation between elevated ambient temperature and<br />

mortality: a review of the epidemiologic evidence. Epidemiol Rev [Internet]. 2002<br />

[cited <strong>2017</strong> Oct 20]; 24(2): 190-202. Available from: https://academic.oup.com/<br />

epirev/article-lookup/doi/10.1093/epirev/mxf007<br />

20. Toloo G, Hu W, FitzGerald G, Aitken P, Tong S. Projecting excess<br />

emergency department visits and associated costs in Brisbane, Australia, under<br />

population growth and climate change scenarios. Sci Rep [Internet]. 2015 Aug 6<br />

[cited <strong>2017</strong> Oct 20]; 5: 12860. Available from: https://eprints.qut.edu.au/86502/1/<br />

Projecting%20excess%20ED%20visits%20and%20associated%20costs%20<br />

in%20Brisbane.pdf<br />

21. Fritze J, Blashki G, Burke S, Wiseman J. Hope, despair and transformation:<br />

Climate change and the promotion of mental health and wellbeing. Int J Ment<br />

Health Syst [Internet]. 2008 Sep 17 [cited <strong>2017</strong> Oct 20]; 2(1): 13. Available from:<br />

https://ijmhs.biomedcentral.com/articles/10.<strong>11</strong>86/1752-4458-2-13<br />

22. Myers N. Environmental refugees: a growing phenomenon of the 21st<br />

century. Philos Trans R Soc Lond B Biol Sci [Internet]. 2002 Apr 29 [cited <strong>2017</strong><br />

Oct 20]; 357(1420): 609-613. Available from: https://www.ncbi.nlm.nih.gov/<br />

pubmed/12028796<br />

23. United Nations High Commissioner for Refugees. Climate change and<br />

disasters [Internet]. Geneva, Switzerland: UNHCR; 2015 Jan 1 [cited <strong>2017</strong> Oct 20].<br />

Available from: http://www.unhcr.org/en-au/climate-change-and-disasters.html<br />

24. The CNA Corporation [Internet]. Virginia, USA: The CAN Corporation;<br />

2007. National security and the threat of climate change; 2007 [cited <strong>2017</strong><br />

Oct 20]; [p15]. Available from: https://www.cna.org/cna_files/pdf/national%20<br />

security%20and%20the%20threat%20of%20climate%20change.pdf<br />

25. Queensland Government. Black lung white lies – Report number 2<br />

[Internet]. Brisbane QLD: Coal Workers’ Pneumoconiosis Select Committee;<br />

<strong>2017</strong> May [cited <strong>2017</strong> Aug 28]. Available from: http://www.parliament.qld.gov.au/<br />

Documents/TableOffice/TabledPapers/<strong>2017</strong>/5517T467.pdf<br />

26. Climate and Clean Air Coalition. State of global air <strong>2017</strong>: A special report<br />

on global exposure to air pollution and its disease burden [Internet]. Paris France:<br />

Climate and Clean Air Coalition; <strong>2017</strong> [cited <strong>2017</strong> Aug 28]. Available from: http://<br />

www.ccacoalition.org/en/resources/state-global-air-<strong>2017</strong>-special-report-globalexposure-air-pollution-and-its-disease-burden<br />

27. United Nations Framework Convention on Climate Change. The Paris<br />

Agreement [Internet]. New York USA: United Nations; Oct 2016 [updated Oct <strong>2017</strong>;<br />

cited <strong>2017</strong> Oct 15]. Available from: http://unfccc.int/paris_agreement/items/9485.<br />

php<br />

28. The Caribbean’s Climate Justice Hub. #1point5toStayAlive [Internet].<br />

Saint Lucia: 1.5; 2015 [cited <strong>2017</strong> Oct 15]. Available from: http://1point5.info/<br />

whatsup<br />

29. Global Coral Reef Monitoring Network. Status of coral reefs of the<br />

world: 2004 – Chapter 2 New initiatives in coral reef monitoring, research,<br />

management and conservation [Internet]. Gland Switzerland: International Union<br />

for Conservation of Nature; 2004 [cited <strong>2017</strong> Aug 28]. Available from: https://www.<br />

iucn.org/sites/dev/files/import/downloads/cr_status_2004_vol1.pdf<br />

30. Australian Government. Climate change impacts on the fishing industry<br />

[Internet]. Townsville QLD: Great Barrier Reef Marine Park Authority; <strong>2017</strong> [cited<br />

<strong>2017</strong> Sept 21]. Available from: http://www.gbrmpa.gov.au/managing-the-reef/<br />

threats-to-the-reef/climate-change/what-does-this-mean-for-communities-andindustries<br />

31. Environmental Defenders Office Queensland. Adani Carmichael project<br />

receives water licences [Internet]. Brisbane QLD: Environmental Defenders Office;<br />

<strong>2017</strong> May 31 [cited <strong>2017</strong> Aug 28]. Available from: http://www.edoqld.org.au/news/<br />

adani-pending-water-licence/<br />

32. Bourke L, Humphreys J, Wakerman J, Taylor J. Understanding rural and<br />

remote health: A framework for analysis in Australia. Health Place [Internet]. 2012<br />

Mar [cited <strong>2017</strong> Oct 15];18:496-503. Available from: http://www.flinders.edu.<br />

au/medicine/fms/sites/southgate/documents/events/2014/Understanding%20<br />

rural%20and%20remote%20health_a%20framework%20analysis%20for%20<br />

Australia.pdf<br />

33. Guannel G, Arkema K, Ruggiero P, Verutes G. The power of three: coral<br />

reefs, seagrasses and mangroves protect coastal regions and increase their<br />

resilience. PLoS One [Internet]. 2016 July 13 [cited <strong>2017</strong> Aug 28]; <strong>11</strong>(7): e0158094.<br />

Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.<br />

pone.0158094<br />

34. Working Group II Contribution to the Fifth Assessment Report of the<br />

Intergovernmental Panel on Climate Change. Fifth Assessment Report – Impacts,<br />

Adaptation and Vulnerabilities [Internet]. New York USA: Intergovernmental Panel<br />

on Climate Change; 2014 [cited <strong>2017</strong> Oct 10]. Available from: https://www.ipcc.ch/<br />

report/ar5/wg2/<br />

35. Glennon, R. The unfolding tragedy of climate change in Bangladesh<br />

[Internet]. New York USA: Scientific American; <strong>2017</strong> Apr 21 [cited <strong>2017</strong> Aug 28].<br />

Available from: https://blogs.scientificamerican.com/guest-blog/theunfoldingtragedy-of-climate-change-in-bangladesh/<br />

36. United Nations Office for the Coordination of Humanitarian Affairs.<br />

Tropical Cyclone Winston – Feb 2016 [Internet]. New York USA: ReliefWeb; 2016<br />

[cited <strong>2017</strong> Aug 28]. Available from: https://reliefweb.int/disaster/tc-2016-000014-<br />

fji<br />

37. Climate Council of Australia. Risky business: Health, climate and<br />

economic risks of the Carmichael coalmine [Internet]. Sydney NSW: Climate<br />

Council of Australia; <strong>2017</strong> [cited <strong>2017</strong> Sep 21]. Available from: https://www.<br />

climatecouncil.org.au/uploads/5cb72fc98342cfc149832293a8901466.pdf<br />

38. Ministers and Assistant Ministers for the Department of Industry,<br />

Innovation and Science [Internet]. Canberra, ACT: Australian Government; 2016<br />

Sep 30. Canavan’s Speech to CEDA; 2016 Sep 30 [cited <strong>2017</strong> Oct 20]. Available<br />

from: http://www.minister.industry.gov.au/ministers/canavan/speeches/speechceda<br />

39. Sharon Warburton, Chair, Northern Australia Infrastructure Facility.<br />

Speech – Developing Northern Australian Conference [Internet]. Cairns, QLD:<br />

Northern Australia Infrastructure Facility; <strong>2017</strong> June 19 [cited <strong>2017</strong> Oct 20].<br />

Available from: https://naif-gov-au.industry.slicedtech.com.au/wp-content/<br />

uploads/<strong>2017</strong>/06/Speech-Sharon-Warburton-DNA-final-for-web.pdf<br />

40. Australian Government. Our north, our future: White paper on developing<br />

northern Australia [Internet]. Canberra, ACT: Australian Government; 2015 [cited<br />

<strong>2017</strong> Oct 20]. 200p. Available from: http://northernaustralia.gov.au/files/files/<br />

NAWP-FullReport.pdf<br />

41. Australian Government. Northern Australia audit – infrastructure for a<br />

developing north [Internet]. Canberra, ACT: Australian Government; 2015 Jan<br />

[cited <strong>2017</strong> Oct 20]. 306p. Available from: http://infrastructureaustralia.gov.au/<br />

policy-publications/publications/files/IA_Northern_Australia_Audit.pdf<br />

42. Swann, T. Don’t be so naif; Adani and Governance of the Northern<br />

Australia Infrastructure Facility (NAIF) [Internet]. Canberra ACT: The Australia<br />

Institute; Mar <strong>2017</strong> [cited <strong>2017</strong> Oct 15]. Available from: http://www.tai.org.au/sites/<br />

defualt/files/P318%20Dont%20be%20so%20naif%20FINAL.pdf<br />

43. Deloitte Access Economics. Economic Contribution of the Great Barrier<br />

Reef [Internet]. Townsville Qld: Great Barrier Reef Marine Park Authority; Mar 2013<br />

[cited <strong>2017</strong> Oct 15]. 52p. Available from: http://www.environment.gov.au/system/<br />

files/resources/a3ef2e3f-37fc-4c6f-ab1b-3b54ffc3f449/files/gbr-economiccontribution.pdf<br />

44. Burton B, Fernandes A. Is the Indian coal domino about to fall? [Internet].<br />

Australia: Renew Economy; Dec 2016 [cited <strong>2017</strong> Oct 15]. Available from: http://<br />

reneweconomy.com.au/indian-coal-domino-fall-91973/<br />

45. United Nations Framework Convention on Climate Change. Paris<br />

Agreement – Status of Ratification [Internet]. New York USA: United Nations; Dec<br />

2015 [updated Apr <strong>2017</strong>; cited <strong>2017</strong> Oct 15]. Available from: http://unfccc.int/<br />

paris_agreement/items/9444.php<br />

46. United Nations Committee on Economic, Social and Cultural Rights.<br />

Concluding observations on the fifth periodic report of Australia [Internet]. Geneva<br />

Switzerland: United Nations Office of the High Commissioner; <strong>2017</strong> July <strong>11</strong> [cited <strong>2017</strong><br />

Aug 28]. Available from: http://tbinternet.ohchr.org/_layouts/treatybodyexternal/<br />

Download.aspx?symbolno=E%2fC.12%2fAUS%2fCO%2f5&Lang=en<br />


Paddling upstream:<br />

Experiences from a medical placement in<br />

rural Papua New Guinea<br />

[Feature Article]<br />

Nicholas Snels<br />

I sit in an office on my GP rotation. My insides burn,<br />

courtesy of my morning doxycycline. The patient, who<br />

has come in with fever and a sore throat, coughs. I flinch.<br />

My eyes fly across the room, searching for a face mask.<br />

Then I remember I am back in Toowoomba, and not<br />

every fever is likely due to an unpronounceable parasitic<br />

infection. This is perhaps a slight<br />

dramatisation of my GP block, however,<br />

I cannot help but cast my mind back to<br />

when a cough could signal something<br />

far more sinister than an URTI.<br />

I was recently given the opportunity<br />

to spend six weeks at the Kiunga<br />

District Hospital in rural Papua New<br />

Guinea (PNG) as part of the Griffith<br />

Rural Medical Education program. Every rotation block,<br />

four students are given the opportunity to spend six<br />

weeks in Kiunga hospital. For those as unfamiliar with<br />

Papua New Guinean geography as me prior to my visit,<br />

Kiunga is a town in the western province of PNG, on<br />

the banks of the Fly River. The hospital serves a town<br />

of approximately 13000 people, in addition to being<br />

a referral centre for the region, with approximately 45<br />

beds spread over numerous wards (medical, surgical,<br />

women’s), as well as a pathology lab and an emergency<br />

department/outpatient department (OPD). The wards<br />

are managed by a physician and a surgical/obstetrics<br />

and gynaecology doctor, health extension officers,<br />

community health workers and nurses. As medical<br />

students we were well accustomed to being at the<br />

bottom of this hierarchy; however, in PNG we were given<br />

far greater responsibility.<br />

General Ward<br />

Nick is a final year medical student from Griffith University. Throughout his degree he<br />

has been interested in gaining clinical exposure in a variety of settings, ranging from<br />

a rural experience in Warwick to furthering an interest in global health in Papua New<br />

Guinea and India.<br />

Common things occur commonly. This phrase had<br />

been thrown at me all throughout my clinical years. Most<br />

coughs are probably not cancer, most sore throats are<br />

not the harbinger of quinsy. However, the medical ward<br />

showed us just how context-specific this phrase is, with<br />

...the words ‘common things<br />

occur commonly, therefore,<br />

this is probably tuberculosis or<br />

malaria’ heard at least once<br />

per ward round.<br />

the words ‘common things occur commonly, therefore,<br />

this is probably tuberculosis or malaria’ heard at least<br />

once per ward round. Ascites was probably due to<br />

abdominal seeding of tuberculosis, a headache was<br />

probably due to cerebral malaria. We quickly learned to<br />

appease the ward doctor by suggesting tuberculosis as<br />

the cause for nearly every presenting<br />

complaint. The range of tropical<br />

diseases surpassed my expectations,<br />

from tuberculosis, malaria and<br />

malnutrition, to less common cases of<br />

severe AIDS and Buruli ulcers. I was<br />

even exposed to diseases I had not<br />

even fathomed I might see, such as<br />

toxic epidermal necrolysis as a result<br />

of leprosy medications.<br />

Our time in the general ward consisted of a morning<br />

ward round followed by jobs, and it was eye-opening<br />

to see how health care could be limited by a lack of<br />

resources. Intramuscular antimalarials often ran out,<br />

meaning that oral antimalarials had to be followed by<br />

an ondansetron chaser. There was no adrenaline in the<br />

emergency room, meaning it was necessary to trawl the<br />

hospital to find some before it was needed. A lack of<br />

funds for staff meant the occupants of the tuberculosis<br />

ward were at the far end of the general ward, placing<br />

the rest of the patients at risk of nosocomial infection.<br />

Consequently, we soon learned that ward rounds began<br />

by applying appropriate PPE as soon as we entered the<br />

building (Figure 1).<br />

One patient made a particular impression on me. M<br />

was a 7-month old female admitted due to malnutrition.<br />

Throughout the week, she slowly gained weight and<br />

started to take an interest in the strange pale humans<br />

trying to make her smile with a toy koala, and was<br />

eventually discharged. The next week she returned with<br />

a cough, initially thought to be viral in origin. However,<br />

common things occur commonly, and imaging suggested<br />

M had tuberculosis. While unable to pinpoint the exact<br />


cause, it was possible that her long stay on the ward<br />

could have been the source. It was incredibly frustrating<br />

knowing that if the hospital had funding, these incidents<br />

could be prevented. Nonetheless, the case of M is not an<br />

isolated one, and the lack of resources was evident in all<br />

the areas of the hospital during our stay.<br />

Surgical Ward<br />

Having heard of other elective experiences, I<br />

expected that surgery in a developing country would<br />

be exceptionally hands-on, however, this was not what<br />

I experienced. The reasons for this were unique. A<br />

number of issues, such as the surgeon having malaria,<br />

or the building having no functioning water with which to<br />

sterilize equipment, resulted in my group having relatively<br />

few surgeries to attend. Something I was exposed to,<br />

however, was overcoming challenges in a resource-poor<br />

setting. In the absence of K-wire cutters, garden pliers<br />

were sterilised with alcohol wipes; on another occasion,<br />

an abdominal drain was secured in place with a tongue<br />

depressor snapped and taped together. The persistence<br />

shown by the staff to make the most of what was<br />

available was inspiring, especially given they face these<br />

challenges continually.<br />

Women’s Ward<br />

Figure 1. Students in PPE<br />

In my third year, I was placed in a rural hospital in<br />

Australia which did not see a huge amount of obstetrics.<br />

You could say I was unprepared for<br />

obstetrics in Kiunga.<br />

Caesarian sections were an<br />

uncommon event, meaning that we<br />

witnessed births which probably<br />

would not have happened in<br />

Australia. Examples of this include<br />

a mother with malaria struggling to<br />

give birth due to severe lethargy, or<br />

the two breech births occurring during my six weeks.<br />

In an Australian setting, we are used to working under<br />

the guidance of a senior team member, especially in<br />

a high-intensity situation. However, in PNG we were<br />

In an Australian setting, we are used<br />

to working under the guidance of a<br />

senior team member, especially in a highintensity<br />

situation. However, in PNG we<br />

were expected to step up and start to<br />

manage situations ourselves.<br />

expected to step up and start to manage situations<br />

ourselves. In the maternity suite births were usually<br />

facilitated by one midwife, and if something went wrong,<br />

the focus was on looking after the mother. This meant<br />

that care of the neonate typically came after the mother’s<br />

situation was controlled.<br />

Therefore, on a number of occasions, a routine birth<br />

would end with the midwife handing a limp neonate to two<br />

medical students. Prior to coming to PNG, I was aware of<br />

the debate regarding medical students overstepping their<br />

boundaries while on elective. However, in that moment we<br />

had to make a choice to either stand by and watch the<br />

neonate die due to a lack of resources and staff, or give<br />

it the best chance it could have in the circumstances by<br />

applying pre-departure training in neonatal resuscitation.<br />

It is hard to imagine the situation where there are no<br />

medical students to assist, but sadly due to lack of<br />

staffing that is the situation this hospital faces every<br />

day. We were involved in three such scenarios during<br />

my time in PNG, and I am thankful for the training we<br />

received on resuscitation prior to departure. In saying<br />

that, the unsuccessful resuscitations were amongst the<br />

most confronting moments in medical school, but I am<br />

glad we were present to intervene when no one else was<br />

available.<br />

Not all births were intense, and even in uncomplicated<br />

births we were routinely supported by the midwives to<br />

assist the mother in delivering the child. The midwives<br />

in PNG are incredible, managing most births without<br />

intervention of a doctor, and even performing procedural<br />

skills such as perineal repair and vacuum-assisted<br />

delivery.<br />

Emergency and Outpatient Department<br />

Although other areas of the hospital were perhaps<br />

more confronting, I felt most out of my depth in the OPD.<br />

We were expected to independently see patients and<br />

prescribe medications, with no guidance offered unless<br />

required. While the OPD allowed us to practice our<br />

Pidgin, the language barrier remained a significant issue.<br />

Personally, I felt very uncomfortable prescribing antimalarials<br />

according to a guideline<br />

I did not know well, to a 4-year-old<br />

whose parents I could not explain<br />

anything to, a situation I found<br />

myself in on our first day in the<br />

hospital. The staff were probably<br />

annoyed by my constant questions,<br />

however, I was worried about<br />

overstepping my boundaries as<br />

a student and potentially causing<br />

significant harm. In saying that, the<br />

range of presentations was diverse (although malaria<br />

was exceptionally common), and the chance to practice<br />

our newly-acquired language skills was excellent.<br />


Similar to the obstetric department, we were<br />

forewarned that if resuscitation needed to be performed,<br />

we would potentially be in charge. Even with this in mind,<br />

I certainly did not expect to be performing compressions<br />

one Sunday afternoon while wearing thongs and board<br />

shorts. Due to a lack of staff on this particular weekend,<br />

three medical students who had been playing soccer with<br />

the local kids were now attempting to resuscitate a man<br />

who had been in the ED since the morning. Eventually the<br />

doctor arrived to take control, but it is hard to imagine<br />

students in Australia ever being in such a situation.<br />

Social<br />

Aside from the clinical experience, one of the<br />

highlights of the placement was the chance to become<br />

involved in the local community. We stayed in a house<br />

a close walk away from the hospital, meaning that we<br />

often had spare time in the afternoons/weekends. Most<br />

afternoons we played sport with the local kids, and every<br />

Sunday we played a movie for them at the hospital. Not all<br />

of the children were so keen, however, as one particular<br />

girl started crying as soon as she saw us, a sobering<br />

reminder that foreign faces are still uncommon in such<br />

parts of the world.<br />

One of the most surreal experiences was going<br />

to a local club and listening to Justin Bieber while<br />

meeting locals over Papua New<br />

Guinean beer. A local gentleman<br />

was adamant Justin was in fact a<br />

Papua New Guinean artist, but in his<br />

defence the local brew was quite<br />

potent. At the end of the night we<br />

were even offered a lift home by<br />

the police chief, provided we let him<br />

finish his drink first. Another highlight<br />

was being shown wild birds of<br />

paradise by a guide who had taken David Attenborough<br />

to see them years ago. The people were exceptionally<br />

welcoming, often stopping on the street or in the markets<br />

to talk to us and see how we were finding the experience.<br />

Reflections<br />

There were a few main lessons I took away from this<br />

experience in regards to students experiencing a global<br />

health elective. The most striking point was the issue<br />

regarding medical students on electives in resource-poor<br />

settings. This issue deserves a review unto itself, but<br />

suffice to say it became very apparent to me how easy<br />

it could be for an overconfident medical student to abuse<br />

the level of trust placed in them by the local population.<br />

Particularly, in a poorly-resourced setting with a lack of<br />

supervision, students may be placed in situations that<br />

are beyond their level of knowledge. However, in certain<br />

circumstances, capable students, and especially those in<br />

their final year, may be able to have a positive impact on<br />

their chosen placement. Such an experience highlighted<br />

At times it seemed like the health care<br />

workers were battling their way upriver<br />

against a tide of financial constraints and<br />

poor government support, however, the<br />

enthusiasm and dedication shown towards<br />

the people of Kiunga was inspiring.<br />

how aware students must be before embarking upon<br />

such an elective, and to have these issues in their minds<br />

while on the placement to avoid overstepping their scope<br />

of practice.<br />

Such difficulty is exacerbated by the challenges<br />

of healthcare provision in resource-poor settings, and<br />

this placement was invaluable in showing me how it<br />

differs compared to Australia. The shortage of staff,<br />

medications and equipment was evident throughout the<br />

hospital, and it was clear that the entire health system<br />

could be improved by further funding. It was confronting<br />

seeing individuals suffer because the medication they<br />

needed was not available, however, it was inspiring to<br />

see the ways staff attempted to overcome these barriers.<br />

Additionally, the attitude of the staff continually stayed<br />

positive, even in the face of these challenges.<br />

Finally, it was evident to me throughout the placement<br />

that global health challenges in developing nations<br />

are changing. While infectious and tropical diseases<br />

were rife, the impact of chronic conditions such as<br />

cardiovascular disease, hypertension and diabetes was<br />

evident during my time in Kiunga. These conditions were<br />

often poorly managed due to lack of proper medications<br />

and monitoring. Their increasing prevalence coupled with<br />

the lack of resources to manage these conditions mean<br />

students doing a similar placement in the future will face<br />

a host of different conditions.<br />

In summary, this elective<br />

was an excellent experience.<br />

Not only for the clinical<br />

exposure, but also for the<br />

chance to see how healthcare<br />

functions in a resource-poor<br />

setting. At times it seemed<br />

like the health care workers<br />

were battling their way upriver against a tide of financial<br />

constraints and poor government support, however, the<br />

enthusiasm and dedication shown towards the people<br />

of Kiunga was inspiring. Additionally, the chance to<br />

experience life in a rural town in PNG was a highlight in<br />

itself. This placement has, undoubtedly, been one of the<br />

most motivating placements of medical school, and I<br />

strongly urge anyone considering something similar to<br />

take the opportunity.<br />

Acknowledgements<br />

QRME and Graeme Hill for continual support of this<br />

program; Aisha, Ryan and Emily for sharing the experience<br />

and for support throughout difficult times.<br />

Conflicts of interest<br />

None declared<br />

Correspondance<br />

nicholas.snels@griffithuni.edu.au<br />


Introduction<br />

Sugar tax -<br />

A sweet solution for obesity?<br />

The obesity epidemic<br />

Over the past few decades, overweight and obesity have<br />

risen to epidemic proportions all over the globe. In 2014,<br />

more than 1.9 billion adults were overweight and 600 million<br />

were obese.[1] In 2013, 42 million children under the age of<br />

five were either overweight or obese, and this is predicted<br />

to increase to 70 million by 2025.[2] The growing prevalence<br />

of childhood obesity is particularly alarming given that it is a<br />

predisposing factor for lifelong obesity.[3] Obesity, defined as<br />

having a body mass index (BMI) greater than or equal to 30, is<br />

a major risk factor for non-communicable diseases such as<br />

cardiovascular disease, diabetes, cancer, and mental illness.<br />

[4] Since non-communicable diseases were responsible for<br />

68% of all deaths in 2012, [5] it is apparent that the health<br />

burden of obesity is high.<br />

Obesity is a complex heterogenous disease that arises<br />

from an interplay between our genes and the environment<br />

we live in. Highly energy-dense diets combined with a lack<br />

of adequate physical activity leads to a positive caloric<br />

balance and hence weight gain in genetically susceptible<br />

individuals. Our diet and physical activity are increasingly<br />

[Review]<br />

Saiuj Bhat<br />

Saiuj is a first year medical student at the University of Western Australia with a passion<br />

for understanding the social and commercial determinants of health. He also has<br />

an interest in tissue engineering, in particular organoid technology, and the promising<br />

that holds for many aspects of medicine in the future. He graduated last year with<br />

Honours in pharmacology.<br />

“<br />

Abstract<br />

Background: The rising prevalence of obesity and obesity-related illnesses parallels the increase in sugar consumption<br />

across the globe. To limit consumption of sugar and tackle obesity, the World Health Organization has recommended<br />

that member states implement a tax on sugar. Such a tax is envisioned to reduce sugar consumption at a societal<br />

level, generate stable revenue for governments, and drive product reformulation. However, at present there is insufficient<br />

evidence to suggest any beneficial effect of a sugar tax on the incidence and prevalence of obesity.<br />

Aim: This review examines the effectiveness of a sugar tax as an obesity prevention strategy.<br />

Methods: A qualitative review of modelling and observational studies investigating the link between sugar tax and<br />

obesity, and conducted over the past ten years, was carried out.<br />

Findings: Modelling studies suggest that a tax on high-sugar foods and beverages is likely to have beneficial effects on<br />

obesity as increased price of taxed items leads to reduced consumption. However, observational studies suggest little<br />

benefit of a sugar tax on actual obesity rates in a population. Taxes in combination with other policy and regulatory<br />

approaches, for example health food subsidies and education campaigns, might be more effective than a tax on its own.<br />

Conclusion: A tax on sugar is likely to be a step in the right direction as it would raise public awareness of the negative<br />

health effects of excess sugar and de-normalise consumption of excess sugar.<br />

shaped and driven by broader social, cultural, economic, and<br />

political landscapes that are often beyond individual control<br />

and awareness.[6] The modern obesogenic environment,<br />

which provides easy access to calorie-rich processed food<br />

and encourages sedentary lifestyle, is mismatched to human<br />

physiology that evolved to survive in an environment of food<br />

scarcity.[7] At a population level, obesity can be viewed as<br />

a manifestation of a global economic system that currently<br />

prioritises wealth creation over health creation.[8]<br />

Obesity’s sweet tooth<br />

”<br />

In recent decades, the rising prevalence of obesity has<br />

closely paralleled the burgeoning consumption of sugar all<br />

over the world.[9] Sugar is recognised as one of the biggest<br />

risk factors for obesity,[10-15] and the leading source of<br />

sugar in the diet is sugar sweetened beverages (SSBs).[15]<br />

Therefore, the current review will focus on SSBs as a proxy<br />

for sugar and the discussion about policies aimed at limiting<br />

sugar intake (i.e. sugar taxes), will predominantly revolve<br />

around SSBs.<br />

SSBs are non-alcoholic beverages with added sugar and<br />

include soft drinks, fruit drinks, sports drinks, energy drinks,<br />


iced tea and coffee, and lemonade. SSBs are becoming<br />

increasingly popular in low- and middle-income countries, with<br />

Latin America and Asia leading the world in consumption.[16]<br />

The worldwide impact of SSBs on the burden of adiposityrelated<br />

cardiovascular disease, cancer, and diabetes is<br />

estimated at a total of 8.5 million (95% CI: 2.8 – 19.2)<br />

disability-adjusted life years (DALYs) [17].<br />

Limiting the intake of free<br />

sugars to less than 10% of total<br />

daily energy consumption is<br />

strongly recommended by the<br />

World Health Organisation and the<br />

US Dietary Guidelines Advisory<br />

Committee.[18, 19] For every additional serving of SSB per<br />

day, the likelihood of a child becoming obese increases by<br />

60% over the course of two years.[20] The energy obtained<br />

from SSBs is added to an individual’s total energy intake<br />

rather than displacing other sources of calories due to the<br />

poor satiating properties of sugar in liquid form.[21] The net<br />

increase in calorie consumption is likely to contribute to an<br />

increase in body mass. Given the high burden of obesityrelated<br />

illnesses on healthcare systems [17] and the strong<br />

evidence linking excess consumption of SSBs to obesity in<br />

children and adults,[15, 22] a reduction in SSB consumption is<br />

warranted. A decrease in consumption is especially pertinent<br />

as the major SSB consumers are children, adolescents and<br />

poorly educated individuals from lower socio-economic<br />

strata of society who may be less aware of the harmful<br />

effects of added sugar.[10]<br />

Sugar tax as an obesity prevention strategy?<br />

“obesity can be viewed as a manifestation<br />

of a global economic system that currently<br />

prioritises wealth creation over health<br />

creation.”<br />

The success of an SSB tax as an obesity prevention<br />

strategy remains controversial. The plethora of studies<br />

investigating the link between sugar taxation and obesity<br />

prevention demonstrate conflicting results. There is currently<br />

no consensus regarding the best approach to implement a<br />

sugar tax. Furthermore, existing meta-analyses on the topic<br />

show inconsistent findings and are<br />

unable to include many primary<br />

studies in their analysis owing to<br />

methodological inconsistencies.<br />

Recognising these limitations,<br />

this review provides a brief<br />

overview of the current literature on the effectiveness of<br />

a sugar tax as an obesity prevention strategy. Given that<br />

existing studies have been performed in both developing and<br />

developed nations, this review adopts a global perspective on<br />

the issue of sugar taxation. The theoretical basis of a sugar<br />

tax, its economic feasibility, and effectiveness with regards<br />

to obesity prevention will be examined. Alternative strategies<br />

for curbing the obesity epidemic, such as regulation of<br />

advertisements and food labels, are beyond the scope of this<br />

review and will not be explored.<br />

Methods<br />

Electronic databases (PubMed and Web of Science) were<br />

searched for relevant journal articles between 1 January<br />

2007 and 1 July <strong>2017</strong>. The year 2007 was chosen to ensure<br />

included studies were relevant to modern dietary habits and<br />

practices.<br />

Population health interventions aimed at curbing the<br />

consumption of excess sugar are pertinent to curtail<br />

the obesity epidemic. Price is one of the key factors<br />

influencing food purchasing behaviour. People tend to reduce<br />

consumption of unhealthy foods in response to increased<br />

prices of such products.[23] To discourage purchase of<br />

SSBs and address the growing burden of obesity, countries<br />

such as France, Mexico, the UK, and Hungary, and several<br />

jurisdictions in the USA, have implemented a tax on sugar.[10]<br />

Following implementation of a €0.<strong>11</strong> per 1.5 L excise tax on<br />

SSBs, which translated to a 6% price increase, France saw<br />

a 6.7% decline in demand for cola in the first two years.[24]<br />

SSBs are a sensible target for a sugar tax as they have a high<br />

calorie density with no additional nutritional value [10, 25] and<br />

can be clearly defined for policy implementation.[2]<br />

A number of assumptions underscore the success of an<br />

SSB tax [26]: first, the tax must be passed onto consumers,<br />

leading to an increase in cost; second, SSBs follow the law<br />

of demand; and finally, the tax leads to a significant net<br />

reduction in energy intake despite substitution by consumers,<br />

for example by increasing consumption of fruit juices with<br />

comparable caloric content.[27] While a tax on sugary<br />

drinks may not be the silver bullet for obesity on its own, it<br />

has the potential to slow the epidemic. For this reason,<br />

recommendations to implement diet-related taxes should be<br />

taken seriously.[28, 29]<br />

The following search strategy was used: (tax* OR price*<br />

OR economic* OR financial*) AND (sugar OR sweetened<br />

OR beverage* OR drink*) AND (intake OR consumption OR<br />

demand OR sale* OR diet OR weight OR overweight OR<br />

obes* OR body mass index OR BMI).<br />

Searches were limited to articles published in English.<br />

Relevant articles were also identified by searching the<br />

reference lists of included studies. Abstracts were assessed<br />

for suitability of inclusion. Studies that were found to be<br />

suitable were read in full and their salient features reported<br />

here.<br />

Economic feasibility of a sugar tax<br />

Consumers do not bear the full costs of their decisions<br />

when it comes to high-calorie foods and beverages.[30] It<br />

is estimated that an individual with a BMI between 30 and<br />

35 will accumulate 30% higher medical costs than a normal<br />

weight individual;[31] this increases to 50% in individuals<br />

with a BMI greater than 35.[32] In Canada, obesity-related<br />

healthcare costs are close to $6 billion [33] whereas in<br />

Australia this figure is close to $10.7 billion.[34] In addition<br />

to direct healthcare costs, there are indirect costs to the<br />

community associated with absenteeism and obesity-related<br />

premature death.[35]<br />


A number of modelling studies have reported substantial<br />

healthcare cost savings and stable revenue streams from a<br />

tax on sugar.[14, 36-38] For example, annual healthcare cost<br />

savings of $23.6 billion (95% CI: 9.33 – 54.9) and annual<br />

revenue of $12.5 billion (95% CI: 8.92 – 14.1) have been<br />

predicted for a tax of $0.01 per ounce of sugar in the United<br />

States (US).[39] Importantly, a sugar tax combined with a fruit<br />

and vegetable subsidy is deemed to be poverty neutral,[37] an<br />

important consideration given the significantly higher relative<br />

cost of fresh produce,[40] especially in rural and remote<br />

communities. The revenue generated from an SSB tax can<br />

be used to cover the healthcare costs of obesity, support<br />

subsidies on healthy food options, and fund public and school<br />

education campaigns promoting childhood nutrition and<br />

obesity prevention.<br />

“a sugar tax combined with a fruit and<br />

vegetable subsidy is deemed to be poverty<br />

neutral, an important consideration given<br />

the significantly higher relative cost of fresh<br />

produce, especially in rural and remote<br />

communities.”<br />

Effectiveness of a sugar tax for preventing obesity<br />

Of various taxes on “unhealthy” foods, a tax on sugar was<br />

modelled to have the biggest health gain in the Australian<br />

population, equating to 270,000 DALYs (95% CI: 250,000<br />

– 290,000) averted.[37] The effect of a sugar tax on BMI<br />

was found to be modest, equating to a BMI reduction of<br />

0.1 in males and 0.06 in females, and a decline in obesity<br />

prevalence of 2.7% in males and 1.2% in females [36]. In a<br />

study modelling the German population, a 20% SSB tax was<br />

shown to reduce the prevalence of obesity by 4% in males<br />

aged 20 to 29.[41] Similarly, a modelling study by Cancer<br />

Research UK estimated that a 20% tax on SSBs could<br />

prevent 3.7 million people from becoming obese by 2025.<br />

Significant, albeit small, inverse associations between SSB<br />

taxes and weight gain have been reported by other modelling<br />

studies.[15] These could represent important changes over<br />

time and alter the prevalence of obesity at a population level.<br />

[42] Importantly, reductions in energy consumption were more<br />

pronounced in low- and middle-income groups.[38, 41, 43]<br />

One of the biggest limitations of these studies is that they<br />

are population models.[37] They rely on national data which<br />

may be outdated and assume a linear relationship between<br />

weight changes and energy consumption without accounting<br />

for substitution behaviour by consumers and often relies on<br />

self-reported data.[41] The substitution effect is an obvious<br />

confounder in studies that do not classify fruit juices as SSBs,<br />

despite juices often containing more sugar than soft drinks.<br />

[14] Another limitation of modelling studies is the lack of<br />

information on long-term SSB price elasticity that is specific<br />

to geographic and economic subgroups.[14]<br />

Six months after implementation of an SSB excise tax<br />

($0.01 per ounce), consumption of SSBs decreased in<br />

Berkeley, California (–21%) and increased in comparable<br />

neighbouring cities that did not levy a sugar tax (+4%). Of the<br />

124 people who reported changing drinking habits as a result<br />

of the tax, 82% reported drinking SSBs less frequently and<br />

40% reported drinking smaller sizes because of the tax.[44]<br />

Similarly, following introduction of an SSB tax (1 peso/litre)<br />

by the Mexican government, the purchase of SSBs declined<br />

by an average of 6% during the first year of the tax and this<br />

decline was greater in low income groups.[45] The average<br />

Mexican purchased 4.2 litres less taxed beverages than<br />

expected during the first year, however, purchase of untaxed<br />

beverages increased by 13 litres on average.[45] Whether the<br />

increased consumption of untaxed beverages compensated<br />

for the reduced caloric intake due to the decline in taxed<br />

beverages was unable to be determined, so the effect of the<br />

sugar tax on net caloric intake remains to be seen. Given<br />

their short time frame, these observational studies provide<br />

no indication of the effect of a sugar tax on actual obesity<br />

rates in a population.<br />

Similarly, surveys investigating consumers’ purchasing<br />

behaviour may not necessarily predict their actual purchasing<br />

habits.[46] This is critical in light of the fact that a 20% tax on<br />

SSBs did not result in an appreciable reduction in consumers’<br />

likelihood to buy SSBs, despite their perception that they were<br />

more expensive.[46] Notwithstanding these pitfalls, a review<br />

of cross-sectional and longitudinal studies investigating the<br />

impact of sugar taxes on weight gain found several studies<br />

that demonstrated an inverse association between price<br />

increase of SSBs and point prevalence of overweight and<br />

obesity.[13] However, the magnitude of change reported in<br />

these studies was small.[13]<br />

Outlook<br />

Reduced consumption of sugar by virtue of an SSB tax<br />

may not necessarily translate to decreased body weight,<br />

particularly if unhealthy alternatives still exist. A tax on<br />

SSBs will only be effective in reducing obesity when there<br />

is no substitution with another untaxed high-calorie food or<br />

beverage.[47] A tax on sugar-rich foods (e.g. confectionary)<br />

in conjunction with a tax on SSBs would reduce the likelihood<br />

of substitution and therefore increase the effectiveness of<br />

the public health intervention. Taxes on high-fat foods will<br />

need to be considered in the future as adjuncts to the sugar<br />

tax. Given the complexity of taxing foods high in sugar and<br />

fat, and limited research on their effectiveness, this requires<br />

further study.<br />

In addition to reducing calorie intake through a sugar<br />

tax, other aspects of the obesogenic environment that<br />

require monitoring and regulation include food labelling,<br />

food portions, food advertisements, and plain packaging. A<br />

sugar tax on its own is unlikely to be the panacea for obesity<br />

prevention. It is widely accepted that taxes have the potential<br />

to reduce sugar consumption, drive production reformulation,<br />

and generate substantial revenue for governments.[16] While<br />

it appears plausible that reduced sugar consumption and<br />

product reformulation would be beneficial to tackle obesity,<br />

whether this is actually the case remains to be seen. To<br />

address the obesity epidemic, a number of other population<br />

level policy measures, including advertising restriction,<br />


eformulation targets, health star rating systems, promotion<br />

of healthy transport choices, and sustained high-impact<br />

education campaigns are warranted.[48]<br />

While the effect of sugar taxes on SSB consumption<br />

and obesity have been carried out in some low- and middleincome<br />

groups,[38, 41, 43] there is a paucity of literature<br />

from developing nations on the impact of decreasing SSB<br />

consumption on obesity rates. This is pertinent given that lowand<br />

middle-income nations are disproportionately impacted<br />

by obesity and related non-communicable diseases.<br />

“A sugar tax on its own is unlikely to be<br />

the panacea for obesity prevention.”<br />

Conclusion<br />

Obesity and obesity-related diseases are a significant<br />

burden on healthcare systems around the world. The global<br />

prevalence of obesity has increased and excess consumption<br />

of sugar, in particular SSBs, is one of the strongest drivers<br />

of that increase. To curb the obesity epidemic, a number of<br />

countries have adopted various forms of sugar taxes. While<br />

theoretically and economically sound, a sugar tax on its own<br />

might be insufficient to curb the obesity epidemic. However,<br />

a tax on sugar is likely to be a step in the right direction as it<br />

would raise public awareness of the adverse health effects<br />

of excess sugar and de-normalise excess consumption.<br />

A tax on SSBs can also encourage industry to reformulate<br />

its products with lower sugar levels. Taxes in combination<br />

with other policy and regulatory approaches, for example<br />

subsidies to healthy foods, graphic warning labels, and<br />

awareness campaigns, might be more effective to curb the<br />

obesity epidemic than a tax on its own. A sustained, focussed,<br />

and multi-pronged public health intervention worked in the<br />

past against Big Tobacco. There is no reason to believe that<br />

similar perseverance will not work against Big Sugar.<br />

Conflicts of interest<br />

None declared<br />

Correspondance<br />

saiujbhat59@hotmail.com<br />

References<br />

1. World Health Organisation. Obesity and overweight [Internet].<br />

2016 [cited <strong>2017</strong> March 24]. Available from: http://www.who.int/<br />

mediacentre/factsheets/fs3<strong>11</strong>/en/<br />

2. World Health Organisation. Report of the commission<br />

of ending childhood obesity [Internet]. 2016 [cited<br />

<strong>2017</strong> March 24]. Available from: http://apps.who.int/iris/<br />

bitstream/10665/204176/1/9789241510066_eng.pdf?ua=1<br />

3. Bays H, Scinta W. Adiposopathy and epigenetics: an<br />

introduction to obesity as a transgenerational disease. Curr Med<br />

Res Opin. 2015 Nov;31(<strong>11</strong>):2059-69.<br />

4. James WP. WHO recognition of the global obesity epidemic.<br />

Int J Obes (Lond). 2008 Dec;32 Suppl 7:S120-6.<br />

5. World Health Organisation. Global status on noncommunicable<br />

diseases 2014 [Internet]. Geneva: WHO Press; 2014<br />

[cited <strong>2017</strong> March 24]. Available from: http://www.who.int/nmh/<br />

publications/ncd-status-report-2014/en/<br />

6. Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT,<br />

Moodie ML, et al. The global obesity pandemic: shaped by global<br />

drivers and local environments. Lancet. 20<strong>11</strong> Aug;378(9793):804-<br />

14.<br />

7. Albuquerque D, Stice E, Rodríguez-López R, Manco L,<br />

Nóbrega C. Current review of genetics of human obesity: from<br />

molecular mechanisms to an evolutionary perspective. Mol Genet<br />

Genomics, 2015 Aug;290(4):<strong>11</strong>91-221.<br />

8. Kickbusch I, Allen L, Franz C. The commercial determinants<br />

of health. Lancet Glob Health. 2016 Dec;4(12):e895-e896. DOI:<br />

10.1016/S2214-109X(16)30217-0.<br />

9. Hu FB, Malik VS. Sugar-sweetened beverages and risk of<br />

obesity and type 2 diabetes: epidemiologic evidence. Physiol Behav.<br />

2010 Apr;100(1):47-54.<br />

10. Brownell KD, Farley T, Willett WC, Popkin BM, Chaloupka<br />

FJ, Thompson JW, et al. The public health and economic benefits<br />

of taxing sugar-sweetened beverages. New Eng J Med. 2009<br />

Oct;361(16):1599-1605.<br />

<strong>11</strong>. Han E, Powell LM. Consumption patterns of sugarsweetened<br />

beverages in the United States. J Acad Nutr Diet. 2013<br />

Jan;<strong>11</strong>3(1):43-53.<br />

12. Welsh JA, Sharma AJ, Grellinger L, Vos MB. Consumption<br />

of added sugars is decreasing in the United States. Am J Clin Nutr.<br />

20<strong>11</strong> Sep;94(3):726-734.<br />

13. Escobar MAC, Veerman JL, Tollman SM, Bertram MY, Hofman<br />

KJ. Evidence that a tax on sugar sweetened beverages reduces the<br />

obesity rate: a meta-analysis. BMC Public Health. 2013 Nov;13:1072.<br />

14. Sanchez-Romero LM, Penko J, Coxson PG, Fernandez<br />

A, Mason A, Moran AE, et al. Projected impact of mexico’s sugarsweetened<br />

beverage tax policy on diabetes and cardiovascular<br />

disease: A modeling study. PLoS Med [Internet]. 2016 Nov [cited <strong>2017</strong><br />

July 6];13(<strong>11</strong>):e1002158. DOI: 10.1371/journal.pmed.1002158.<br />

15. Bes-Rastrollo M, Sayon-Orea C, Ruiz-Canela M, Martinez-<br />

Gonzalez MA. Impact of sugars and sugar taxation on body weight<br />

control: A comprehensive literature review. Obesity (Silver Spring).<br />

2016 Jul;24(7):1410-26.<br />

16. Roache SA, Gostin LO. The untapped power of soda taxes:<br />

incentivizing consumers, generating revenue, and altering corporate<br />

behavior. Int J Health Policy Manag. <strong>2017</strong> Sep;6(9):489-493.<br />

17. Singh GM, Micha R, Khatibzadeh S, Lim S, Ezzati M,<br />

Mozaffarian D. Estimated global, regional, and national disease<br />

burdens related to sugar-sweetened beverage consumption in<br />

2010. Circulation. 2015 Aug; 132(8):639-66.<br />

18. World Health Organisation Guideline: Sugars intake for adults<br />

and children [Internet]. 2015 [cited <strong>2017</strong> March 24]. Available from: http://<br />

apps.who.int/iris/bitstream/10665/149782/1/9789241549028_<br />

eng.pdf<br />

19. Dietary Guidelines Advisory Committe. Advisory report<br />

to the secretory of health and human services and the secretary<br />

of agriculture [Internet]. 2015 [cited <strong>2017</strong> March 24]. Available<br />

from: https://health.gov/dietaryguidelines/2015-scientific-report/<br />

pdfs/scientific-report-of-the-2015-dietary-guidelines-advisorycommittee.pdf<br />

20. Ludwig DS, Peterson KE, Gortmaker SL. Relation<br />

between consumption of sugar-sweetened drinks and childhood<br />

obesity: a prospective, observational analysis. Lancet. 2001<br />

Feb;357(9255):505-508.<br />

21. De Castro JM. The effects of the spontaneous ingestion<br />

of particular foods or beverages on the meal pattern and overall<br />

nutrient intake of humans. Physiol Behav. 1993 Jun; 53(6):<strong>11</strong>33-44.<br />

22. Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened<br />

beverages and weight gain in children and adults: a systematic<br />

review and meta-analysis. Am J Clin Nutr. 2013 Oct; 98(4):1084-102.<br />

23. Epstein LH, Jankowiak N, Nederkoorn C, Raynor HA, French<br />

SA, Finkelstein E. Experimental research on the relation between<br />


food price changes and food-purchasing patterns: a targeted<br />

review. Am J Clin Nutr. 2012 Apr;95(4):789-809.<br />

24. European Competitiveness and Sustainable Industrial Policy<br />

Consortium. Food taxes and their impact on competitiveness<br />

in the agri-food sector [Internet]. Rotterdam, The Netherlands;<br />

2014. Available from: http://webcache.googleusercontent.com/<br />

search?q=cache:zVN-mS-b6wEJ:ec.europa.eu/DocsRoom/<br />

documents/5827/attachments/1/translations/en/renditions/<br />

pdf+&cd=1&hl=en&ct=clnk&gl=au&client=safari<br />

25. Malik VS, Popkin BM, Bray GA, Després J-P, Hu FB. Sugarsweetened<br />

beverages, obesity, type 2 diabetes mellitus, and<br />

cardiovascular disease risk. Circulation. 2010;121(<strong>11</strong>):1356-1364.<br />

26. Nakhimovsky SS, Feigl AB, Avila C, O’Sullivan G, Macgregor-<br />

Skinner E, Spranca M. Taxes on sugar-sweetened beverages<br />

to reduce overweight and obesity in middle-income countries: a<br />

systematic review. PLoS One [Internet]. 2016 Sep [cited <strong>2017</strong> July<br />

6];<strong>11</strong>(9):e0163358. DOI: 10.1371/journal.pone.0163358.<br />

27. Bonnet C, Requillart V. Does the EU sugar policy reform<br />

increase added sugar consumption? An empirical evidence on the<br />

soft drink market. Health Econ. 20<strong>11</strong> Sep;20(9):1012-24.<br />

28. World Health Organisation. Population-based approaches<br />

to childhood obesity prevention [Internet]. 2012 [cited <strong>2017</strong><br />

October 15]. Available from: http://www.who.int/dietphysicalactivity/<br />

childhood/approaches/en/<br />

29. World Health Organisation. Global action plan for the<br />

prevention and control of non-communicable diseases [Internet].<br />

2013 [cited <strong>2017</strong> October 15]. Available from: http://www.who.int/<br />

nmh/events/ncd_action_plan/en/<br />

30. Drewnowski A, Darmon N. The economics of obesity: dietary<br />

energy density and energy cost. Am J Clin Nutr. 2005 Jul;82(1):265S-<br />

273S.<br />

31. Withrow D, Alter DA. The economic burden of obesity<br />

worldwide: a systematic review of the direct costs of obesity. Obes<br />

Rev. 20<strong>11</strong> Feb;12(2):131-41.<br />

32. Buchmueller TC, Johar M. Obesity and health expenditures:<br />

evidence from Australia. Econ Hum Biol. 2015 Apr;17:42-58.<br />

33. Anis AH, Zhang W, Bansback N, Guh DP, Amarsi Z, Birmingham<br />

CL. Obesity and overweight in Canada: an updated cost-of-illness<br />

study. Obes Rev. 2010 Jan;<strong>11</strong>(1):31-40.<br />

34. Colagiuri S, Lee CM, Colagiuri R, Magliano D, Shaw JE,<br />

Zimmet PZ, et al. The cost of overweight and obesity in Australia.<br />

Med J Aust. 2010 Mar;192(5):260-4.<br />

35. Lehnert T, Sonntag D, Konnopka A, Riedel-Heller S, König<br />

HH. Economic costs of overweight and obesity. Best Pract Res Clin<br />

Endocrinol Metab. 2013 Apr; 27(2):105-15.<br />

36. Veerman JL, Sacks G, Antonopoulos N, Martin J. The impact<br />

of a tax on sugar-sweetened beverages on health and health care<br />

costs: a modelling study. PLoS One [Internet]. 2016 Apr [cited <strong>2017</strong><br />

July 6];<strong>11</strong>(4):e0151460. DOI: 10.1371/journal.pone.0151460.<br />

37. Cobiac LJ, Tam K, Veerman L, Blakely T. Taxes and subsidies<br />

for improving diet and population health in Australia: a costeffectiveness<br />

modelling study. PLoS Med [Internet]. <strong>2017</strong> Feb [cited<br />

<strong>2017</strong> July 6];14(2):e1002232. DOI: 10.1371/journal.pmed.1002232.<br />

38. Finkelstein EA, Zhen C, Nonnemaker J, Todd JE. Impact of<br />

targeted beverage taxes on higher- and lower-income households.<br />

Arch Intern Med. 2010 Dec;170(22):2028-2034.<br />

39. Long MW, Gortmaker SL, Ward ZJ, Resch SC, Moodie ML,<br />

Sacks G, et al. Cost effectiveness of a sugar-sweetened beverage<br />

excise tax in the US. Am J Prev Med. 2015 Jul;49(1):<strong>11</strong>2-123.<br />

40. Brownell KD, Frieden TR. Ounces of prevention - the public<br />

policy case for taxes on sugared beverages. New Eng J Med. 2009<br />

Apr;360(18):1805-1808.<br />

41. Schwendicke F, Stolpe M. Taxing sugar-sweetened<br />

beverages: impact on overweight and obesity in Germany. BMC<br />

Public Health. <strong>2017</strong> Jan;17(1):88.<br />

42. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria<br />

P, et al. Priority actions for the non-communicable disease crisis.<br />

Lancet. 20<strong>11</strong> Apr; 377(9775):1438-47.<br />

43. Sharma A, Hauck K, Hollingsworth B, Siciliani L. The effects<br />

of taxing sugar-sweetened beverages across different income<br />

groups. Health Econ. 2014 Sep;23(9):<strong>11</strong>59-<strong>11</strong>84.<br />

44. Falbe J, Thompson HR, Becker CM, Rojas N, McCulloch CE,<br />

Madsen KA. Impact of the Berkeley excise tax on sugar-sweetened<br />

beverage consumption. Am J Public Health. 2016 Oct;106(10):1865-<br />

71.<br />

45. Colchero MA, Guerrerro-López CM, Molina M, Rivera JA.<br />

Beverages sales in Mexico before and after implementation<br />

of a sugar sweetened beverage tax. PLoS One [Internet]. 2016<br />

Sep [cited <strong>2017</strong> July 6];<strong>11</strong>(9): e0163463. DOI: 10.1371/journal.<br />

pone.0163463.46.<br />

46. Bollard T, Maubach N, Walker N, Ni Mhurchu C. Effects of plain<br />

packaging, warning labels, and taxes on young people’s predicted<br />

sugar-sweetened beverage preferences: an experimental study. Int<br />

J Behav Nutr Phys Act. 2016 Sep;13(1):95.<br />

47. Bíró A. Did the junk food tax make the Hungarians eat<br />

healthier? Food Policy. 2015 July;54:107-<strong>11</strong>5.<br />

48. Obesity Policy Coalition and Global Obesity Centre. Tipping<br />

the Scales: Australian Obesity Prevention Consensus [Internet].<br />

<strong>2017</strong> [cited <strong>2017</strong> October 15]. Available from: http://www.opc.org.<br />

au/tipping-the-scales.aspx<br />


Drug Control in Australia: Where to next?<br />

[Review]<br />

Raquel Maggacis<br />

Raquel Maggacis is a final year medical student at the University of Queensland. She has<br />

a keen passion for public health endeavours and hopes to one day intertwine this with a<br />

career as a medical physician.<br />

Abstract<br />

Substance use and associated disorders are increasingly recognised as a global health issue. As attitudes towards drug<br />

use disorders evolve, varying drug control policies worldwide are called into question. Nations such as the United States<br />

of America utilise the criminal justice system to place sanctions on those contravening drug control policy, which often<br />

results in cycles of incarceration, further drug use, and poverty. In contrast, Portugal has revolutionised its approach to drug<br />

control since the turn of the century by decriminalising all drugs to great effect. In view of this wide spectrum of attitudes<br />

“towards drug control, the future of Australia’s approach to drug control policy is examined.<br />

”<br />

Introduction<br />

without aiming to reduce consumption.[1] Substance use<br />

disorders are perpetuated by social stigma and thus the<br />

political context is a key determinant of long-term health<br />

outcomes.[3]<br />

Benefits and detriments of different policy approaches<br />

The International Classification of Diseases defines<br />

substance use disorders as “continuing drug consumption<br />

despite severe adverse consequences”.[1] A report by<br />

the office of National Drug Control Policy in 2010 outlined<br />

the detriments of substance use disorders using a<br />

biopsychosocial paradigm (Figure 1).[1, 2]<br />

Substance use disorders are managed through three main<br />

drug policy approaches: decriminalisation, criminalisation,<br />

and harm minimisation. Decriminalisation involves prohibiting<br />

and regulating drugs but excluding sanctions from criminal<br />

law jurisdiction, whereas criminalisation is the attribution<br />

of criminal offences to drug-related activities.[3, 4] Harm<br />

minimisation strives to decrease adverse consequences<br />

Criminalisation of drugs, and the subsequent incarceration<br />

of drug users, provides the immediate benefit of removing the<br />

individual from an environment that exacerbates their drug<br />

use, and prevents the community from being threatened<br />

by drug-affected behaviour. Additionally, incarceration<br />

allows the government to demonstrate the work being<br />

done to tackle drugs in a manner that is tangible and easily<br />

understood by the general public. However, punitive drug law<br />

enforcement alone may fail to address or even worsen health<br />

Figure 1: The biopsychosocial adverse outcomes related to substance use disorders [1, 2]<br />


complications of drug use. It can marginalise populations at<br />

risk of poorer health and increase barriers to seeking health<br />

services, as illustrated by the growing epidemic of HIV/AIDS<br />

and hepatitis C amongst injecting drug users.[5] Moreover,<br />

drug law enforcement has minimal impact on the drug market<br />

itself, although there is some evidence that it may alleviate a<br />

degree of associated harm.[1, 6]<br />

Advantages of the harm minimisation approach include<br />

curbing the progression of the HIV/AIDs epidemic through<br />

safe needle programs and deterring criminal behaviours.[1,<br />

7] This is achieved through demand and supply reduction,<br />

prevention campaigns, and improved access to treatment<br />

and harm reduction.[8] Critiques of this approach include<br />

maintaining demand for the illicit drug market, and ineffectively<br />

addressing all biopsychosocial facets of substance use<br />

disorders.[8]<br />

“Decriminalisation addresses substance<br />

use disorders in a biopsychosocial context<br />

and identifies it as a key public health issue”<br />

The main benefit of decriminalisation is that it reframes<br />

drug use as a public health problem, which allows for<br />

reallocation of funds from drug-related criminal justice<br />

proceedings and the prison system to rehabilitation services<br />

focusing on long-term health outcomes.[3] This, coupled with<br />

a shift in criminal justice focus to high-level drug offenders,<br />

ultimately results in less drug use and better long-term<br />

health outcomes.[3] Decriminalisation addresses substance<br />

use disorders in a biopsychosocial context and identifies<br />

it as a key public health issue, both key steps in arresting<br />

the perpetuation of stigma which only serves to isolate drug<br />

users from health services.[3] Criticisms of decriminalisation<br />

include potential for increased accessibility to drugs and a<br />

cheaper street value, which could result in increased uptake<br />

of drug use.[9]<br />

In 2009, Antonio Costa, the executive director of the<br />

United Nations Office on Drugs and Crime, affirmed that<br />

“drug use should be treated as an illness in need of medical<br />

help”, and appealed for universal access to drug treatment.[2]<br />

In 20<strong>11</strong>, the Global Commission on Drug Policy emphasised<br />

that it was time to “end the criminalization, marginalization<br />

and stigmatization of people who use drugs but who do<br />

no harm to others”.[1] The World Health Organization and<br />

the United Nations echoed this view in their joint statement<br />

published in June <strong>2017</strong>, stating that to ignore such a call to<br />

“[review] and [repeal] punitive laws...[including] drug use or<br />

possession of drugs for personal use” would be to “[violate]<br />

the most fundamental human rights protected in international<br />

treaties and in national laws and constitutions”.[10] This<br />

strong stance against discrimination in health care settings<br />

reflects the global shift in attitudes towards drug policy, from<br />

incarceration to rehabilitation of drug offenders.<br />

Drug control approaches worldwide<br />

Criminalisation: the United States<br />

The United States (US) has a strong stance of<br />

criminalisation towards illicit drugs and has a low threshold<br />

to prosecute drug offenders.[3] Its prison population<br />

has increased by almost 800% since 1980, in marked<br />

disproportion to its population growth, with 47% of all<br />

inmates imprisoned for drug-related crimes, and many with<br />

drug use disorders.[3] In 2010 alone, US $80 billion was<br />

spent on continuing incarceration of inmates.[3] Drug users,<br />

possessors and traffickers are treated equally in this criminal<br />

system, with mandatory minimum prison sentences.[3]<br />

Without adequate rehabilitation services or emphasis on<br />

drug use and use disorders as a public health issue, the high<br />

rates of recidivism are unsurprising, often resulting in a cycle<br />

of criminality, incarceration and poverty, with subsequent<br />

economic burden on the community.[3] This is an issue fuelled<br />

by media sensationalism, portraying drug law enforcement in<br />

an enamouring light with dramatic drug busts and arrests,<br />

acting only to perpetuate fear within the general population.<br />

Where drug courts - legal committees which redirect nonviolent<br />

drug offenders from incarceration to treatment - have<br />

been trialled in the US, they have proven to decrease crime<br />

rates (7-14%) and recidivism (up to 35%), and improving<br />

rehabilitation uptake, treatment outcomes and stability of the<br />

family unit.[2] Such models are estimated to reduce health<br />

care costs related to substance use disorders by US $4 for<br />

every US $1 spent.[2]<br />

“This is an issue fuelled by media<br />

sensationalism, portraying drug law<br />

enforcement in an enamouring light with<br />

dramatic drug busts and arrests, acting<br />

only to perpetuate fear within the general<br />

population.”<br />

While marijuana is considered illicit under US federal law,<br />

states are able to make independent laws, which are only<br />

disregarded in cases concerning juveniles, cross-border<br />

trafficking, or organised crime.[9, <strong>11</strong>] Presently, over half of<br />

American states have legalised medicinal marijuana, and<br />

eight have further allowed recreational use.[9] Given the<br />

relatively recent legalisation of marijuana, data on its impact<br />

on usage patterns is currently conflicting, and more time is<br />

required for reliable assessment.[9] Studies have indicated<br />

that diversion of black market marijuana from legalised to<br />

criminalised states is likely to decrease marijuana prices,<br />

although the degree and impact of this is uncertain.[12, 13]<br />

Notably, there are significant economic benefits associated<br />

with the legalisation of marijuana.[9] In Colorado, where<br />

recreational marijuana use is legal, marijuana tax and<br />

licensing fees have been implemented, together generating<br />

over US $70 million in the first year alone.[9] This revenue was<br />

subsequently funnelled into school construction and youth<br />


and substance use programs).[9]<br />

Criminalisation: Central Asia<br />

Central Asian countries, such as Tajikistan, Kazakhstan,<br />

and Uzbekistan, have adopted an increasingly stringent<br />

approach to drugs.[14] In the year following the September<br />

<strong>11</strong> attacks, these countries received US $187.5 million<br />

from the US government to improve border control, counterterrorism<br />

measures and counter-narcotics initiatives.[14]<br />

Between 2004 and 2007, a strong criminal justice-based<br />

approach was further reinforced in Central Asia with funding<br />

from international agencies, other foreign governments and<br />

national budgets directed to legal action against drug use.<br />

[14]<br />

Further, national campaigns in Central Asia often label<br />

drug users as evil, increasing the stigma and discrimination<br />

which perpetuates cycles of drug use.[15] Little or no<br />

rehabilitation or treatment is available for substance users,<br />

with such countries preferring a model of criminalisation and<br />

incarceration.[14] For example, opioid substitution treatment<br />

is prohibited in Tajikistan and Turkmenistan, minimally<br />

available in Uzbekistan and Kyrgyzstan, and non-existent in<br />

Kazakhstan.[14] The lack of treatment for drug users and<br />

increasing accessibility of opiates has resulted in a growing<br />

HIV epidemic in Central Asian prison systems with poor longterm<br />

health outcomes.[14]<br />

Decriminalisation: Portugal<br />

Prior to 2001, drug use was criminalised in Portugal,<br />

yet rates of heroin use and drug trafficking continued to<br />

increase.[3] Consequently, the Portuguese government<br />

drafted a law decriminalising all drugs purchased, possessed<br />

or consumed for personal use. This law also had a public<br />

health focus towards rehabilitating those with substance<br />

use disorders, and a punitive focus towards high-level drug<br />

trafficking. This involves a committee of two medicallytrained<br />

persons and one legally-trained person, deciding first<br />

whether an offence is protected by this law, and then whether<br />

the offender is suffering from a drug use disorder.[3] This law<br />

only aimed to decriminalise low-level drug offences; strict<br />

laws remain against high-level offenders and drug traffickers<br />

who propagate this vicious cycle and endanger the general<br />

community.[16]<br />

After this law was passed,<br />

Portugal reduced its burden on the<br />

criminal-justice system, allowing<br />

more funding allocation towards<br />

public health endeavours, including<br />

prevention campaigns, treatment,<br />

and facilities.[17] Treatment<br />

uptake consequently increased,<br />

resulting in decreasing rates of drug-associated illnesses.[4,<br />

18] During the four years following decriminalisation in 2000<br />

to 2006, there was a significant decrease in the incidence<br />

of new cases of HIV/AIDS amongst drug users in Portugal,<br />

from almost 1400 to 400 persons.[18] Decreased rates of<br />

new hepatitis B and C infections have also been evident,<br />

attributed to the improved treatment and rehabilitation<br />

programs afforded by decriminalisation.[17, 18] Moreover,<br />

“...a staggering 400 Australians die yearly<br />

from heroin overdose, and most areas have<br />

a demand for substitution products far outweighing<br />

the supply”<br />

absolute numbers of drug-related deaths by each prohibited<br />

substance decreased; the total number of drug-related<br />

deaths decreased from 400 in 1999 to 290 in 2006.[18]<br />

Importantly, while some speculated that decriminalisation<br />

would lead to lower prices of drugs and subsequent<br />

higher rates of usage, the cost of drugs did not decrease.<br />

[19] In fact, the rates of cannabis and cocaine use after<br />

decriminalisation have been three times lower than before.<br />

[18] Further, data extrapolations have predicted lower lifetime<br />

prevalence rates of drug use for almost all drug categories<br />

post-decriminalisation.[18]<br />

Decriminalisation: West Africa<br />

West African countries must contend with both<br />

international drug cartels and the growing transit of illicit<br />

substances to Europe and North America. Consequently, local<br />

consumption of illicit substances has increased, especially<br />

among younger persons, with significant economic, health<br />

and social consequences.[20] While data is scarce, in 2008 it<br />

was estimated there were 1.8 million intravenous drug users<br />

in Sub-Saharan Africa, of whom 12% were thought to be living<br />

with HIV.[20, 21]<br />

In 2014, the West Africa Commission on Drugs published<br />

a declaration specifically stating that “criminalisation of drug<br />

use worsens health and social problems, puts huge pressures<br />

on the criminal justice system and incites corruption”, and<br />

that “drug use must be regarded primarily as a public health<br />

problem”, mirroring the movements of Portugal.[20] Despite<br />

these recommendations, there is currently no evidence<br />

that any West African countries have been successful in<br />

implementing drug decriminalisation policies.<br />

Drug policy in Australia and the way forward<br />

In 1985, the Australian Government adopted an official<br />

national drug policy of harm minimisation.[1] In the 2002-<br />

03 financial year, the Australian Government allocated $3.2<br />

billion to managing illicit drugs, 75% of which was spent on<br />

drug law enforcement, aiming to decrease drug and drugrelated<br />

crime, and improve public health and safety.[1,<br />

16] Despite this investment, a staggering 400 Australians<br />

die yearly from heroin overdose, and most areas have<br />

a demand for substitution products far out-weighing the<br />

supply, notwithstanding the costly<br />

co-payment.[1] The methadone<br />

substitution program and syringe<br />

exchange services available in<br />

Australia have made an impact, yet<br />

with a growing affected population<br />

and the root cause unaddressed,<br />

the need is largely unmet.[1]<br />

Harm minimisation still perpetuates discrimination and<br />

marginalisation of drug users, instead, decriminalisation can<br />

reduce stigma and is essential to better health outcomes.[3]<br />

The Australia21 report, published in 2012, was effective<br />

in initiating a debate on drug reform. The report not only<br />

illustrated the harmful effects of criminalising possession<br />

and personal use on drug-dependent individuals in an<br />


Australian context, but also highlighted the potential health<br />

benefits of some currently illicit drugs.[1, 8] This report left<br />

Australians to decide which legal system would allow for<br />

better biopsychosocial health and economic stability for<br />

the community with respect to those consuming drugs –<br />

rehabilitation or incarceration.<br />

Australia should act to follow countries like Portugal<br />

that have prospered from revolutionising drug policy with<br />

respect to low-level offences and reform to decriminalise<br />

all drugs. As supported by the Global Commission on Drug<br />

Policy, a move towards decriminalisation of low-level drug<br />

offenses in Australia would allow for decreased economic<br />

burden on the criminal justice system, reallocation of funds<br />

to drug rehabilitation programs, and a sharpened focus on<br />

the illegality of high-level drug trafficking offenses.[3] Viewing<br />

drug use as a public health problem is the key first step to<br />

reducing stigma and consequently improving access to<br />

treatment and long-term health outcomes.<br />

Conclusion<br />

Criminalisation marginalises those afflicted with drug use<br />

disorders, who are already burdened with significant health,<br />

social and economic disadvantage. Where there is demand,<br />

there is supply, and tackling drug use disorders with criminal<br />

law is simply too late to create a meaningful impact on the<br />

individual or society at large. Poverty breeds poverty; while<br />

incarceration may remove the immediate threat from society,<br />

it does nothing to address the root cause.<br />

Substance use disorders are a medical condition and<br />

public health problem, not a moral choice. Epitomised<br />

by Portugal, decriminalisation of drugs and rehabilitation<br />

fortifies a community, not just immediately, but with long-term<br />

positive effects in the workforce and crime rates, spanning<br />

generations. Substance use disorders, therefore, need to be<br />

reframed from a criminal, punitive problem, to one befitting<br />

the biopsychosocial model of health. Fortunately, throughout<br />

the world this is increasingly becoming the case.<br />

Acknowledgements<br />

Sophie Lim, <strong>Vector</strong> Associate Editor<br />

IDEAS Working Paper Series from RePEc. <strong>2017</strong>.<br />

5. Elliott R, Csete J, Palepu A, Kerr T. Reason and rights in global<br />

drug control policy. CMAJ. 2005;172(5):655-6.<br />

6. Mazerolle L, Soole DW, Rombouts S. Street-level drug law<br />

enforcement: A meta-analytical review. Journal of Experimental<br />

Criminology. 2006;2(4):409-35.<br />

7. Webster IW. Managing legal and medical complexities in<br />

caring for people with drug and alcohol problems: a call for change.<br />

Med J Aust. 2016;204(4):141-2.<br />

8. The prohibition of illicit drugs is killing and criminalising<br />

our children and we are all letting it happen. [press release].<br />

Canberra2012.<br />

9. Homel PB, Rick. Marijuana legalisation in the United States:<br />

An Australian perspective. Canberra: Australian Institute of<br />

Criminology; <strong>2017</strong> June <strong>2017</strong>.<br />

10. Joint United Nations statement on ending discrimination in<br />

health care settings [press release]. World Health Organisation<strong>2017</strong>.<br />

<strong>11</strong>. Adler J. Symposium Marijuana, Federal Power, and the States:<br />

Introduction. Case Western Reserve Law Review. 2015;65(3):505-<br />

12.<br />

12. Caulkins JP, Bond BM. Marijuana Price Gradients. Journal of<br />

Drug <strong>Issue</strong>s. 2012;42(1):28-45.<br />

13. Hall W, Weier M. Assessing the public health impacts of<br />

legalizing recreational cannabis use in the USA. Clin Pharmacol<br />

Ther. 2015;97(6):607-15.<br />

14. Latypov A. Understanding post 9/<strong>11</strong> drug control policy and<br />

politics in Central Asia. Int J Drug Policy. 2009;20(5):387-91.<br />

15. Wolfe D. Paradoxes in antiretroviral treatment for injecting<br />

drug users: access, adherence and structural barriers in Asia and<br />

the former Soviet Union. Int J Drug Policy. 2007;18(4):246-54.<br />

16. Willis K. Measuring the effectiveness of drug law enforcement.<br />

Trends and <strong>Issue</strong>s in Crime and Criminal Justice. 20<strong>11</strong>;406(1):1-7.<br />

17. Hughes CE, Stevens A. What Can We Learn From The<br />

Portuguese Decriminalization of Illicit Drugs? British Journal of<br />

Criminology. 2010;50(6):999-1022.<br />

18. Greenwald G. Drug Decriminalization in Portugal: Lessons for<br />

Creating Fair and Successful Drug Policies. Washington, DC: Cato<br />

Institute; 2009.<br />

19. Felix S, Portugal P. Drug decriminalization and the price of<br />

illicit drugs. Int J Drug Policy. <strong>2017</strong>;39:121-9.<br />

20. Drugs WACo. Not Just in Transit: Drugs, the State and Society<br />

in West Africa. West Africa Commission on Drugs; 2014.<br />

21. Mathers BMD, Louisa; Phillips, Benjamin; Wiessing, Lucas;<br />

Hickman, Matthew; Strathdee, Steffanie A; Wodak, Alex; Panda,<br />

Samiran; Tyndall, Mark; Toufik, Abdalla; Mattick, Richard P. Global<br />

epidemiology of injecting drug use and HIV among people who inject<br />

drugs: a systematic review. The Lancet. 2008;372(9651):1733-45.<br />

Conflict of Interest<br />

None declared<br />

Correspondance<br />

raquel.maggacis@uqconnect.edu.au<br />

References<br />

1. Wodak AD. The need and direction for drug law reform in<br />

Australia. The Medical Journal of Australia. 2012;197(6):312-3.<br />

2. Madras BK. Office of National Drug Control Policy: a scientist<br />

in drug policy in Washington, DC. Ann N Y Acad Sci. 2010;<strong>11</strong>87:370-<br />

402.<br />

3. Sapp CE. Rehabilitate or incarcerate? A comparative analysis<br />

of the United States’ sentencing laws on low-level drug offenders<br />

and Portugal’s decriminalization of low-level drug offenses. Cardozo<br />

Journal of International & Comparative Law. 2014;23(1):63-97.<br />

4. Félix S, Portugal P, Tavares A. Going after the Addiction, Not<br />

the Addicted: The Impact of Drug Decriminalization in Portugal.<br />


Dengue in the Pacific Islands<br />

[Review]<br />

Madeleine Marsland and Dunya Tomic<br />

Madeleine is a fourth year medical student who is interested in global health and research.<br />

She combines these interests in her role as Chief of Editorials and Publications<br />

for the Pacific Medical Students’ Association, and is also undertaking research with the<br />

Department of Anatomy and Developmental Biology at Monash University. She hopes<br />

to pursue global health research and policy.<br />

Dunya is a fourth year medical student at Monash University with a particular interest<br />

in clinical research and medical ethics. She hopes to one day combine this with a<br />

career as a physician.<br />

Abstract<br />

Without a fully effective vaccine, prophylactic measures, or sufficient treatment options, dengue has emerged as a significant<br />

global health threat. The Pacific Islands are particularly susceptible to dengue as they provide favourable conditions for<br />

the Aedes mosquito population, the vector responsible for spreading the virus. Strong public health protocols with an<br />

emphasis on vector control are considered to be the best way to combat dengue in this region. However, for a variety of<br />

social, economic, environmental and political factors, vector surveillance and control mechanisms are failing. This review<br />

seeks to provide an overview on the emergence of dengue in the Pacific Islands, why this region is susceptible due to virus<br />

“and vector factors, and what has been done and can be done in the future to contain the dengue threat in this region.<br />

Introduction<br />

Dengue virus is a vector-borne disease primarily<br />

spread by the Aedes mosquito population; it is one of the<br />

most significant infectious diseases that remains without<br />

definitive prevention or treatment options. Due to a variety<br />

of environmental and social factors, the Pacific Islands are<br />

particularly susceptible to dengue and other arbovirus.[1,<br />

2] This has significant associated morbidity, mortality and<br />

economic cost, particularly when patients contract ‘severe<br />

dengue’.[1-3] A diagnosis of dengue can be based on clinical<br />

signs and/or laboratory diagnosis, whilst a diagnosis of ‘severe<br />

dengue’ is based on serious complications including plasma<br />

leakage, severe haemorrhage or severe organ impairment.[3]<br />

These clinical manifestations and complications of dengue<br />

can cause severe illness, particularly in susceptible patient<br />

groups including children.[3]<br />

Treatment options are limited particularly in resource<br />

poor settings, and thus preventing dengue and recognising<br />

outbreaks is critical.[3] Dengvaxia, a world-first dengue<br />

vaccine, has recently been approved for use in endemic<br />

settings, with the World Health Organization recommending<br />

high-risk nations implement it as part of their vaccination<br />

program.[4-6] However, the vaccine has variable levels of<br />

efficacy, and is not yet considered a cost-effective solution.<br />

[5, 6] Whilst dengue remains a growing threat, the Pacific<br />

Island region must urgently develop alternative cost-effective<br />

diagnostic, detection, treatment and prevention strategies.[4,<br />

7, 8]<br />

Methods<br />

The intended focus of this literature review was dengue<br />

in the Pacific Island region. An Ovid MEDLINE search was<br />

conducted combining the search terms “Dengue”, “Aedes”<br />

and “Pacific”. Grey literature and data was also sourced from<br />

the World Health Organization (WHO) and other non-profit<br />

organisations. Additional resources were identified through<br />

analysing the articles retrieved through these searches.<br />

Epidemiology<br />

”<br />

Prevalence<br />

Dengue has been reported in several Pacific Island<br />

nations since the 1950s, but in the past decade the incidence<br />

has grown exponentially.[1, 9] Whilst in 2000 there was only<br />

50 reported cases per 1000 people, by 2012 this had grown<br />

to 350 per 1000.[1] It is difficult to determine reliable data<br />

on the endemic levels of dengue in the Pacific Islands, as<br />

this depends on accurate and timely reporting to the Pacific<br />

Public Health Surveillance Network, still under development.<br />

[2] However, whilst dengue is not endemic in all Pacific Islands,<br />

it is emerging in previously untouched islands including the<br />

Solomon Islands and Papua New Guinea.[9] From 2016 to<br />

<strong>2017</strong> alone, there has been an unusual increase in dengue<br />


Table 1: Dengue Serotypes and Epidemiology<br />

DENV Serotype Notable related epidemiology and outbreaks<br />

DENV-1<br />

The most prominent serotype in 2012-2013, causing the largest-ever documented<br />

outbreak affecting New Caledonia.[21]<br />

DENV-2 Caused recent outbreaks in Tuvalu and a current outbreak in Samoa.[10, 22]<br />

DENV-3<br />

After 18 years of absence, has recently become the dominant serotype in the<br />

Pacific islands causing five ongoing outbreaks [23].<br />

DENV-4 Caused one outbreak since 2012, is rare in the Pacific Islands [10].<br />

illness reported in the Solomon Islands, Vanuatu, Fiji and<br />

Palau.[10] With this growth, some reports indicate that the<br />

vast majority of the Pacific Island population will be infected<br />

at some point in their lives.[1] In Samoa, one study showed<br />

96% of the population tested positive for IgG antibodies,<br />

indicating prior infection.[<strong>11</strong>] With 89% of 18-25 year olds<br />

testing positive, this demonstrated that most Samoans first<br />

contracted dengue during childhood, when dengue illness is<br />

more likely to be fatal.[7, <strong>11</strong>]<br />

Outbreaks<br />

Dengue typically follows an epidemic pattern with 1 of<br />

the 4 serotypes causing outbreaks across the Pacific every<br />

three to five years. However, the number of outbreaks of<br />

concurrent serotypes has been growing.[2] After an outbreak<br />

of a single serotype, this strain of the virus tends to circulate<br />

throughout the region until the next outbreak of a different<br />

strain occurs.[12] A single outbreak can affect a large portion<br />

of the population, with the 2009 outbreaks affecting 14<br />

Pacific nations.[13] During such outbreaks, complications<br />

increase, placing a burden on hospital resources, with 4%<br />

of the Federated States of Micronesia’s population requiring<br />

hospitalisation during the Kosrae state outbreak.[14] The<br />

frequency of outbreaks appears to be increasing,[4] though<br />

this may be due to improved surveillance.<br />

The virus<br />

Dengue virus (DENV) is a single-stranded, positivesense<br />

RNA virus of the Flavivirus genus.[15] There are<br />

four serotypes DENV-1 to DENV-4. Though they only share<br />

65% of their genomes, their clinical syndromes are nearly<br />

identical, and they all occupy the same ecological niche.<br />

[16, 17] Dengue epidemics usually result from introduction of<br />

a single serotype from hyper-endemic countries, which will<br />

remain dominant in the region for several years.[12,18,19]<br />

However, in 2012, outbreaks of all four DENV serotypes were<br />

noted in a single year [20]. Each DENV serotype has caused<br />

outbreaks or been prevalent in the Pacific Islands at various<br />

times (Table 1).<br />

Repeated infection of DENV of the same serotype is<br />

associated with increase risk of progressing to severe<br />

dengue, which is associated with higher morbidity and<br />

mortality if left untreated.[24] Those living in endemic areas<br />

such as the Pacific Islands are at an increased risk of being<br />

reinfected and thus complications are more common.<br />

The <strong>Vector</strong><br />

Dengue, zika, chikungunya and other arboviruses are<br />

transmitted to humans through the bites of infected Aedes<br />

mosquitoes.[25] Aedes aegypti is the primary vector in the<br />

Pacific Islands and is widespread across the region except<br />

for Futuna and other isolated islands.[26,27] Aedes aegypti is<br />

associated with human migration and urbanisation, enabling<br />

it to be dominant in the region, however, Aedes albopictus,<br />

Aedes polynesiensis and nine other potential vectors have<br />

also been identified in the Pacific Islands.[27, 28]<br />

Aedes mosquitoes begin their transmission cycle upon<br />

acquiring the dengue virus from the blood of a viraemic<br />

person; the virus then replicates in mosquito midgut<br />

epithelium before shedding its progeny into the haemocoel,<br />

which then disseminates into secondary target tissues such<br />

as salivary glands.[29] During the next feeding event, the<br />

mosquito transmits the virus to the host through saliva.[29,30]<br />

Aedes aegypti is capable of repeatedly transmitting the virus<br />

through this process irrespective of its number of hosts.[30]<br />

The introduction of Aedes aegypti into different islands has<br />

been spurred by human migration; there have been intense<br />

population migrations in the Pacific Islands since European<br />

colonization.[31] Though the first dengue epidemic in the<br />

Pacific Islands was reported in the 1880s, descriptions of<br />

Aedes aegypti didn’t emerge until the 1960s in Fiji and Tonga.<br />

[20, 32, 33] Aedes aegypti then spread during World War II,<br />

when travel between the Pacific Islands and Asia, Europe,<br />

and America became more frequent.[34] Recent studies<br />

have now identified genetic variability in nine locations<br />

across Fiji, New Caledonia, Tonga and French Polynesia,<br />

suggesting a link between human migration and Aedes<br />

aegypti populations, possibly related to island isolation and<br />

environmental conditions.[25]<br />

Several factors influence the transmission of DENV<br />

from mosquitoes to humans, including climate.[30] Higher<br />

temperatures enable the virus to replicate in higher<br />

concentrations, enhancing the vectors’ risk for pathogen<br />

transmission and contributing to the high prevalence of<br />

dengue infection in the tropical Pacific Islands[30] Globally,<br />

climate-induced variations in modelled Aedes aegypti<br />

populations were strongly correlated to historical dengue<br />

cases between 1958 to 1995.[35] Recent research from New<br />

Caledonia, where dengue spread by Aedes aegypti is a major<br />


public health problem, showed that the epidemic dynamics of<br />

dengue were predominantly driven by climate in the last forty<br />

years.[36] Another study found a positive correlation between<br />

dengue infection and El Nino southern oscillation in ten<br />

countries, with evidence of infection spreading from larger<br />

islands to smaller surrounding islands.[37] It is predicted that<br />

global warming will increase the latitudinal and altitudinal<br />

distribution of Aedes aegypti and subsequently DENV.[38,39]<br />

Dengue Surveillance Methods<br />

Dengue surveillance and tracking is essential to enable<br />

timely epidemic responses.[8] Though representatives from<br />

the Pacific Islands believe there is adequate surveillance<br />

infrastructure and systems, governments have not<br />

emphasised prevention. These systems must be strengthened<br />

to more accurately track dengue epidemiological data [8, 40].<br />

Given financial difficulties, this may be better accomplished<br />

through alternative mechanisms.<br />

One such alternative is the transport of serum and blood<br />

samples internationally.[41] When a new serotype emerges<br />

in one Pacific country, this is often followed by outbreaks in<br />

neighbouring countries [42]; using blood samples to identify<br />

emerging serotypes enables surveillance of viral spread<br />

across the region. Filter paper (FP)-dried blood spots have<br />

minimal health risk and so are not bound by dangerous<br />

goods regulations present in several Pacific nations [43].<br />

Blood spiked with cultured DENV can be blotted on FP-cards<br />

and the serotype determined using reverse-transcriptase<br />

polymerase chain reaction.[44]. The serotype and genotype<br />

of DENV can be identified using FP-dried serum even after<br />

being transported over thousands of kilometres at tropical<br />

temperatures.[41] This method of surveillance particularly<br />

useful in the Pacific Islands, where samples may need to be<br />

transported over long distances.<br />

Another method to monitor dengue levels is the use of<br />

international travellers as ‘sentinels’, so that the risk of dengue<br />

infection can be estimated through proxies who travelled to<br />

particular areas.[45] Patterns of local dengue incidence in<br />

the Pacific Islands were shown to be closely correlated with<br />

patterns of dengue incidence imported from the Pacific to<br />

New Zealand.[46] However, this method is more commonly<br />

retrospective and cannot provide an indication of outbreaks.<br />

A combination of both methods could be implemented to<br />

cheaply and effectively improve dengue surveillance in the<br />

regions.<br />

Dengue Prevention and Control, Now and in the Future<br />

Strategies and Policies<br />

Many nations have been attempting to meet the<br />

WHO infectious disease strategy objectives (Figure 1) by<br />

implementing policies that address vector surveillance,<br />

health education for vector control and dengue prevention,<br />

and emergency response capacity.[8] However, an urgent<br />

policy review to combat dengue is needed, with a focus on<br />

emphasising dengue in climate change and environmental<br />

medicine policies.[48] It is also essential that dengue is<br />

classed as a notifiable disease across all Pacific Islands<br />

through legislation.[48]<br />

A Dengue Vaccine<br />

Although several live-attenuated dengue vaccines are<br />

undergoing phase III clinical trials, currently Dengvaxia (CYD-<br />

TDV) is the only vaccine that is licensed and registered for use<br />

in individuals aged 9-45 years and living in dengue endemic<br />

areas.[40] Modelling has shown that Dengvaxia would only<br />

have the highest net benefit and be most cost-effective if the<br />

majority of the population is vaccinated in dengue-endemic<br />

nations.[52] The WHO has recommended that nations with<br />

a high burden of disease, defined as seroprevalence >70%<br />

in 9 year-olds, introduce the vaccine.[4, 1] However, many<br />

nations worldwide are still debating this, and Dengvaxia is not<br />

currently licensed for use in Pacific Island nations.[5, 51]<br />

From the two major phase III clinical trials for Dengvaxia,<br />

overall vaccine efficacy against severe dengue was 79%,<br />

however, this varied by serotype, age at vaccination, and<br />

previous dengue infection.[52] For those with a previous<br />

dengue infection, vaccination efficacy was 78%, however, it<br />

was only 38% for those with no prior infection.[52] In fact, a<br />

study has shown that Dengvaxia can also increase the risk of<br />

hospitalisation when seronegative individuals are vaccinated<br />

and later experience natural secondary dengue infection.<br />

[51] The pooled efficacy for those older than 9 years old was<br />

higher than those under 9 years of age, who have a higher<br />

risk of severe dengue (66% vs 44%).[3, 52] Finally, in terms<br />

of serotype, vaccine efficacy was shown to be higher against<br />

Figure 1: Outline of the World Health Organization Infectious Disease Strategy [47]<br />


serotypes 3 (72%) and 4 (77%) than for serotypes 1 (55%)<br />

and 2 (43%).[52]<br />

Further study is ongoing to determine whether dengue<br />

illness and hospitalisation has reduced in nations that have<br />

implemented Dengvaxia.[53, 54] However, with varying<br />

efficacy, and questions regarding long-term safety and<br />

cost-effectiveness, it is predicted that vaccination will only<br />

be possible in the Pacific Islands if it is priced competitively.<br />

[53, 54] Thus, for the time being, vector control will remain the<br />

focus of dengue control strategy in the Pacific Islands, with<br />

the aim of integrating vaccination once it is more efficacious<br />

and cost-effective.[55] At present, it is far more affordable<br />

and effective to combat dengue by improving vector control<br />

mechanisms, and vaccination will be most useful as an<br />

adjunct if appropriate for specific nations.<br />

<strong>Vector</strong> Control: Currently Used Methods<br />

<strong>Vector</strong> control currently offers the best option for<br />

preventing dengue, but delivery of prevention programmes<br />

in the Pacific Islands is often inefficient, ineffective or both.<br />

[7] Several mechanisms exist in various Pacific Islands to<br />

control outbreaks once they occur, however some of the<br />

most common efforts, such as pesticide spraying, have<br />

limited effectiveness.[56]<br />

Factors that increase the risk of dengue transmission have<br />

included poor household drainage and hygiene problems,<br />

issues that can be addressed by health education programs<br />

to build a ‘prevention attitude’ among Pacific residents.[57,<br />

58] However, it is believed that improving health education,<br />

awareness campaigns and technical support is necessary<br />

to ensure successful vector control.[8] Environmental factors<br />

such as buckets of stagnant water, allowing mosquitoes to<br />

breed, and host larvae and pupae, are other key risk factor<br />

which could be targeted through education campaigns.<br />

[59] Chemical treatment of breeding sites, insecticide<br />

spraying and biological control by introducing predators are<br />

mechanisms already utilised by some Pacific Islands which<br />

could be further implemented for vector control in the future.<br />

[60]<br />

<strong>Vector</strong> Control: Innovative Approaches<br />

Novel vector-based approaches aimed at controlling<br />

dengue include the use of obligate intracellular bacterium<br />

Wolbachia pipientis,[61] which interferes with reproduction in<br />

over 40% of insect species.[62] Although Wolbachia does not<br />

occur naturally in Aedes aegypti species, transinfection has<br />

been shown to be successful.[63] Recent studies in Cairns,<br />

Australia have shown stable transinfection of natural A.<br />

aegypti populations with the wMel strain of Wolbachia, rising<br />

to near-fixation within a matter of months and remaining<br />

established in those field sites unaided.[64] The antiviral<br />

activity of wMel has shown to be highly effective in laboratory<br />

studies even one year after field release.[65] The evidence<br />

supports the long-term stability of Wolbachia against the<br />

dengue virus, however, the effects on reduction of human<br />

disease in dengue-endemic regions is yet to be established,<br />

this is currently under investigation in Indonesia and Vietnam.<br />

[61]<br />

Another promising vector control method is the sterile<br />

insect technique (SIT), which has historically been successful<br />

against a multitude of agricultural pests.[66] In the 1960s,<br />

large-scale SIT programs enabled the elimination of A.<br />

aegypti from 23 American countries.[67] SIT has recently<br />

re-emerged as a vector control strategy due to innovative<br />

technological advances including genetic modification<br />

of mosquitoes.[68] Using SIT, Cuba has come close to the<br />

eradication of A. aegypti [69] and Singapore has kept levels<br />

of the mosquitoes down for more than 30 years.[70] Though<br />

neither of these methods is currently used widely in Pacific<br />

Islands, these innovative strategies are potential costeffective<br />

vector reduction methods.<br />

Emergency Response Capacity<br />

There is a significant need to grow emergency-response<br />

and outbreak-response to combat dengue.[8] Currently, the<br />

WHO and Red Cross manage the majority of outbreak control,<br />

both logistically and financially[14, 71] The Pacific Public<br />

Health Surveillance Network has provided some support in<br />

capacity building, and multiagency response teams have<br />

successfully been implemented during some outbreaks,<br />

but there remains a need to engage Pacific Directors and<br />

Ministers of Health to help prepare these multidisciplinary<br />

response teams for future outbreaks.[2, 14]<br />

Conclusion<br />

Dengue remains a significant threat in the Pacific Islands,<br />

with prevalence levels and the number of outbreaks continuing<br />

to increase. Until Dengvaxia or another dengue vaccine has<br />

a proven cost-effective public health benefit beyond the<br />

currently calculated values, it is unlikely to be deployed in<br />

Pacific Islands.[5, 51] The best hope for containing dengue<br />

is by improving region-wide surveillance and cost-effective,<br />

sustainable vector control mechanisms [6-8]. This requires<br />

Pacific Island governments to integrate dengue prevention<br />

into their environmental and public health policy, and work to<br />

improve vector surveillance and control methods, which may<br />

involve implementing innovative approaches [8, 48]. Another<br />

area that requires significant improvement is outbreak<br />

response, and upskilling all Pacific doctors to appropriately<br />

respond to dengue outbreaks [8, 60]. Ultimately, until the<br />

objectives outlined by the WHO are addressed, dengue<br />

will remain a growing challenge in the Pacific Islands.<br />

[7, 47] These islands must engage with the growing body<br />

of organisations working in the region to develop new and<br />

innovative surveillance and control approaches and combat<br />

dengue in the future.[7]<br />

Conflicts of interest<br />

None declared<br />

Correspondance<br />

dtom4@student.monash.edu<br />

References<br />

1. Arima Y, Chiew M, Matsui T. Epidemiological update on the<br />

dengue situation in the Western Pacific Region, 2012. Western<br />

Pacific Surveillance and Response Journal. 2015;6(2):82-89.<br />

2. Roth A, Mercier A, Lepers C, Hoy D, Duituturaga S, Benyon E<br />


et al. Concurrent outbreaks of dengue, chikungunya and Zika virus<br />

infections – an unprecedented epidemic wave of mosquito-borne<br />

viruses in the Pacific 2012–2014. Eurosurveillance. 2014;19(41):1<br />

- 8.<br />

3. Dengue Guidelines for Diagnosis, Treatment, Prevention and<br />

Control [Internet]. World Health Organization (WHO) and the Special<br />

Programme for Research and Training in Tropical Diseases (TDR);<br />

2009 [cited 27 July <strong>2017</strong>]. Available from: http://www.who.int/tdr/<br />

publications/documents/dengue-diagnosis.pdf<br />

4. Dengue and Severe Dengue [Internet]. World Health<br />

Organization. <strong>2017</strong> [cited <strong>11</strong> August <strong>2017</strong>]. Available from: http://<br />

www.who.int/mediacentre/factsheets/fs<strong>11</strong>7/en/<br />

5. Wilder-Smith A, Vannice KS, Hombach J, Farrar J, Nolan<br />

T. Population Perspectives and World Health Organization<br />

Recommendations for CYD-TDV Dengue Vaccine. J Infect Dis.<br />

2016;214(12):1796-1799.<br />

6. Olivera-Botello G, Coudeville L, Fanouillere K, Guy B,<br />

Chambonneau L, Noriega F et al. Tetravalent Dengue Vaccine<br />

Reduces Symptomatic and Asymptomatic Dengue Virus Infections<br />

in Healthy Children and Adolescents Aged 2-16 Years in Asia and<br />

Latin America. J Infect Dis. 2016;214(7):994-1000.<br />

7. Guzman M, Halstead S, Artsob H, Buchy P, Farrar J, Gubler D et<br />

al. Dengue: a continuing global threat. Nature Reviews Microbiology.<br />

2010;8(12):S7-S16.<br />

8. Tambo E, Chen J, Zhou X, Khater E. Outwitting dengue threat<br />

and epidemics resurgence in Asia-Pacific countries: strengthening<br />

integrated dengue surveillance, monitoring and response systems.<br />

Infectious Diseases of Poverty. 2016;5(1).<br />

9. Kline K, McCarthy J, Pearson M, Loukas A, Hotez P. Neglected<br />

Tropical Diseases of Oceania: Review of Their Prevalence,<br />

Distribution, and Opportunities for Control. PLoS Neglected Tropical<br />

Diseases. 2013;7(1):1 - 6.<br />

10. Pacific: Dengue Outbreak – Oct 2016 [Internet]. Disasters.<br />

ReliefWeb. <strong>2017</strong> [cited <strong>11</strong> August <strong>2017</strong>]. Available from: http://<br />

reliefweb.int/disaster/ep-2016-000<strong>11</strong>2-slb<br />

<strong>11</strong>. Duncombe J, Lau C, Weinstein P, Aaskov J, Rourke M, Grant<br />

R et al. Seroprevalence of Dengue in American Samoa, 2010.<br />

Emerging Infectious Diseases. 2013;19(2):324-326.<br />

12. Dupont-Rouzeyrol M, Aubry M, O’Connor O, Roche C, Gourinat<br />

A, Guigon A et al. Epidemiological and molecular features of dengue<br />

virus type-1 in New Caledonia, South Pacific, 2001–2013. Virology<br />

Journal. 2014;<strong>11</strong>(1):61.<br />

13. Dengue in the Western Pacific Region [Internet]. World Health<br />

Organization Western Pacific Region. <strong>2017</strong> [cited 26 February<br />

<strong>2017</strong>]. Available from: http://www.wpro.who.int/emerging_diseases/<br />

Dengue/en/<br />

14. Taulung L, Masao C, Palik H, Samo M, Barrow L, Pretrick M<br />

et al. Dengue Outbreak — Federated States of Micronesia, 2012–<br />

2013 [Internet]. Morbidity and Mortality Weekly Report. 2013 [cited<br />

26 February <strong>2017</strong>]. Available from: https://www.cdc.gov/mmwr/<br />

preview/mmwrhtml/mm6228a3.htm<br />

15. Dupont-Rouzeyrol M, Aubry M, O’Connor O, Roche C,<br />

Gourinat AC, Guigon A et al. Epidemiological and molecular features<br />

of dengue virus type-1 in New Caledonia, South Pacific, 2001-2013.<br />

Virol J. 2014;<strong>11</strong>:61.<br />

16. Sabin AB. Research on dengue during World War II. Am J Trop<br />

Med Hyg. 1952;1:30–50.<br />

17. Halstead SB. Dengue virus – mosquito interactions. Annu Rev<br />

Entomol. 2008;53:273-91.<br />

18. A-Nuegoonpipat A, Berlioz-Arthaud A, Chow V, Endy T, Lowry<br />

K, le Mai Q et al. Sustained transmission of dengue virus type 1 in<br />

the Pacific due to repeated introductions of different Asian strains.<br />

Virology. 2004;329(2):505-12.<br />

19. Morens DM. Dengue fever: a prevention summary for Pacific<br />

health workers. Pacific Health Dialog. 1996;3(1):240-52.<br />

20. Singh N, Kiedrzynski T, Lepers C, Benyon EK. Dengue in the<br />

Pacific – an update of the current situation. Pacific Health Dialog.<br />

2005;12(2):<strong>11</strong>1-9.<br />

21. Roth A, Mercier A, Lepers C, Hoy D, Duituturaga S, Benyon E<br />

et al. Concurrent outbreaks of dengue, chikungunya and Zika virus<br />

infections - an unprecedented epidemic wave of mosquito-borne<br />

viruses in the Pacific 2012-2014. Euro Surveill. 2014;19(41):20929.<br />

22. Centers for Disease Control and Prevention (CDC). Dengue<br />

outbreak – Federated States of Micronesia, 2012-2013. MMWR.<br />

Morbidity and mortality weekly report. 2013;62(28):570-3.<br />

23. Cao-Lormeau VM, Roche C, Musso D, Mallet HP, Dalipanda<br />

T, Dofai A, et al. Dengue virus type 3, South Pacific Islands, 2013.<br />

Emerg Infect Dis. 2014;20(6):1034-6.<br />

24. World Health Organization. Dengue haemorrhagic fever.<br />

Diagnosis, Treatment, Prevention and Control. Geneva (CH); 1997.<br />

92 p. Report No.: 2.<br />

25. Calvez E, Guillaumot L, Millet L, Marie J, Bossin H, Rama V et<br />

al. and Phylogeny of Aedes aegypti, the Main Arbovirus <strong>Vector</strong> in the<br />

Pacific. PLoS Negl Trop Dis. 2016;10(1):1-2.<br />

26. Guillaumot L. Arboviruses and their vectors in the Pacific –<br />

status report. Pac Health Dialog. 2005;12(2):45-52.<br />

27. Lounibos LP. Invasions by insect vectors of human disease.<br />

Annu Rev Entomol. 2002;47(1):233-66.<br />

28. Paupy C, Vazeille-Falcoz M, Mousson L, Rodhain F, Failloux<br />

AB. Aedes aegypti in Tahiti and Moorea (French Polynesia):<br />

isoenzyme differentiation in the mosquito population according to<br />

human population density. Am J Trop Med Hyg. 2000;62(2):217-24.<br />

29. Carrington LB, Simmons CP. Human to Mosquito Transmission<br />

of Dengue Viruses. Front Immunol. 2014;5:290.<br />

30. Scott T, Takken W. Feeding strategies of anthropophilic<br />

mosquitoes result in increased risk of pathogen transmission.<br />

Trends Parasitol. 2012;28(3):<strong>11</strong>4-121.<br />

31. Rallu JL. Tendance recentes des migrations dans le Pacifique<br />

Sud. Espace, population, sociétés. 1994;12(2):201-212.<br />

32. Perry WJ. The mosquitoes and mosquito-borne diseases on<br />

New Caledonia, an historic account; 1885–1946. Am J Trop Med<br />

Hyg. 1950;30(1):103-14.<br />

33. Chow CY. Aedes aegypti in the Western Pacific Region. Bull<br />

World Health Organ. 1967;36(4):544-6.<br />

34. Kuno G. Research on dengue and dengue-like illness in East<br />

Asia and the Western Pacific during the First Half of the 20th century.<br />

Rev Med Virol. 2007;17(5):327-41.<br />

35. Hopp MJ, Foley JA. Worldwide fluctuations in dengue fever<br />

cases related to climate variability. Clim Res. 2003;25:85-94.<br />

36. Descloux E, Mangeas M, Menkes CE, Lengaigne M,<br />

Leroy A, Tehei T et al. Climate-Based Models for Understanding<br />

and Forecasting Dengue Epidemics. PLoS Negl Trop Dis.<br />

2012;6(2):e1470.<br />

37. Hales S, Weinstein P, Souares Y, Woodward A. El Nino and<br />

the Dynamics of <strong>Vector</strong>borne Disease Transmission. Environ Health<br />

Perspect. 1999;107(2):99-102.<br />

38. Hales S, de Wet N, Maindonald J, Woodward A. Potential<br />

effect of population and climate changes on global distribution of<br />

dengue fever: an empirical model. Lancet. 2002;360:830-834.<br />

39. Jetten TH, Focks DA. Potential changes in the distribution of<br />

dengue transmission under climate warming. Am J Trop Med Hyg.<br />

1997;57:285-297.<br />

40. Masahiro U, Sengebau-Kinzio M, Nakamura K, Ridep E,<br />

Watanabe M, Takano T. Household risk factors associated with<br />

dengue-like illness, Republic of Palau, 2000-2001. BioScience<br />

Trends. 2007;1(1):33 - 37.<br />

41. Aubry M, Roche C, Dupont-Rouzeyrol M, Aaskov J, Viallon<br />

J, Marfel M et al. Use of serum and blood samples on filter paper<br />

to improve the surveillance of dengue in Pacific Island Countries.<br />

Journal of Clinical Virology. 2012;55(1):23-29.<br />

42. Cao-Lormeau VM, Roche C, Descloux E, Viallon J, Lastere<br />

S, Wiegandt A et al. Lost in French Polynesia: which strategies for a<br />

dengue virus to spread? Am J Trop Med Hyg Suppl. 2007;12:<strong>11</strong>1-19.<br />

43. Guidance on regulations for the transport of infectious<br />

substances 20<strong>11</strong>–2012 [Internet]. World Health Organization; 2010<br />

[cited 31 July <strong>2017</strong>]. Available from: http://www.who.int/entity/ihr/<br />


publications/who_hse_ihr_20100801/en/index.html<br />

44. Prado I, Rosario D, Bernardo L, Alvarez M, Rodriguez R,<br />

Vasquez S et al. PCR detection of dengue virus using dried whole<br />

blood spotted on filter paper. J Virol Methods. 2005;125:75-81.<br />

45. Fukusumi M, Arashiro T, Arima Y, Matsui T, Shimada T,<br />

Kinoshita H et al. Dengue Sentinel Traveler Surveillance: Monthly<br />

and Yearly Notification Trends among Japanese Travelers, 2006–<br />

2014. PLOS Neglected Tropical Diseases. 2016;10(8):1 - 14.<br />

46. Lau CL, Weinstein P, Slaney D. Dengue surveillance by proxy:<br />

travellers as sentinels for outbreaks in the Pacific Islands. Epidemiol<br />

Infect. 2013 Nov;141(<strong>11</strong>): 2328–34.<br />

47. Strategy [Internet]. Emerging Disease Surveillance and<br />

Response. <strong>2017</strong> [cited 26 February <strong>2017</strong>]. Available from: http://<br />

www.wpro.who.int/emerging_diseases/strategy/Strategy/en/<br />

48. Beatty M, Stone A, Fitzsimons D, Hanna J, Lam S, Vong S et<br />

al. Best Practices in Dengue Surveillance: A Report from the Asia-<br />

Pacific and Americas Dengue Prevention Boards. PLoS Neglected<br />

Tropical Diseases. 2010;4(<strong>11</strong>):e890.<br />

49. Malavige GN, Fernando S, Fernando DJ, Seneviratne SL.<br />

Dengue viral infections. Postgrad Med J. 2004;80(948):588-601.<br />

50. Rodriguez T. Dengvaxia Most Effective in High-Transmission<br />

Areas [Internet]. Infectious Disease Advisor. 2016 [cited 3 April<br />

<strong>2017</strong>]. Available from: http://www.infectiousdiseaseadvisor.com/<br />

vector-borne-illnesses/dengvaxia-effective-in-high-transmissionareas/article/579948/<br />

51. Aguiar M, Stollenwerk N, Halstead S. The Impact of the Newly<br />

Licensed Dengue Vaccine in Endemic Countries. PLOS Neglected<br />

Tropical Diseases. 2016;10(12):e0005179.<br />

52. Questions and Answers on Dengue Vaccines [Internet].<br />

Immunization, Vaccines and Biologicals. World Health Organization.<br />

<strong>2017</strong> [cited <strong>11</strong> August <strong>2017</strong>]. Available from: http://www.who.int/<br />

immunization/research/development/dengue_q_and_a/en<br />

53. Hadinegoro S, Arredondo-García J, Capeding M, Deseda<br />

C, Chotpitayasunondh T, Dietze R et al. Efficacy and Long-Term<br />

Safety of a Dengue Vaccine in Regions of Endemic Disease.<br />

New England Journal of Medicine [Internet]. 2015 [cited 3 April<br />

<strong>2017</strong>];373(13):<strong>11</strong>95-1206. Available from: http://www.nejm.org/doi/<br />

full/10.1056/NEJMoa1506223#t=article<br />

54. Flasche S, Jit M, Rodríguez-Barraquer I, Coudeville L, Recker<br />

M, Koelle K et al. The Long-Term Safety, Public Health Impact, and<br />

Cost-Effectiveness of Routine Vaccination with a Recombinant,<br />

Live-Attenuated Dengue Vaccine (Dengvaxia): A Model Comparison<br />

Study. PLOS Medicine. 2016;13(<strong>11</strong>):e1002181.<br />

55. Background Paper on Dengue Vaccines [Internet]. 1st ed.<br />

SAGE Working Group on Dengue Vaccines and WHO Secretariat;<br />

2016 [cited 3 April <strong>2017</strong>]. Available from: http://www.who.int/<br />

immunization/sage/meetings/2016/april/1_Background_Paper_<br />

Dengue_Vaccines_2016_03_17.pdf<br />

56. Masahiro U, Sengebau-Kinzio M, Nakamura K, Ridep E,<br />

Watanabe M, Takano T. Household risk factors associated with<br />

dengue-like illness, Republic of Palau, 2000-2001. BioScience<br />

Trends. 2007;1(1):33 - 37.<br />

57. Noel M. Dengue fever larval control in New Caledonia:<br />

assessment of a door-to-door health educators program. Pacific<br />

Health Surveillance and Response. 2005;12(2):39 - 44.<br />

58. Morrow GBowen K. Accounting for health in climate change<br />

policies: a case study of Fiji. Global Health Action. 2014;7(1):23550.<br />

59. Burkot T, Handzel T, Schmaedick M, Tufa J, Roberts J,<br />

Graves P. Productivity of natural and artificial containers for Aedes<br />

polynesiensis and Aedes aegypti in four American Samoan villages.<br />

Medical and Veterinary Entomology. 2007;21(1):22-29.<br />

60. Chang M, Christophel E, Gopinath D, Abdur R. Challenges and<br />

future perspective for dengue vector control in the Western Pacific<br />

Region. Western Pacific Surveillance and Response. 20<strong>11</strong>;2(2):1 - 7.<br />

61. McGraw EA, O’Neill SL. Beyond insecticides: new thinking on<br />

an ancient problem. Nat Rev Microbiol. 2013 Mar;<strong>11</strong>(3):181-93.<br />

62. Zug R, Koehncke A, Hammerstein P. Epidemiology in<br />

evolutionary time: the case of Wolbachia horizontal transmission<br />

between arthropod host species. J Evol Biol. 2012 Nov;25(<strong>11</strong>):2149-<br />

60.<br />

63. Xi Z, Khoo CC, Dobson SL. Wolbachia establishment and<br />

invasion in an Aedes aegypti laboratory population. Science. 2005<br />

Oct;310(5746):326-8.<br />

64. Walker T, Johnson PH, Moreira LA, Iturbe-Ormaetxe I, Frentiu<br />

FD, McMeniman CJ, et al. The wMel Wolbachia strain blocks dengue<br />

and invades caged Aedes aegypti populations. Nature. 20<strong>11</strong><br />

Aug;476:450-3.<br />

65. Frentiu FD, Zakir T, Walker T, Popovici J, Pyke AT, van der<br />

Hurk A, et al. Limited Dengue Virus Replication in Field-Collected<br />

Aedes aegypti Mosquitoes Infected with Wolbachia. PLoS Negl Trop<br />

Dis. 2014 Feb;8(2):e2688.<br />

66. Dyck VA, Hendrichs J, Robinson AS, editors. Sterile Insect<br />

Technique: Principles and Practice in Area-Wide Integrated Pest<br />

Management. Dordrecht: Springer; 2005. 787 p.<br />

67. Soper FL. The elimination of urban yellow fever in the<br />

Americas through the eradication of Aedes aegypti. Am J Public<br />

Health Nations Health. 1963 Jan;53(1):7-16.<br />

68. Phuc HK, Andreasen MH, Burton RS, Vass C, Epton MJ, Pape<br />

G, et al. Late-acting dominant lethal genetic systems and mosquito<br />

control. BMC Biol. 2007 Mar;5:<strong>11</strong>.<br />

69. Kourí G, Guzmán MG, Bravo J. Hemorrhagic dengue in Cuba:<br />

history of an epidemic. Bull Pan Am Health Organ. 1986;20(1):24-30.<br />

70. Ooi EE, Goh KT, Gubler DJ. Dengue prevention and 35 years<br />

of vector control in Singapore. Emerg Infect Dis. 2006 Jun;12(6):887-<br />

93.<br />

71. Disaster relief and emergency fund enables dengue outbreak<br />

response [Internet]. Fédération internationale des Sociétés de la<br />

Croix-Rouge. 2014 [cited 26 February <strong>2017</strong>]. Available from: http://<br />

www.ifrc.org/fr/nouvelles/nouvelles/common/disaster-relief-andemergency-fund-enables-dengue-outbreak-response-65371/<br />


Family, Unity and Success - Australian<br />

Indigenous Doctors’ Association (AIDA) <strong>2017</strong><br />

[Conference report]<br />

Narawi Foley Boscott<br />

Narawi completed a Bachelor of Science (Biomed) at the University of<br />

Queensland and is currently completing a Doctor of Medicine as well as<br />

a Graduate Certificate in Business Leadership. Narawi is pssionate about<br />

Badtjala culture and aspiring to improve Indigenous and mental health.<br />

Hunter Valley<br />

The Australian Indigenous Doctors’ Association<br />

(AIDA) celebrated 20 years strong by holding their annual<br />

conference for <strong>2017</strong> in the Hunter Valley, traditionally<br />

owned by the Wonnarua people. This four-day long intensive<br />

collaboration of keynote speakers, engaging workshops as<br />

well as invaluable cultural and networking events created<br />

a leading platform to connect and be inspired. The AIDA<br />

<strong>2017</strong> conference focussed on “family, unity and success”<br />

with the overarching theme of supporting and connecting<br />

Aboriginal and Torres Strait Islander medical students and<br />

doctors to ultimately improve the health of Indigenous people<br />

in Australia.[1] This conference has grown to not only bring<br />

Indigenous students and doctors together but also to provide<br />

networking opportunities for associate members, medical<br />

college representatives, other health professionals and key<br />

invited guests, making it an important medical and political<br />

event.<br />

“...in the medical curriculum, where<br />

education about Aboriginal and Torres<br />

Strait Islander culture and cultural safety<br />

is often poor, undervalued or realistically<br />

done too late to change some attitudes<br />

and beliefs.”<br />

Family<br />

This was the second AIDA conference I have attended as a<br />

medical student. I believe many people would underestimate<br />

the value of bringing together fellow Indigenous medical<br />

students and doctors from across Australia. However, this<br />

sense of belonging and knowing you are not alone in medicine,<br />

whether it be through sharing stories in the yarning circle<br />


or networking in the lunch break, is why I believe the AIDA<br />

conference and AIDA itself is so successful. Recently, AMSA<br />

Blue Week highlighted conversations regarding the need to<br />

do more about the mental health crisis amongst medical<br />

students and doctors.[2] Research also shows that mental<br />

health disorders are more prevalent amongst Indigenous<br />

Australians than their non-Indigenous counterparts [3] and it<br />

is well documented that good social support is protective for<br />

mental illness.[4] This highlights the importance for Aboriginal<br />

and Torres Strait Islander medical students and doctors, in<br />

particular, to have a strong support network throughout their<br />

medical journey. AIDA provides a support network as a familylike<br />

organisation, its members backing each other as they<br />

embark on their medical careers and embrace the enormous<br />

task of improving Indigenous health.<br />

Unity<br />

So what do we know about Indigenous health? There is<br />

still a lot to do, but as an attendee of the AIDA conference, I<br />

was surrounded by people who are already are, or are soon<br />

to be, making a real impact on many people’s lives. However,<br />

the media continues to portray a narrative that there are<br />

only a few well-educated Aboriginal or Torres Strait Islander<br />

people. Australia’s history of Aboriginal and Torres Strait<br />

Islander people is still poorly taught in schools. Not only this<br />

but key Aboriginal and Torres Strait Islander people in the<br />

past who have formed a better path for our people are either<br />

unheard of or undervalued in our society.[5] This is reflected<br />

in the medical curriculum, where education about Aboriginal<br />

and Torres Strait Islander culture and cultural safety is often<br />

poor, undervalued or realistically done too late to change<br />

some attitudes and beliefs.[6]<br />

broader society, particularly in how we value Aboriginal and<br />

Torres Strait Islander lives, challenge racism and become<br />

more culturally aware. At this year’s AIDA conference,<br />

it was encouraging to see many of the medical college<br />

representatives understand the need for more Indigenous<br />

doctors, and the need for cultural change to challenge racism<br />

and improve cultural awareness within their own colleges.<br />

Medicare exclusions for prisoners is a key issue that<br />

highlights systemic racism and contributes to health<br />

disparities. Currently, prisoners in Australia are excluded<br />

from Medicare and the Pharmaceutical Benefits Scheme<br />

subsidies. This limited access to good healthcare is<br />

shortening life expectancy and decreasing the quality of life<br />

of many people who are incarcerated.[<strong>11</strong>] Aboriginal and<br />

Torres Strait Islander people are over-represented in prisons<br />

and are 13 times more likely to be incarcerated.[12] This is<br />

not closing the gap but in fact, widening the existing chasm in<br />

health disparities.[13]<br />

The beautiful but complex aspect to Aboriginal and Torres<br />

Strait Islander people and culture is that there are many<br />

communities, languages and cultural protocols; in improving<br />

Indigenous health there is no “one size fits all” approach. The<br />

best outcomes at a grass-roots level are when a community<br />

is meaningfully involved, a lengthy but essential strategy to<br />

drive improvements to Indigenous health.[14] Targeting the<br />

social determinants of health are also key, however tackling<br />

systemic racism, the lack in cultural awareness and creating<br />

a cultural change in society to value Aboriginal and Torres<br />

Strait Islander lives should be our focus for enduring change.<br />

All medical students and medical schools in Australia<br />

The question then arises: is the problem really about the<br />

lack of teaching about Aboriginal and Torres Strait Islander<br />

culture, when racism (both institutional and interpersonal) is<br />

known to be associated with poorer health and poorer health<br />

outcomes?[7] Should the curriculum entail teachings on<br />

racism, both identifying it and stopping it? This conference<br />

asked whether it is the job of Indigenous people to educate<br />

non-Indigenous people on racism itself. The term “hidden<br />

curriculum” – the values and attitudes that medical students<br />

see around them – highlights the importance of lecturers,<br />

tutors, administrators and academics in showing strong<br />

leadership and changing the culture of our universities to<br />

stop racism and strongly value Aboriginal and Torres Strait<br />

Islander culture and health.[8]<br />

It is not just universities that need to step up. The United<br />

Nations (UN) recently described Australia’s progress in<br />

Closing the Gap as “woefully inadequate”.[9] Hearing this<br />

in a room full of people who are driving positive change<br />

and having real impacts on lives can be very disheartening,<br />

especially when Aboriginal and Torres Strait Islander people<br />

make up only 2.8% of Australia’s population.[10] However,<br />

this highlights the importance for all Australians to unite to<br />

make Indigenous health an absolute priority amongst many<br />

key stakeholders. There needs to be a cultural change in<br />

Painted stethoscope<br />


should start talking about the idea that you are not clinically<br />

competent until you are culturally competent. This is<br />

imperative to reduce existing health disparities and eradicate<br />

diseases still present in remote Indigenous communities.<br />

AIDA and their supporters are ready to save and improve<br />

Aboriginal and Torres Strait Islander peoples lives, but<br />

everyone should also feel a sense of responsibility to unite to<br />

change the narrative from “woeful” to making real and lasting<br />

change.<br />

Success<br />

One of the most anticipated events of the conference<br />

every year is the stethoscope ceremony. This ceremony is<br />

where newly graduated Indigenous medical students and<br />

newly qualified Indigenous fellows are recognised for their<br />

hard work, sleepless nights, sacrifice and often added<br />

weight of responsibility by being presented with a handpainted<br />

stethoscope. This creates mentorship at AIDA and<br />

inspiration that success is possible and very achievable as<br />

an Indigenous medical student and graduate.<br />

The other most anticipated event (for me anyway) is the<br />

cultural excursion on the last day. I had very high expectations<br />

after last year, living dangerously and tasting a particular<br />

species of ant that tasted like citrus. However, I survived<br />

that last year, and can tell you that I thoroughly enjoyed the<br />

trip this year when people of the Wonnarua nation took us<br />

to Biame cave, the site of a significant piece of rock art in<br />

the Hunter Valley. These opportunities to have culture and<br />

knowledge shared are invaluable. What I also learnt was<br />

about how the traditional owners had worked with the non-<br />

Indigenous property owners on which this significant site sits<br />

in order to protect it, and make it accessible for those who<br />

wish to visit and appreciate its significance - thousands of<br />

“All medical students and medical schools<br />

in Australia should start talking about the<br />

idea that you are not clinically competent<br />

until you are culturally competent.<br />

years of culture and knowledge. The Wonnarua people also<br />

believe there are many other significant sites around that<br />

area. They hope that by setting this as precedent, not only<br />

can they work with other property owners in the region, but<br />

this can be applied to other significant sites across Australia.<br />

So, if you, your family or your friends own a property with an<br />

Indigenous site on it, or if you are unsure, please be in contact<br />

with your local Indigenous community because there may<br />

be thousands of important sites nationwide that need to be<br />

protected for generations to come.<br />

When talking about medicine today, we often think of just<br />

the mind and body, but for many Indigenous people, there<br />

is an element of the spirit. It is also important to recognise<br />

that before colonisation, traditional healers or Ngangkari<br />

looked after our people, probably with the same care and<br />

dedication we hope to have as good doctors one day. These<br />

Ngangkari included the spirit in healing; some are still around<br />

today treating Indigenous people. So from an Indigenous<br />

medical student’s perspective, in a society faced with racism<br />

and disparity, perhaps we should put the humanity back into<br />

medical school and not just hope, but work hard to create<br />

a better world and health outcomes for this nation’s first<br />

peoples.<br />

Conflict of Interest<br />

None declared<br />

Correspondance<br />

narawi.kefb@gmail.com<br />

References<br />

1. Australian Indigenous Doctors’ Association. AIDA Conference<br />

<strong>2017</strong> [Internet].[cited <strong>2017</strong> Oct 1]<br />

Available from: https://www.aida.org.au/conference/<br />

2. AMSA mental health. About the Campaign. [Internet]. [cited<br />

<strong>2017</strong> Oct 1].<br />

Available from: http://mentalhealth.amsa.org.au/about-thecampaign/<br />

3. Jorm A, Bourchier S, Cvetkovski S, Stewart G. Mental health<br />

of Indigenous Australians: a review of findings from community<br />

surveys. Med J Aust. 2012 196 (2):<strong>11</strong>8-121.<br />

4. Ozbay F, Johnson D, Dimoulas E, Morgan C, Charney D,<br />

Southwick S. Social Support and Resilience to Stress. Psychiatry<br />

(Edgmont). 2007 May 4(5):35-40.<br />

5. NITV. Do our teachers care enough about Indigenous<br />

Australia to bring it into the classroom? [Internet]. <strong>2017</strong> May 9<br />

[updated <strong>2017</strong> May 9; cited <strong>2017</strong> Oct 1].<br />

Available from: http://www.sbs.com.au/nitv/article/<strong>2017</strong>/05/09/<br />

do-our-teachers-care-enough-about-indigenous-australia-bring-itclassroom<br />

6. Durey A. Reducing racism in Aboriginal health care in<br />

Australia: where does cultural education fit? Australian and New<br />

Zealand Journal of Public Health. 2010 July 34(1):87-92.<br />

7. Larson A, Gillies M, Howard P, Coffin J. It’s enough to make<br />

you sick: the impact of racism on the health of Aboriginal Australians.<br />

Australian and New Zealand Journal of Public Health. 2007 August<br />

31(4):322-229.<br />

8. Mahood S. Medical education-Beware the hidden curriculum.<br />

Can Fam Physician. 20<strong>11</strong> September 57(9):983-985.<br />

9. Brennan, B. Australia’s progress on Closing the Gap ‘woefully<br />

inadequate’, UN says. [Internet]. ABC News. <strong>2017</strong> September <strong>11</strong><br />

[cited <strong>2017</strong> Oct 2].<br />

Available from: http://www.abc.net.au/news/<strong>2017</strong>-09-<strong>11</strong>/closingthe-gap-progress-woeful-un-says/8892980<br />

10. Australian Bureau of Statistics. Census: Aboriginal<br />

and Torres Strait Islander population. [Internet]. <strong>2017</strong><br />

June 27 [updated <strong>2017</strong> June 26; cited <strong>2017</strong> Oct 2]<br />

Available from: http://www.abs.gov.au/ausstats/abs@.nsf/<br />


Four perspectives on<br />

the World Congress on public health<br />

[Conference report]<br />

Michael Au, Ka Man Li, Helena<br />

Qian and Michael Wu<br />

“Leadership is the capacity to translate vision into reality”<br />

– Warren Bennis<br />

The World Congress on Public Health (WCPH) is held every<br />

2-4 years and organised by the World Federation of Public<br />

Health Associations (WFPHA). Attracting between 2000-<br />

4000 delegates from over 80 countries, the main objective of<br />

this international forum was to engage diverse voices, ideas,<br />

vision and actions of committed professionals and citizens<br />

to strengthen and transform the global public health effort<br />

and influence decision makers.[1] With a comprehensive<br />

academic program, field trips, World Leadership Dialogues,<br />

satellite events and meetings, and a glitzy social program,<br />

this is truly the ultimate conference for public health inclined<br />

peers.<br />

To apply, there was a simple online questionnaire and<br />

requirement to volunteer at least 20 hours throughout the<br />

conference. As this meant volunteering for four hours per day,<br />

I wasn’t able to attend all the academic workshops/sessions.<br />

I mainly worked with the media department whereby I sent<br />

interesting quotes from plenary sessions to the team for<br />

Twitter content. I also had the opportunity to directly converse<br />

with speakers in a relaxed setting, after their interview with<br />

the media team.<br />

We evaluate the experiences of attending the WCPH,<br />

the benefits of meeting like-minded individuals, the sense<br />

of optimism in the face of challenge and the problems on<br />

financial supports in four different perspectives: a volunteer,<br />

a presenter, a medical student and a young researcher.<br />

A Volunteer’s Perspective - Helena Qian<br />

Helena is a third year medical student at the University<br />

of Newcastle with a keen interest in improving global health<br />

and aiding underserved communities. She hopes to work with<br />

WHO and MSF in the future as a collaborative researcher,<br />

advocate, field doctor and volunteer.<br />

“When ‘I’ is replaced with ‘We’, even ‘Illness’ becomes<br />

‘Wellness’.” - Malcolm X<br />

As someone passionate about improving public health,<br />

I noticed a curriculum gap in which public health was only<br />

briefly touched upon. WCPH was the perfect meeting of<br />

likeminded individuals, leaders and global health enthusiasts<br />

from which I could gain a holistic understanding of public<br />

health from a grassroots standpoint to a global perspective.<br />

With a registration fee of $770 for students (excluding<br />

accommodation and flights) and being on a uni student<br />

budget, I opted to attend the conference for free as a<br />

volunteer.<br />

Despite the vast array of expertise and interests,<br />

discussion points centred around the confluence of global<br />

environmental degradation, differing political agendas,<br />

civil unrest and widening inequities in health outcomes.<br />

Interestingly, despite proven health detriments from excess<br />

alcohol, tobacco and sugar consumption, Prof. Mike Daube<br />

stated, ‘Where engagement has occurred, it has invariably<br />

been counterproductive.’ Hence, a significant barrier<br />

preventing implementation of effective public health policies<br />

are the industry groups who place private profits over the<br />

health of their consumers. As Dr Bronwyn King eloquently<br />

encapsulated, “60% of the tobacco industry involves child<br />

labour - is there no baseline standard below which we will<br />

sink to raise money?” Where negotiations with industry have<br />

failed, focus has shifted to the consumer. Exposing the fund<br />

managers who invest in these corporations and highlighting<br />

that indirect health and environmental costs rest with<br />

taxpayers, whereas revenue stays with manufacturers, have<br />

resulted in approximately $5 billion AUD being withdrawn<br />

from investment in the tobacco industry alone.[2]<br />


Ultimately, the conference epitomised the power of public<br />

health to draw connections to unseen patterns of disease,<br />

highlighted hidden societal inequalities and served as a<br />

platform for marginalised or underserved populations to have<br />

a say. Backed by epidemiology and evidence based medicine,<br />

public health brings ugly truths to the forefront of discussion<br />

and ‘has a duty to speak truth to power’.<br />

I’m immensely grateful to have attended as a volunteer and<br />

to have met such an inspiring network of public health leaders<br />

and fellow peers. As a student, I highly recommend attending<br />

as a volunteer, especially as you gain unprecedented access<br />

to event organisers and plenary speakers. Hope to see you at<br />

the 16th WCPH in Rome 2020!<br />

A Delegate’s Perspective - Michael Wu<br />

Michael is a second year medical student and current Chair<br />

of GlobalHOME at the University of Sydney with a burning<br />

passion for health that disregards borders. Like Helena, he<br />

dreams of working all over the world with MSF. His heroes include<br />

inspirational figures such as Dr Catherine Hamlin. He also enjoys<br />

sunsets and hummus.<br />

The most palpable feeling one senses at a gathering of<br />

minds tackling the most complex social health issues in the<br />

world is that of positivity. Despite the clear adversity, there is<br />

a strong belief that we have the tools and allies needed to<br />

succeed in our agendas.<br />

As anyone that is interested in optimising health outcomes<br />

and promoting medical equity, the words “World Congress<br />

of Public Health” instantly caught my attention when I first<br />

heard them. The WCPH was a melting pot of inspiration,<br />

edgy research and health reform superstars from all over the<br />

world. This gathering does not come cheap but it also comes<br />

only once every 2-4 years and can be anywhere in the world.<br />

It was an opportunity I couldn’t miss.<br />

To pay for my privilege to be a fly on the wall I sought<br />

the assistance of the University. Unfortunately, the Sydney<br />

Medical Program only sets aside funds for conferences if you<br />

are a presenter, however, the Sydney University Postgraduate<br />

Association was more than happy to hear me out. All I had<br />

to do was attend a general meeting, provide background<br />

information on the event and my interest and how this can<br />

benefit their interests then prepare an “ask”. They saw fit<br />

to offer me a grant for $480 to subsidise my registration in<br />

exchange for sharing what I learnt with their Women’s Officer<br />

and Environmental Officer.<br />

This year, the University of Sydney’s Global Health<br />

Society - GlobalHOME - committed to numerous key areas<br />

of interest, including climate change and the impact on<br />

Healthcare. The plenaries for the WCPH not only had this,<br />

but also talks about Female Genital Mutilation, First Nations<br />

people, Non-Communicable Disease and Tobacco Control.<br />

These were talks dedicated to some of the most difficult<br />

healthcare issues today, and WCPH would see some of the<br />

greatest minds gather to discuss them. With Plain Packaging<br />

2.0, we may start seeing cigarettes marked along their length<br />

with the cost to your life expectancy. There was research<br />

on the resiliency of health care systems in warzones. One<br />

researcher working on his PhD had just returned from Eritrea<br />

to add to his pool of data from nine other countries into which<br />

he had ventured during active fighting.<br />

As a student, it is a little daunting to attend a professional<br />

conference out of your direct field but all you need is an<br />

interest and passion. I made many connections and took<br />

home plenty of key messages. I would encourage anyone<br />

looking to attend a professional conference to do so<br />

and to not be fazed by a lack of scholarship availability. It<br />

would be worthwhile approaching your student council or<br />

representative organisation and present to them to secure a<br />

bursary of your own making.<br />

A Presenter’s Perspective - Michael Au<br />

Michael is a fourth year medical student at James Cook<br />

University. He is committed towards the promotion of human rights,<br />

social justice, and health equity. His interests lie in refugee and<br />

maternal health, health systems and the social determinants of<br />

health. He is currently completing research investigating refugee<br />

health systems in Far North Queensland.<br />

Although there is much to celebrate in public health, Dr<br />

Margaret Chan at the conference described “new challenges<br />

of unprecedented complexities” facing the world in the areas<br />

of antibiotic resistance, obesity and chronic diseases. These<br />

issues are intertwined with social, political and cultural issues<br />

which make them increasingly difficult to address.<br />

The status quo is not enough and there is still so much to be<br />

achieved in public health. However, many students, including<br />

myself, fall into the trap of complacency towards the state<br />

of affairs in global health. As Australian students, we view<br />

the rest of the world through the lens of a developed country,<br />

distorted by daily privileges which we take for granted. The<br />

solution? A continual pursuit for truth and information with a<br />

high degree of scientific scepticism. This was just one of the<br />

few gems I gathered from this conference.<br />

With the support of the Royal Australasian College of<br />

Physicians (RACP), I was fortunate to be given full registration<br />

and travel assistance to attend the WCPH as a John Snow<br />

Scholar. The scholarship gave me the opportunity to present<br />

research which I had completed as a medical student, entitled<br />


“HIV/HCV Prevention in Australian Incarcerated Populations:<br />

A Review into Preventative Practices and Outcomes”. My<br />

review highlighted the growing disparity in health outcomes<br />

between prison populations and the community due to a<br />

lack of preventative programs in Australian prisons against<br />

infectious blood-borne diseases. I encourage all medical<br />

students to consider applying for the John Snow Scholarship.<br />

[3]<br />

Attending this conference gave me the opportunity to<br />

meet with leading academics in my area of research. In<br />

addition to bringing together academics from across the<br />

globe, both government and private sectors were closely<br />

involved. It was my great pleasure to meet with the Australian<br />

Capital Territory (ACT) Chief Health Officer who was leading<br />

the reform in needle-syringe programs as well as other<br />

academics prominent within the field of my research topic. I<br />

found this most peculiar and warming, that an event like this<br />

is able to bring people together from different parts of the<br />

world, addressing a certain issue and to share, foster and<br />

inspire other like-minded individuals.<br />

Many medical students would have had experience<br />

in attending AMSA Global Health and AMSA National<br />

Convention events. The WCPH differs to AMSA events in that<br />

it is a professional research intensive conference. These<br />

events demarcate the knowledge frontier in public health<br />

in a setting that aims to create professional networks and<br />

expanding partnerships.<br />

A Young Researcher’s Perspective - Ka Man Li<br />

Ka Man is a final year Biomedical Science student at<br />

the University of Melbourne with a strong devotion to furnish<br />

approaches for current health concerns: healthy ageing and<br />

preventive cardiology. She aims to serve as a part of WHO<br />

and WFPHA to optimise global health in the nearest future.<br />

“Pioneering spirit should continue, not to conquer the<br />

planet or space... but rather to improve the quality of life.” –<br />

Bertrand Piccard<br />

As a young researcher, I always dreamt about either<br />

standing behind the podium presenting my novel research<br />

findings in front of experts in the field, or seeing my name on<br />

publications. On the 4th of April this year, my dream finally<br />

came true.<br />

It all began an hour before a regular Monday meeting with<br />

my supervisor. With little progression in my thesis, I did not<br />

want to be a disappointment thus I googled an upcoming<br />

conference related to my research field. I submitted an<br />

abstract in the spur of the moment to this conference. Months<br />

later, I got accepted as an orator for my study entitled, “The<br />

Effect of Physical Activity, Body Mass Index on Cardiovascular<br />

Risk in Australian Older Women”. I was overwhelmed by a<br />

cocktail of excitement and anxiety.<br />

Weeks before the conference commenced, I spent<br />

countless days and nights working on my results for the<br />

presentation, enduring many failures along the way. Numerous<br />

times, I had to go back and forth changing the inclusion and<br />

exclusion criteria for my literature review, refining the rationale<br />

and interpreting my statistical regressions. However, with<br />

the support and encouragements from my supervisor and<br />

colleagues, I finally finished my results for the presentation.<br />

As soon as I arrived at the venue of WCPH, my first<br />

international conference, all my doubts, insecurities and<br />

anxieties suddenly vanished. I was impressed by the scale,<br />

the conference production value and the number of people<br />

participating! It was a pleasure to meet with a diverse group<br />

of delegates from different professional fields across<br />

the globe. We were able to share personal experiences,<br />

discuss typical research mistakes and exchange knowledge<br />

about improving global health. One of the most memorable<br />

highlights was meeting with leading academics, including Dr<br />

Michael Moore, President of the World Federation of Public<br />

Health Associations (WFPHA) and the CEO of Public Health<br />

Association of Australia. Not only did he inspire me with his<br />

persistence and belief in research but he also expanded my<br />

vision for certain health issues with different perspectives.<br />

Ultimately, WCPH was a life-changing conference. I was<br />

delighted to achieve my dream at such an early stage of my<br />

research career, presenting formally at one of the biggest<br />

international conferences. WCPH has certainly reignited my<br />

unwavering passion for public health research despite all the<br />

challenges. It has given me an opportunity to engage, learn<br />

and foster ideas with many like-minded individuals.<br />

Although funding is not always available for research<br />

students, conferences like WCPH are worth the cost! As Mr<br />

Greg Hunt, MP, stated at the opening ceremony, we need<br />

more frontier researchers to contribute to and enhance<br />

quality of life. We, as tomorrow’s researchers, ought to raise<br />

our voices to develop a comprehensive vision to take action<br />

and improve global health nationally and globally.<br />

Acknowledgements<br />

Sydney University Postgraduate Representative Association<br />

(Michael Wu)<br />

Royal Australasian College of Physicians (RACP) (Ka Man Li)<br />

Photo Credit<br />

Helena Qian, Michael Wu, Michael Au, Ka Man Li<br />

Conflicts of interest<br />

None declared<br />

Correspondance<br />

helena.qian@uon.edu.au<br />

References<br />

1. WCPH About [Internet] Retrieved on 28th August <strong>2017</strong>; Last<br />

Updated <strong>2017</strong>. Available from: http://www.wcph<strong>2017</strong>.com/about.php<br />

2. WCPH Program Handbook. Proceedings of the World Congress<br />

of Public Health; <strong>2017</strong> Apr 3-7; Melbourne, AU. <strong>2017</strong>.<br />

3. John Snow Scholarship Information website [Internet]<br />

Retrieved on 10th September <strong>2017</strong>; Last Updated <strong>2017</strong>. Available<br />

from: https://www.racp.edu.au/about/racp-foundation-awards/<br />

division-faculty-chapter-regional-awards/australasian-faculty-ofpublic-health-medicine/john-snow-scholarship<br />


Welfare cuts to refugees, AMSA Global Health<br />

Crossing Borders National Managers<br />

[Commentary]<br />

Sibella Breidahl<br />

and Jasmin Sekhon<br />

Crossing Borders For Health is AMSA Global Health’s project that aims to advocate for<br />

refugees and people seeking asylum. With arms covering Education, Advocacy and<br />

Projects we aim to give students a functional understand of the refugee crisis, with a<br />

focus on the Australian context, as well as contributing to the advocacy based around<br />

creating a fair and fast processing system for people seeking asylum in Australia. Jasmin<br />

and Sib are Crossing Border’s <strong>2017</strong> National Project Managers<br />

We live in a society founded on the values of fairness,<br />

reciprocity and freedom. Whether you call it a scallop<br />

or a potato cake, you’re a millennial or older than Phillip<br />

Ruddock, across lines of politics and race, these values<br />

hold true.<br />

We would all like to think that in our moment of<br />

need we would be supported by our<br />

community. Daily across Facebook and<br />

the media, there are countless examples<br />

of people proudly going above and<br />

beyond for members of their community,<br />

even for complete strangers. The<br />

#sofaforlondon movement in the wake<br />

of the London Bridge attack earlier this<br />

year is a perfect example of this. People<br />

posted on social media offering beds<br />

(and salt and vinegar chips) to strangers who were left<br />

stranded in the attacks.[1] Examples of this exist at<br />

home as well, like the overwhelming response after the<br />

Victorian bushfires in the last decade. We are great at<br />

jumping into action when people need help. Why then,<br />

are Australians so happy to eschew these values when<br />

We are great at jumping into<br />

action when people need<br />

help. Why then, are Australians<br />

so happy to eschew these<br />

values when considering the<br />

question of refugees?<br />

considering the question of refugees?<br />

Many social and economic factors inform the health<br />

and wellbeing of humans. Housing insecurity, job hunting,<br />

lack of access to proper medical care, limited education<br />

pathways, lack of transport. These things pile up. Not<br />

only do refugees face these stresses with no supportive<br />

community or family, but also after years<br />

of trying to get to Australia, often fleeing<br />

horrific wars, genocides and famines.[2]<br />

At the time of their greatest need, the<br />

government resolves that the best thing<br />

to do it to lock them up and throw away<br />

the key.<br />

The government decided in late<br />

August to cut welfare payments to 100<br />

of the 400 people seeking asylum in Australia that have<br />

come to the mainland from regional processing centres<br />

for medical treatment.[3] They plan to extend the cuts to<br />

the other 300 people in this group in the coming months,<br />

including pregnant women, 37 babies and 90 children<br />

who attend school in Australia. This means they will stop<br />


eceiving the paltry $200 a fortnight they have to support<br />

their family, and will also be kicked out of supported<br />

accommodation. With a name that would not be out of<br />

place in an Orwell novel, the “Final Departure bridging E<br />

visa” which stipulates these conditions, was given to 100<br />

people with no notice.<br />

It is deeply concerning that<br />

post-arrival factors have a<br />

worse impact on the outcomes<br />

for children seeking asylum,<br />

than the trauma of the wartorn<br />

countries they come from<br />

As a young, qualified person with an acceptable grasp<br />

of the English Language and a good knowledge of the<br />

workings of Australian society, I know how hard it can be<br />

to find a job. These people who have been transferred to<br />

Australia for serious medical illness must find a way to<br />

support themselves in just three weeks, with the possibility<br />

of being deported at any time, a prospect sure to turn<br />

off any employer. To add insult to injury, the government<br />

has also stuck by its policy that those over 18 years old<br />

cannot access education or training programs, giving<br />

them even less opportunity to find jobs. This has huge<br />

implications for those at school. Why bother applying<br />

yourself and working hard, just to be barred from further<br />

education and face a desperate future?<br />

Being transferred to Australia in the first place is no<br />

mean feat, as we have seen in several cases, such of<br />

that of Hamid Kazhei, who died on Manus Island of sepsis<br />

from a cut in his foot because the government would<br />

not transfer him to the mainland to get the attention<br />

he needed. Or the multiple pregnant mothers with preeclampsia<br />

who have been refused transfer and have no<br />

access to obstetric care. This shows that the group in<br />

question who did make it to Australia are extraordinarily<br />

resilient and are in genuine need of care.<br />

There is strong evidence to show that reduction in<br />

funding for welfare has major effects on the health of<br />

newcomers. Eroding economic and social conditions<br />

negatively impacts on health by reducing access to<br />

healthcare, deterioration in mental health and increases<br />

domestic violence. [4]<br />

The government has already made people seeking<br />

asylum vulnerable, through damaging policies that<br />

incorporate unnecessarily long processing times, keep<br />

people in detention under inhospitable conditions, offer<br />

few options for family reunification, deny full work rights<br />

and withhold social services. This new policy will further<br />

exacerbate the disadvantage that these people currently<br />

endure.<br />

It is deeply concerning that post-arrival factors have<br />

a worse impact on the outcomes for children seeking<br />

asylum, than the trauma of the war-torn countries they<br />

come from.[1] A recent study published in the Journal<br />

of Paediatrics and Child Health showed that childrens’<br />

environment after arriving in Australia had more impact<br />

on their physical health and wellbeing than the process<br />

of getting to Australia and the traumas they experienced<br />

before arriving.[5] Irresponsible policies like the recent<br />

welfare cuts contribute strongly to this observation. The<br />

government even went as far as threatening children in<br />

their letter about the Bridging E visa, writing to parents<br />

“Please remind your children that they will also be<br />

required to abide by Australian values and laws. Breaking<br />

Australian laws may result in their removal from the<br />

community.”[3]<br />

Refugees and people seeking<br />

asylum are starting from a point of<br />

compromise. It is our obligation as a<br />

caring community that values equity<br />

to springboard them into starting their<br />

lives in Australia<br />

The Government is pushing the financial burden to<br />

support asylum seekers on community and not-for-profit<br />

organisations, straining their already limited resources.<br />

Refugees and people seeking asylum are starting from<br />

a point of compromise. It is our obligation as a caring<br />

community that values equity to springboard them<br />

into starting their lives in Australia, rather than holding<br />

them back or providing a flimsy safety net. It’s time to<br />

say enough is enough and stop them bullying the most<br />

vulnerable members of our society.<br />

Conflicts of interes<br />

None declared<br />

Correspondance<br />

jasmin.sekhon@amsa.org.au<br />

sibella.harebreidahl@amsa.org.au<br />

References<br />

1. The Guardian staff and Press Association (<strong>2017</strong>).<br />

#sofaforlondon: residents open their doors in wake of London<br />

Bridge attack. The Guardian.<br />

2. Marmot, M., Wilkinson R. (2003). Social Determinants<br />

of Health, The Solid Facts. [online] The World Health<br />

Organisation. Available at: https://books.google.com.au/<br />


Start where you are, use what you<br />

have, do what you can<br />

-<br />

Adelaide Global Health Conference <strong>2017</strong> Closing Address<br />

AMSA Global Health Chair <strong>2017</strong><br />

Liz Bennett<br />

Good afternoon, wonderful GHC delegates. I’m Liz,<br />

the Chair of AMSA Global Health and a final year medical<br />

student at Flinders. As some of you would have heard<br />

yesterday, my experiences in global health have taken me<br />

from Adelaide, to Tennant Creek, to Oxford, to Geneva,<br />

and to Tanzania, but GHC has always held a special<br />

place in my heart and attending my first GHC was one of<br />

the first steps on my global health journey.<br />

I wanted to start by taking some time to reflect<br />

on my time with AMSA Global Health this year. AMSA<br />

Global Health is a team of 22 people from around the<br />

country who work year round to advocate for, represent<br />

and educate medical students like you on global health<br />

issues. We focus on refugee and asylum seeker health,<br />

climate health, sexual and reproductive health and most<br />

recently non-communicable diseases.<br />

There have been so many incredible moments this<br />

year, from watching Sib, one of our Crossing Borders<br />

For Health National Project managers, shine in her first<br />

radio interview on refugee and asylum seeker health; to<br />

watching Georgia, our Vice Chair Operations seamlessly<br />

put the Council agenda together; to reading the amazing<br />

divestment action plan for AMSA put together by the<br />

Code Green National Project Managers, the Belles; to<br />

seeing Carrie publish the first copy of <strong>Vector</strong>, our student<br />

written, peer-reviewed global health journal, in two years<br />

and then watch her guard the hard, print copies with her<br />

life! I’ve participated in AMSA Global Health meetings<br />

from Byron Bay, from Alice Springs, Darwin, Geneva and<br />

most recently using dodgy airport internet in Tanzania,<br />

and every single one has been a joy.<br />

I would like to thank my AMSA Global Health team for<br />

all of the amazing work they have done this year. It has<br />

been a privilege to work with each and everyone one of<br />

you and it has been incredible to watch your passion grow<br />

into tangible products that have benefited so many.<br />

At GHC, we are given the chance to learn how<br />

phenomenal and passionate individuals - who are<br />

often our idols - are making change. We are inspired,<br />

challenged and empowered to then go forth and change<br />

ourselves. I still remember sitting in plenary hall in Hobart<br />

at my first GHC in 2013, listening to Julian Burnside talk<br />

about his work in refugee and asylum seeker advocacy.<br />

It was one of the first times I actually heard about the<br />

impacts of immigration detention and I started crying<br />

because I had never heard someone speak so candidly<br />


about its devastating mental health effects. I could not<br />

believe that this was happening in our country and that<br />

our government was knowingly subjecting vulnerable<br />

people to institutionalised torture. After a small period of<br />

feeling hopeless, I began to get angry. It was this seed of<br />

anger that has fuelled my passion for health inequalities<br />

more broadly since then and I think this is a reason why I<br />

am up here today.<br />

But it is not enough to be<br />

inspired. There is too much<br />

to be done. We do not have<br />

the luxury of apathy and you<br />

cannot afford to waste time<br />

thinking that you are too small<br />

to make a difference.<br />

However, if you had told me then that four years from<br />

now, I would have been able to learn about global health<br />

research with the George Institute in Oxford, I would have<br />

been fortunate enough to spend 6 weeks being inspired<br />

by global health babe, Sandro Demaio at the WHO in<br />

Geneva, and that I would eventually publish an article with<br />

Julian Burnside in the Lancet calling for immediate action<br />

on refugee and asylum seeker health, I would not have<br />

believed you. But it all started at GHC.<br />

have the luxury of apathy and you cannot afford to waste<br />

time thinking that you are too small to make a difference.<br />

I encourage all of you to leave here and be productive<br />

with the seed of inspiration that has been planted this<br />

week. Continue to challenge yourself to make change and<br />

always foster inquisitiveness and love of global health.<br />

Ensure that you it, watch it grow and share its fruit with<br />

those around you. This might be something as simple as<br />

starting a conversation with someone using some of the<br />

knowledge you gained, it could be putting pen to paper<br />

and recording your ideas to share with others, it could be<br />

joining a local advocacy group doing great work that you<br />

are passionate about in your community, or it could be<br />

joining an organisation like AMSA Global Health.<br />

Start where you are, use what you have and do what<br />

you can.<br />

Photo credit<br />

Karl Asmussen, Vienna Tran<br />

Correspondance<br />

liz.bennett@amsa.org.au<br />

And so I would to thank Holly and her amazing team<br />

for this fantastic event. Since that first GHC in Hobart,<br />

this conference has gone from strength to strength and it<br />

would not be possible without individuals like you.<br />

This conference has given us the ability to challenge<br />

ourselves in many different areas. We have been<br />

provided with an opportunity to realise our strengths, as<br />

well as our faults and imperfections. But it is not enough<br />

to be inspired. There is too much to be done. We do not<br />


Where to now?<br />

-<br />

<strong>Vector</strong> Journal & GHC Writing Competition<br />

Helena Qian<br />

Helena is a 3rd year medical student at the University of Newcastle with a keen<br />

interest in improving global health and aiding underserved communities. She hopes<br />

to work with WHO and MSF in the future as a collaborative researcher, advocate,<br />

field doctor and volunteer.<br />

What: “We are resolved to free the human race within<br />

this generation from the tyranny of poverty and want,<br />

and to heal and secure our planet for the present and for<br />

future generations.” – The 2030 Agenda for Sustainable<br />

Development<br />

Society is at a critical juncture in world history<br />

whereby a fragile balance exists between global health,<br />

effects of modern-life, social constructs, politics and<br />

economy.[1] The 2003 SARS epidemic encapsulates<br />

how unprecedented population growth and adverse<br />

living conditions have facilitated cross-species shift of<br />

organisms.[1] Despite incredible medical advances, our<br />

exponential increase in knowledge has not matched<br />

public health progress as seen with the re-emergence of<br />

polio in conflict-affected areas.[2]<br />

Why: “If we see injustice, why can’t we make a change<br />

right now?” – Mr Kon Karapanagiotidis GHC <strong>2017</strong><br />

From conversing with Dr Stewart Condon, poor<br />

application of knowledge due to differing political/<br />

financial agendas have largely been to blame. These<br />

stem from a failure of stakeholders/society to appreciate<br />

the ‘complex links between social and economic aspects’<br />

[1] of disease and address health at a world-population<br />

level.<br />

Contrary to popular belief, there is no shortage of<br />

resources to improve global health,[3] only a lack of moral<br />

imagination and political will to change long-standing,<br />

inefficient healthcare systems and implement strategies<br />

to broaden attitudes towards health.<br />

Where to now? “The world is coming to recognise<br />

more and more that problems in one country reverberate<br />

in another...this is why it is so important to make the most<br />

of our collective strengths.” - Ban Ki Moon<br />

As privileged medical students with access to<br />

platforms that engage our community, we can challenge<br />

the complacency of those who don’t fully comprehend<br />

the magnitude of impact every individual has on others<br />

less fortunate. As future doctors, we should endeavour<br />

to couple excellent care of individual patients to public<br />

health programs that more efficiently disseminates<br />

information and healthcare.<br />

Although the way forward is challenging, it’s not<br />

impossible with positive steps such as the creation of the<br />

Coalition for Epidemic Preparedness Innovations (CEPI)<br />

aiming to efficiently develop new vaccines to prevent<br />

epidemics.<br />

“It is because it is so dark that we need to burn the<br />

brightest right now.”- Mr Kon Karapanagiotidis GHC <strong>2017</strong><br />

Conflicts of Interest<br />

None declared<br />

Correspondance<br />

helena.qian@uon.edu.au<br />

References<br />

1. Solomon R Benatar Global Health: Where to Now?<br />

Retrieved <strong>2017</strong>, August 19; Last Updated Unknown; Global<br />

Health Governance, 2009;<strong>11</strong>;2 Available from: <br />

2. Akil L, Ahmad HA. The recent outbreaks and<br />

reemergence of poliovirus in war and conflict-affected areas.<br />

Retrieved <strong>2017</strong>, August 19; Last Updated 2016; International<br />

journal of infectious diseases : IJID : official publication of the<br />

International Society for Infectious Diseases. 2016;49:40-46.<br />

doi:10.1016/j.ijid.2016.05.025.<br />

3. Benatar, Daar, and Singer, “Global health ethics: the<br />

rationale for mutual caring”; Benatar, Gill and Bakker, “Making<br />

progress in global health: the need for new paradigms.”<br />

Retrieved <strong>2017</strong>, August 21; Last Updated Unknown<br />

Moving forward, societal introspection are shifting<br />

from a narrow, monetised view of global health to a multifaceted<br />

appreciation for an interdependent world that<br />

can drive forces for change. Greater emphasis should<br />

be placed on collaboration to address health inequalities<br />

and social determinants of health.<br />


A Walk to Remember<br />

[Book review]<br />

Anna Marie Plant<br />

Anna Marie Plant is a Medical student at the University of Sydney with a<br />

strong interest in Global Health. She wishes to pursue a career in surgery<br />

with a humanitarian focus and work for an organisation such as Médecins<br />

Sans Frontières (MSF) to address the global shortage of safe surgical care,<br />

especially in orthopaedics and trauma.<br />

Walking Free<br />

by A/Prof Munjed Al Muderis with<br />

Patrick Weaver.<br />

p 336. Allen & Unwin. $22.99<br />

Despite our common motivations and<br />

dedication to learning, the journey of each<br />

medical student is unique. Despite managing<br />

intense study loads, we probably cannot<br />

imagine the added stress of living under a<br />

brutal dictatorship, as was the experience of<br />

Associate Professor Munjed Al Muderis. He<br />

began his Medical studies at Basra University<br />

in southern Iraq, near the Kuwaiti border that<br />

former Iraqi President Saddam Hussein’s<br />

forces had invaded a month prior. It was clear<br />

from the outset that A/Prof Al Muderis’ journey<br />

was never going to be straightforward.<br />

awoken the following morning to the sound<br />

of planes overhead and explosions nearby;<br />

it was the 17th of January 1991 and the<br />

commencement of Operation Desert Storm.<br />

After he tended to civilian casualties at his<br />

teaching hospital, he made the journey along<br />

the war-ravaged Western highway, and passed<br />

the Imam Ali Air Base that was under active<br />

airstrikes by the US-led coalition, to Baghdad.<br />

Al Muderis’ gripping vignette ensures that one<br />

will never again complain about long flights or<br />

drives to visit family.<br />

Fast forward and the young Dr Al Muderis<br />

found himself in one of the worst imaginable<br />

situations: he had to choose between honouring<br />

the Hippocratic Oath by refusing to remove the<br />

ears of army deserters, or facing death at the<br />

hands of Saddam’s military police. For most<br />

of us this is a nightmare situation but sadly it<br />

is the reality for some healthcare workers in<br />

unstable geopolitical environments.<br />

“the young Dr Al Muderis found himself<br />

in one of the worst imaginable situations:<br />

he had to choose between honouring the<br />

Hippocratic Oath by refusing to remove<br />

the ears of army deserters, or facing<br />

death at the hands of Saddam’s military<br />

police”<br />

Midway through his first year of medical<br />

school, his parents called one evening and<br />

implored him to return home to safety. He was<br />

After the journey to Australia, his stay in<br />

Curtin Detention Centre would prove another<br />


major hurdle. As detainee 982 (names were<br />

replaced by numbers), his experience was the<br />

rule, not the exception: extended periods of<br />

solitary confinement, a general lack of privacy,<br />

and navigating the complex web of rumours and<br />

tensions that a confined environment instigated<br />

between detainees. Detainees were constantly<br />

reminded that their stay was indefinite and they<br />

may never be resettled in Australia, but could<br />

return to their country of origin at any time.<br />

Al Muderis has presented the events of<br />

his life as actions and reactions, rather than<br />

delving into whether his experiences had any<br />

long term psychological toll, however in writing<br />

your own story you afford to keep some cards<br />

close to your chest. Walking Free is the journey<br />

of someone who achieved their dreams against<br />

the odds of complex, challenging and evolving<br />

geopolitical circumstances. It gives a face and<br />

story to those on the other side of the fence:<br />

“Al Muderis has presented the events<br />

of his life as actions and reactions, rather<br />

than delving into whether his experiences<br />

had any long term psychological toll”<br />

The story only briefly covered Al Muderis’ rise<br />

through the medical ranks in Australia, most<br />

likely because the day-to-day experiences<br />

of surgical training are seemingly mundane<br />

in comparison to the preceding journey.<br />

Nevertheless, a more in-depth discussion of his<br />

pioneering use of osseointegration surgery in<br />

Australia would have been appreciated.<br />

Despite the seemingly unbelievable events<br />

of Walking Free, there are some commonalities<br />

about life that hold true irrespective of personal<br />

context. Marriage and a newborn child midway<br />

through medical school was never an easy<br />

undertaking but religious differences and<br />

constant interference from both families<br />

may ensure any union is doomed. There is<br />

the sobering reminder that a bond and later<br />

marriage forged through a treacherous boat<br />

journey and stay in detention could be broken<br />

by the strain of long working hours and constant<br />

relocations associated with a surgical career.<br />

My favourite anecdotes involve the<br />

savviness of Mrs Al Muderis. She managed the<br />

family finances during wartime and economic<br />

sanctions, she provided USD $22 000 in cash<br />

to her son upon hearing his need to flee during a<br />

time in which owning US dollars in Iraqi banks was<br />

prohibited, and organised legal representation<br />

during his stay in Australian detention centres.<br />

When family is involved, mothers will always find<br />

a way.<br />

locked up, anonymous individuals only seen<br />

in glimpses of news reports as the ‘dangerous<br />

other’; individuals that are every bit as human<br />

as us, but who have been dealt a very different<br />

hand in life.<br />

As medical students, it can be easy to<br />

become entangled in the inevitable drama and<br />

competition that surrounds us, and lose sight<br />

of why we are pursuing this goal. Walking Free<br />

is a humbling reminder that everything can<br />

change in the blink of an eye and that no matter<br />

how tortuous the journey becomes, there is<br />

something to be learnt from every step of the<br />

way.<br />

Conflicts of interest<br />

The author of this book review declares that<br />

they have no conflict of interest.<br />

Correspondance<br />

apla9692@uni.sydney.edu.au<br />



Hooray! Your file is uploaded and ready to be published.

Saved successfully!

Ooh no, something went wrong!