Vector Volume 11 Issue 2 - 2017

1

Advisory Board
The Advisory Board, established in 2017, consists of academic mentors who provide guidance for the present and future
direction of Vector.
Dr Claudia Turner
Consultant paediatrician and clinician scientist with the University of Oxford & Chief Executive Officer of Angkor Hospital for
Children.
Professor David Hilmers
Professor in the Departments of Internal Medicine and Pediatrics, the Center for Global Initiatives, and the Center for Space
Medicine at the Baylor College of Medicine
Associate Professor Nicodemus Tedla
Associate Professor at the University of New South Wales School of Medical Sciences
Dr Nick Walsh
Medical Doctor (RACP) & Regional Advisor for Viral Hepatitis at the Pan American Health Organization / World Health
Organization Regional Office for the Americas
Thank you to the Vector Journal peer reviewers for 2017:
Dr Phil Baker
Dr Denton Callander
Professor Nicholas Crofts
Dr Greg Fox
Dr Alexandra Gibson
Dr Max Hopwood
Ms Alexandra Jones
Dr Erik Martin
Dr Bridianne O’Dea
Dr Dominique Martin
Professor Geetha Ranmuthugala
Dr Mitchell Smith
Dr Adrienne Torda
Dr Leonie Watterson
Professor Bridget Wills
2017 Vector Committee
Editor-in-chief
Carrie Lee carrie.lee@amsa.org.au
Associate Editors
Kryollos Hanna Sophie Lim Koshy Matthew Nic Mattock Aidan Tan
Ash Wilson-Smith Sophie Worsfold Danica Xie
Publication Designer
Lucy Yang
Design and layout
© 2017, Vector
Australian Medical Students’ Association Ltd, 42 Macquarie Street, Barton ACT 2600
vector@globalhealth.amsa.org.au
vector.amsa.org.au
Content
© 2017, The Authors
Cover design image accessed from https://pixabay.com/p-2349893/?no_redirect
Vector Journal is the official student-run journal of AMSA Global Health.
Responsibility for article content rests with the respective authors. Any views contained within articles are those of the authors and do not necessarily
reflect the views of the Vector Journal or the Australian Medical Students’ Association.
i

Contents
Editor’s Note: Turning Up the Heat 1
Features
Non-Health for Non-Persons: Rohingya Muslims in Crisis 2
Jumaana Abdu
LGBTIQ people’s experiences of and barriers to healthcare 5
Salwa Barmaky and Alex Lee
Commercial surrogacy in Australia: the benefits of harm minimisation through legalisation 10
Keyur Doolabh and Emily Feng-Gu
Polio vs Politics: The Case of Pakistan 15
Jeanine Hourani
Turning up the heat 17
Tara Kannan
Coal mining, climate change and the global impacts on health: examining Adani’s proposed Carmichael coal mine 21
John E Morgan
Paddling upstream: Experiences from a medical placement in rural Papua New Guinea 26
Nicholas Snels
Reviews
Sugar tax: a sweet solution for obesity? 29
Saiuj Bhat
Drug control in Australia: where to next? 34
Raquel Maggacis
Dengue in the Pacific Islands 38
Madeleine Marsland and Dunya Tomic
Conference reports
AIDA 2017 - Family, Unity and Success 44
Narawi Foley Boscott
World Congress on Public Health 47
Michael Au, Ka Man Li, Helena Qian, Michael Wu
Commentary
Welfare cuts to refugees 50
AMSA Global Health Crossing Borders National Managers Sibella Breidahl, Jasmine Sekhon
GHC 2017
Start where you are, use what you have, do what you can - Adelaide Global Health Conference 2017 Closing
Address 52
Liz Bennett, AMSA Global Health Chair 2017
GHC Competition Winner: “Where to now?” 54
Helena Qian
Book review
A walk to remember 55
Anna Marie Plant
ii

Editor’s Note- Turning up the heat
Global health is intrinsically linked to the changing social,
economic, cultural and political environment. Political leaders
powerfully shape responses to global health, whether in a
positive or negative way. Historically, when health issues
have risen on the political agenda, they received greater
media attention, and importantly, funding – the HIV/AIDS
epidemic exemplifies this. The change in leadership in the
World Health Organization under the new Director-General Dr
Tedros offers new opportunities to advocate for issues such
as universal health coverage, women’s health and rights, and
climate health.
However, like many others, I find myself disappointed
by the lack of political will to assist refugees and people
seeking asylum. This is an ongoing problem, in Australia with
the recent welfare cuts to refugees, described by Sibella
Briedahl and Jasmine Sekhon (pg 2) , and internationally,
with the plight of the stateless Rohingya people fleeing
persecution in Myanmar, in a feature article by Jumaana Abdu
(pg 50).
Over the past year, controversial policies have dominated
public health discourse on both a national and international
scale. Non-communicable diseases continues to rise on
the agenda. A tax set to cut sugar-sweetened beverage
consumption takes a step towards tackling Big Sugar in the
footsteps of movements against Big Tobacco, as covered in
a review by Saiuj Bhat (pg 29).
In Australia, we have also seen pushes for safe injecting
rooms and pill testing at festivals. Does this reflect the
global shift in attitudes from criminalisation towards harm
minimisation, with decriminalisation in Portugal providing
successful proof-of-concept? Raquel Maggacis overviews
drug control approaches worldwide, arguing that Australia
should adopt a harm minimisation approach (pg 34).
Global health does not obey borders, and health policies
have far-reaching effects. Infectious diseases certainly
require no passport to spread from country to country,
and Madeleine Marsland and Dunya Tomic highlight the
importance of strong regional surveillance systems and
prevention strategies (pg 38) Moreover, so long as one child
has polio, all countries remain at risk, as described by Jeanine
Hourani (pg 19). However, polio eradication in Pakistan, one
of the last remaining polio-endemic countries, is incredibly
complex due to political instability and competing agendas.
Local policies certainly have broader international
consequences, and Keyur Doolabh and Emily Feng-Gu
explore issues around commercial surrogacy such as
exploitation in countries where surrogacy is cheaper or
poorly regulated (pg 10). Similar to drug control approaches,
a harm minimisation approach may offer a better alternative
to regulate processes and protect the rights of parents and
children.
Other contentious topics in Australia include the Adani
coal mine and the postal vote for same sex marriage. These
will have significant implications both now and in the future.
With the recent postal vote, the mental health and wellbeing
of LGBTIQA+ people could not be of more relevance.
However, as Salwa Barmaky and Alex Lee write, LGBTIQA+
people also face barriers in access to healthcare, including
discrimination from the medical profession itself (pg 5).
Aboriginal and Torres Strait Islander people also
experience discrimination within the health care system,
as Narawi Foley-Boscott explains (pg 44). So what then is
the way forward for such issues? Both authors emphasise
the importance of educating medical professionals to be
culturally sensitive, to be open to learning, and to be aware of
the structural factors that contribute to discrimination.
Evan Morgan (pg 21) argues that the Adani coal mine
endangers our health and the environment and is a poor
investment for tax-payers. It hinders Australia’s ability to fulfil
its global commitments under the Paris Agreement to reduce
carbon emissions and temperature rises.
Divestment offers a solution to climate change: take money
away from the fossil fuel industry. We, as medical societies
and the future medical profession, have an important role to
add to this social movement, as thoughtfully argued by Tara
Kannan (pg 17) The title of her article, “Turning up the heat”,
captures the energy that connects the articles in this issue, a
panoramic range of contemporary and controversial issues.
It calls on us to take action and to challenge the paradigm of
seeing health as purely a biomedical issue, but one inherently
connected to regional and international social and political
forces.
As medical students, we are well-placed to educate
and upskill ourselves to contribute to global health in the
future. Attend conferences (Australian Indigenous Doctors’
Association, pg 44 World Congress of Public Health, pg
47. Take elective placements in developing countries, and
prepare yourself with pre-departure training (Nicholas Snels,
pg 26 ). As yourself, what can we do about these global health
issues? (Helena Qian, pg 54)
One of the statements that left a lasting impression on
me from this year’s Global Health Conference was from the
AMSA Global Health Chair, Liz Bennett: “It is not enough to be
inspired... We do not have the luxury of apathy and you cannot
afford to waste time thinking that you are too small to make
a difference.” (pg 52).
I am continually amazed and grateful to the incredible
work of the authors, editorial team, peer reviewers and
Advisory Board. It has been a privilege and a half to lead
Vector Journal this year and hope that this issue inspires you
and challenges you to take action.
Carrie Lee
Editor-in-chief, 2017
1

Non-Health for Non-Persons:
Rohingya Muslims in Crisis
[Feature article]
Jumaana Abdu
Jumaana is currently finishing her first year of medicine at the University of New South Wales.
She aims to find a career path which combines her passion for medicine and human rights.
She also hopes her future involves as a side-profession of writing, fiction or otherwise.
In a tightening spiral of human suffering that winds
back five decades, the Rohingya have come to be
mentioned as a customary precursor to the phrase “most
persecuted minority in the world”. The long-disowned
nationals of Myanmar are estimated at a population
of 1.2 million,[1] stateless victims of humanitarian
violations so comprehensive and extensive that the
world’s empathy can only be directed towards a vague
fog of injustice. However, as flagbearers of the right to
health and human dignity, healthcare professionals must
be able to shine a torch into the fog and discern the
faces within.
Current Situation
While systematic persecution of the Rohingya Muslims
has been noted since the stripping of voting rights and
the military “purges” of the 1970s, events within the past
year have seen violence escalate dramatically. A border
attack by a group of radicalised Rohingya Muslims on
Myanmar’s police last October resulted in an estimated
10 casualties. Extremist violence is unacceptable and
unhelpful, though one can see the desperation, injustice
and generations-worth of marginalisation from which
this radicalisation was inevitably born. Since the attack,
disproportionate and indiscriminate military retaliation
has resulted in hundreds of deaths and torrents of
Rohingya fleeing Myanmar’s northern Rakhine state,
where the situation is worst. The United Nations (UN)
reports that from the last week of October 2017 to the
first week of September 2017 alone – just two weeks –
270,000 people fled to Bangladesh for safety.[2]
The humanitarian crisis in which the Rohingya find
themselves is undeniable. Officially stateless, access
to basics such as healthcare, education, employment,
security and freedom is often impossible. Tragically,
these deprivations are far less confronting than other
reasons for which the Rohingya have been forced to flee.
With UNHCR reports documenting common experiences
2

of “mass gang-rape, killings, including of babies and
young children, brutal beatings, disappearances and
other serious human rights violations by the country’s
security forces”, returning to Myanmar is not an option.[3]
UNHCR interviews with
Rohingya refugees detail random
shooting at crowds who were
fleeing houses, schools, mosques
and markets that had been set
alight by Myanmar’s army, police
and occasionally civilian mobs.[4]
Destruction of food, livestock and
food sources; cases where the army or Rakhine civilians
have trapped an entire family, including the elderly and
disabled, inside a house and set it on fire “killing them all”;
mothers assaulted by “security” forces while being forced
to watch their babies stabbed and killed – words cannot
do it justice.[4]
Recent news reveals that Burmese officials have
planted landmines along the Bangladesh border, posing
a lethal threat to Rohingya peoples fleeing atrocities.
Deemed unlawful for their inability to distinguish between
civilians and militants, children and adults, landmines have
been banned in many countries under the 1997 Mine Ban
Treaty. Not a signatory to this, Myanmar officials continue
to use them against Rohingya civilians, protected by the
unsurprising denial by the Burmese government that such
landmine plantings have taken place.
An assortment of condemnations have been offered
by the UN; crimes against humanity,[3] genocide, ethnic
cleansing. The UN High Commissioner for Human
Rights Zeid Ra’ad Al Hussein, concludes his report on
the Myanmar atrocities by despairing, “What kind of
‘clearance operation’ is this? What national security
goals could possibly be served by this?”.[3] As Hussein
seems painfully aware, these words fall on deaf ears.
Medical Crisis
Humanitarian agencies are floundering, desperately
attempting to provide emergency care for the monsoonal
influx of Rohingya refugees, most of whom have a variety
of physical and psychological conditions. Studies of the
health conditions within Bangladesh’s two main registered
refugee camps present unsurprisingly dire findings.
One psychiatric study surveyed a group of registered
Rohingya refugees and reported experiences of torture
(39.9%), sexual abuse (12.8%), rape (8%), forced
abortions (2.4%), PTSD (36%), depressive symptoms
(89%), suicidal ideations (19%) and deaths of friends or
family due to illness or starvation while fleeing (22.4%).
[5] Hopelessness was the common theme, with one
Rohingyan interviewee asking, “Our future has been
spoiled, but what will happen to the future of our children?”
Hopelessness was the common theme,
with one Rohingyan interviewee asking,
“Our future has been spoiled, but what
will happen to the future of our children?”
In 2015, another study investigated the general health
conditions of Bangladesh’s largest Rohingya refugee
camp, Nayapara.[1] With a population of 18,777, the camp
was attended by only four trained doctors and six nurses.
The infant mortality rate was 45.4 per 1000 livebirths and
one quarter of the population was
children, most of whom were born
in a camp. Additionally, the study
reported widespread stunting due
to malnutrition (57%), anaemia
(49%), and a high prevalence of
respiratory (46.9%), endocrine
(21.9%) and cardiovascular
disorders (14.8%). Mental health
conditions were ubiquitously poor; 18.7% of camp
injuries were caused by self-harm, and in Bangladesh’s
other major camp, 43.3% of Rohingya refugees were
diagnosed with a psychotic disorder.
Importantly, health conditions in registered refugee
camps far surpass those of the many unregistered camps
in countries neighbouring Myanmar. These makeshift
shelters, which house twice as many Rohingya as the
registered camps, are conferred no security or support
from the already-drowning NGOs servicing the area.
This, however, is still favourable to staying in the northern
Rakhine state of Myanmar where health conditions are
so abysmal that, for example, mortality in children under 5
has reached 224 per 1000 livebirths.[6]
Role of Health Professionals in Social Justice
In situations where political and military injustice
seem impenetrable, often the most basic human
right affordable is emergency medical care, but is the
assumption that medical aids are exempt from political
and military violence still applicable today? As seen
in reports of hospitals targeted in Syria by Western
military, it seems that medical neutrality is no longer a
guarantee. Combined with the Myanmar government’s
notoriously uncooperative relationship with humanitarian
organisations, one must ask what responsibility
healthcare professionals are expected to bear in the
realm of human rights.
In 2014, Médecins Sans Frontières was banned
in Rakhine, and a month later, when humanitarian aid
agencies were attacked by Buddhist anti-Rohingya
radicals, Myanmar’s government only further restricted
humanitarian aid.[6] This ban has since been lifted
but access is now parlous again due to the Myanmar
government’s “formulated and disseminated accusations
against the UN and international NGOs, denial of required
travel and activity authorisations, and threatening
statements and actions by hardline groups”.[7] Also
recently, the UNHCR High Commissioner Hussein has
struggled with repeated government restrictions on
humanitarian access to the worst affected regions of
Rakhine, and bans on UN investigative officials entering
3

Rohingyan regions of Myanmar. Forced to work within the
law, the UN can only deploy officers to the Bangladeshi
border.[2]
These tensions between humanitarian aid and the
state beg the question: in health emergencies and human
rights violations as staggering as those experienced by
the Rohingya Muslims, should human rights and healthcare
organisations bend to the will of unjust – even criminal –
governments? It is a problem the UN and its subcommittee,
the World Health Organization, still grapple with. Do they
obey their mandate to respect the sovereignty of their
member states? Or do they perform their constitutional
role of helping member states “respond to... emergencies
with public health consequences”?[8] How can they, when
the member state itself is perpetuating the emergency?
Additionally, the aforementioned lack of confidence in
medical neutrality makes it unsafe for health workers to
stand against government and military opposition.
The only solution where a full response to this
... should human rights and healthcare
organisations bend to the will of unjust –
even criminal – governments?
humanitarian crisis can be appropriated lies in either
cooperation with Myanmar’s government – which seems
unlikely – or direct actions against the government by
UN member states. Ideally, the Burmese government
would grant the Rohingya some form of internationally
recognised citizenship, allowing for better organisation
of refugee status and resettlement programs for the
Rohingya in neighbouring countries. Sanctions intended
to force the Burmese government’s hand have failed in
the past,[6] but if the global community can unite with
harsher repercussions for the continued persecution of
Rohingya Muslims, surely the situation can only improve.
Conclusion
The Rohingya peoples are born into a cycle of
poor health outcomes that begin with low birthweight
and continue with dismal access to healthcare. Timid
international responses to the systematic abuse, torture
and dehumanisation of this minority have allowed for the
continuation of historical persecution. The 2015 election
of Nobel Prize laurate Aung San Suu Kyi as Myanmar’s
Prime Minister presented an opportunity for a Myanmar
government to end their denial and dismissal of decades
of Rohingyan suffering. However, as stated by her aide,
it seems she has “other priorities”,[6] which probably
includes avoiding conflict with her majority-Buddhist
supporters and the hugely politically influential Burmese
military. For now, Rohingya Muslims will have to continue
to relying on NGOs who are drowning under resource
insufficiencies and legal restrictions, attempting to deal
with the desperate masses in any way possible.
History paints a picture of peaceful generations
of Rohingya living in Myanmar. Their future seems
increasingly uncertain, although ideally it involves them
returning safely home. One and a half million people await
a saving grace, security for their children, medicine, clean
water. If international global health organisations cannot
work within Myanmar’s policies, then they must find a
conclusive alternative. It is unacceptable that there is still
not a light at the end of this half-a-century long tunnel.
Photo credit
EU/ECHO/Pierre Prakash
Accessed from https://www.flickr.com/photos/eu_
echo/17337141093/in/photostream/
Conflicts of interest
None declared
Correspondance
jumaana.a6000@gmail.com
References
1. Milton, A. H., Rahman, M., Hussain, S., Jindal, C., Choudhury,
S., Akter, S., ... & Efird, J. T. (2017). Trapped in Statelessness:
Rohingya Refugees in Bangladesh. International Journal of
Environmental Research and Public Health, 14(8).
2. United Nations (2017). UN scales up response as
270,000 flee Myanmar into Bangladesh in two weeks. Retrieved
from http://www.un.org/apps/news/story.asp?NewsID=57480#.
WbZ6eK2B3Vo
3. United Nations (2017). UN report details ‘devastating
cruelty’ against Rohingya population in Myanmar’s Rakhine
province. Retrieved from http://www.un.org/apps/news/story.
asp?NewsID=56103#.WbZ4w62B3Vp
4. OHCHR Zeid Ra’ad Al Hussein (2017). Interviews with
Rohingyas fleeing from Myanmar since 9 October 2016.
Retrieved from http://www.ohchr.org/Documents/Countries/MM/
FlashReport3Feb2017.pdf
5. Riley, A., Varner, A., Ventevogel, P., Taimur Hasan, M. M.,
& Welton-Mitchell, C. (2017). Daily stressors, trauma exposure,
and mental health among stateless Rohingya refugees in
Bangladesh. Transcultural Psychiatry, 54(3), 304-331.
6. Mahmood, S. S., Wroe, E., Fuller, A., & Leaning, J. (2017).
The Rohingya people of Myanmar: health, human rights, and
identity. The Lancet, 389(10081), 1841-1850.
7. Médecins Sans Frontières (2017). Myanmar:
International humanitarian access to Rakhine State must
urgently be permitted. Retrieved from http://www.msf.org/en/
article/myanmar-international-humanitarian-access-rakhinestate-must-urgently-be-permitted
8. Kennedy, J., & McCoy, D. (2017). WHO and the health
crisis among the Rohingya people of Myanmar. The Lancet,
389(10071), 802-803.
4

LGBTIQ people’s experiences of and
barriers to healthcare
[Feature Article]
Salwa Barmaky and Alexander Lee
Salwa is a fourth year medical student at the University of New South Wales. and a public
health enthusiast, especially interested in health disparities and programme interventions.
Alexander is an undergraduate medical student currently studying at the University of New
South Wales. His interests include improving healthcare access for marginalised populations
including gender and sexuality diverse groups and reproductive health.
Introduction
Increasing data on sexual orientation and gender
identities in large scale social studies has revealed
that significant portions of the Australian community
are sexuality and/or gender diverse. In the 2014 ABS
General Social Survey, 3% of the Australian population
identified as not heterosexual,[1] and whilst Australian
data is unavailable, a study of 8500 New Zealand
secondary school students revealed that 1.2% identified
as transgender.[2]
LGBTQIA+ refers to lesbian, gay, bisexual,
transgender, queer and questioning, intersex, asexual
and aromantic individuals, with the ‘+’ connoting other
diverse sexualities, sexes and genders. LGBTQIA+
Australians continue to face significant barriers to care
which in turn impact individuals’ help seeking behaviours.
[3, 4]
Until 1973, homosexuality was considered a mental
disorder. Similarly, transgender and gender diverse (TGD)
identities were classified as ‘gender identity disorder’
until the 2013 edition of the Diagnostic & Statistical
Manual (DSM-5) [4] and continues to
be listed as such by the World Health
Organization’s International Statistical
Classification of Diseases and
Related Health Problems (ICD-10).[5]
Furthermore, access to hormonal and/
or surgical intervention largely remains
tied to gatekeeper models requiring
TGD individuals to be ‘diagnosed’.[6, 7]
Despite having been widely condemned as ineffective
and causing significant psychological harm,[8, 9]
pseudoscientific ‘gay conversion therapy’ continues to
persist. Most recently, a New South Wales GP appearing
in a ‘Vote No’ television campaign against same-sex
marriage was identified as a founder of a ‘family values’
Whilst questions such as
“do you have a boyfriend/
girlfriend?” seem innocent, they
carry value judgements on what
is considered ‘normal’.
group advocating this practice. Many intersex individuals
have also been subjected to risky, non-consensual
genital mutilation surgery as infants in a bid to ‘normalise’
them.[10] Furthermore, some clinicians expressly feel
awkward treating LGBTQIA+ individuals.[11] Hence, to
effectively advocate for greater inclusivity and equity, it
is paramount that health professionals understand both
current and historical healthcare barriers as well as the
specific health concerns of LGBTQIA+ communities
As such, this article will outline:
1) Effects of individual, interpersonal and structural
social determinants of health on healthcare access for
LGBTQIA+ individuals;
2) Key health issues affecting LGBTQIA+ individuals;
and
3) Recommendations for improving access.
Social determinants of healthcare access for
LGBTQIA+ individuals
Despite the acronym LGBTQIA+ construing
homogeneity, LGBTQIA+ communities are distinctly
heterogeneous. Individuals may have different
experiences of their identity and come from different
social contexts such as ethnic
background or socioeconomic
class.[12] However, they do share a
continued exposure to societal stigma
associated with their diverse identities.
This stigma plays into all levels of the
social determinants of health which in
turn impact both individuals’ health and
healthcare access. These include individual internalised
shame, interpersonal discrimination and ignorance and
structural legal, administrative and systemic challenges.
These determinants limit LGBTQIA+ Australians’
confidence in our healthcare system.
5

Individual and interpersonal
While accessing healthcare, LGBTQIA+ individuals
face interpersonal barriers in the form of clinicians’ lack
of knowledge and discrimination as well as their own
individual internalised homophobia.
DSM-5 now allows for self-identification as asexual as
an alternative to diagnosis with ‘hypoactive sexual desire
disorder’ or ‘female sexual arousal/interest disorder’ [25],
historically, a lack of interest in sex has been pathologised
by Western medicine.[26]
Many practitioners have limited training and
awareness around the importance of comprehensive,
non-judgmental sexual history taking. Clinicians’
unconscious biases often result in LGBTQIA+ clients
being forced to ‘out’ themselves in response to questions
that assume heterosexuality and do not recognise
gender diverse or intersex experiences (e.g. asking a
trans woman about birth control). This exacerbates
existing awkwardness around sexual and mental health
and is associated with significant discomfort, which
may contribute to patients’ decisions
not to disclose their sexuality or gender
identity.[13] Additionally, some GPs did not
understand different sexual practices and
felt uncomfortable broaching the topic.
[14] One third of LGBTQ* Australians
still hide their sexuality or gender identity
when accessing healthcare.[15] In youths, half did not
disclose.[16] This not only impacts individuals’ ability to
build trust with healthcare providers but also undermines
the provision of targeted health services such as human
immunodeficiency virus (HIV) testing in men who have sex
with men (MSM).
Healthcare providers’ lack of knowledge regarding
TGD identities and unique health needs is a common
theme.[17-20] Having to educate healthcare providers
was found to be a key contributor to negative GP
encounters in Australia.[17] A lack of sensitivity [19, 20]
with practitioners asking invasive or offensive questions
[17] and misgendering clients through the use of incorrect
pronouns or old names [15, 21] contributes to these
barriers. Clinicians not working in TGD-specific fields
often have little knowledge on the issue, resulting in
these clients’ exclusion from mainstream health services.
[2, 15, 21] Even clinicians regularly engaged with TGD
clients enlist gatekeeping behaviours which restricts
access to hormonal and surgical intervention.[17, 22] This
discourages TGD individuals from raising mental health
concerns and many find this process of “assessment”
to be degrading and pathologising.[21] Moreover, rigid,
binary views of gender results in non-binary individuals
feeling invisible and unwelcome to services.[23]
LGBTI people in Australia
are five times more likely to
attempt suicide in their lifetimes
Internalised homophobia may manifest as a further
barrier to seeking healthcare services. Consequently,
during periods of illness, individuals turn to pharmacies
and only seek health services when self-medication has
been unsuccessful.[27]
Structural
LGBTQIA+ communities also face a myriad of
structural barriers to quality healthcare.
Australia is currently the only
Western country which requires TGD
adolescents to gain Family Court
‘approval’ to access hormones.
Despite the time-sensitive nature of
hormone therapy, the legal process
can take up to 10 months, and cost
tens of thousands of dollars.[28] However, this is currently
under review by the Family Court.[29]
TGD communities, especially non-binary individuals,
also face inaccurate medical record keeping that do
not reflect individual’s chosen names, genders and/or
pronouns and a lack of gender-neutral bathroom access.
[18, 23] Moreover, TGD individuals experience discomfort
in gendered spaces such as gynaecologists’ clinics [23]
and heightened discomfort surrounding pap smears and
breast checks.[18, 22] The relegation of TGD services to
the realm of expensive private healthcare[15] is at heads
with their increased risk of poverty, underemployment and
housing instability.[18, 19, 23]
Additionally, the view of LGBTQIA+ identities as
inherently pathological by some providers is discriminatory.
[13, 21, 24] TGD individuals may face clinician discomfort,
disgust, ridicule, contempt and even refusal of treatment.
[19, 21-23] One participant of the Australian and New
Zealand TranZnation report was told by their doctor
that she was ‘the filthiest, most perverted thing on earth’
while another was informed they ‘needed to find god not
hormones’.[21] Asexuality is also pathologised. While
Furthermore, unconscious bias can also manifest
in the distribution of research funding and practitioner
training. Compared to the relative visibility of gay men’s
health around the HIV/AIDS epidemic, TGD health as well
as queer women’s health have largely been ignored.[13]
6

Sexual health
LGBTQIA+ individuals may also experience poorer
sexual health. There is evidence to suggest that women
who have sex with women (WSW) are at higher risk for
cervical cancer.[32] Both patients and clinicians lack
awareness around sexually transmitted infection (STI),
specifically human papilloma virus (HPV), transmission
during cisgender woman to woman sexual contact.
Consequently, WSW are less likely to have Pap or other
cervical smears.[33]
Key LGBTQIA+ health issues
Besides issues of access, LGBTQIA+ individuals have
specific healthcare risks, needs and concerns. Pertinently,
LGBTQIA+ individuals have significantly poorer mental
and sexual health. They also have higher incidence of
certain chronic diseases such as cardiovascular disease,
asthma and diabetes.[30]
Mental health
Poorer mental health is one of the ways that stigma
affects LGBTQIA+ individuals’ wellbeing. Compared to
the general population, LGBTI people in Australia are
five times more likely to attempt suicide in their lifetimes
and more specifically, TGD-identifying individuals are
eleven times more likely.[31] LGBT people are also twice
as likely to be diagnosed and treated for mental health
disorders, and 24.4% of LGBT people aged 16 and over
currently meet the full criteria for a major depressive
episode.[31]
Reasons for poorer mental health are also based in
internalised, inter-personal, organisational and structural
stigma and discrimination.[31] These include: bullying at
schools, lack of bullying laws, ostracism from families
and faith communities, fear of employment and economic
stability, and inner conflict and internalised phobia
about their respective identities. LGBTQIA+ individuals
also have higher risk for poor coping mechanisms and
substance abuse.[32]
In addition, MSM have greater incidence of HIV. In
Australia, HIV transmission occurs primarily through
male-to-male sex with 68% of new HIV diagnoses in 2015
having been attributed to male-to-male sex.[34] Besides
the greater susceptibility of anal mucosa, this increased
incidence arises from the concentration of HIV within
MSM sexual networks in Western nations.[35] Receptive
anal intercourse in male-to-male sex may also increase
risk of hepatitis B, HPV and herpes.[32] In NSW, MSM
are also more likely to report ever having had an STI,
particularly chlamydia, pubic lice, genital herpes, syphilis,
anal warts and gonorrhoea.[36] As some of these STIs
are risk factors for anal cancer, MSM are also at greater
risk for anal cancer.[32] However, MSM are also more
likely than any non-MSM to be tested for STIs.[36]
Furthermore, poor data collection means that the
sexual health of TGD populations in Australia remain
poorly understood. The tendency to collapse TGD
experiences into a single ‘third gender’ category ignores
the vast differences in risk associated with different
gender identities, sexual orientations and partners. For
example, the Kirby Institutes’ 2016 annual report on
STIs recorded sex as ‘male’, ‘female’ and ‘transgender/
missing’.[37] This is particularly disappointing in the
context of trans women in particular being significantly
overrepresented in global HIV prevalence.[38]
Aging
Owing to Australia’s aging population, the issue of older
Key messages
• LGBTIQA+ people face barriers to healthcare access,
historically influenced by discrimination from the medical profession
• Health disparities exist between LGBTIQA+ individuals and
the general population, particularly in the areas of mental health,
sexual health and chronic disease
• Further research and education, a collective effort to treat
LGBTIQA+ people with individual respect, and a willingness to learn,
will help to reduce health inequalities
*In certain parts of this article, terms to refer to the sex, sexuality and gender diverse individuals may change dependent
on the groups of people being researched in the various research articles cited.
7

LGBTQIA+ individuals is topical. LGBTQIA+ individuals in
aged care have specific care needs such as ongoing
HIV/AIDS treatment and hormone therapy. Having lived
through the criminalisation of homosexuality, many may
be impacted by an internalised need to go ‘back into the
closet’ for fear of discrimination.[39]
Improving access
To reduce the aforementioned barriers and risks,
various areas can be improved. Institutionally, education
around LGBTQIA+ issues of sexuality, gender diversity,
access and risk should be integrated into the medical
curriculum. Trainees should be taught to adopt
non-judgmental approaches to history taking and
communication.[16, 40] Whilst questions such as “do you
have a boyfriend/girlfriend?” seem innocent, they carry
value judgements on what is considered ‘normal’. Instead,
more inclusive terminology should be encouraged to
enable clinicians to invite discussion around sexual health
without assuming heterosexuality or gender binaries.
Encouragingly, previous efforts in introducing LGBTQIA+
content through lectures and clinical simulations have
been effective in decreasing at least clinician discomfort
in providing LGBTQIA+ related care.[41-44]
Clinicians should also create environments of
inclusiveness. This includes respecting patients’ chosen
pronouns and names, and keeping open minds about
their relationships. This is imperative to building trust.
Introducing intake forms that include diverse gender
identities and LGBTQIA+ specific signage or educational
brochures also increase patient comfort.[40] Additionally,
revision of current data collection systems would enable
more targeted healthcare delivery for TGD populations.
This could be aided through mandatory recording of
both sex assigned at birth and current gender identity
which would enable the disaggregation of different TGD
experiences.[45]
Conclusion
LGBTQIA+ people face on-going barriers to healthcare
on individual, interpersonal and structural levels and have
an increased risk of mental, sexual and chronic illnesses.
Thus, in order to improve health outcomes, barriers to
access should be targeted on both interpersonal and
structural levels. Ultimately, treating LGBTQIA+ people
with individual respect and a willingness to learn will go a
long way in in reducing these inequities.
Acknowledgements
The authors acknowledge and thank Gale Chan for
their contributions to the drafting and revising of this
article.
Photo credit
©2008 laverrue, accessed from https://www.flickr.
com/photos/23912576@N05/2942525739
Ryan melaugh, accessed from https://www.flickr.com/
photos/120632374@N07/13974181800
Conflicts of interest
None declared
Correspondance
salwasayeed70@hotmail.com
alexanderlee193@gmail.com
References
1. Australian Bureau of Statistics. General Social Survey:
Summary Results, Australia, 2014 2014 [cited 2017 September
9]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/
mf/4159.0.
2. Clark TC, Lucassen MFG, Bullen P, Denny SJ, Fleming
TM, Robinson EM, et al. The health and well-being of transgender
high school students: Results from the New Zealand Adolescent
Health Survey. Journal of Adolescent Health. 2014;55:93-9.
3. Mulé NJ, Ross LE, Deeprose B, Jackson BE, Daley A,
Travers A, et al. Promoting LGBT health and wellbeing through
inclusive policy development. International Journal for Equity in
Health. 2009;8(18).
4. Potter J, Goldhammer H, Makadon M. Clinicians and the
care of sexual minorities Potter J, Goldhammer H, Makadon M,
Mayer K, editors. Philadelphia: American College of Physicians;
2008.
5. World Health Organisation. International Statistical
Classification of Diseases and Related Health Problems 10th
Revision 1992 [updated 2016. 10:[Available from: http://apps.
who.int/classifications/icd10/browse/2016/en#/F60-F69.
6. Australian and New Zealand Professional Association
for Transgender Health. Standards of Care [Available from:
http://www.anzpath.org/about/standards-of-care/.
7. World Professional Association for Transgender Health.
Standards of care for the health of transsexual, transgender
and gender nonconforming people 2011 [Available from: http://
www.wpath.org/site_page.cfm?pk_association_webpage_
menu=1351&pk_association_webpage=3926.
8. Mayers L, Chow K. Same-sex marriage survey: Petition
to deregister Pansy Lai, doctor in No campaign ad, taken down.
ABC News. 2017.
9. Daniel H, Butkus R. Lesbian, Gay, Bisexual, and
Transgender Health Disparities: Executive Summary of a Policy
Position Paper From the American College of Physicians.
Annals of Internal Medicine. 215(163):135 — 7.
10. Minto CL, Liao L-M, Creighton SM, Woodhouse CRJ,
Ransley PG. The effect of clitoral surgery on sexual outcome
in individuals who have intersex conditions with ambiguous
genitalia: A cross-sectional study. Lancet. 2003;361(9365):1252
— 7.
11. Smith D, Mattews W. Physicians’ attitudes toward
homosexuality and HIV: a survey of a California medical Societyal
of Homosexuality. Journal of Homosexuality. 2007;52(3/4):1 — 9
12. Ard KL, Makadon HJ. Improving the health care of
lesbian, gay, bisexual an transgender people: understanding
and eliminating health disparities. Boston, Massachusetts: The
Fenway Institutee; 2012.
13. Australian Human Rights Commission. Resilient
Individuals: Sexual Orientation, Gender Identity & Intersex
Rights 2015.
14. Hinchliff S, Gott M, Galena E. ‘I daresay I might find
it embarrassing’: general practitioners’ perspectives on
discussing sexual health issues with lesbian and gay patients.
Health & Social Care in the Community. 2005;13(4):345.
8

15. Leonard W, Pitts M, Mitchell A, Lyons A, Smith A, Patel S,
et al. Private Lives 2: The second national survey of the health
and wellbeing of gay, lesbian, bisexual and transgender (GLBT)
Australians. Melbourne: The Australian Research Centre in Sex,
Health & Society, La Trobe University; 2012.
16. Robinson KH, Bansel P, Denson N, Ovenden G, Davies
C. Growing Up Queer: Issues Facing Young Australians Who Are
Gender Variant and Sexuality Diverse. Melbourne Young and
Well, Cooperative Research Centre 2014.
17. Riggs DW, Coleman K, Due C. Healthcare experiences
of gender diverse Australians: a mixed-methods, self-report
survey. BMC Public Health. 2014;14(1):230.
18. Roberts TK, Fantz CR. Barriers to quality health care for
the transgender population. Clinical biochemistry. 2014;47(10-
11):983-7.
19. Safer JD, Coleman E, Feldman J, Garofalo R, Hembree
W, Radix A, et al. Barriers to healthcare for transgender
individuals. Current opinion in endocrinology, diabetes, and
obesity. 2016;23(2):168-71.
20. Snelgrove JW, Jasudavisius AM, Rowe BW, Head EM,
Bauer GR. “Completely out-at-sea” with “two-gender medicine”:
A qualitative analysis of physician-side barriers to providing
healthcare for transgender patients. BMC Health Services
Research. 2012;12(1):110.
21. Couch M, Pitts M, Mulcare H, Croy S, Mitchell A, Patel
S. TranZnation: A report on the health and wellbeing of
transgendered people in Australia and New Zealand Melbourne
Australain Research Centre in Sex, Health & Society, La Trobe
University 2007.
22. Pitts M, Couch M, Croy S, Mitchell A, Hunter M. Health
service use and experiences of transgender people: Australian
and New Zealand Perspectives Gay & Lesbian Issues and
Psychology. 2009;5(3):167-76.
23. Mogul-Adlin H. Unanticipated: Healthcare Experiences of
Gender Nonbinary Patients and Suggestions for Inclusive Care.
United States, Connecticu: Yale University; 2015.
24. Transgender and Gender Diverse Health and Wellbeing:
Background paper. Victoria Gay, Lesbian, Bisexual, Transgender
and Intersex Health and Wellbeing Ministerial Advisory
Committee, ; 2014.
25. Bogaert A. Asexuality: What It Is and Why It Matters. The
Journal of Sex Research. 2015;52(4):362-79.
26. Gupta K. “And Now I’m Just Different, but There’s
Nothing Actually Wrong With Me”: Asexual Marginalization and
Resistance. Journal of Homosexuality. 2017;64(8):991-1013.
27. Alencar Albuquerque G, De Lima Garcia C, Da Silva
Quirino G, Alves MJH, Belém JM, Dos Santos Figueiredo FW,
et al. Access to health services by lesbian, gay, bisexual,
and transgender persons: systematic literature review. BMC
international health and human rights. 2016;16(2):22.
28. Taylor J. Chief Justice vows change to ‘traumatic’ court
process for transgender children. ABC News. 2016.
29. Ryan E. Access to justice for young transgender
Australians: Laywers Weekly 2017 [Available from: https://www.
lawyersweekly.com.au/opinion/21101-access-to-justice-foryoung-transgender-australians.
30. Bolderston A, Ralph S. Improving the health care
experiences of lesbian, gay, bisexual and transgender patients.
Radiography. 2016;22:207 — 11.
31. Alliance NLH. Snapshot of mental health and suicide
prevention statistics for LGBTI people. National LGBTI Health
Alliance; 2016.
32. Lee R. Health care problems of lesbian, gay, bisexual,
and transgender patients. The Western Journal of Medicine.
2000;172(6):403 — 8.
33. Curmi C, Peters K, Salamonson Y. Lesbians’ attitudes
and practices of cervical cancer screening: a qualitative study.
BMC Women’s Health. 2014;14(153).
34. The Kirby Institute. HIV, viral hepatitis and sexually
transmissible infections in Australia. The Kirby Institute; 2016.
35. Amirkhanian YA. Social Networks, Sexual Networks and
HIV Risk in Men Who Have Sex with Men. Current HIV/AIDS
reports. 2014;11(1):81-92.
36. Richters J, Zou H, Yeung A, Caruana T, O de Visser R,
Rissel C, et al. Sexual health and behaviour of men in New South
Wales 2013–2014. School of Public Health and Community
medicine 2015.
37. The Kirby Institute. HIV, viral hepatitis and sexually
transmissible infections in Australia Annual Surveillance Report
2016. Sydney, Sydney NSW 2052: The Kirby Institute
38. Groves A. Transgender women and HIV: A footnote to the
epidemic. HIV Australia. 2012;9(4):30-2.
39. Australian Department of Health and Aging. National
Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI):
Ageing and Aged Care Strategy. 2012.
40. Ard KL, Makadon HJ. Improving the Health Care of
Lesbian, Gay, Bisexual and Transgender People: Understanding
and Eliminating Health Disparities Boston, MA: The National
LGBT Health Education Center; 2012.
41. Arora M, Walker K, Duvivier RJ, Wynne K. Transgender
health delivery and education in the Hunter New England local
health district. ANZPATH 2017 Biennial Conference; Sydney,
Australia2017.
42. Canty J, Gray L. The last taboo? Teaching skills for
clinical consultations with sex/gender diverse people in medical
education. . ANZPATH 2017 Biennial Conference; Sydney,
Australia2017.
43. Grosz AM, Gutierrez D, Lui AA, Chang JJ, Cole-Kelly K,
Ng H. A Student-Led Introduction to Lesbian, Gay, Bisexual, and
Transgender Health for First-Year Medical Students. Family
Medicine. 2017;49(1):52-6.
44. Safer JD, Pearce E. A simple curriculum content change
increased medical student comfort with transgender medicine.
Endocrine Practice. 2013;19(4):633-7.
45. Sizemore LA, Rebeiro PF, Mcgoy SL. Improving HIV
Surveillance Among Transgender Populations in Tennessee.
LGBT Health. 2016;3(3):208-13.
9

Commercial surrogacy in Australia:
the benefits of harm minimization
through legalisation
[Feature Article]
Emily Feng-Gu and Keyur Doolabh
Emily is an enthusiastic fourth year medical student at Monash University. She is completing
a Diploma of Liberal Arts (Philosophy), and hopes to complete a Bachelor of Medical
Science next year in her area of interest: bioethics. In her spare moments, she can be found
with a coffee in one hand and a book in the other.
Keyur is a medical student with an interest in philosophy. He enjoys writing, and is particularly
interested in poverty, climate change and animal welfare.
Surrogate /sʌrəɡət/
A substitute, or someone or something that
represents another person or thing in their
stead.[1]
The status quo
There is much controversy around surrogacy
in Australia. We have what is known as ‘altruistic
surrogacy,’ whereby a woman cannot be compensated
beyond reasonable expenses for gestating a baby
intended for someone else. Even the name puts our
moral intuitions at ease. Altruistic. Contrast this with
the term ‘commercial surrogacy’, which makes many
of us instinctively recoil. So what is it about commercial
surrogacy, where a woman is paid to gestate a baby, that
we take issue with?
The most common type of surrogacy is gestational
surrogacy, wherein the commissioning parent(s)
uses IVF to create an embryo from their own or donor
gametes and transfer it into the uterus of the gestational
surrogate. With this method, the surrogate mother does
not provide any genetic material. People that seek out
surrogacy commonly include infertile heterosexual
couples and homosexual couples desiring children of
their own. The demand for surrogacy has heightened in
recent years following changes to child protection policy,
which lead to drastic falls in the number of children for
adoption and stricter criteria implemented by overseas
countries regarding the age and family types who
can adopt. For example, none of Australia’s current
international adoption agreements allow same-sex
couples to adopt.[2] The status quo in Australia (except
the Northern Territory) only allows altruistic surrogacy,
where one must not compensate the surrogate mother
beyond out-of-pocket expenses like medical cost, travel,
and time off work. The options are further limited by the
fact that surrogacy is illegal for single people and samesex
couples in certain states like Western Australia and
South Australia. The increasing number of roadblocks
to accessing surrogacy has left many desperate
couples resorting to offshore commercial surrogacy.
But even this option is becoming more restricted now
that Thailand, Cambodia, India, and Nepal have banned
foreigners from commercial surrogacy following the
notorious “Gammy scandal” in 2014.[3]
Objections to commercial surrogacy
Commercial surrogacy commonly encounters several
types of objections. Some think it is inescapably a form
of exploitation of women, reducing the surrogate to her
base reproductive capability, and effectively turning her
into a walking incubator. Certainly, the idea of a class
of ‘breeders’ is eerily reminiscent of Margaret Atwood’s
classic novel The Handmaid’s Tale, which could be
interpreted as a cautionary tale warning against the
harms of surrogacy. In a similar vein, some argue that
pregnancy belongs in a special moral realm, and that by
bringing market forces into the arena we degrade the
intrinsic value of creating life. Maybe there are some
things in life which simply should not come with a price
tag.
Certainly, the idea of a class
of ‘breeders’ is eerily reminiscent
of Margaret Atwood’s classic
novel The Handmaid’s Tale
10

Commercial surrogacy also raises objections that
intersect with other ethical and societal issues. Some
assume that a child is best raised with both a father
and a mother figure, and therefore believe that enabling
same-sex couples to access surrogacy would be harmful
for children. However, existing Australian law allows
same-sex couples to adopt, and it is difficult to see why,
on the grounds of concern for the child, surrogacy would
be different. Furthermore, the assumption that samesex
parenting is harmful to children is not borne-out in
the evidence,[4] and so we do not see this as a relevant
argument against commercial surrogacy.
Another objection to commercial
surrogacy is that it would change the
nature of the family unit by involving the
surrogate as a third parent figure. But
these changes to the more ‘traditional’
family unit are already common in
society. Take for example adoption,
where both biological and adoptive
parents may be involved in the child’s
life. It is also possible for women to
become single parents through the help
of donor sperm and IVF. In neither case has disruption
of the ‘traditional’ family unit been viewed as reason for
prohibition, and it would be inconsistent ban commercial
surrogacy on these grounds.
These ethical objections may be why Australia has
made commercial surrogacy illegal. But given that no one
has ever been prosecuted on these grounds,[5] the legal
threat is a poor deterrence.[6] For people desperate to
have a baby of their own, but who are otherwise unable
to, the risks of commissioning illegal surrogacy can pale
in comparison to the intoxicating notion of holding a fleshand-blood
child.
Banning commercial surrogacy
domestically has created a
transnational black market of
commercial surrogacy that does
not protect the best interests of
the surrogate, the child, or the
intended parents
Undesirable consequences
The supply of altruistic surrogates in Australia falls
well short of demand, driving Australian couples to search
for surrogates overseas. Most are travelling to countries
like India or Thailand where the process was until recently
legal, cheaper, and poorly regulated. It is this scene that
has become inextricably associated with commercial
surrogacy. The transnational surrogacy market operating
out of developing countries has been widely criticised in
popular media,[7,8] and rightly so. Women who become
surrogates in these countries tend to be poorly educated,
have low incomes, and may even
be coerced into surrogacy by family
members or intermediaries seeking to
turn a profit.[9] Often, very little of the
money actually reaches the surrogate
herself. There are some surrogacy
agencies which effectively imprison
surrogates, controlling their diet, sleep,
sexual activity, and contact with the
outside world. All this is done under the
guise of antenatal care, which is in truth
scant and inadequate.[9] It is difficult to
see how informed consent could truly be said to exist in
this environment.[10]
Even if the surrogacy results in a liveborn child, the
challenges do not necessarily resolve. The lack of
enforceable contracts between commissioning parents
and surrogates, combined with issues of legal citizenship
and parentage, can create a veritable labyrinth if
conflict arises or if commissioning parents change their
minds and no longer want the child. Case examples of
transnational surrogacy debacles abound in the media.
For example, commissioning parents have divorced
before the surrogacy was complete, leaving the child
11

with an uncertain future.[11] Another case saw a baby left
stranded with no identity or legal papers for as long as two
years.[11] Fortunately, Australian laws allow a child born
from an international surrogacy arrangement to be given
Australian citizenship, provided that at least one parent
is an Australia citizen and a parent-child relationship is
proven with DNA testing, although other measures of
‘parent’ can be used. If ineligible, commissioning parents
may be required to apply for a permanent visa or an
adoption visa. Despite being lengthy and difficult for
parents to navigate, these processes and laws minimise
the risk of children born internationally via surrogacy
being left stateless.[12,13]
Australia’s current approach is to prohibit commercial
surrogacy because it is regarded as immoral, but is this
policy helping the situation or making it worse? At present,
Australians for whom altruistic surrogacy is simply not
feasible appear to be turning to transnational surrogacy.
In 2011, only 21 births by altruistic surgery were recorded
in Australia.[14] In the same year, it is estimated over 270
babies were born via transnational commercial surrogacy
arrangements.[6] Banning commercial surrogacy
domestically has created a transnational black market
of commercial surrogacy that does not protect the best
interests of the surrogate, the child, or the intended
parents; the process is expensive, risky, poorly regulated,
and is largely a profit-making exercise for overseas
surrogacy agencies. Despite being designed to prevent
exploitation, our current system might in fact ironically be
encouraging it.
Harm minimisation
Simply prohibiting a behaviour on the basis of its
supposed immorality is not necessarily an effective
strategy. Data shows that in Australia and overseas,
drug use and morbidity increased under policies of
prohibition, and decreased with decriminalization and
regulation.[15] Harm minimisation is a principle we see
being used more often in Australia’s approach to illicit
drug use and prostitution. It recognises that prohibition
can be counterproductive in achieving its overarching
goal of improving the lives of Australian citizens. Instead,
our laws regulate the potentially damaging behaviour or
substance in a way that realistically protects the people
involved. So why not apply a similar harm-minimization
approach to surrogacy? Given that our prohibitive model
is failing to protect Australian couples seeking surrogacy,
and instead funnelling business into exploitative
transnational surrogacy agencies, we should instead look
to harm minimisation to guide how we approach the issue
at hand. This could be best accomplished through the
decriminalisation of commercial surrogacy in Australia.
Decriminalisation and the establishment of a strictly
regulated system would better enable us to protect the
interests and rights of the intending parents, surrogates,
and children. But what should these regulations actually
look like?
A suggested solution
Ideally, a reformed system in Australia would be
carried out by a centralised institution that could oversee
the entire process, from psychological screening and
matching, to counselling, and support services. This
centralised institution could be national, state-run or notfor-profit.
Strict criteria of eligibility could then more easily
be applied, screening out individuals who are unsuitable
for surrogacy arrangements due to medical, social, or
psychological reasons. This assessment could draw on
existing assessment processes for adoption.[16]
The relationship between the surrogate and intending
couple appears to be the most crucial factor affecting
satisfaction with the experience and the likelihood of
conflict regarding parentage of the baby.[17] In fact,
some studies suggest the most common reason for a
surrogate to want to keep the baby is being unsure of the
commissioning couples ability to provide adequate care.
[17] With this in mind, matching surrogates and intended
parents with similar values and desired levels of contact,
12

as well as facilitating educated discussion about the
possibilities of chromosomal abnormalities or multifetal
gestation, would also mitigate conflict. Antenatal and
postnatal support, including mental health checks, could
also be provided through this system.
The exclusion of profiting intermediaries increases the
likelihood that the interests of all parties would be equally
considered, rather than sacrificing the surrogate’s health
and experience in favour of maximising profits. Moreover,
any surrogacy arrangements would still be constrained
by Australia’s existing common law and family law. This
ensures that the surrogate maintains all the decisionmaking
powers throughout the pregnancy, including her
rights to access termination of pregnancy and to bodily
autonomy.
In terms of the appropriate compensation, it seems
prudent to set both a minimum and a maximum limit.
Pregnancy is unavoidably risky for a woman, and gestating
a growing fetus is no easy task. Why should it not, like
many other jobs, receive recompense proportionate to
the task? Moreover, pregnancy is intrinsically care-based
‘women’s work’, which is still insidiously undervalued
even in modern times. Conversely, to titrate the price of
surrogacy to the intensity of a commissioning couple’s
desire for a child is hardly ethical. The US can shed light
on what prices may look like in an uncapped surrogacy
market; the estimated reimbursement for surrogates
advertised by leading US agency Circle Surrogacy, not
including medical or otherwise associated expenses,
is US$30,000.[18] Most couples experiencing infertility
would struggle to pay this price, which does not include
medical and legal costs. The aim of setting both minimum
and maximum limits on a surrogate’s compensation is to
strike a balance between the interests of the surrogate
and the commissioning parents - or more simply put,
ensuring fair pay for fair work.
Furthermore, a centralised agency would also offer
benefits for children born from surrogacy arrangements.
There would exist a database through which children
could later in life track down their surrogates should
they choose to, just as adopted children can request
information regarding their birth origins after turning 18.
The laws regarding surrogacy should be standardised
across all Australian states and territories. At present, the
laws are fractured and discordant, diverging on points
including whether same-sex couples should be eligible
to be intended parents, the legality of advertisement for
surrogacy, as well as that of seeking overseas surrogates.
The murky legalities of surrogacy make it confusing for
surrogates without deterring commissioning parents; if
they are willing to pay tens of thousands of dollars for
surrogacy, they would probably be happy to travel to
states with more favourable laws.[6]
Challenges of decriminalisation of commercial
surrogacy
One might argue that by decriminalising commercial
surrogacy in Australia, we simply shift the burden of
exploitation from overseas to our own shores. The
concern is that commercial surrogates will be uneducated
and disempowered, and have little informed choice in
the matter. If we assume that the demographic of paid
surrogates in Australia would resemble that of the US,
then this concern does not appear to be relevant.[17, 19]
Small studies of commercial surrogates in the US have
suggested the while surrogates do tend to have lower
incomes and less education than commissioning parents,
they are generally not of a vulnerable population. In one
study, most had gone to college, or at least finished high
13

school, were from middle income earning families, and
were in long-term relationships.[17,20] Furthermore, their
primary motivation was not the money, but rather to help
a couple start their families. While self-report studies
do have limitations, perhaps we are too quick to assign
altruistic and commercial surrogates into two camps:
those who are doing it purely for selfless reasons and
those who are doing it for money.
The move may also be politically unpopular, with
possible public resistance making the implementation
slow and difficult. Moreover, creating a system which
successfully protects commissioning parents, surrogates,
and children born from surrogate arrangements would
be a time-consuming and expensive exercise, fraught
with pitfalls. Unless it is well-designed, decriminalising
commercial surrogacy could perpetuate the very
consequences it was designed to mitigate.
Why should it not, like many
other jobs, receive recompense
proportionate to the task?
Conclusion
Our approach is not to judge the morality of
surrogacy, neither promoting or undermining its value
as a reproductive option relative to other methods
such as adoption. The problem is a thorny and possibly
intractable one, and requires careful consideration of
racial politics, gender and income inequality, and human
rights. Even in a moral grey zone, however, there are
things which are arguably more morally reprehensible
than others. Australian couples are resorting to the
unregulated and deeply unethical commercial surrogacy
market in developing countries, as a result of the failure
of our current system. Working towards a safer, more
regulated model of surrogacy should be on the Australian
and international agenda.
Acknowledgements
The authors would like to acknowledge the contribution
of ideas and research from their fellow medical students,
Su Ern Poh and Eli Ivey.
Photo credit
http://maxpixel.freegreatpicture.com/Pregnant-
Pregnancy-Pregnant-Woman-M-Mother-2640994
https://www.pexels.com/photo/pregnancy-pregnantmotherboard-parenthoof-57529/
http://www.publicdomainpictures.net/view-image.
php?image=54223&picture=man-holding-newborn
Conflicts of interest:
None declared
Correspondance
keyurd12@gmail.com
References
1. Company H. The American Heritage Dictionary entry:
surrogate [Internet]. Ahdictionary.com. 2017. Available from:
https://www.ahdictionary.com/word/search.html?q=surrogate
2. Australian Institute of Health and Welfare. Adoptions
Australia 2011-12. Canberra: AIHW; 2012. Contract No.: CWS
42.
3. Baby Gammy case reveals murky side of commercial
surrogacy [Internet]. The Conversation. 2014 [cited 1
October 2017]. Available from: https://theconversation.com/
baby-gammy-case-reveals-murky-side-of-commercialsurrogacy-30081
4. Crouch S, Waters E, McNair R, Power J, Davis E. Parentreported
measures of child health and wellbeing in same-sex
parent families: a cross-sectional survey. BMC Public Health.
2014;14(1).
5. Stuhmcke A. The regulation of commercial surrogacy:
The wrong answers to the wrong questions. Journal of Law and
Medicine. 2015;23:333.
6. Everingham SG, Stafford-Bell MA, Hammarberg K.
Australians’ use of surrogacy. The Medical Journal of Australia.
2014;201(5):270-3.
7. Alford P. Surrogacy Scandal Widens with Southeast Asia
Infant Trafficking Operation Exposed. The Australian. 2014 9
August 2014.
8. Murdoch L. Australian couples’ baby plans in limbo as
Cambodia bans commercial surrogacy. The Sydney Morning
Herald. 2016 4 November 2016.
9. Saxena P, Mishra A, Malik S. Surrogacy: ethical and legal
issues. Indian Journal of Community Medicine. 2012;37(4):211.
10. Deonandan R, Green S, van Beinum A. Ethical concerns
for maternal surrogacy and reproductive tourism. Journal of
Medical Ethics. 2012;38(12):742-5.
11. Trimmings K, Beaumont P. International surrogacy
arrangements: legal regulation at the international level:
Bloomsbury Publishing; 2013.
12. Fact sheet - International surrogacy arrangements
[Internet]. Border.gov.au. [cited 1 October 2017]. Available from:
http://www.border.gov.au/about/corporate/information/factsheets/36a-surrogacy#offshore
13. Birth, adoption and surrogacy [Internet]. Smartraveller.gov.
au. [cited 1 October 2017]. Available from: http://smartraveller.
gov.au/guide/all-travellers/birth-death-marriage/pages/birthadoption-and-surrogacy.aspx
14. Macaldowie A, Wang YA, Chambers GM, Sullivan EA.
Assisted reproductive technology in Australia and New Zealand
2010: AIHW; 2012.
15. Wodak A. The failure of drug prohibition and the
future of drug law reform in Australia. Australian Prescriber.
2015;38(5):148-9.
16. Review of the Adoption Act 1984. Melbourne: Victorian
Law Reform Commission; 2015.
17. Busby K, Vun D. Revisiting The Handmaid’s Tale: Feminist
theory meets empirical research on surrogate mothers. Can J
Fam L. 2010;26:13.
18. Circle Surrogacy. Anticipated Costs for Gestational
Surrogacy [Available from: http://www.circlesurrogacy.com/
costs.
19. Jadva V, Murray C, Lycett E, MacCallum F, Golombok
S. Surrogacy: the experiences of surrogate mothers. Human
Reproduction. 2003;18(10):2196-204.
20. Ciccarelli J, Beckman L. Navigating Rough Waters:
An Overview of Psychological Aspects of Surrogacy. Journal of
Social Issues. 2005;61(21):21-43.
14

Polio vs Politics: The Case of Pakistan
[Feature Article]
Jeanine Hourani
Jeanine has just completed her first year of the Master of Public Health at the University of
Melbourne, having come from an Immunology & Microbiology background. She is particularly
interested in refugee and migrant health as well as the effect of warfare on Public Health.
Her previous work includes ‘As Syria Bleeds’ which explores the effect of the Syrian Crisis on
the health system.
Polio is a highly infectious disease caused by
poliovirus which predominantly infects young children by
invading the nervous system and can result in paralysis.
[1] Polio reached epidemic proportions in the early 1900s
but was brought under control after the introduction of
effective vaccines in the 1950s and 1960s.[1] Despite
the progress that has been made, as long as a single
child remains infected with poliovirus, children in all
countries are at risk of contracting the disease.[2] This
is because poliovirus can easily be imported into poliofree
countries and subsequently spread, potentially
resulting in as many as 200,000 new cases every year.
There is no cure for polio, it can only be prevented by
the polio vaccine which, if administered correctly, can
protect a child for life.[2] As such, vaccination programs
are key to achieving global polio eradication.
War and civil unrest have a destructive effect on
population health. In particular, conflict increases
the prevalence of vaccine preventable diseases and
decreases the success of vaccination programs.[3] For
instance, Pakistan is one of the few countries in the world
where polio is still endemic [1, 4, 5] and this is largely
due to its geopolitical and socioeconomic challenges.
[6] In 2006, Taliban insurgency intensified in Pakistan
and the resulting political insecurity has been directly
associated with the rise in polio transmission.[7] Failure
to achieve polio eradication in Pakistan demonstrates
the importance of non-health sector issues, such as
barriers to access in war and conflict zones [6].
Conflict and insecurity in Pakistan is clustered in
Khyber Pakhtunkhwa (KP) and Federally Administered
Tribal Areas (FATA) which are home base to the Taliban
and al-Qaeda.[5, 7, 8] The conflict and insecurity in KP
and FATA has led to a dramatic rise of reported paralytic
polio cases in Pakistan with more than 85% of the
global polio cases coming from these regions.[7, 9] The
establishment of KP and FATA as major polio reservoirs
is undeniably linked to active conflict and insecurity in
these regions.[7-10]
It is clear that global health
programs can no longer isolate
themselves from economic,
security, and political interests.
Polio eradication in Pakistan jeopardises worldwide
efforts aimed at eradicating polio.[6] In 2013, polio
strains originating in Pakistan were detected in sewage
samples in Egypt, Israel, the West Bank, the Gaza Strip,
Syria, and Iraq.[1, 7] The first subsequent polio case
occurred in Syria in October 2013, resulting in 35 children
being paralysed by November.[1] The first Iraqi polio
case was confirmed in March 2014.[1] Polio has spread
from Pakistan in South Asia to countries in the Middle
East that have been polio-free for decades, unraveling
progress that has been made on a global scale [1, 7]
and confirming that polio eradication is no longer solely
Pakistan’s problem, but a global one.
Fueling this problem is the United States’ involvement
in Pakistan. In 2011, the CIA attempted to obtain DNA
samples from the children in KP as part of the search for
Osama bin Laden. In order to do this, the CIA conducted
a fake vaccination program against hepatitis B, leading
to an erosion of public trust in immunisation.[1, 7-9]
The use of aid workers for intelligence purposes and
the use of health initiatives to advance security and
15

foreign policy motives has undermined global healthcare
initiatives aimed at polio eradication, jeopardising longterm
global health goals.[7]
Recent fatal attacks on polio vaccination workers in
politically fragile parts of Pakistan pose a further threat
to the global eradication of polio.[11] It is believed that
the international attention paid to polio eradication may
have led terrorist groups to believe that they can achieve
some of their aims by interfering with its eradication.
[11] As such, the Pakistani Taliban announced in June
2012 that it would place a ban on all vaccinations until
the United States ended drone strikes.[9] Since then,
the Taliban have orchestrated targeted attacks on
immunisation teams that have tragically killed over 40
vaccinators.[1, 7] This includes the killing of Abdul Ghani
(who was the head of the government’s vaccination
campaign) by a road-side bomb after upon his return
from a meeting with tribal elders to dispel rumours that
vaccination is a U.S. conspiracy to sterilize their children.
[5] To this day, vaccination program staff remain under
threat of kidnappings, beatings, harassment, and even
assassinations in conflict zones.[9]
It is believed that the actions against polio workers may
be driven by two objectives; to terrorise local populations
and government workers, or to stop the house-to-house
movement of polio workers who some terrorist groups
suspect of carrying out US surveillance activity (brought
about by the fake hepatitis B campaign).[11] Regardless
of the reason, it is clear that polio eradication has evolved
into a war tactic resulting in an environment of fear and
anarchy.
Global health initiatives are becoming increasingly
intertwined with diplomatic, foreign policy, and security
interests.[7] This is not limited to Pakistan: earlier this
year, six Red Cross Aid workers were killed in Afghanistan
[12], and healthcare in Syria has been transformed into a
target of war.[13] It is clear that global health programs
can no longer isolate themselves from economic,
security, and political interests.[7] The recent portrayal of
polio as the new battleground between Western forces
and terrorist groups illustrates the importance of efforts
to depoliticise polio activities.[11] We can no longer allow
security or foreign policy motives to undermine polio
eradication and thus compromise the wellbeing of the 7.5
billion people living on earth.
Photo credit
Sanofi Pasteur / Almeena Ahmed / Sanaullah Afridi,
accessed from https://www.flickr.com/photos/sanofipasteur/29837040256/in/album-72157673062558422/
Conflicts of interest
None declared
Correspondance
jeaninehourania@live.com.au
References
1. Akil L, Ahmad HA. The recent outbreaks and reemergence
of poliovirus in war and conflict-affected areas. Int J Infect Dis.
2016;49:40-6.
2. WHO. Does polio still exist? Is it curable? 2017 [Available
from: http://www.who.int/features/qa/07/en/.
3. Glatman-Freedman A, Nichols K. The effect of
social determinants on immunization programs. Hum Vaccin
Immunother. 2012;8(3):293-301.
4. Afzal O, Rai MA. Battling polio in Pakistan: breaking new
ground. Vaccine. 2009;27(40):5431.
5. Ahmad K. Pakistan struggles to eradicate polio. The
Lancet Infectious Diseases. 2007;7(4):247.
6. Nishtar S. Pakistan, politics and polio. Bull World Health
Organ. 2010;88(2):159-60.
7. Hussain SF, Boyle P, Patel P, Sullivan R. Eradicating polio
in Pakistan: an analysis of the challenges and solutions to this
security and health issue. Global Health. 2016;12(1):63.
8. Roberts L. Fighting Polio in Pakistan. Science. 2012;337.
9. Chang A, Chavez E, Hameed S, Lamb RD, Mixon K.
Eradicating Polio in Afghanistan and Pakistan. A Report of the
CSIS Global Health Policy Center. 2012.
10. Shah M, Khan MK, Shakeel S, Mahmood F, Sher Z, Sarwar
MB, et al. Resistance of polio to its eradication in Pakistan. Virol
J. 2011;8:457.
11. Abimbola S, Malik AU, Mansoor GF. The Final Push for
Polio Eradication: Addressing the Challenge of Violence in
Afghanistan, Pakistan, and Nigeria. PloS Med. 2013;10(10):1-4.
12. SBS. Opinion: Aid workers are not a target, and never
should be 2017 [Available from: http://www.sbs.com.au/news/
article/2017/02/17/opinion-aid-workers-are-not-target-andnever-should-be.
13. The Guardian. Syria ‘the most dangerous place on
earth for healthcare providers’ 2017 [Available from: https://
www.theguardian.com/world/2017/mar/15/syria-conflict-studycondemns-weaponisation-of-healthcare.
Key Messages
• The persistence of polio in Pakistan jeopardises worldwide
efforts aimed at eradicating the disease.
• Global health initiatives are becoming increasingly
intertwined with the diplomatic, foreign policy, and security interests
• With the portrayal of polio as a battleground between
Western forces and terrorist groups, greater effort should be made
to depoliticise polio activities
16

turning up the heat
[Feature Article]
Tara Kannan
Tara Kannan is a first-year MD student at the University of Newcastle. Passionate about
global health, she represents AMSA’s 2017 Code Green portfolio within her university’s
global heath group. She believes that a major way forward in advancing medicine on the
world stage is through nursing our environment back to good health. Aside from that, when
she’s not busy dissecting Guyton’s diagrams, she enjoys perusing news articles online and
loves her Cadbury.
American environmentalist and journalist, Bill
McKibben, offers a simple yet revolutionary proposition
in the climate debate: “Leave oil in the soil, coal in the
hole and gas under the grass”.
The birth of an idea
Divestment is a very simple idea. You just remove your
money from companies that are involved in extracting
fossil fuels. It’s a novel movement in the climate debate
that is different from your traditional change-yourlightbulb
kind of ideas.
Its underlying basis is that to avoid catastrophic
global warming, we will need to reduce our carbon dioxide
emissions. There are three key numbers that explain
this. First, 2˚C is the maximum global temperature rise
this century that is aspired to in the Paris Agreement.[1]
Secondly, we have a ‘carbon budget’ of 565 gigatons
which is essentially the amount of carbon dioxide that
can safely be released into the atmosphere while still
complying to our 2˚C rule.[2] Most importantly, the third
number to know is 2795 gigatons. This is the amount
of carbon dioxide that will be released if all of the
documented fossil fuel reserves
were burned.[2]
Addressing a sixfold rise
in energy demand in the last
50 years, fossil fuels provide
roughly 80% of the energy we
need through coal, gas and oil.[3]
Yet, the money-making industry
releases greenhouse gases into
the atmosphere and thickens Earth’s blanket of air
pollution which led to 3.7 million deaths in 2012 due to
pneumonia, asthma, heart disease, stroke and cancer.
[3] Needless to say, carbon dioxide is a tiny molecule with
a big bite.
So, while as individuals we could make some
adjustments such as changing our lightbulbs and
switching from car use to public transport, if companies
continue to dig up and burn their reserves, these
measures will prove rather insignificant. This is where
divestment comes in - a movement about shifting your
money away from the problem and towards the solution.
Turning back time
So, while as individuals we could make
some adjustments such as changing our
lightbulbs and switching from car use to
public transport, if companies continue
to dig up and burn their reserves, these
measures will prove rather insignificant.
In history, divestment has been shown to be a powerful
political tool in several major movements.
In the latter half of the 20th century, a time when South
Africa’s Apartheid was our world’s largest moral issue,
two prominent figures created massive change. Nelson
Mandela and Desmond Tutu suggested a revolutionary
tactic to help counter institutionalised racial segregation
and white supremacy, imploring Western institutions
to cut their economic ties with companies backing
the Apartheid regime. Experts often deem this as the
model of symbolic pressure as it raised awareness and
embarrassed many American businesses.[4]
Then, through the 1990s, a
movement against the tobacco
industry took place to shun the
industry’s negative impacts on
health. Along with regulation and
taxation, tobacco divestment had
a sizeable impact on society,
shrinking the industry and
smoking rates.[4]
Most recently, divestment has had a role in the
Darfur genocide - the first genocide of the 21st century.
Darfur divestment involves removing money away from
companies with ties to the Sudanese government. Some
17

Western institutions including Brown University divested;
however, other investors interested in the nation’s
valuable resources simply filled their place. Drawing from
this rather unsuccessful campaign, fossil free activists
are encouraged to consider how their actions could lead
to the success or failure of the divestment movement.
More specifically, it is important to weigh the impact of
divesting from a company relative to giving up your voice
as a shareholder.
Fuelling a movement
Nevertheless, the balance scales show that
divestment is well worth the bet. Major goals of the
fossil fuel divestment campaign can be captured in the
following:[4]
a) leverage the power of investors and institutions to
make strong political statements and influence policy
change
b) raise awareness of the impact of the fossil fuel
industry in our society
c) lead the market to consider the effects of climate
change when evaluating any investments
d) drive capital investment into clean energy and
other climate mitigation strategies
Above all else, divestment stigmatises the fossil fuel
industry, eroding its social license to operate and posing
the largest threat to these companies.
Back home, Australian universities are making
bold statements with the help of several fossil free
organisations on campus. La Trobe University, Swinburne
University and the Queensland University of Technology
pledged to divest their A$40 million, A$150 million and
A$300 million portfolios from fossil fuels respectively.
[7] Recently, both Monash University and the Australian
National University have partially divested.[8] But sadly,
Westpac, ANZ, NAB and the Commonwealth Bank –
which make up the ‘big four’ banks of Australia — have
failed to divest, instead funding the industry to the tune of
A$5.5 billion in 2015.[7]
the ‘carbon bubble’ has its
underlying roots in the fact that
our financial markets maintain
an extraordinary overvaluation
of fossil fuel reserves that has
the potential to burst.
Pop goes the bubble
From an economic point of view, fossil fuel divestment
is falsely thought to come with financial uncertainty and
major repercussions. Addressing this, a key argument
in the fossil fuel divestment campaign is that returns
will, in fact, improve once investors have divested – an
And, if you have not figured it out yet, the fossil fuel
divestment campaign is not a normal movement. There
are no great leaders. There is no Gandhi or Martin Luther
King Jr. of the climate movement. But, establishing firm
roots in society, the fossil fuel movement is set to be
colossal with or without a figurehead.
...divestment stigmatises the
fossil fuel industry, eroding its
social license to operate and
posing the largest threat to
these companies.
Blossoming ideas
Since its initial conception in 2010, the idea of fossil
fuel divestment has been spreading like wildfire. The
campaign celebrated its first major victory in mid-2014
when Stanford University committed to divesting its
US$18.7 billion endowment from the industry.[5] Later that
year, the campaign inspired the People’s Climate March
where a 400,000-strong crowd flooded Manhattan’s
streets, demanding U.N. action on global warming.[4] By
2015, around 2500 investors representing US$2.6 trillion
in assets had divested, including major organisations
such as the Rockefeller Brothers Fund and the Canadian
Medical Association.[6]
Figure 1: Global health groups are leading the fossil fuel divestment game
with eight societies having divested; while, only three medical societies have
divested so far.
18

argument based on a concept called the ‘carbon bubble’
– named by the Carbon Tracker Initiative. Much like the
US housing bubble of 2009, the ‘carbon bubble’ has its
underlying roots in the fact that our financial markets
maintain an extraordinary overvaluation of fossil fuel
reserves that has the potential to burst.[4, 8] The problem
here is that all reserves simply cannot be burned if we
intend to comply with the ‘carbon budget’, or else, there’s
no doubt that we will find ourselves amidst catastrophic
climate change.
More importantly, with increasing pressure from
pollution regulations, competition from renewables
and one of history’s fastest growing stigmatisation
...the fossil fuel divestment
campaign is not a normal
movement. There are no great
leaders. There is no Gandhi
or Martin Luther King Jr. of the
climate movement.
campaigns, the value of fossil fuels is already diminishing.
[4,8] Last year, energy use emissions grew less than
1% for the third consecutive year.[9] Oxford University
researchers and commercial analysts are predicting that
fossil fuels are likely to become ‘stranded assets’ which
cannot be used, rendering them worthless to investors.
[8, 9] It follows that investors should prepare for such a
scenario by selling their assets now rather than after the
‘carbon bubble’ bursts when investors are likely to lose
money.
Preparing accordingly, investors in Wall Street banks,
such as HSBC and Chase, have demanded that fossil
fuel companies discuss the risks of the bubble; while,
oil companies, including Shell, are now committed to
disclosing their asset portfolios and discussing the
bubble.[4] Similarly, with major financial news venues such
as Bloomberg and the Financial Times now backing the
movement, we are beginning to achieve one of our primary
aims: influencing the economy’s thinking on climate
change.[4] In fact, as of September 2017, US$5.53 trillion
has been divested by almost 800 institutions.[7]
Renewable energy: a brave new world of investment
So, you move your money away from the fossil fuel
industry and then what? Many experts have shown that
investing in ethical funds such as the renewable energy
industry will have financial returns similar to, if not better
than, the fossil fuel industry.[10]
Renewable energy has made ambitious headlines
around the world. For instance, China recently became
home to the world’s largest solar farm at 27-squarekilometres
which can produce 850 mega-watts of power
- enough to supply around 200,000 households.[11]
However, even though renewable technology needs to be
used by all, it’s only accessible to those who can afford
it. Addressing this gap, many grassroots movements are
committed to providing renewable energy to developing
nations. For instance, one such foundation, Liter of Light,
teaches communities to recycle plastic bottles and use
locally sourced materials with the aim of illuminating their
homes – a strategy which has received much recognition
and is often adopted for use in UNHCR camps.[12]
Figure 2: the committee of the University of Newcastle’s global health group, Wake Up!, proudly put their W’s up to
celebrate their divestment win. Congrats Wake Up!
19

Key messages
• Fossil fuel divestment is a very simple idea: a global movement
focussed on shifting money away from a problem and towards a solution.
• Divestment has been shown to be historically successful
• Establishing firm and expansive roots in our society, divestment now
sets out to radically influence the world’s thinking on climate change
The power of smaller players
Speaking of smaller players making big waves,
medical societies and faculties, are major targets of
the fossil fuel divestment campaign. As highly regarded
entities within universities, they are large enough to
matter but small enough to have an influence on. Now,
more than ever, we are seeing Australian medical
university groups divesting (Figure 1). Most recently, the
University of Newcastle’s global health group, Wake Up!,
switched from the Commonwealth Bank to Newcastle
Permanent – a major win in our medical scene (Figure 2).
Although divestment will not cripple the fossil fuel industry
overnight, this strategy can still operate effectively,
conveying a loud and clear message of disapproval – an
objective we are closer to achieving thanks to societies
like Wake Up!
One of divestment’s main jobs is to draw attention
and challenge the status quo – a powerful opportunity to
be noticed, and be remembered, in times of tragedy and
turbulence. It’s a movement that inspires students, banks
and universities alike to make ethical commitments
and invest in a sustainable future. With global warming
looming large, now is the time to blaze trails and boldly
transform the climate debate.
2015; 82:913-37.
5. Carroll R. Major University Divests $18 Billion Endowment
From Coal Companies [Internet]. HuffPost. 2017 [cited 15
September 2017]. Available from: http://www.huffingtonpost.
com/2014/05/07/stanford-university-divesting_n_5276899.
html
6. Rowe JK, Dempsey J, Gibbs P. The Power of Fossil
Fuel Divestment (And its Secret). The University of California
eScholarship. 2016.
7. Go Fossil Free. Divestment Commitment [Internet]. Go
Fossil Free. 2017 [cited 15 September 2017]. Available from:
http://gofossilfree.org/commitments
8. Ansar A, Caldecott B, Tilbury J. Stranded assets and
the fossil fuel divestment campaign: what does divestment
mean for the valuation of fossil fuel assets?. Smith School of
Enterprise and the Environment. 2013.
9. Brahic C. Living with climate change: Have we reached
peak emissions? New Scientist. 2017; 234: 32-4.
10. De George R. Ethics, corruption, and doing business in
Asia. Asia Pacific Journal of Economics and Business. 1997; 1:
39–52.
11. Phillips T. China builds world’s biggest solar farm in
journey to become green superpower #GlobalWarning [Internet].
The Guardian. 2017 [cited 15 September 2017]. Available from:
https://www.theguardian.com/environment/2017/jan/19/chinabuilds-worlds-biggest-solar-farm-in-journey-to-become-greensuperpower
12. Liter of Light. Liter of Light - About Us [Internet]. Liter of
Light. 2017 [cited 15 September 2017]. Available from: http://
literoflight.org/about-us/
Conflicts of interest
None declared
Correspondance
taranikita@hotmail.com
References
1. United Nations Framework Convention on Climate
Change: Adoption of the Paris Agreement. 21st Conference of
the Parties, 2015: Paris, France: United Nations.
2. 350.org. Do the Math [Internet]. Math.350.org. 2017 [cited
15 September 2017]. Available from: http://math.350.org/
3. Perera F. Multiple Threats to Child Health from Fossil
Fuel Combustion: Impacts of Air Pollution and Climate
Change. Environmental Health Perspectives. 2017; 125: 141-8.
Doi:10.1289/EHP299
4. Apfel DC. Exploring Divestment as a Strategy for
Change: An Evaluation of the History, Success, and Challenges
of Fossil Fuel Divestment. New School for Social Research.
20

Coal mining, climate change and the
global impacts on health: examining
Adani’s proposed Carmichael coal mine
Introduction
The proposed Adani-owned Carmichael coal mine
in central Queensland is currently in the final stages of
planning with the support of both the Queensland and
Australian governments. It is in the interest of human
health, locally and abroad, for the medical profession
to advocate on behalf of the community and lobby our
legislators to reject this project.
The Carmichael site will be the world’s largest export
coal venture and the biggest mining site in Australia,
consisting of six open cut pits and five underground
mines. Mined in the Galilee Basin, 160km north-west
of Clermont, coal will then be transported on a new
railway network before connecting to shipping terminals
bound for India via the Great Barrier Reef Marine Park.[1]
Adani has stated that it plans to mine 60 million tonnes
of coal every year over the expected 60 year lifespan
of the Carmichael mine site.[2] The estimated annual
average emissions of the proposed Adani coal mine are
equivalent to the annual emissions of Malaysia, Vietnam
or Sri Lanka.[3]
The Carmichael mine is
a highly politicised topic with
widespread implications. This
article considers some of the
impacts on Australia’s economy,
our natural environment (and that
of our regional neighbours), and
crucially; the seriousness of the
Carmichael mine’s contribution to climate change and
its effect on human health.
Health Implications on a Global Scale
The World Health Organization (WHO) has said that
climate change is the greatest threat to human health
this century.[4] This gigantic coal mine is set to contribute
significantly to climate change. It will adversely affect
[Feature Article]
John E Morgan
John Morgan is a fourth year medical student at James Cook University. He is
passionate about advocacy, climate change and issues facing the developing
countries within our region. He is a member of Doctors for the Environment and
AMSA’s Mental Health Campaign. Based in Cairns, he loves bushwalking and
camping (and so far hasn’t had any crocodiles up close).
A report recently published in The
Lancet has condemned the planned
Adani Carmichael project as a “public
health disaster”
population health through greenhouse gas emissions,
waterway damage and land clearing. A report recently
published in The Lancet has condemned the planned
Adani Carmichael project as a “public health disaster”,
arguing that the health impacts and environmental
damage will be significant for Australia and its regional
neighbours.[5]
The net effect of obtaining and using coal from the
Carmichael site is estimated to release 4.7 billion tonnes
of greenhouse gas emissions,[6] which will contribute
to climate change. This will result in increased human
exposure to pollen, moulds and air pollution, reducing
air quality and increase the incidence of respiratory
diseases.[7] Ambient pollution in Australia is primarily
derived from fossil fuel powered electricity generation,
heavy industry and wood or coal based home heating.[8]
Annually, 3000 Australians die due to urban air pollution,
more than the national road toll.[9] In its current state,
the air pollution problem is already being insufficiently
addressed. Additionally, exposure to ozone is linked with
increased hospital admissions for respiratory diseases
amongst both children and the elderly.[10] Our legislators
must act decisively and commit meaningful action to
reduce the impact of climate change as it will affect the
health of future generations and
our present vulnerable elderly
population.
Currently, 5% of the
population will experience an
allergic respiratory response to
airborne moulds during their lifetime.[11] Changes in
global precipitation are likely to increase the prevalence
of airborne moulds.[7] Additionally, ambient air pollutants
and allergens are most likely to exacerbate respiratory
disease in individuals with pre-existing respiratory
conditions.[12] Climate change associated air pollution
will undoubtedly worsen the quality of life of patients
living with chronic airway diseases.
21

Coal combustion affects the water as well as the air.
Rising water temperatures linked to climate change will
cause further aerosolisation of marine toxins, thereby
increasing respiratory disease prevalence globally.[7]
Asthmatics exposed to the harmful algal bloom Karenia
brevis’ marine aerosols on the south east coast of the
United States of America (USA) experienced respiratory
symptoms after just one hour of exposure. Inland
residents experienced an average of 3.49 symptoms,
more than coastal residents, who experienced an
average of 2.24 symptoms.[13] This suggests that
aerosolisation of marine toxins will increase respiratory
morbidity as climate change related aerosols proliferate
and distribute further afield.
The cardiovascular burden of disease will worsen
in the future if action is not taken now to reduce the
impacts of climate change.[7] Airborne particulate
matter is associated with compromised heart function,
atherosclerotic disease, deep vein thrombosis,[14] and
pulmonary embolism.[15] The particulates contributing
to air pollution include black carbon, sulphates, nitrates,
a complex mixture of metals and other byproducts
from the incomplete combustion
of fossil fuels.[16] In areas with long term
exposure to high levels of particulate matter
air pollution, it was found that an increase
of just 10 ug/m3 is associated with a 70%
increase in DVT risk.[15] Ozone is another
key pollutant - exposure to a 10g/m3
increment has demonstrated an increase
in the risk of cardiopulmonary mortality by 1.014 times.
[14] Both particulate matter and ozone type air pollution
cause adverse cardiovascular outcomes.
Increased global temperatures will exacerbate heat
related deaths due to an increased frequency of heat
stress events.[7] Untreated heat exhaustion can progress
to heat stroke,[17] of which 15% of cases are fatal.[18]
Heat related health events typically occur on the same
day as initial exposure.[19] Emergency departments (ED)
in Brisbane have demonstrated that during days ≥35°C,
elderly patients were 1.9 times as likely to present
to the ED and 3.75 times as likely to present due to
heat-related complications specifically.[20] Based on
current modelling of Brisbane’s population growth, ED
presentations on days ≥35°C and the projected climate
change related temperature increases, it is predicted to
cause a 125-2065% increase in excess visits by 2060.
[20] Consequently, political inaction now will continue to
worsen the burden on public ED services.
In areas with long term
exposure to high levels of
particulate matter air pollution,
it was found that an increase of
just 10 ug/m3 is associated with
a 70% increase in DVT risk.
[22] This emerging group of environmentally displaced
people will need support to cope.[23] Climate change
has the potential to create disasters beyond the capacity
of developing nations’ public health systems.[24] Action
must be taken to reduce the impact of climate change
for the sake of public health. The global community is
interconnected and each nation has the responsibility to
reduce its contributions to climate change. Consequently,
the impact of the planned Carmichael mine site and its
extensive environmental damage will have substantial
impact on human health into the future.
Locally, coal worker’s pneumoconiosis has reemerged
in Queensland with at least 20 cases recently
diagnosed, highlighting the lack of appropriate health
protection within the Queensland coal industry.[25] If the
Queensland and Australian governments can’t manage
these Occupational Health and Safety issues at home,
how can they contribute to the ‘safe’ delivery and burning
of this coal in Adani’s power stations in India – a country
where air pollution already kills an estimated 1.1 million
people annually.[26] If the mine proceeds, the flow on
effects of poor governing locally will
have detrimental health impacts on a
global scale.
Environmental Implications
The establishment of the
proposed Carmichael coal mine
and its shipping impact will damage
vital ecosystems and reshape the lives and health of the
people reliant on waterways and reefs. More than 500
million people around the planet rely on coral reefs for
food, income and storm protection.[29] Climate related
changes in waves, ocean circulation, cyclone frequency,
temperature and precipitation will impact fisheries in
tropical Queensland and further north.[30] Additionally,
fisheries in our region may be contaminated by chemicals
released into seawater by the mine and from increased
shipping traffic. This will have economic, social and
health implications and affect the productivity of the
seafood industry in Australia and surrounding nations,
especially those that rely on it as a major industry and
cultural cornerstone.[30] Climate change associated
contamination of food staples is also likely to impact on
nutrition and human development.[7] In parallel, the social
aspects of recreational fishing are also highly sensitive
to climate change.[30] Thus, along with the state of the
environment, multiple social determinants of health are
at risk of declining for our coastal communities.
The psychological impacts of climate change are
generally indirect and have only recently been considered
as part of the widespread impacts of climate change on
health. Extreme weather events can lead to mental health
disorders associated with loss, displacement and social
disruption. This can increase anxiety about the future, with
already-disadvantaged communities most likely to suffer
the most severe consequences.[21] Two hundred million
people will be displaced by climate change by 2050.
Implications for Australia
In Central Queensland, the proposed Adani mine
will see more than 10,000 hectares of native bushland
cleared from around the Galilee Basin. Combined
with the Carmichael mine’s generous water licence
enabling unlimited groundwater use from the Great
Artesian Basin,[31] this has huge potential for irreversible
environmental damage.
22

The Great Artesian Basin is a drought-prone area that
is critically responsible for supplying an estimated 200
towns and settlements with irrigation and drinking water.
[31] The construction of the world’s largest coal mine at
this site could risk the livelihoods and lives of Australian
primary producers in this region. The importance of
water security in drought-prone areas is tantamount and
supporting this mine renders these remote Australians
even more vulnerable. Australians living in rural and
remote settings already have a lower standard of health
service provision and are more likely to suffer worse
health outcomes as a consequence of their social
determinants.[32] The health impacts from the proposed
mine are likely to impact rural Australians to an even
greater magnitude.
Massive quantities of coal will be shipped overseas
through the Great Barrier Reef.[3] It is feared that this will
exacerbate the already extensive coral bleaching. This
will impact Australian coastal communities as the Great
Barrier Reef and other coral reefs provide protection
from wave and storm damage.[33]
Implications for Australia’s regional neighbours
Climate change is projected to slow economic growth,
erode food security and hinder poverty reduction. The
negative effects will be most felt by those who are already
disadvantaged.[34] This is especially pertinent for our
regional neighbours, predominately developing countries.
prevent the temperature associated rises in sea levels
in order to prevent their nations going underwater. A 2°C
goal requires a 40-70% reduction in greenhouse gas
emissions compared with 2010 levels, whereas a 1.5°C
increase will require a 70-95% reduction.[28] As one of
the most influential developed countries in our region,
Australia has a responsibility to support the continuing
development of our regional peers. This begins with
supporting their call for action to reduce the global
temperature rise to 1.5°C. There is simply no room for
the proposed Carmichael coal mine and its extensive
pollution in a sustainable future – a future that needs
action now.
Economic and Political implications
The proposed Carmichael mine project has struggled
to achieve financing. Nineteen banks (including
Australia’s ‘Big Four’) have refused to fund the venture
due to ethical concerns, environmental policies, or the
likelihood that renewable energy will outprice fossil fuels
over the proposed life of the mine. The use of Australian
mined coal in Indian power plants will also inevitably
become economically foolhardy.[37] Both the Australian
and Queensland governments should not continue to
support this proposal as it will create few lasting jobs and
crucially it will increase the loss of human life and burden
of disease locally and abroad.
Many of our regional neighbours are already suffering
from the effects of climate change. Bangladesh has
experienced increased temperatures, swollen rivers and
sea level rises; all which threaten infrastructure, livelihoods
and homes and undermining the region’s development.
[35] Climate change is now making cyclones on many
of our neighbouring Pacific Islands even more powerful
and destructive. In 2016, Tropical Cyclone Winston hit Fiji,
affecting more than half a million people and decreasing
its national GDP by one-fifth.[36] As a developed nation,
our government has a responsibility to contribute to the
prosperity, safety and health of our region by supporting
these developing nations. This begins with reducing our
carbon footprint by stopping the expansion of our fossil
fuel industry, including the proposed Carmichael coal
mine.
The climate impacts of the proposed Carmichael coal
mine go against Australia’s international commitment
to promote a sustainable future by limiting increases in
global temperatures. The United Nations Framework
Convention on Climate Change (UNFCCC) promotes the
work of the Paris Agreement to limit a global temperature
rise this century to below 2°C above pre-industrial levels.
[27] Many of our regional neighbours do not believe this
goes far enough. The “1point5toStayAlive” movement
by the Caribbean and their partner states is fighting to
The continued approval of Adani’s Carmichael
mine by the Australian and Queensland governments is
unwise as the economic return on taxpayer investment
23

is questionable. The Northern Australia Infrastructure
Facility (NAIF) has proposed a $1 billion AUD loan to
Adani for the North Galilee Basin Rail Project – a 310km
rail link from the mine site to the Abbot Point export
terminal. Despite widespread coverage, little information
was publicly available at the time of writing; only four
documents were published on NAIF’s website, with none
focussing explicitly on coal mining in the Galilee Basin.
[38-41] Both Adani and the former Minister for Resources
and Northern Development have suggested that the
loan is “not critical” and consequently the mine should
be ineligible for NAIF funding.[42] Other requirements
for NAIF funding include public benefit and commercial
viability, both of which are questionable.[42]
Adani continues to claim that the Carmichael mine
will create 10,000 direct and indirect jobs. However, reef
industries threatened by the mine provide approximately
69,000 jobs.[43] The proposed “10,000 jobs” is even more
questionable because Adani has, under oath, stated only
1,464 jobs will be created.[42] A loan of this magnitude
seems wasteful for taxpayers. In September 2016, the
Minister for Resources and Northern Australia Matthew
Canavan stated that opening the Galilee Basin for coal
mining would “not damage the environment”.[38] The
political mismanagement and fabrications surrounding
the Carmichael mine site are a disservice to Australian
taxpayers.
The lifespan of the proposed Carmichael coal mine
is 60 years.[2] Australian coal is expected to be burnt in
India, a country where the Power Minister plans to ban
coal imports. India’s draft National Electricity plan states
that until 2022, India will not require an increase of coal
from its current rate of supply.[44] India is also a signatory
to the Paris Agreement and has declared commitment
to utilising emerging “cleaner sources of energy” as
they become feasible.[45] The long term profitability of
Adani’s Carmichael coal mine is even more questionable
as there is growing public discontent in India with coalbased
power sources and its resulting air pollution. Whilst
there was an absolute increase in the use of coal in India,
renewable generation grew at over six times the rate
of conventional sources. Between April-October 2016,
28% of Indian energy production came from renewable
resources.[44] This demonstrates that the global trend
towards increasing utilisation of renewable energy
sources is extending to India and the coal industry is
declining.
The United Nations (UN) recognises that climate
change is a threat to human health and rights.[4] In 2016,
Australia ratified the Paris Agreement with a declaration
to work towards combatting climate change. Yet due to
the export nature of the proposed Adani Carmichael coal
mine, these Australian sourced emissions will not count as
part of our Intended Nationally Determined Contributions.
The UN’s Committee on Economic, Social and Cultural
Rights (CESCR) stated that Australia’s increasing carbon
footprint is “at risk of worsening in the coming years”[46]
which would undermine the vision of the Paris Agreement
and its predecessor, the Kyoto Protocol, both of which we
are signatories to. The CESCR’s panel of international
human rights experts has recommended Australian
politicians “review (their) position in support of coal
mines and coal export”.[46] In light of the USA’s recent
withdrawal from the Paris Agreement, it is of increased
importance for Australia and other developed countries
to consider the impact of our carbon footprint beyond our
national border.
Conclusion
The real cost of Australia enabling the continuing
burning of coal will be measured in health impacts, hunger
and humanitarian disasters. Therefore, the Australian and
Queensland governments must act now to preserve the
health of Australian and global citizens into the future.
The medical profession has a long and proud history of
protecting public health. We must add our voices to the
wave of protest to stop the construction of the world’s
largest coal mine, and for the sake of our patients’ health,
to make coal history.
Acknowledgements
Doctors for the Environment Australia
Photo credit
Julian Meehan, accessed from https://www.flickr.com/
photos/takver/31283359832
Conflict of Interest
None declared
Correspondance
evan.morgan@my.jcu.edu.au
References
1. Queensland Government. Carmichael coal mine and rail project [Internet].
Brisbane QLD: Department of State Development; 2010 Oct 22 [updated 2017
June 19; cited 2017 Aug 28]. Available from: https://www.statedevelopment.qld.
gov.au/assessments-and-approvals/carmichael-coal-mine-and-rail-project.html
2. Australian Government. Carmichael coal and rail infrastructure factsheet
[Internet]. Canberra ACT: Minister for the Environment’s office; 2014 [cited 2017
Aug 28]. Available from: https://www.environment.gov.au/minister/hunt/2014/pubs/
mr20140728-factsheet.pdf
3. Amos, C. Carmichael in context [Internet]. Canberra ACT: The Australia
Institute; 2015 [cited 2017 Aug 28]. Available from: http://www.tai.org.au/content/
carmichael-context
4. World Health Organisation. WHO calls for urgent action to protect health
from climate change [Internet]. Geneva Switzerland: World Health Organisation;
2015 [cited 2017 Aug 28]. Available from: http://www.who.int/globalchange/globalcampaign/cop21/en/
5. McCall, C. Australia’s new coal mine plan: a “public health disaster”.
Lancet [Internet]. 2017 Feb 11[cited 2017 Aug 28];389(10069):p588.
Available from: http://www.thelancet.com/journals/lancet/article/PIIS0140-
6736(17)30329-X/fulltext
6. McGrath, C. Carmichael coal mine cases in the Land Court and Supreme
Court of Qld [Internet]. Brisbane QLD: Environmental Law Australia; 2010 [updated
2017 Aug 25; cited 2017 Aug 28]. Available from: http://envlaw.com.au/carmichaelcoal-mine-case/
7. Portier C, Thigpen Tart K. A human health perspective on climate
change [Internet]. North Carolina, USA: National Institute of Environmental Health
Sciences; 2010 Apr 22 [cited 2017 Oct 15]. 80p. Available from: https://www.niehs.
nih.gov/health/materials/a_human_health_perspective_on_climate_change_
full_report_508.pdf
8. Dennekamp M, Carey M. Air quality and chronic disease: why action on
climate change is also good for health. NSW Public Health Bulletin. 2010 July 16
[cited 2017 Oct 20]; 21(6): 115-121. Available from: http://www.publish.csiro.au/
NB/NB10026
9. State of the Environment 2011 Committee. Australia State of the
environment 2011 [Internet]. Canberra, ACT: Department of Sustainability,
Environment, Water, Population and Communities; 2011 [cited 2017 Oct 20]. 940p.
Available from: https://soe.environment.gov.au/sites/g/files/net806/f/soe2011-
report-complete.pdf?v=1488164460
10. Yang Q, Chen Y, Shi Y, Burnett R, McGrail K, Krewski D. Association
between ozone and respiratory admissions among children and the elderly in
Vancouver, Canada. Inhal Toxicol [Internet]. 2003 Nov [cited 2017 Oct 20]; 15(13):
24

1297-308. Available from: https://www.ncbi.nlm.nih.gov/
11. Hardin B, Kelman B, Saxon A. Adverse human health effects associated
with molds in the indoor environment. J Occup Environ Med [Internet]. 2003 May
[cited 2017 Oct 20]; 45(5): 470-478. Available from: https://www.ncbi.nlm.nih.gov/
pubmed/12762072
12. D’Amato G, Cecchi L. Effects of climate change on environmental factors
in respiratory allergic diseases. Clin Exp Allergy. 2008 Aug [cited 2017 Oct 20];
38(8): 1264-1274. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18537982
13. Kirkpatrick B, Fleming L, Bean J, Nierenberg K. Aerosolized red tide toxins
(Brevetoxins) and asthma: Continued health effects after 1 hour beach exposure.
Harmful Algae [Internet]. 2011 Jan 1 [cited 2017 Oct 20]; 10(2): 138-143. Available
from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076944/
14. Bacarelli A, Martinelli I, Zanobetti A. Exposure to particulate air pollution
and risk of deep vein thrombosis. Arch Intern Med [Internet]. 2008 [cited 2017
Oct 20]; 168(9): 920-927. Available from: https://jamanetwork.com/journals/
jamainternalmedicine/fullarticle/414214
15. Brook R. Cardiovascular effects of air pollution. Clin Sci (Lond) [Internet].
2008 Sep [cited 2017 Oct 20]; 115(6): 175-187. Available from: https://www.ncbi.
nlm.nih.gov/pubmed/18691154
16. Jerret M, Burnett R, Pope C, Kazuhiko I. Long-term ozone exposure and
mortality. N Engl J Med [Internet]. 2009 Mar 12 [cited 2017 Oct 20]; 360: 1085-1095.
Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa0803894#t=article
17. Donoghue E, Graham M, Jentzen J, Liftschulz B, Luke J, Mirchandani H.
Criteria for the diagnosis of heat-related deaths: National Association of Medical
Examiners. Position Paper. National Association of Medical Examiners Ad Hoc
Committee on the Definition of Heat-Related Fatalities. Am J Forensic Med Pathol
[Internet]. 1997 Mar [cited 2017 Oct 20]; 18(1): 11-14. Available from: https://www.
ncbi.nlm.nih.gov/pubmed/9095294?dopt=Abstract
18. Kilbourne E. Heat waves and hot environments. In: Noji E, editor. The
public health consequences of disasters. New York, USA; Oxford University Press;
1997. p245-269.
19. Basu R, Samet J. Relation between elevated ambient temperature and
mortality: a review of the epidemiologic evidence. Epidemiol Rev [Internet]. 2002
[cited 2017 Oct 20]; 24(2): 190-202. Available from: https://academic.oup.com/
epirev/article-lookup/doi/10.1093/epirev/mxf007
20. Toloo G, Hu W, FitzGerald G, Aitken P, Tong S. Projecting excess
emergency department visits and associated costs in Brisbane, Australia, under
population growth and climate change scenarios. Sci Rep [Internet]. 2015 Aug 6
[cited 2017 Oct 20]; 5: 12860. Available from: https://eprints.qut.edu.au/86502/1/
Projecting%20excess%20ED%20visits%20and%20associated%20costs%20
in%20Brisbane.pdf
21. Fritze J, Blashki G, Burke S, Wiseman J. Hope, despair and transformation:
Climate change and the promotion of mental health and wellbeing. Int J Ment
Health Syst [Internet]. 2008 Sep 17 [cited 2017 Oct 20]; 2(1): 13. Available from:
https://ijmhs.biomedcentral.com/articles/10.1186/1752-4458-2-13
22. Myers N. Environmental refugees: a growing phenomenon of the 21st
century. Philos Trans R Soc Lond B Biol Sci [Internet]. 2002 Apr 29 [cited 2017
Oct 20]; 357(1420): 609-613. Available from: https://www.ncbi.nlm.nih.gov/
pubmed/12028796
23. United Nations High Commissioner for Refugees. Climate change and
disasters [Internet]. Geneva, Switzerland: UNHCR; 2015 Jan 1 [cited 2017 Oct 20].
Available from: http://www.unhcr.org/en-au/climate-change-and-disasters.html
24. The CNA Corporation [Internet]. Virginia, USA: The CAN Corporation;
2007. National security and the threat of climate change; 2007 [cited 2017
Oct 20]; [p15]. Available from: https://www.cna.org/cna_files/pdf/national%20
security%20and%20the%20threat%20of%20climate%20change.pdf
25. Queensland Government. Black lung white lies – Report number 2
[Internet]. Brisbane QLD: Coal Workers’ Pneumoconiosis Select Committee;
2017 May [cited 2017 Aug 28]. Available from: http://www.parliament.qld.gov.au/
Documents/TableOffice/TabledPapers/2017/5517T467.pdf
26. Climate and Clean Air Coalition. State of global air 2017: A special report
on global exposure to air pollution and its disease burden [Internet]. Paris France:
Climate and Clean Air Coalition; 2017 [cited 2017 Aug 28]. Available from: http://
www.ccacoalition.org/en/resources/state-global-air-2017-special-report-globalexposure-air-pollution-and-its-disease-burden
27. United Nations Framework Convention on Climate Change. The Paris
Agreement [Internet]. New York USA: United Nations; Oct 2016 [updated Oct 2017;
cited 2017 Oct 15]. Available from: http://unfccc.int/paris_agreement/items/9485.
php
28. The Caribbean’s Climate Justice Hub. #1point5toStayAlive [Internet].
Saint Lucia: 1.5; 2015 [cited 2017 Oct 15]. Available from: http://1point5.info/
whatsup
29. Global Coral Reef Monitoring Network. Status of coral reefs of the
world: 2004 – Chapter 2 New initiatives in coral reef monitoring, research,
management and conservation [Internet]. Gland Switzerland: International Union
for Conservation of Nature; 2004 [cited 2017 Aug 28]. Available from: https://www.
iucn.org/sites/dev/files/import/downloads/cr_status_2004_vol1.pdf
30. Australian Government. Climate change impacts on the fishing industry
[Internet]. Townsville QLD: Great Barrier Reef Marine Park Authority; 2017 [cited
2017 Sept 21]. Available from: http://www.gbrmpa.gov.au/managing-the-reef/
threats-to-the-reef/climate-change/what-does-this-mean-for-communities-andindustries
31. Environmental Defenders Office Queensland. Adani Carmichael project
receives water licences [Internet]. Brisbane QLD: Environmental Defenders Office;
2017 May 31 [cited 2017 Aug 28]. Available from: http://www.edoqld.org.au/news/
adani-pending-water-licence/
32. Bourke L, Humphreys J, Wakerman J, Taylor J. Understanding rural and
remote health: A framework for analysis in Australia. Health Place [Internet]. 2012
Mar [cited 2017 Oct 15];18:496-503. Available from: http://www.flinders.edu.
au/medicine/fms/sites/southgate/documents/events/2014/Understanding%20
rural%20and%20remote%20health_a%20framework%20analysis%20for%20
Australia.pdf
33. Guannel G, Arkema K, Ruggiero P, Verutes G. The power of three: coral
reefs, seagrasses and mangroves protect coastal regions and increase their
resilience. PLoS One [Internet]. 2016 July 13 [cited 2017 Aug 28]; 11(7): e0158094.
Available from: http://journals.plos.org/plosone/article?id=10.1371/journal.
pone.0158094
34. Working Group II Contribution to the Fifth Assessment Report of the
Intergovernmental Panel on Climate Change. Fifth Assessment Report – Impacts,
Adaptation and Vulnerabilities [Internet]. New York USA: Intergovernmental Panel
on Climate Change; 2014 [cited 2017 Oct 10]. Available from: https://www.ipcc.ch/
report/ar5/wg2/
35. Glennon, R. The unfolding tragedy of climate change in Bangladesh
[Internet]. New York USA: Scientific American; 2017 Apr 21 [cited 2017 Aug 28].
Available from: https://blogs.scientificamerican.com/guest-blog/theunfoldingtragedy-of-climate-change-in-bangladesh/
36. United Nations Office for the Coordination of Humanitarian Affairs.
Tropical Cyclone Winston – Feb 2016 [Internet]. New York USA: ReliefWeb; 2016
[cited 2017 Aug 28]. Available from: https://reliefweb.int/disaster/tc-2016-000014-
fji
37. Climate Council of Australia. Risky business: Health, climate and
economic risks of the Carmichael coalmine [Internet]. Sydney NSW: Climate
Council of Australia; 2017 [cited 2017 Sep 21]. Available from: https://www.
climatecouncil.org.au/uploads/5cb72fc98342cfc149832293a8901466.pdf
38. Ministers and Assistant Ministers for the Department of Industry,
Innovation and Science [Internet]. Canberra, ACT: Australian Government; 2016
Sep 30. Canavan’s Speech to CEDA; 2016 Sep 30 [cited 2017 Oct 20]. Available
from: http://www.minister.industry.gov.au/ministers/canavan/speeches/speechceda
39. Sharon Warburton, Chair, Northern Australia Infrastructure Facility.
Speech – Developing Northern Australian Conference [Internet]. Cairns, QLD:
Northern Australia Infrastructure Facility; 2017 June 19 [cited 2017 Oct 20].
Available from: https://naif-gov-au.industry.slicedtech.com.au/wp-content/
uploads/2017/06/Speech-Sharon-Warburton-DNA-final-for-web.pdf
40. Australian Government. Our north, our future: White paper on developing
northern Australia [Internet]. Canberra, ACT: Australian Government; 2015 [cited
2017 Oct 20]. 200p. Available from: http://northernaustralia.gov.au/files/files/
NAWP-FullReport.pdf
41. Australian Government. Northern Australia audit – infrastructure for a
developing north [Internet]. Canberra, ACT: Australian Government; 2015 Jan
[cited 2017 Oct 20]. 306p. Available from: http://infrastructureaustralia.gov.au/
policy-publications/publications/files/IA_Northern_Australia_Audit.pdf
42. Swann, T. Don’t be so naif; Adani and Governance of the Northern
Australia Infrastructure Facility (NAIF) [Internet]. Canberra ACT: The Australia
Institute; Mar 2017 [cited 2017 Oct 15]. Available from: http://www.tai.org.au/sites/
defualt/files/P318%20Dont%20be%20so%20naif%20FINAL.pdf
43. Deloitte Access Economics. Economic Contribution of the Great Barrier
Reef [Internet]. Townsville Qld: Great Barrier Reef Marine Park Authority; Mar 2013
[cited 2017 Oct 15]. 52p. Available from: http://www.environment.gov.au/system/
files/resources/a3ef2e3f-37fc-4c6f-ab1b-3b54ffc3f449/files/gbr-economiccontribution.pdf
44. Burton B, Fernandes A. Is the Indian coal domino about to fall? [Internet].
Australia: Renew Economy; Dec 2016 [cited 2017 Oct 15]. Available from: http://
reneweconomy.com.au/indian-coal-domino-fall-91973/
45. United Nations Framework Convention on Climate Change. Paris
Agreement – Status of Ratification [Internet]. New York USA: United Nations; Dec
2015 [updated Apr 2017; cited 2017 Oct 15]. Available from: http://unfccc.int/
paris_agreement/items/9444.php
46. United Nations Committee on Economic, Social and Cultural Rights.
Concluding observations on the fifth periodic report of Australia [Internet]. Geneva
Switzerland: United Nations Office of the High Commissioner; 2017 July 11 [cited 2017
Aug 28]. Available from: http://tbinternet.ohchr.org/_layouts/treatybodyexternal/
Download.aspx?symbolno=E%2fC.12%2fAUS%2fCO%2f5&Lang=en
25

Paddling upstream:
Experiences from a medical placement in
rural Papua New Guinea
[Feature Article]
Nicholas Snels
I sit in an office on my GP rotation. My insides burn,
courtesy of my morning doxycycline. The patient, who
has come in with fever and a sore throat, coughs. I flinch.
My eyes fly across the room, searching for a face mask.
Then I remember I am back in Toowoomba, and not
every fever is likely due to an unpronounceable parasitic
infection. This is perhaps a slight
dramatisation of my GP block, however,
I cannot help but cast my mind back to
when a cough could signal something
far more sinister than an URTI.
I was recently given the opportunity
to spend six weeks at the Kiunga
District Hospital in rural Papua New
Guinea (PNG) as part of the Griffith
Rural Medical Education program. Every rotation block,
four students are given the opportunity to spend six
weeks in Kiunga hospital. For those as unfamiliar with
Papua New Guinean geography as me prior to my visit,
Kiunga is a town in the western province of PNG, on
the banks of the Fly River. The hospital serves a town
of approximately 13000 people, in addition to being
a referral centre for the region, with approximately 45
beds spread over numerous wards (medical, surgical,
women’s), as well as a pathology lab and an emergency
department/outpatient department (OPD). The wards
are managed by a physician and a surgical/obstetrics
and gynaecology doctor, health extension officers,
community health workers and nurses. As medical
students we were well accustomed to being at the
bottom of this hierarchy; however, in PNG we were given
far greater responsibility.
General Ward
Nick is a final year medical student from Griffith University. Throughout his degree he
has been interested in gaining clinical exposure in a variety of settings, ranging from
a rural experience in Warwick to furthering an interest in global health in Papua New
Guinea and India.
Common things occur commonly. This phrase had
been thrown at me all throughout my clinical years. Most
coughs are probably not cancer, most sore throats are
not the harbinger of quinsy. However, the medical ward
showed us just how context-specific this phrase is, with
...the words ‘common things
occur commonly, therefore,
this is probably tuberculosis or
malaria’ heard at least once
per ward round.
the words ‘common things occur commonly, therefore,
this is probably tuberculosis or malaria’ heard at least
once per ward round. Ascites was probably due to
abdominal seeding of tuberculosis, a headache was
probably due to cerebral malaria. We quickly learned to
appease the ward doctor by suggesting tuberculosis as
the cause for nearly every presenting
complaint. The range of tropical
diseases surpassed my expectations,
from tuberculosis, malaria and
malnutrition, to less common cases of
severe AIDS and Buruli ulcers. I was
even exposed to diseases I had not
even fathomed I might see, such as
toxic epidermal necrolysis as a result
of leprosy medications.
Our time in the general ward consisted of a morning
ward round followed by jobs, and it was eye-opening
to see how health care could be limited by a lack of
resources. Intramuscular antimalarials often ran out,
meaning that oral antimalarials had to be followed by
an ondansetron chaser. There was no adrenaline in the
emergency room, meaning it was necessary to trawl the
hospital to find some before it was needed. A lack of
funds for staff meant the occupants of the tuberculosis
ward were at the far end of the general ward, placing
the rest of the patients at risk of nosocomial infection.
Consequently, we soon learned that ward rounds began
by applying appropriate PPE as soon as we entered the
building (Figure 1).
One patient made a particular impression on me. M
was a 7-month old female admitted due to malnutrition.
Throughout the week, she slowly gained weight and
started to take an interest in the strange pale humans
trying to make her smile with a toy koala, and was
eventually discharged. The next week she returned with
a cough, initially thought to be viral in origin. However,
common things occur commonly, and imaging suggested
M had tuberculosis. While unable to pinpoint the exact
26

cause, it was possible that her long stay on the ward
could have been the source. It was incredibly frustrating
knowing that if the hospital had funding, these incidents
could be prevented. Nonetheless, the case of M is not an
isolated one, and the lack of resources was evident in all
the areas of the hospital during our stay.
Surgical Ward
Having heard of other elective experiences, I
expected that surgery in a developing country would
be exceptionally hands-on, however, this was not what
I experienced. The reasons for this were unique. A
number of issues, such as the surgeon having malaria,
or the building having no functioning water with which to
sterilize equipment, resulted in my group having relatively
few surgeries to attend. Something I was exposed to,
however, was overcoming challenges in a resource-poor
setting. In the absence of K-wire cutters, garden pliers
were sterilised with alcohol wipes; on another occasion,
an abdominal drain was secured in place with a tongue
depressor snapped and taped together. The persistence
shown by the staff to make the most of what was
available was inspiring, especially given they face these
challenges continually.
Women’s Ward
Figure 1. Students in PPE
In my third year, I was placed in a rural hospital in
Australia which did not see a huge amount of obstetrics.
You could say I was unprepared for
obstetrics in Kiunga.
Caesarian sections were an
uncommon event, meaning that we
witnessed births which probably
would not have happened in
Australia. Examples of this include
a mother with malaria struggling to
give birth due to severe lethargy, or
the two breech births occurring during my six weeks.
In an Australian setting, we are used to working under
the guidance of a senior team member, especially in
a high-intensity situation. However, in PNG we were
In an Australian setting, we are used
to working under the guidance of a
senior team member, especially in a highintensity
situation. However, in PNG we
were expected to step up and start to
manage situations ourselves.
expected to step up and start to manage situations
ourselves. In the maternity suite births were usually
facilitated by one midwife, and if something went wrong,
the focus was on looking after the mother. This meant
that care of the neonate typically came after the mother’s
situation was controlled.
Therefore, on a number of occasions, a routine birth
would end with the midwife handing a limp neonate to two
medical students. Prior to coming to PNG, I was aware of
the debate regarding medical students overstepping their
boundaries while on elective. However, in that moment we
had to make a choice to either stand by and watch the
neonate die due to a lack of resources and staff, or give
it the best chance it could have in the circumstances by
applying pre-departure training in neonatal resuscitation.
It is hard to imagine the situation where there are no
medical students to assist, but sadly due to lack of
staffing that is the situation this hospital faces every
day. We were involved in three such scenarios during
my time in PNG, and I am thankful for the training we
received on resuscitation prior to departure. In saying
that, the unsuccessful resuscitations were amongst the
most confronting moments in medical school, but I am
glad we were present to intervene when no one else was
available.
Not all births were intense, and even in uncomplicated
births we were routinely supported by the midwives to
assist the mother in delivering the child. The midwives
in PNG are incredible, managing most births without
intervention of a doctor, and even performing procedural
skills such as perineal repair and vacuum-assisted
delivery.
Emergency and Outpatient Department
Although other areas of the hospital were perhaps
more confronting, I felt most out of my depth in the OPD.
We were expected to independently see patients and
prescribe medications, with no guidance offered unless
required. While the OPD allowed us to practice our
Pidgin, the language barrier remained a significant issue.
Personally, I felt very uncomfortable prescribing antimalarials
according to a guideline
I did not know well, to a 4-year-old
whose parents I could not explain
anything to, a situation I found
myself in on our first day in the
hospital. The staff were probably
annoyed by my constant questions,
however, I was worried about
overstepping my boundaries as
a student and potentially causing
significant harm. In saying that, the
range of presentations was diverse (although malaria
was exceptionally common), and the chance to practice
our newly-acquired language skills was excellent.
27

Similar to the obstetric department, we were
forewarned that if resuscitation needed to be performed,
we would potentially be in charge. Even with this in mind,
I certainly did not expect to be performing compressions
one Sunday afternoon while wearing thongs and board
shorts. Due to a lack of staff on this particular weekend,
three medical students who had been playing soccer with
the local kids were now attempting to resuscitate a man
who had been in the ED since the morning. Eventually the
doctor arrived to take control, but it is hard to imagine
students in Australia ever being in such a situation.
Social
Aside from the clinical experience, one of the
highlights of the placement was the chance to become
involved in the local community. We stayed in a house
a close walk away from the hospital, meaning that we
often had spare time in the afternoons/weekends. Most
afternoons we played sport with the local kids, and every
Sunday we played a movie for them at the hospital. Not all
of the children were so keen, however, as one particular
girl started crying as soon as she saw us, a sobering
reminder that foreign faces are still uncommon in such
parts of the world.
One of the most surreal experiences was going
to a local club and listening to Justin Bieber while
meeting locals over Papua New
Guinean beer. A local gentleman
was adamant Justin was in fact a
Papua New Guinean artist, but in his
defence the local brew was quite
potent. At the end of the night we
were even offered a lift home by
the police chief, provided we let him
finish his drink first. Another highlight
was being shown wild birds of
paradise by a guide who had taken David Attenborough
to see them years ago. The people were exceptionally
welcoming, often stopping on the street or in the markets
to talk to us and see how we were finding the experience.
Reflections
There were a few main lessons I took away from this
experience in regards to students experiencing a global
health elective. The most striking point was the issue
regarding medical students on electives in resource-poor
settings. This issue deserves a review unto itself, but
suffice to say it became very apparent to me how easy
it could be for an overconfident medical student to abuse
the level of trust placed in them by the local population.
Particularly, in a poorly-resourced setting with a lack of
supervision, students may be placed in situations that
are beyond their level of knowledge. However, in certain
circumstances, capable students, and especially those in
their final year, may be able to have a positive impact on
their chosen placement. Such an experience highlighted
At times it seemed like the health care
workers were battling their way upriver
against a tide of financial constraints and
poor government support, however, the
enthusiasm and dedication shown towards
the people of Kiunga was inspiring.
how aware students must be before embarking upon
such an elective, and to have these issues in their minds
while on the placement to avoid overstepping their scope
of practice.
Such difficulty is exacerbated by the challenges
of healthcare provision in resource-poor settings, and
this placement was invaluable in showing me how it
differs compared to Australia. The shortage of staff,
medications and equipment was evident throughout the
hospital, and it was clear that the entire health system
could be improved by further funding. It was confronting
seeing individuals suffer because the medication they
needed was not available, however, it was inspiring to
see the ways staff attempted to overcome these barriers.
Additionally, the attitude of the staff continually stayed
positive, even in the face of these challenges.
Finally, it was evident to me throughout the placement
that global health challenges in developing nations
are changing. While infectious and tropical diseases
were rife, the impact of chronic conditions such as
cardiovascular disease, hypertension and diabetes was
evident during my time in Kiunga. These conditions were
often poorly managed due to lack of proper medications
and monitoring. Their increasing prevalence coupled with
the lack of resources to manage these conditions mean
students doing a similar placement in the future will face
a host of different conditions.
In summary, this elective
was an excellent experience.
Not only for the clinical
exposure, but also for the
chance to see how healthcare
functions in a resource-poor
setting. At times it seemed
like the health care workers
were battling their way upriver against a tide of financial
constraints and poor government support, however, the
enthusiasm and dedication shown towards the people
of Kiunga was inspiring. Additionally, the chance to
experience life in a rural town in PNG was a highlight in
itself. This placement has, undoubtedly, been one of the
most motivating placements of medical school, and I
strongly urge anyone considering something similar to
take the opportunity.
Acknowledgements
QRME and Graeme Hill for continual support of this
program; Aisha, Ryan and Emily for sharing the experience
and for support throughout difficult times.
Conflicts of interest
None declared
Correspondance
nicholas.snels@griffithuni.edu.au
28

Introduction
Sugar tax -
A sweet solution for obesity?
The obesity epidemic
Over the past few decades, overweight and obesity have
risen to epidemic proportions all over the globe. In 2014,
more than 1.9 billion adults were overweight and 600 million
were obese.[1] In 2013, 42 million children under the age of
five were either overweight or obese, and this is predicted
to increase to 70 million by 2025.[2] The growing prevalence
of childhood obesity is particularly alarming given that it is a
predisposing factor for lifelong obesity.[3] Obesity, defined as
having a body mass index (BMI) greater than or equal to 30, is
a major risk factor for non-communicable diseases such as
cardiovascular disease, diabetes, cancer, and mental illness.
[4] Since non-communicable diseases were responsible for
68% of all deaths in 2012, [5] it is apparent that the health
burden of obesity is high.
Obesity is a complex heterogenous disease that arises
from an interplay between our genes and the environment
we live in. Highly energy-dense diets combined with a lack
of adequate physical activity leads to a positive caloric
balance and hence weight gain in genetically susceptible
individuals. Our diet and physical activity are increasingly
[Review]
Saiuj Bhat
Saiuj is a first year medical student at the University of Western Australia with a passion
for understanding the social and commercial determinants of health. He also has
an interest in tissue engineering, in particular organoid technology, and the promising
that holds for many aspects of medicine in the future. He graduated last year with
Honours in pharmacology.
“
Abstract
Background: The rising prevalence of obesity and obesity-related illnesses parallels the increase in sugar consumption
across the globe. To limit consumption of sugar and tackle obesity, the World Health Organization has recommended
that member states implement a tax on sugar. Such a tax is envisioned to reduce sugar consumption at a societal
level, generate stable revenue for governments, and drive product reformulation. However, at present there is insufficient
evidence to suggest any beneficial effect of a sugar tax on the incidence and prevalence of obesity.
Aim: This review examines the effectiveness of a sugar tax as an obesity prevention strategy.
Methods: A qualitative review of modelling and observational studies investigating the link between sugar tax and
obesity, and conducted over the past ten years, was carried out.
Findings: Modelling studies suggest that a tax on high-sugar foods and beverages is likely to have beneficial effects on
obesity as increased price of taxed items leads to reduced consumption. However, observational studies suggest little
benefit of a sugar tax on actual obesity rates in a population. Taxes in combination with other policy and regulatory
approaches, for example health food subsidies and education campaigns, might be more effective than a tax on its own.
Conclusion: A tax on sugar is likely to be a step in the right direction as it would raise public awareness of the negative
health effects of excess sugar and de-normalise consumption of excess sugar.
shaped and driven by broader social, cultural, economic, and
political landscapes that are often beyond individual control
and awareness.[6] The modern obesogenic environment,
which provides easy access to calorie-rich processed food
and encourages sedentary lifestyle, is mismatched to human
physiology that evolved to survive in an environment of food
scarcity.[7] At a population level, obesity can be viewed as
a manifestation of a global economic system that currently
prioritises wealth creation over health creation.[8]
Obesity’s sweet tooth
”
In recent decades, the rising prevalence of obesity has
closely paralleled the burgeoning consumption of sugar all
over the world.[9] Sugar is recognised as one of the biggest
risk factors for obesity,[10-15] and the leading source of
sugar in the diet is sugar sweetened beverages (SSBs).[15]
Therefore, the current review will focus on SSBs as a proxy
for sugar and the discussion about policies aimed at limiting
sugar intake (i.e. sugar taxes), will predominantly revolve
around SSBs.
SSBs are non-alcoholic beverages with added sugar and
include soft drinks, fruit drinks, sports drinks, energy drinks,
29

iced tea and coffee, and lemonade. SSBs are becoming
increasingly popular in low- and middle-income countries, with
Latin America and Asia leading the world in consumption.[16]
The worldwide impact of SSBs on the burden of adiposityrelated
cardiovascular disease, cancer, and diabetes is
estimated at a total of 8.5 million (95% CI: 2.8 – 19.2)
disability-adjusted life years (DALYs) [17].
Limiting the intake of free
sugars to less than 10% of total
daily energy consumption is
strongly recommended by the
World Health Organisation and the
US Dietary Guidelines Advisory
Committee.[18, 19] For every additional serving of SSB per
day, the likelihood of a child becoming obese increases by
60% over the course of two years.[20] The energy obtained
from SSBs is added to an individual’s total energy intake
rather than displacing other sources of calories due to the
poor satiating properties of sugar in liquid form.[21] The net
increase in calorie consumption is likely to contribute to an
increase in body mass. Given the high burden of obesityrelated
illnesses on healthcare systems [17] and the strong
evidence linking excess consumption of SSBs to obesity in
children and adults,[15, 22] a reduction in SSB consumption is
warranted. A decrease in consumption is especially pertinent
as the major SSB consumers are children, adolescents and
poorly educated individuals from lower socio-economic
strata of society who may be less aware of the harmful
effects of added sugar.[10]
Sugar tax as an obesity prevention strategy?
“obesity can be viewed as a manifestation
of a global economic system that currently
prioritises wealth creation over health
creation.”
The success of an SSB tax as an obesity prevention
strategy remains controversial. The plethora of studies
investigating the link between sugar taxation and obesity
prevention demonstrate conflicting results. There is currently
no consensus regarding the best approach to implement a
sugar tax. Furthermore, existing meta-analyses on the topic
show inconsistent findings and are
unable to include many primary
studies in their analysis owing to
methodological inconsistencies.
Recognising these limitations,
this review provides a brief
overview of the current literature on the effectiveness of
a sugar tax as an obesity prevention strategy. Given that
existing studies have been performed in both developing and
developed nations, this review adopts a global perspective on
the issue of sugar taxation. The theoretical basis of a sugar
tax, its economic feasibility, and effectiveness with regards
to obesity prevention will be examined. Alternative strategies
for curbing the obesity epidemic, such as regulation of
advertisements and food labels, are beyond the scope of this
review and will not be explored.
Methods
Electronic databases (PubMed and Web of Science) were
searched for relevant journal articles between 1 January
2007 and 1 July 2017. The year 2007 was chosen to ensure
included studies were relevant to modern dietary habits and
practices.
Population health interventions aimed at curbing the
consumption of excess sugar are pertinent to curtail
the obesity epidemic. Price is one of the key factors
influencing food purchasing behaviour. People tend to reduce
consumption of unhealthy foods in response to increased
prices of such products.[23] To discourage purchase of
SSBs and address the growing burden of obesity, countries
such as France, Mexico, the UK, and Hungary, and several
jurisdictions in the USA, have implemented a tax on sugar.[10]
Following implementation of a €0.11 per 1.5 L excise tax on
SSBs, which translated to a 6% price increase, France saw
a 6.7% decline in demand for cola in the first two years.[24]
SSBs are a sensible target for a sugar tax as they have a high
calorie density with no additional nutritional value [10, 25] and
can be clearly defined for policy implementation.[2]
A number of assumptions underscore the success of an
SSB tax [26]: first, the tax must be passed onto consumers,
leading to an increase in cost; second, SSBs follow the law
of demand; and finally, the tax leads to a significant net
reduction in energy intake despite substitution by consumers,
for example by increasing consumption of fruit juices with
comparable caloric content.[27] While a tax on sugary
drinks may not be the silver bullet for obesity on its own, it
has the potential to slow the epidemic. For this reason,
recommendations to implement diet-related taxes should be
taken seriously.[28, 29]
The following search strategy was used: (tax* OR price*
OR economic* OR financial*) AND (sugar OR sweetened
OR beverage* OR drink*) AND (intake OR consumption OR
demand OR sale* OR diet OR weight OR overweight OR
obes* OR body mass index OR BMI).
Searches were limited to articles published in English.
Relevant articles were also identified by searching the
reference lists of included studies. Abstracts were assessed
for suitability of inclusion. Studies that were found to be
suitable were read in full and their salient features reported
here.
Economic feasibility of a sugar tax
Consumers do not bear the full costs of their decisions
when it comes to high-calorie foods and beverages.[30] It
is estimated that an individual with a BMI between 30 and
35 will accumulate 30% higher medical costs than a normal
weight individual;[31] this increases to 50% in individuals
with a BMI greater than 35.[32] In Canada, obesity-related
healthcare costs are close to $6 billion [33] whereas in
Australia this figure is close to $10.7 billion.[34] In addition
to direct healthcare costs, there are indirect costs to the
community associated with absenteeism and obesity-related
premature death.[35]
30

A number of modelling studies have reported substantial
healthcare cost savings and stable revenue streams from a
tax on sugar.[14, 36-38] For example, annual healthcare cost
savings of $23.6 billion (95% CI: 9.33 – 54.9) and annual
revenue of $12.5 billion (95% CI: 8.92 – 14.1) have been
predicted for a tax of $0.01 per ounce of sugar in the United
States (US).[39] Importantly, a sugar tax combined with a fruit
and vegetable subsidy is deemed to be poverty neutral,[37] an
important consideration given the significantly higher relative
cost of fresh produce,[40] especially in rural and remote
communities. The revenue generated from an SSB tax can
be used to cover the healthcare costs of obesity, support
subsidies on healthy food options, and fund public and school
education campaigns promoting childhood nutrition and
obesity prevention.
“a sugar tax combined with a fruit and
vegetable subsidy is deemed to be poverty
neutral, an important consideration given
the significantly higher relative cost of fresh
produce, especially in rural and remote
communities.”
Effectiveness of a sugar tax for preventing obesity
Of various taxes on “unhealthy” foods, a tax on sugar was
modelled to have the biggest health gain in the Australian
population, equating to 270,000 DALYs (95% CI: 250,000
– 290,000) averted.[37] The effect of a sugar tax on BMI
was found to be modest, equating to a BMI reduction of
0.1 in males and 0.06 in females, and a decline in obesity
prevalence of 2.7% in males and 1.2% in females [36]. In a
study modelling the German population, a 20% SSB tax was
shown to reduce the prevalence of obesity by 4% in males
aged 20 to 29.[41] Similarly, a modelling study by Cancer
Research UK estimated that a 20% tax on SSBs could
prevent 3.7 million people from becoming obese by 2025.
Significant, albeit small, inverse associations between SSB
taxes and weight gain have been reported by other modelling
studies.[15] These could represent important changes over
time and alter the prevalence of obesity at a population level.
[42] Importantly, reductions in energy consumption were more
pronounced in low- and middle-income groups.[38, 41, 43]
One of the biggest limitations of these studies is that they
are population models.[37] They rely on national data which
may be outdated and assume a linear relationship between
weight changes and energy consumption without accounting
for substitution behaviour by consumers and often relies on
self-reported data.[41] The substitution effect is an obvious
confounder in studies that do not classify fruit juices as SSBs,
despite juices often containing more sugar than soft drinks.
[14] Another limitation of modelling studies is the lack of
information on long-term SSB price elasticity that is specific
to geographic and economic subgroups.[14]
Six months after implementation of an SSB excise tax
($0.01 per ounce), consumption of SSBs decreased in
Berkeley, California (–21%) and increased in comparable
neighbouring cities that did not levy a sugar tax (+4%). Of the
124 people who reported changing drinking habits as a result
of the tax, 82% reported drinking SSBs less frequently and
40% reported drinking smaller sizes because of the tax.[44]
Similarly, following introduction of an SSB tax (1 peso/litre)
by the Mexican government, the purchase of SSBs declined
by an average of 6% during the first year of the tax and this
decline was greater in low income groups.[45] The average
Mexican purchased 4.2 litres less taxed beverages than
expected during the first year, however, purchase of untaxed
beverages increased by 13 litres on average.[45] Whether the
increased consumption of untaxed beverages compensated
for the reduced caloric intake due to the decline in taxed
beverages was unable to be determined, so the effect of the
sugar tax on net caloric intake remains to be seen. Given
their short time frame, these observational studies provide
no indication of the effect of a sugar tax on actual obesity
rates in a population.
Similarly, surveys investigating consumers’ purchasing
behaviour may not necessarily predict their actual purchasing
habits.[46] This is critical in light of the fact that a 20% tax on
SSBs did not result in an appreciable reduction in consumers’
likelihood to buy SSBs, despite their perception that they were
more expensive.[46] Notwithstanding these pitfalls, a review
of cross-sectional and longitudinal studies investigating the
impact of sugar taxes on weight gain found several studies
that demonstrated an inverse association between price
increase of SSBs and point prevalence of overweight and
obesity.[13] However, the magnitude of change reported in
these studies was small.[13]
Outlook
Reduced consumption of sugar by virtue of an SSB tax
may not necessarily translate to decreased body weight,
particularly if unhealthy alternatives still exist. A tax on
SSBs will only be effective in reducing obesity when there
is no substitution with another untaxed high-calorie food or
beverage.[47] A tax on sugar-rich foods (e.g. confectionary)
in conjunction with a tax on SSBs would reduce the likelihood
of substitution and therefore increase the effectiveness of
the public health intervention. Taxes on high-fat foods will
need to be considered in the future as adjuncts to the sugar
tax. Given the complexity of taxing foods high in sugar and
fat, and limited research on their effectiveness, this requires
further study.
In addition to reducing calorie intake through a sugar
tax, other aspects of the obesogenic environment that
require monitoring and regulation include food labelling,
food portions, food advertisements, and plain packaging. A
sugar tax on its own is unlikely to be the panacea for obesity
prevention. It is widely accepted that taxes have the potential
to reduce sugar consumption, drive production reformulation,
and generate substantial revenue for governments.[16] While
it appears plausible that reduced sugar consumption and
product reformulation would be beneficial to tackle obesity,
whether this is actually the case remains to be seen. To
address the obesity epidemic, a number of other population
level policy measures, including advertising restriction,
31

eformulation targets, health star rating systems, promotion
of healthy transport choices, and sustained high-impact
education campaigns are warranted.[48]
While the effect of sugar taxes on SSB consumption
and obesity have been carried out in some low- and middleincome
groups,[38, 41, 43] there is a paucity of literature
from developing nations on the impact of decreasing SSB
consumption on obesity rates. This is pertinent given that lowand
middle-income nations are disproportionately impacted
by obesity and related non-communicable diseases.
“A sugar tax on its own is unlikely to be
the panacea for obesity prevention.”
Conclusion
Obesity and obesity-related diseases are a significant
burden on healthcare systems around the world. The global
prevalence of obesity has increased and excess consumption
of sugar, in particular SSBs, is one of the strongest drivers
of that increase. To curb the obesity epidemic, a number of
countries have adopted various forms of sugar taxes. While
theoretically and economically sound, a sugar tax on its own
might be insufficient to curb the obesity epidemic. However,
a tax on sugar is likely to be a step in the right direction as it
would raise public awareness of the adverse health effects
of excess sugar and de-normalise excess consumption.
A tax on SSBs can also encourage industry to reformulate
its products with lower sugar levels. Taxes in combination
with other policy and regulatory approaches, for example
subsidies to healthy foods, graphic warning labels, and
awareness campaigns, might be more effective to curb the
obesity epidemic than a tax on its own. A sustained, focussed,
and multi-pronged public health intervention worked in the
past against Big Tobacco. There is no reason to believe that
similar perseverance will not work against Big Sugar.
Conflicts of interest
None declared
Correspondance
saiujbhat59@hotmail.com
References
1. World Health Organisation. Obesity and overweight [Internet].
2016 [cited 2017 March 24]. Available from: http://www.who.int/
mediacentre/factsheets/fs311/en/
2. World Health Organisation. Report of the commission
of ending childhood obesity [Internet]. 2016 [cited
2017 March 24]. Available from: http://apps.who.int/iris/
bitstream/10665/204176/1/9789241510066_eng.pdf?ua=1
3. Bays H, Scinta W. Adiposopathy and epigenetics: an
introduction to obesity as a transgenerational disease. Curr Med
Res Opin. 2015 Nov;31(11):2059-69.
4. James WP. WHO recognition of the global obesity epidemic.
Int J Obes (Lond). 2008 Dec;32 Suppl 7:S120-6.
5. World Health Organisation. Global status on noncommunicable
diseases 2014 [Internet]. Geneva: WHO Press; 2014
[cited 2017 March 24]. Available from: http://www.who.int/nmh/
publications/ncd-status-report-2014/en/
6. Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT,
Moodie ML, et al. The global obesity pandemic: shaped by global
drivers and local environments. Lancet. 2011 Aug;378(9793):804-
14.
7. Albuquerque D, Stice E, Rodríguez-López R, Manco L,
Nóbrega C. Current review of genetics of human obesity: from
molecular mechanisms to an evolutionary perspective. Mol Genet
Genomics, 2015 Aug;290(4):1191-221.
8. Kickbusch I, Allen L, Franz C. The commercial determinants
of health. Lancet Glob Health. 2016 Dec;4(12):e895-e896. DOI:
10.1016/S2214-109X(16)30217-0.
9. Hu FB, Malik VS. Sugar-sweetened beverages and risk of
obesity and type 2 diabetes: epidemiologic evidence. Physiol Behav.
2010 Apr;100(1):47-54.
10. Brownell KD, Farley T, Willett WC, Popkin BM, Chaloupka
FJ, Thompson JW, et al. The public health and economic benefits
of taxing sugar-sweetened beverages. New Eng J Med. 2009
Oct;361(16):1599-1605.
11. Han E, Powell LM. Consumption patterns of sugarsweetened
beverages in the United States. J Acad Nutr Diet. 2013
Jan;113(1):43-53.
12. Welsh JA, Sharma AJ, Grellinger L, Vos MB. Consumption
of added sugars is decreasing in the United States. Am J Clin Nutr.
2011 Sep;94(3):726-734.
13. Escobar MAC, Veerman JL, Tollman SM, Bertram MY, Hofman
KJ. Evidence that a tax on sugar sweetened beverages reduces the
obesity rate: a meta-analysis. BMC Public Health. 2013 Nov;13:1072.
14. Sanchez-Romero LM, Penko J, Coxson PG, Fernandez
A, Mason A, Moran AE, et al. Projected impact of mexico’s sugarsweetened
beverage tax policy on diabetes and cardiovascular
disease: A modeling study. PLoS Med [Internet]. 2016 Nov [cited 2017
July 6];13(11):e1002158. DOI: 10.1371/journal.pmed.1002158.
15. Bes-Rastrollo M, Sayon-Orea C, Ruiz-Canela M, Martinez-
Gonzalez MA. Impact of sugars and sugar taxation on body weight
control: A comprehensive literature review. Obesity (Silver Spring).
2016 Jul;24(7):1410-26.
16. Roache SA, Gostin LO. The untapped power of soda taxes:
incentivizing consumers, generating revenue, and altering corporate
behavior. Int J Health Policy Manag. 2017 Sep;6(9):489-493.
17. Singh GM, Micha R, Khatibzadeh S, Lim S, Ezzati M,
Mozaffarian D. Estimated global, regional, and national disease
burdens related to sugar-sweetened beverage consumption in
2010. Circulation. 2015 Aug; 132(8):639-66.
18. World Health Organisation Guideline: Sugars intake for adults
and children [Internet]. 2015 [cited 2017 March 24]. Available from: http://
apps.who.int/iris/bitstream/10665/149782/1/9789241549028_
eng.pdf
19. Dietary Guidelines Advisory Committe. Advisory report
to the secretory of health and human services and the secretary
of agriculture [Internet]. 2015 [cited 2017 March 24]. Available
from: https://health.gov/dietaryguidelines/2015-scientific-report/
pdfs/scientific-report-of-the-2015-dietary-guidelines-advisorycommittee.pdf
20. Ludwig DS, Peterson KE, Gortmaker SL. Relation
between consumption of sugar-sweetened drinks and childhood
obesity: a prospective, observational analysis. Lancet. 2001
Feb;357(9255):505-508.
21. De Castro JM. The effects of the spontaneous ingestion
of particular foods or beverages on the meal pattern and overall
nutrient intake of humans. Physiol Behav. 1993 Jun; 53(6):1133-44.
22. Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened
beverages and weight gain in children and adults: a systematic
review and meta-analysis. Am J Clin Nutr. 2013 Oct; 98(4):1084-102.
23. Epstein LH, Jankowiak N, Nederkoorn C, Raynor HA, French
SA, Finkelstein E. Experimental research on the relation between
32

food price changes and food-purchasing patterns: a targeted
review. Am J Clin Nutr. 2012 Apr;95(4):789-809.
24. European Competitiveness and Sustainable Industrial Policy
Consortium. Food taxes and their impact on competitiveness
in the agri-food sector [Internet]. Rotterdam, The Netherlands;
2014. Available from: http://webcache.googleusercontent.com/
search?q=cache:zVN-mS-b6wEJ:ec.europa.eu/DocsRoom/
documents/5827/attachments/1/translations/en/renditions/
pdf+&cd=1&hl=en&ct=clnk&gl=au&client=safari
25. Malik VS, Popkin BM, Bray GA, Després J-P, Hu FB. Sugarsweetened
beverages, obesity, type 2 diabetes mellitus, and
cardiovascular disease risk. Circulation. 2010;121(11):1356-1364.
26. Nakhimovsky SS, Feigl AB, Avila C, O’Sullivan G, Macgregor-
Skinner E, Spranca M. Taxes on sugar-sweetened beverages
to reduce overweight and obesity in middle-income countries: a
systematic review. PLoS One [Internet]. 2016 Sep [cited 2017 July
6];11(9):e0163358. DOI: 10.1371/journal.pone.0163358.
27. Bonnet C, Requillart V. Does the EU sugar policy reform
increase added sugar consumption? An empirical evidence on the
soft drink market. Health Econ. 2011 Sep;20(9):1012-24.
28. World Health Organisation. Population-based approaches
to childhood obesity prevention [Internet]. 2012 [cited 2017
October 15]. Available from: http://www.who.int/dietphysicalactivity/
childhood/approaches/en/
29. World Health Organisation. Global action plan for the
prevention and control of non-communicable diseases [Internet].
2013 [cited 2017 October 15]. Available from: http://www.who.int/
nmh/events/ncd_action_plan/en/
30. Drewnowski A, Darmon N. The economics of obesity: dietary
energy density and energy cost. Am J Clin Nutr. 2005 Jul;82(1):265S-
273S.
31. Withrow D, Alter DA. The economic burden of obesity
worldwide: a systematic review of the direct costs of obesity. Obes
Rev. 2011 Feb;12(2):131-41.
32. Buchmueller TC, Johar M. Obesity and health expenditures:
evidence from Australia. Econ Hum Biol. 2015 Apr;17:42-58.
33. Anis AH, Zhang W, Bansback N, Guh DP, Amarsi Z, Birmingham
CL. Obesity and overweight in Canada: an updated cost-of-illness
study. Obes Rev. 2010 Jan;11(1):31-40.
34. Colagiuri S, Lee CM, Colagiuri R, Magliano D, Shaw JE,
Zimmet PZ, et al. The cost of overweight and obesity in Australia.
Med J Aust. 2010 Mar;192(5):260-4.
35. Lehnert T, Sonntag D, Konnopka A, Riedel-Heller S, König
HH. Economic costs of overweight and obesity. Best Pract Res Clin
Endocrinol Metab. 2013 Apr; 27(2):105-15.
36. Veerman JL, Sacks G, Antonopoulos N, Martin J. The impact
of a tax on sugar-sweetened beverages on health and health care
costs: a modelling study. PLoS One [Internet]. 2016 Apr [cited 2017
July 6];11(4):e0151460. DOI: 10.1371/journal.pone.0151460.
37. Cobiac LJ, Tam K, Veerman L, Blakely T. Taxes and subsidies
for improving diet and population health in Australia: a costeffectiveness
modelling study. PLoS Med [Internet]. 2017 Feb [cited
2017 July 6];14(2):e1002232. DOI: 10.1371/journal.pmed.1002232.
38. Finkelstein EA, Zhen C, Nonnemaker J, Todd JE. Impact of
targeted beverage taxes on higher- and lower-income households.
Arch Intern Med. 2010 Dec;170(22):2028-2034.
39. Long MW, Gortmaker SL, Ward ZJ, Resch SC, Moodie ML,
Sacks G, et al. Cost effectiveness of a sugar-sweetened beverage
excise tax in the US. Am J Prev Med. 2015 Jul;49(1):112-123.
40. Brownell KD, Frieden TR. Ounces of prevention - the public
policy case for taxes on sugared beverages. New Eng J Med. 2009
Apr;360(18):1805-1808.
41. Schwendicke F, Stolpe M. Taxing sugar-sweetened
beverages: impact on overweight and obesity in Germany. BMC
Public Health. 2017 Jan;17(1):88.
42. Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria
P, et al. Priority actions for the non-communicable disease crisis.
Lancet. 2011 Apr; 377(9775):1438-47.
43. Sharma A, Hauck K, Hollingsworth B, Siciliani L. The effects
of taxing sugar-sweetened beverages across different income
groups. Health Econ. 2014 Sep;23(9):1159-1184.
44. Falbe J, Thompson HR, Becker CM, Rojas N, McCulloch CE,
Madsen KA. Impact of the Berkeley excise tax on sugar-sweetened
beverage consumption. Am J Public Health. 2016 Oct;106(10):1865-
71.
45. Colchero MA, Guerrerro-López CM, Molina M, Rivera JA.
Beverages sales in Mexico before and after implementation
of a sugar sweetened beverage tax. PLoS One [Internet]. 2016
Sep [cited 2017 July 6];11(9): e0163463. DOI: 10.1371/journal.
pone.0163463.46.
46. Bollard T, Maubach N, Walker N, Ni Mhurchu C. Effects of plain
packaging, warning labels, and taxes on young people’s predicted
sugar-sweetened beverage preferences: an experimental study. Int
J Behav Nutr Phys Act. 2016 Sep;13(1):95.
47. Bíró A. Did the junk food tax make the Hungarians eat
healthier? Food Policy. 2015 July;54:107-115.
48. Obesity Policy Coalition and Global Obesity Centre. Tipping
the Scales: Australian Obesity Prevention Consensus [Internet].
2017 [cited 2017 October 15]. Available from: http://www.opc.org.
au/tipping-the-scales.aspx
33

Drug Control in Australia: Where to next?
[Review]
Raquel Maggacis
Raquel Maggacis is a final year medical student at the University of Queensland. She has
a keen passion for public health endeavours and hopes to one day intertwine this with a
career as a medical physician.
Abstract
Substance use and associated disorders are increasingly recognised as a global health issue. As attitudes towards drug
use disorders evolve, varying drug control policies worldwide are called into question. Nations such as the United States
of America utilise the criminal justice system to place sanctions on those contravening drug control policy, which often
results in cycles of incarceration, further drug use, and poverty. In contrast, Portugal has revolutionised its approach to drug
control since the turn of the century by decriminalising all drugs to great effect. In view of this wide spectrum of attitudes
“towards drug control, the future of Australia’s approach to drug control policy is examined.
”
Introduction
without aiming to reduce consumption.[1] Substance use
disorders are perpetuated by social stigma and thus the
political context is a key determinant of long-term health
outcomes.[3]
Benefits and detriments of different policy approaches
The International Classification of Diseases defines
substance use disorders as “continuing drug consumption
despite severe adverse consequences”.[1] A report by
the office of National Drug Control Policy in 2010 outlined
the detriments of substance use disorders using a
biopsychosocial paradigm (Figure 1).[1, 2]
Substance use disorders are managed through three main
drug policy approaches: decriminalisation, criminalisation,
and harm minimisation. Decriminalisation involves prohibiting
and regulating drugs but excluding sanctions from criminal
law jurisdiction, whereas criminalisation is the attribution
of criminal offences to drug-related activities.[3, 4] Harm
minimisation strives to decrease adverse consequences
Criminalisation of drugs, and the subsequent incarceration
of drug users, provides the immediate benefit of removing the
individual from an environment that exacerbates their drug
use, and prevents the community from being threatened
by drug-affected behaviour. Additionally, incarceration
allows the government to demonstrate the work being
done to tackle drugs in a manner that is tangible and easily
understood by the general public. However, punitive drug law
enforcement alone may fail to address or even worsen health
Figure 1: The biopsychosocial adverse outcomes related to substance use disorders [1, 2]
34

complications of drug use. It can marginalise populations at
risk of poorer health and increase barriers to seeking health
services, as illustrated by the growing epidemic of HIV/AIDS
and hepatitis C amongst injecting drug users.[5] Moreover,
drug law enforcement has minimal impact on the drug market
itself, although there is some evidence that it may alleviate a
degree of associated harm.[1, 6]
Advantages of the harm minimisation approach include
curbing the progression of the HIV/AIDs epidemic through
safe needle programs and deterring criminal behaviours.[1,
7] This is achieved through demand and supply reduction,
prevention campaigns, and improved access to treatment
and harm reduction.[8] Critiques of this approach include
maintaining demand for the illicit drug market, and ineffectively
addressing all biopsychosocial facets of substance use
disorders.[8]
“Decriminalisation addresses substance
use disorders in a biopsychosocial context
and identifies it as a key public health issue”
The main benefit of decriminalisation is that it reframes
drug use as a public health problem, which allows for
reallocation of funds from drug-related criminal justice
proceedings and the prison system to rehabilitation services
focusing on long-term health outcomes.[3] This, coupled with
a shift in criminal justice focus to high-level drug offenders,
ultimately results in less drug use and better long-term
health outcomes.[3] Decriminalisation addresses substance
use disorders in a biopsychosocial context and identifies
it as a key public health issue, both key steps in arresting
the perpetuation of stigma which only serves to isolate drug
users from health services.[3] Criticisms of decriminalisation
include potential for increased accessibility to drugs and a
cheaper street value, which could result in increased uptake
of drug use.[9]
In 2009, Antonio Costa, the executive director of the
United Nations Office on Drugs and Crime, affirmed that
“drug use should be treated as an illness in need of medical
help”, and appealed for universal access to drug treatment.[2]
In 2011, the Global Commission on Drug Policy emphasised
that it was time to “end the criminalization, marginalization
and stigmatization of people who use drugs but who do
no harm to others”.[1] The World Health Organization and
the United Nations echoed this view in their joint statement
published in June 2017, stating that to ignore such a call to
“[review] and [repeal] punitive laws...[including] drug use or
possession of drugs for personal use” would be to “[violate]
the most fundamental human rights protected in international
treaties and in national laws and constitutions”.[10] This
strong stance against discrimination in health care settings
reflects the global shift in attitudes towards drug policy, from
incarceration to rehabilitation of drug offenders.
Drug control approaches worldwide
Criminalisation: the United States
The United States (US) has a strong stance of
criminalisation towards illicit drugs and has a low threshold
to prosecute drug offenders.[3] Its prison population
has increased by almost 800% since 1980, in marked
disproportion to its population growth, with 47% of all
inmates imprisoned for drug-related crimes, and many with
drug use disorders.[3] In 2010 alone, US $80 billion was
spent on continuing incarceration of inmates.[3] Drug users,
possessors and traffickers are treated equally in this criminal
system, with mandatory minimum prison sentences.[3]
Without adequate rehabilitation services or emphasis on
drug use and use disorders as a public health issue, the high
rates of recidivism are unsurprising, often resulting in a cycle
of criminality, incarceration and poverty, with subsequent
economic burden on the community.[3] This is an issue fuelled
by media sensationalism, portraying drug law enforcement in
an enamouring light with dramatic drug busts and arrests,
acting only to perpetuate fear within the general population.
Where drug courts - legal committees which redirect nonviolent
drug offenders from incarceration to treatment - have
been trialled in the US, they have proven to decrease crime
rates (7-14%) and recidivism (up to 35%), and improving
rehabilitation uptake, treatment outcomes and stability of the
family unit.[2] Such models are estimated to reduce health
care costs related to substance use disorders by US $4 for
every US $1 spent.[2]
“This is an issue fuelled by media
sensationalism, portraying drug law
enforcement in an enamouring light with
dramatic drug busts and arrests, acting
only to perpetuate fear within the general
population.”
While marijuana is considered illicit under US federal law,
states are able to make independent laws, which are only
disregarded in cases concerning juveniles, cross-border
trafficking, or organised crime.[9, 11] Presently, over half of
American states have legalised medicinal marijuana, and
eight have further allowed recreational use.[9] Given the
relatively recent legalisation of marijuana, data on its impact
on usage patterns is currently conflicting, and more time is
required for reliable assessment.[9] Studies have indicated
that diversion of black market marijuana from legalised to
criminalised states is likely to decrease marijuana prices,
although the degree and impact of this is uncertain.[12, 13]
Notably, there are significant economic benefits associated
with the legalisation of marijuana.[9] In Colorado, where
recreational marijuana use is legal, marijuana tax and
licensing fees have been implemented, together generating
over US $70 million in the first year alone.[9] This revenue was
subsequently funnelled into school construction and youth
35

and substance use programs).[9]
Criminalisation: Central Asia
Central Asian countries, such as Tajikistan, Kazakhstan,
and Uzbekistan, have adopted an increasingly stringent
approach to drugs.[14] In the year following the September
11 attacks, these countries received US $187.5 million
from the US government to improve border control, counterterrorism
measures and counter-narcotics initiatives.[14]
Between 2004 and 2007, a strong criminal justice-based
approach was further reinforced in Central Asia with funding
from international agencies, other foreign governments and
national budgets directed to legal action against drug use.
[14]
Further, national campaigns in Central Asia often label
drug users as evil, increasing the stigma and discrimination
which perpetuates cycles of drug use.[15] Little or no
rehabilitation or treatment is available for substance users,
with such countries preferring a model of criminalisation and
incarceration.[14] For example, opioid substitution treatment
is prohibited in Tajikistan and Turkmenistan, minimally
available in Uzbekistan and Kyrgyzstan, and non-existent in
Kazakhstan.[14] The lack of treatment for drug users and
increasing accessibility of opiates has resulted in a growing
HIV epidemic in Central Asian prison systems with poor longterm
health outcomes.[14]
Decriminalisation: Portugal
Prior to 2001, drug use was criminalised in Portugal,
yet rates of heroin use and drug trafficking continued to
increase.[3] Consequently, the Portuguese government
drafted a law decriminalising all drugs purchased, possessed
or consumed for personal use. This law also had a public
health focus towards rehabilitating those with substance
use disorders, and a punitive focus towards high-level drug
trafficking. This involves a committee of two medicallytrained
persons and one legally-trained person, deciding first
whether an offence is protected by this law, and then whether
the offender is suffering from a drug use disorder.[3] This law
only aimed to decriminalise low-level drug offences; strict
laws remain against high-level offenders and drug traffickers
who propagate this vicious cycle and endanger the general
community.[16]
After this law was passed,
Portugal reduced its burden on the
criminal-justice system, allowing
more funding allocation towards
public health endeavours, including
prevention campaigns, treatment,
and facilities.[17] Treatment
uptake consequently increased,
resulting in decreasing rates of drug-associated illnesses.[4,
18] During the four years following decriminalisation in 2000
to 2006, there was a significant decrease in the incidence
of new cases of HIV/AIDS amongst drug users in Portugal,
from almost 1400 to 400 persons.[18] Decreased rates of
new hepatitis B and C infections have also been evident,
attributed to the improved treatment and rehabilitation
programs afforded by decriminalisation.[17, 18] Moreover,
“...a staggering 400 Australians die yearly
from heroin overdose, and most areas have
a demand for substitution products far outweighing
the supply”
absolute numbers of drug-related deaths by each prohibited
substance decreased; the total number of drug-related
deaths decreased from 400 in 1999 to 290 in 2006.[18]
Importantly, while some speculated that decriminalisation
would lead to lower prices of drugs and subsequent
higher rates of usage, the cost of drugs did not decrease.
[19] In fact, the rates of cannabis and cocaine use after
decriminalisation have been three times lower than before.
[18] Further, data extrapolations have predicted lower lifetime
prevalence rates of drug use for almost all drug categories
post-decriminalisation.[18]
Decriminalisation: West Africa
West African countries must contend with both
international drug cartels and the growing transit of illicit
substances to Europe and North America. Consequently, local
consumption of illicit substances has increased, especially
among younger persons, with significant economic, health
and social consequences.[20] While data is scarce, in 2008 it
was estimated there were 1.8 million intravenous drug users
in Sub-Saharan Africa, of whom 12% were thought to be living
with HIV.[20, 21]
In 2014, the West Africa Commission on Drugs published
a declaration specifically stating that “criminalisation of drug
use worsens health and social problems, puts huge pressures
on the criminal justice system and incites corruption”, and
that “drug use must be regarded primarily as a public health
problem”, mirroring the movements of Portugal.[20] Despite
these recommendations, there is currently no evidence
that any West African countries have been successful in
implementing drug decriminalisation policies.
Drug policy in Australia and the way forward
In 1985, the Australian Government adopted an official
national drug policy of harm minimisation.[1] In the 2002-
03 financial year, the Australian Government allocated $3.2
billion to managing illicit drugs, 75% of which was spent on
drug law enforcement, aiming to decrease drug and drugrelated
crime, and improve public health and safety.[1,
16] Despite this investment, a staggering 400 Australians
die yearly from heroin overdose, and most areas have
a demand for substitution products far out-weighing the
supply, notwithstanding the costly
co-payment.[1] The methadone
substitution program and syringe
exchange services available in
Australia have made an impact, yet
with a growing affected population
and the root cause unaddressed,
the need is largely unmet.[1]
Harm minimisation still perpetuates discrimination and
marginalisation of drug users, instead, decriminalisation can
reduce stigma and is essential to better health outcomes.[3]
The Australia21 report, published in 2012, was effective
in initiating a debate on drug reform. The report not only
illustrated the harmful effects of criminalising possession
and personal use on drug-dependent individuals in an
36

Australian context, but also highlighted the potential health
benefits of some currently illicit drugs.[1, 8] This report left
Australians to decide which legal system would allow for
better biopsychosocial health and economic stability for
the community with respect to those consuming drugs –
rehabilitation or incarceration.
Australia should act to follow countries like Portugal
that have prospered from revolutionising drug policy with
respect to low-level offences and reform to decriminalise
all drugs. As supported by the Global Commission on Drug
Policy, a move towards decriminalisation of low-level drug
offenses in Australia would allow for decreased economic
burden on the criminal justice system, reallocation of funds
to drug rehabilitation programs, and a sharpened focus on
the illegality of high-level drug trafficking offenses.[3] Viewing
drug use as a public health problem is the key first step to
reducing stigma and consequently improving access to
treatment and long-term health outcomes.
Conclusion
Criminalisation marginalises those afflicted with drug use
disorders, who are already burdened with significant health,
social and economic disadvantage. Where there is demand,
there is supply, and tackling drug use disorders with criminal
law is simply too late to create a meaningful impact on the
individual or society at large. Poverty breeds poverty; while
incarceration may remove the immediate threat from society,
it does nothing to address the root cause.
Substance use disorders are a medical condition and
public health problem, not a moral choice. Epitomised
by Portugal, decriminalisation of drugs and rehabilitation
fortifies a community, not just immediately, but with long-term
positive effects in the workforce and crime rates, spanning
generations. Substance use disorders, therefore, need to be
reframed from a criminal, punitive problem, to one befitting
the biopsychosocial model of health. Fortunately, throughout
the world this is increasingly becoming the case.
Acknowledgements
Sophie Lim, Vector Associate Editor
IDEAS Working Paper Series from RePEc. 2017.
5. Elliott R, Csete J, Palepu A, Kerr T. Reason and rights in global
drug control policy. CMAJ. 2005;172(5):655-6.
6. Mazerolle L, Soole DW, Rombouts S. Street-level drug law
enforcement: A meta-analytical review. Journal of Experimental
Criminology. 2006;2(4):409-35.
7. Webster IW. Managing legal and medical complexities in
caring for people with drug and alcohol problems: a call for change.
Med J Aust. 2016;204(4):141-2.
8. The prohibition of illicit drugs is killing and criminalising
our children and we are all letting it happen. [press release].
Canberra2012.
9. Homel PB, Rick. Marijuana legalisation in the United States:
An Australian perspective. Canberra: Australian Institute of
Criminology; 2017 June 2017.
10. Joint United Nations statement on ending discrimination in
health care settings [press release]. World Health Organisation2017.
11. Adler J. Symposium Marijuana, Federal Power, and the States:
Introduction. Case Western Reserve Law Review. 2015;65(3):505-
12.
12. Caulkins JP, Bond BM. Marijuana Price Gradients. Journal of
Drug Issues. 2012;42(1):28-45.
13. Hall W, Weier M. Assessing the public health impacts of
legalizing recreational cannabis use in the USA. Clin Pharmacol
Ther. 2015;97(6):607-15.
14. Latypov A. Understanding post 9/11 drug control policy and
politics in Central Asia. Int J Drug Policy. 2009;20(5):387-91.
15. Wolfe D. Paradoxes in antiretroviral treatment for injecting
drug users: access, adherence and structural barriers in Asia and
the former Soviet Union. Int J Drug Policy. 2007;18(4):246-54.
16. Willis K. Measuring the effectiveness of drug law enforcement.
Trends and Issues in Crime and Criminal Justice. 2011;406(1):1-7.
17. Hughes CE, Stevens A. What Can We Learn From The
Portuguese Decriminalization of Illicit Drugs? British Journal of
Criminology. 2010;50(6):999-1022.
18. Greenwald G. Drug Decriminalization in Portugal: Lessons for
Creating Fair and Successful Drug Policies. Washington, DC: Cato
Institute; 2009.
19. Felix S, Portugal P. Drug decriminalization and the price of
illicit drugs. Int J Drug Policy. 2017;39:121-9.
20. Drugs WACo. Not Just in Transit: Drugs, the State and Society
in West Africa. West Africa Commission on Drugs; 2014.
21. Mathers BMD, Louisa; Phillips, Benjamin; Wiessing, Lucas;
Hickman, Matthew; Strathdee, Steffanie A; Wodak, Alex; Panda,
Samiran; Tyndall, Mark; Toufik, Abdalla; Mattick, Richard P. Global
epidemiology of injecting drug use and HIV among people who inject
drugs: a systematic review. The Lancet. 2008;372(9651):1733-45.
Conflict of Interest
None declared
Correspondance
raquel.maggacis@uqconnect.edu.au
References
1. Wodak AD. The need and direction for drug law reform in
Australia. The Medical Journal of Australia. 2012;197(6):312-3.
2. Madras BK. Office of National Drug Control Policy: a scientist
in drug policy in Washington, DC. Ann N Y Acad Sci. 2010;1187:370-
402.
3. Sapp CE. Rehabilitate or incarcerate? A comparative analysis
of the United States’ sentencing laws on low-level drug offenders
and Portugal’s decriminalization of low-level drug offenses. Cardozo
Journal of International & Comparative Law. 2014;23(1):63-97.
4. Félix S, Portugal P, Tavares A. Going after the Addiction, Not
the Addicted: The Impact of Drug Decriminalization in Portugal.
37

Dengue in the Pacific Islands
[Review]
Madeleine Marsland and Dunya Tomic
Madeleine is a fourth year medical student who is interested in global health and research.
She combines these interests in her role as Chief of Editorials and Publications
for the Pacific Medical Students’ Association, and is also undertaking research with the
Department of Anatomy and Developmental Biology at Monash University. She hopes
to pursue global health research and policy.
Dunya is a fourth year medical student at Monash University with a particular interest
in clinical research and medical ethics. She hopes to one day combine this with a
career as a physician.
Abstract
Without a fully effective vaccine, prophylactic measures, or sufficient treatment options, dengue has emerged as a significant
global health threat. The Pacific Islands are particularly susceptible to dengue as they provide favourable conditions for
the Aedes mosquito population, the vector responsible for spreading the virus. Strong public health protocols with an
emphasis on vector control are considered to be the best way to combat dengue in this region. However, for a variety of
social, economic, environmental and political factors, vector surveillance and control mechanisms are failing. This review
seeks to provide an overview on the emergence of dengue in the Pacific Islands, why this region is susceptible due to virus
“and vector factors, and what has been done and can be done in the future to contain the dengue threat in this region.
Introduction
Dengue virus is a vector-borne disease primarily
spread by the Aedes mosquito population; it is one of the
most significant infectious diseases that remains without
definitive prevention or treatment options. Due to a variety
of environmental and social factors, the Pacific Islands are
particularly susceptible to dengue and other arbovirus.[1,
2] This has significant associated morbidity, mortality and
economic cost, particularly when patients contract ‘severe
dengue’.[1-3] A diagnosis of dengue can be based on clinical
signs and/or laboratory diagnosis, whilst a diagnosis of ‘severe
dengue’ is based on serious complications including plasma
leakage, severe haemorrhage or severe organ impairment.[3]
These clinical manifestations and complications of dengue
can cause severe illness, particularly in susceptible patient
groups including children.[3]
Treatment options are limited particularly in resource
poor settings, and thus preventing dengue and recognising
outbreaks is critical.[3] Dengvaxia, a world-first dengue
vaccine, has recently been approved for use in endemic
settings, with the World Health Organization recommending
high-risk nations implement it as part of their vaccination
program.[4-6] However, the vaccine has variable levels of
efficacy, and is not yet considered a cost-effective solution.
[5, 6] Whilst dengue remains a growing threat, the Pacific
Island region must urgently develop alternative cost-effective
diagnostic, detection, treatment and prevention strategies.[4,
7, 8]
Methods
The intended focus of this literature review was dengue
in the Pacific Island region. An Ovid MEDLINE search was
conducted combining the search terms “Dengue”, “Aedes”
and “Pacific”. Grey literature and data was also sourced from
the World Health Organization (WHO) and other non-profit
organisations. Additional resources were identified through
analysing the articles retrieved through these searches.
Epidemiology
”
Prevalence
Dengue has been reported in several Pacific Island
nations since the 1950s, but in the past decade the incidence
has grown exponentially.[1, 9] Whilst in 2000 there was only
50 reported cases per 1000 people, by 2012 this had grown
to 350 per 1000.[1] It is difficult to determine reliable data
on the endemic levels of dengue in the Pacific Islands, as
this depends on accurate and timely reporting to the Pacific
Public Health Surveillance Network, still under development.
[2] However, whilst dengue is not endemic in all Pacific Islands,
it is emerging in previously untouched islands including the
Solomon Islands and Papua New Guinea.[9] From 2016 to
2017 alone, there has been an unusual increase in dengue
38

Table 1: Dengue Serotypes and Epidemiology
DENV Serotype Notable related epidemiology and outbreaks
DENV-1
The most prominent serotype in 2012-2013, causing the largest-ever documented
outbreak affecting New Caledonia.[21]
DENV-2 Caused recent outbreaks in Tuvalu and a current outbreak in Samoa.[10, 22]
DENV-3
After 18 years of absence, has recently become the dominant serotype in the
Pacific islands causing five ongoing outbreaks [23].
DENV-4 Caused one outbreak since 2012, is rare in the Pacific Islands [10].
illness reported in the Solomon Islands, Vanuatu, Fiji and
Palau.[10] With this growth, some reports indicate that the
vast majority of the Pacific Island population will be infected
at some point in their lives.[1] In Samoa, one study showed
96% of the population tested positive for IgG antibodies,
indicating prior infection.[11] With 89% of 18-25 year olds
testing positive, this demonstrated that most Samoans first
contracted dengue during childhood, when dengue illness is
more likely to be fatal.[7, 11]
Outbreaks
Dengue typically follows an epidemic pattern with 1 of
the 4 serotypes causing outbreaks across the Pacific every
three to five years. However, the number of outbreaks of
concurrent serotypes has been growing.[2] After an outbreak
of a single serotype, this strain of the virus tends to circulate
throughout the region until the next outbreak of a different
strain occurs.[12] A single outbreak can affect a large portion
of the population, with the 2009 outbreaks affecting 14
Pacific nations.[13] During such outbreaks, complications
increase, placing a burden on hospital resources, with 4%
of the Federated States of Micronesia’s population requiring
hospitalisation during the Kosrae state outbreak.[14] The
frequency of outbreaks appears to be increasing,[4] though
this may be due to improved surveillance.
The virus
Dengue virus (DENV) is a single-stranded, positivesense
RNA virus of the Flavivirus genus.[15] There are
four serotypes DENV-1 to DENV-4. Though they only share
65% of their genomes, their clinical syndromes are nearly
identical, and they all occupy the same ecological niche.
[16, 17] Dengue epidemics usually result from introduction of
a single serotype from hyper-endemic countries, which will
remain dominant in the region for several years.[12,18,19]
However, in 2012, outbreaks of all four DENV serotypes were
noted in a single year [20]. Each DENV serotype has caused
outbreaks or been prevalent in the Pacific Islands at various
times (Table 1).
Repeated infection of DENV of the same serotype is
associated with increase risk of progressing to severe
dengue, which is associated with higher morbidity and
mortality if left untreated.[24] Those living in endemic areas
such as the Pacific Islands are at an increased risk of being
reinfected and thus complications are more common.
The Vector
Dengue, zika, chikungunya and other arboviruses are
transmitted to humans through the bites of infected Aedes
mosquitoes.[25] Aedes aegypti is the primary vector in the
Pacific Islands and is widespread across the region except
for Futuna and other isolated islands.[26,27] Aedes aegypti is
associated with human migration and urbanisation, enabling
it to be dominant in the region, however, Aedes albopictus,
Aedes polynesiensis and nine other potential vectors have
also been identified in the Pacific Islands.[27, 28]
Aedes mosquitoes begin their transmission cycle upon
acquiring the dengue virus from the blood of a viraemic
person; the virus then replicates in mosquito midgut
epithelium before shedding its progeny into the haemocoel,
which then disseminates into secondary target tissues such
as salivary glands.[29] During the next feeding event, the
mosquito transmits the virus to the host through saliva.[29,30]
Aedes aegypti is capable of repeatedly transmitting the virus
through this process irrespective of its number of hosts.[30]
The introduction of Aedes aegypti into different islands has
been spurred by human migration; there have been intense
population migrations in the Pacific Islands since European
colonization.[31] Though the first dengue epidemic in the
Pacific Islands was reported in the 1880s, descriptions of
Aedes aegypti didn’t emerge until the 1960s in Fiji and Tonga.
[20, 32, 33] Aedes aegypti then spread during World War II,
when travel between the Pacific Islands and Asia, Europe,
and America became more frequent.[34] Recent studies
have now identified genetic variability in nine locations
across Fiji, New Caledonia, Tonga and French Polynesia,
suggesting a link between human migration and Aedes
aegypti populations, possibly related to island isolation and
environmental conditions.[25]
Several factors influence the transmission of DENV
from mosquitoes to humans, including climate.[30] Higher
temperatures enable the virus to replicate in higher
concentrations, enhancing the vectors’ risk for pathogen
transmission and contributing to the high prevalence of
dengue infection in the tropical Pacific Islands[30] Globally,
climate-induced variations in modelled Aedes aegypti
populations were strongly correlated to historical dengue
cases between 1958 to 1995.[35] Recent research from New
Caledonia, where dengue spread by Aedes aegypti is a major
39

public health problem, showed that the epidemic dynamics of
dengue were predominantly driven by climate in the last forty
years.[36] Another study found a positive correlation between
dengue infection and El Nino southern oscillation in ten
countries, with evidence of infection spreading from larger
islands to smaller surrounding islands.[37] It is predicted that
global warming will increase the latitudinal and altitudinal
distribution of Aedes aegypti and subsequently DENV.[38,39]
Dengue Surveillance Methods
Dengue surveillance and tracking is essential to enable
timely epidemic responses.[8] Though representatives from
the Pacific Islands believe there is adequate surveillance
infrastructure and systems, governments have not
emphasised prevention. These systems must be strengthened
to more accurately track dengue epidemiological data [8, 40].
Given financial difficulties, this may be better accomplished
through alternative mechanisms.
One such alternative is the transport of serum and blood
samples internationally.[41] When a new serotype emerges
in one Pacific country, this is often followed by outbreaks in
neighbouring countries [42]; using blood samples to identify
emerging serotypes enables surveillance of viral spread
across the region. Filter paper (FP)-dried blood spots have
minimal health risk and so are not bound by dangerous
goods regulations present in several Pacific nations [43].
Blood spiked with cultured DENV can be blotted on FP-cards
and the serotype determined using reverse-transcriptase
polymerase chain reaction.[44]. The serotype and genotype
of DENV can be identified using FP-dried serum even after
being transported over thousands of kilometres at tropical
temperatures.[41] This method of surveillance particularly
useful in the Pacific Islands, where samples may need to be
transported over long distances.
Another method to monitor dengue levels is the use of
international travellers as ‘sentinels’, so that the risk of dengue
infection can be estimated through proxies who travelled to
particular areas.[45] Patterns of local dengue incidence in
the Pacific Islands were shown to be closely correlated with
patterns of dengue incidence imported from the Pacific to
New Zealand.[46] However, this method is more commonly
retrospective and cannot provide an indication of outbreaks.
A combination of both methods could be implemented to
cheaply and effectively improve dengue surveillance in the
regions.
Dengue Prevention and Control, Now and in the Future
Strategies and Policies
Many nations have been attempting to meet the
WHO infectious disease strategy objectives (Figure 1) by
implementing policies that address vector surveillance,
health education for vector control and dengue prevention,
and emergency response capacity.[8] However, an urgent
policy review to combat dengue is needed, with a focus on
emphasising dengue in climate change and environmental
medicine policies.[48] It is also essential that dengue is
classed as a notifiable disease across all Pacific Islands
through legislation.[48]
A Dengue Vaccine
Although several live-attenuated dengue vaccines are
undergoing phase III clinical trials, currently Dengvaxia (CYD-
TDV) is the only vaccine that is licensed and registered for use
in individuals aged 9-45 years and living in dengue endemic
areas.[40] Modelling has shown that Dengvaxia would only
have the highest net benefit and be most cost-effective if the
majority of the population is vaccinated in dengue-endemic
nations.[52] The WHO has recommended that nations with
a high burden of disease, defined as seroprevalence >70%
in 9 year-olds, introduce the vaccine.[4, 1] However, many
nations worldwide are still debating this, and Dengvaxia is not
currently licensed for use in Pacific Island nations.[5, 51]
From the two major phase III clinical trials for Dengvaxia,
overall vaccine efficacy against severe dengue was 79%,
however, this varied by serotype, age at vaccination, and
previous dengue infection.[52] For those with a previous
dengue infection, vaccination efficacy was 78%, however, it
was only 38% for those with no prior infection.[52] In fact, a
study has shown that Dengvaxia can also increase the risk of
hospitalisation when seronegative individuals are vaccinated
and later experience natural secondary dengue infection.
[51] The pooled efficacy for those older than 9 years old was
higher than those under 9 years of age, who have a higher
risk of severe dengue (66% vs 44%).[3, 52] Finally, in terms
of serotype, vaccine efficacy was shown to be higher against
Figure 1: Outline of the World Health Organization Infectious Disease Strategy [47]
40

serotypes 3 (72%) and 4 (77%) than for serotypes 1 (55%)
and 2 (43%).[52]
Further study is ongoing to determine whether dengue
illness and hospitalisation has reduced in nations that have
implemented Dengvaxia.[53, 54] However, with varying
efficacy, and questions regarding long-term safety and
cost-effectiveness, it is predicted that vaccination will only
be possible in the Pacific Islands if it is priced competitively.
[53, 54] Thus, for the time being, vector control will remain the
focus of dengue control strategy in the Pacific Islands, with
the aim of integrating vaccination once it is more efficacious
and cost-effective.[55] At present, it is far more affordable
and effective to combat dengue by improving vector control
mechanisms, and vaccination will be most useful as an
adjunct if appropriate for specific nations.
Vector Control: Currently Used Methods
Vector control currently offers the best option for
preventing dengue, but delivery of prevention programmes
in the Pacific Islands is often inefficient, ineffective or both.
[7] Several mechanisms exist in various Pacific Islands to
control outbreaks once they occur, however some of the
most common efforts, such as pesticide spraying, have
limited effectiveness.[56]
Factors that increase the risk of dengue transmission have
included poor household drainage and hygiene problems,
issues that can be addressed by health education programs
to build a ‘prevention attitude’ among Pacific residents.[57,
58] However, it is believed that improving health education,
awareness campaigns and technical support is necessary
to ensure successful vector control.[8] Environmental factors
such as buckets of stagnant water, allowing mosquitoes to
breed, and host larvae and pupae, are other key risk factor
which could be targeted through education campaigns.
[59] Chemical treatment of breeding sites, insecticide
spraying and biological control by introducing predators are
mechanisms already utilised by some Pacific Islands which
could be further implemented for vector control in the future.
[60]
Vector Control: Innovative Approaches
Novel vector-based approaches aimed at controlling
dengue include the use of obligate intracellular bacterium
Wolbachia pipientis,[61] which interferes with reproduction in
over 40% of insect species.[62] Although Wolbachia does not
occur naturally in Aedes aegypti species, transinfection has
been shown to be successful.[63] Recent studies in Cairns,
Australia have shown stable transinfection of natural A.
aegypti populations with the wMel strain of Wolbachia, rising
to near-fixation within a matter of months and remaining
established in those field sites unaided.[64] The antiviral
activity of wMel has shown to be highly effective in laboratory
studies even one year after field release.[65] The evidence
supports the long-term stability of Wolbachia against the
dengue virus, however, the effects on reduction of human
disease in dengue-endemic regions is yet to be established,
this is currently under investigation in Indonesia and Vietnam.
[61]
Another promising vector control method is the sterile
insect technique (SIT), which has historically been successful
against a multitude of agricultural pests.[66] In the 1960s,
large-scale SIT programs enabled the elimination of A.
aegypti from 23 American countries.[67] SIT has recently
re-emerged as a vector control strategy due to innovative
technological advances including genetic modification
of mosquitoes.[68] Using SIT, Cuba has come close to the
eradication of A. aegypti [69] and Singapore has kept levels
of the mosquitoes down for more than 30 years.[70] Though
neither of these methods is currently used widely in Pacific
Islands, these innovative strategies are potential costeffective
vector reduction methods.
Emergency Response Capacity
There is a significant need to grow emergency-response
and outbreak-response to combat dengue.[8] Currently, the
WHO and Red Cross manage the majority of outbreak control,
both logistically and financially[14, 71] The Pacific Public
Health Surveillance Network has provided some support in
capacity building, and multiagency response teams have
successfully been implemented during some outbreaks,
but there remains a need to engage Pacific Directors and
Ministers of Health to help prepare these multidisciplinary
response teams for future outbreaks.[2, 14]
Conclusion
Dengue remains a significant threat in the Pacific Islands,
with prevalence levels and the number of outbreaks continuing
to increase. Until Dengvaxia or another dengue vaccine has
a proven cost-effective public health benefit beyond the
currently calculated values, it is unlikely to be deployed in
Pacific Islands.[5, 51] The best hope for containing dengue
is by improving region-wide surveillance and cost-effective,
sustainable vector control mechanisms [6-8]. This requires
Pacific Island governments to integrate dengue prevention
into their environmental and public health policy, and work to
improve vector surveillance and control methods, which may
involve implementing innovative approaches [8, 48]. Another
area that requires significant improvement is outbreak
response, and upskilling all Pacific doctors to appropriately
respond to dengue outbreaks [8, 60]. Ultimately, until the
objectives outlined by the WHO are addressed, dengue
will remain a growing challenge in the Pacific Islands.
[7, 47] These islands must engage with the growing body
of organisations working in the region to develop new and
innovative surveillance and control approaches and combat
dengue in the future.[7]
Conflicts of interest
None declared
Correspondance
dtom4@student.monash.edu
References
1. Arima Y, Chiew M, Matsui T. Epidemiological update on the
dengue situation in the Western Pacific Region, 2012. Western
Pacific Surveillance and Response Journal. 2015;6(2):82-89.
2. Roth A, Mercier A, Lepers C, Hoy D, Duituturaga S, Benyon E
41

et al. Concurrent outbreaks of dengue, chikungunya and Zika virus
infections – an unprecedented epidemic wave of mosquito-borne
viruses in the Pacific 2012–2014. Eurosurveillance. 2014;19(41):1
- 8.
3. Dengue Guidelines for Diagnosis, Treatment, Prevention and
Control [Internet]. World Health Organization (WHO) and the Special
Programme for Research and Training in Tropical Diseases (TDR);
2009 [cited 27 July 2017]. Available from: http://www.who.int/tdr/
publications/documents/dengue-diagnosis.pdf
4. Dengue and Severe Dengue [Internet]. World Health
Organization. 2017 [cited 11 August 2017]. Available from: http://
www.who.int/mediacentre/factsheets/fs117/en/
5. Wilder-Smith A, Vannice KS, Hombach J, Farrar J, Nolan
T. Population Perspectives and World Health Organization
Recommendations for CYD-TDV Dengue Vaccine. J Infect Dis.
2016;214(12):1796-1799.
6. Olivera-Botello G, Coudeville L, Fanouillere K, Guy B,
Chambonneau L, Noriega F et al. Tetravalent Dengue Vaccine
Reduces Symptomatic and Asymptomatic Dengue Virus Infections
in Healthy Children and Adolescents Aged 2-16 Years in Asia and
Latin America. J Infect Dis. 2016;214(7):994-1000.
7. Guzman M, Halstead S, Artsob H, Buchy P, Farrar J, Gubler D et
al. Dengue: a continuing global threat. Nature Reviews Microbiology.
2010;8(12):S7-S16.
8. Tambo E, Chen J, Zhou X, Khater E. Outwitting dengue threat
and epidemics resurgence in Asia-Pacific countries: strengthening
integrated dengue surveillance, monitoring and response systems.
Infectious Diseases of Poverty. 2016;5(1).
9. Kline K, McCarthy J, Pearson M, Loukas A, Hotez P. Neglected
Tropical Diseases of Oceania: Review of Their Prevalence,
Distribution, and Opportunities for Control. PLoS Neglected Tropical
Diseases. 2013;7(1):1 - 6.
10. Pacific: Dengue Outbreak – Oct 2016 [Internet]. Disasters.
ReliefWeb. 2017 [cited 11 August 2017]. Available from: http://
reliefweb.int/disaster/ep-2016-000112-slb
11. Duncombe J, Lau C, Weinstein P, Aaskov J, Rourke M, Grant
R et al. Seroprevalence of Dengue in American Samoa, 2010.
Emerging Infectious Diseases. 2013;19(2):324-326.
12. Dupont-Rouzeyrol M, Aubry M, O’Connor O, Roche C, Gourinat
A, Guigon A et al. Epidemiological and molecular features of dengue
virus type-1 in New Caledonia, South Pacific, 2001–2013. Virology
Journal. 2014;11(1):61.
13. Dengue in the Western Pacific Region [Internet]. World Health
Organization Western Pacific Region. 2017 [cited 26 February
2017]. Available from: http://www.wpro.who.int/emerging_diseases/
Dengue/en/
14. Taulung L, Masao C, Palik H, Samo M, Barrow L, Pretrick M
et al. Dengue Outbreak — Federated States of Micronesia, 2012–
2013 [Internet]. Morbidity and Mortality Weekly Report. 2013 [cited
26 February 2017]. Available from: https://www.cdc.gov/mmwr/
preview/mmwrhtml/mm6228a3.htm
15. Dupont-Rouzeyrol M, Aubry M, O’Connor O, Roche C,
Gourinat AC, Guigon A et al. Epidemiological and molecular features
of dengue virus type-1 in New Caledonia, South Pacific, 2001-2013.
Virol J. 2014;11:61.
16. Sabin AB. Research on dengue during World War II. Am J Trop
Med Hyg. 1952;1:30–50.
17. Halstead SB. Dengue virus – mosquito interactions. Annu Rev
Entomol. 2008;53:273-91.
18. A-Nuegoonpipat A, Berlioz-Arthaud A, Chow V, Endy T, Lowry
K, le Mai Q et al. Sustained transmission of dengue virus type 1 in
the Pacific due to repeated introductions of different Asian strains.
Virology. 2004;329(2):505-12.
19. Morens DM. Dengue fever: a prevention summary for Pacific
health workers. Pacific Health Dialog. 1996;3(1):240-52.
20. Singh N, Kiedrzynski T, Lepers C, Benyon EK. Dengue in the
Pacific – an update of the current situation. Pacific Health Dialog.
2005;12(2):111-9.
21. Roth A, Mercier A, Lepers C, Hoy D, Duituturaga S, Benyon E
et al. Concurrent outbreaks of dengue, chikungunya and Zika virus
infections - an unprecedented epidemic wave of mosquito-borne
viruses in the Pacific 2012-2014. Euro Surveill. 2014;19(41):20929.
22. Centers for Disease Control and Prevention (CDC). Dengue
outbreak – Federated States of Micronesia, 2012-2013. MMWR.
Morbidity and mortality weekly report. 2013;62(28):570-3.
23. Cao-Lormeau VM, Roche C, Musso D, Mallet HP, Dalipanda
T, Dofai A, et al. Dengue virus type 3, South Pacific Islands, 2013.
Emerg Infect Dis. 2014;20(6):1034-6.
24. World Health Organization. Dengue haemorrhagic fever.
Diagnosis, Treatment, Prevention and Control. Geneva (CH); 1997.
92 p. Report No.: 2.
25. Calvez E, Guillaumot L, Millet L, Marie J, Bossin H, Rama V et
al. and Phylogeny of Aedes aegypti, the Main Arbovirus Vector in the
Pacific. PLoS Negl Trop Dis. 2016;10(1):1-2.
26. Guillaumot L. Arboviruses and their vectors in the Pacific –
status report. Pac Health Dialog. 2005;12(2):45-52.
27. Lounibos LP. Invasions by insect vectors of human disease.
Annu Rev Entomol. 2002;47(1):233-66.
28. Paupy C, Vazeille-Falcoz M, Mousson L, Rodhain F, Failloux
AB. Aedes aegypti in Tahiti and Moorea (French Polynesia):
isoenzyme differentiation in the mosquito population according to
human population density. Am J Trop Med Hyg. 2000;62(2):217-24.
29. Carrington LB, Simmons CP. Human to Mosquito Transmission
of Dengue Viruses. Front Immunol. 2014;5:290.
30. Scott T, Takken W. Feeding strategies of anthropophilic
mosquitoes result in increased risk of pathogen transmission.
Trends Parasitol. 2012;28(3):114-121.
31. Rallu JL. Tendance recentes des migrations dans le Pacifique
Sud. Espace, population, sociétés. 1994;12(2):201-212.
32. Perry WJ. The mosquitoes and mosquito-borne diseases on
New Caledonia, an historic account; 1885–1946. Am J Trop Med
Hyg. 1950;30(1):103-14.
33. Chow CY. Aedes aegypti in the Western Pacific Region. Bull
World Health Organ. 1967;36(4):544-6.
34. Kuno G. Research on dengue and dengue-like illness in East
Asia and the Western Pacific during the First Half of the 20th century.
Rev Med Virol. 2007;17(5):327-41.
35. Hopp MJ, Foley JA. Worldwide fluctuations in dengue fever
cases related to climate variability. Clim Res. 2003;25:85-94.
36. Descloux E, Mangeas M, Menkes CE, Lengaigne M,
Leroy A, Tehei T et al. Climate-Based Models for Understanding
and Forecasting Dengue Epidemics. PLoS Negl Trop Dis.
2012;6(2):e1470.
37. Hales S, Weinstein P, Souares Y, Woodward A. El Nino and
the Dynamics of Vectorborne Disease Transmission. Environ Health
Perspect. 1999;107(2):99-102.
38. Hales S, de Wet N, Maindonald J, Woodward A. Potential
effect of population and climate changes on global distribution of
dengue fever: an empirical model. Lancet. 2002;360:830-834.
39. Jetten TH, Focks DA. Potential changes in the distribution of
dengue transmission under climate warming. Am J Trop Med Hyg.
1997;57:285-297.
40. Masahiro U, Sengebau-Kinzio M, Nakamura K, Ridep E,
Watanabe M, Takano T. Household risk factors associated with
dengue-like illness, Republic of Palau, 2000-2001. BioScience
Trends. 2007;1(1):33 - 37.
41. Aubry M, Roche C, Dupont-Rouzeyrol M, Aaskov J, Viallon
J, Marfel M et al. Use of serum and blood samples on filter paper
to improve the surveillance of dengue in Pacific Island Countries.
Journal of Clinical Virology. 2012;55(1):23-29.
42. Cao-Lormeau VM, Roche C, Descloux E, Viallon J, Lastere
S, Wiegandt A et al. Lost in French Polynesia: which strategies for a
dengue virus to spread? Am J Trop Med Hyg Suppl. 2007;12:111-19.
43. Guidance on regulations for the transport of infectious
substances 2011–2012 [Internet]. World Health Organization; 2010
[cited 31 July 2017]. Available from: http://www.who.int/entity/ihr/
42

publications/who_hse_ihr_20100801/en/index.html
44. Prado I, Rosario D, Bernardo L, Alvarez M, Rodriguez R,
Vasquez S et al. PCR detection of dengue virus using dried whole
blood spotted on filter paper. J Virol Methods. 2005;125:75-81.
45. Fukusumi M, Arashiro T, Arima Y, Matsui T, Shimada T,
Kinoshita H et al. Dengue Sentinel Traveler Surveillance: Monthly
and Yearly Notification Trends among Japanese Travelers, 2006–
2014. PLOS Neglected Tropical Diseases. 2016;10(8):1 - 14.
46. Lau CL, Weinstein P, Slaney D. Dengue surveillance by proxy:
travellers as sentinels for outbreaks in the Pacific Islands. Epidemiol
Infect. 2013 Nov;141(11): 2328–34.
47. Strategy [Internet]. Emerging Disease Surveillance and
Response. 2017 [cited 26 February 2017]. Available from: http://
www.wpro.who.int/emerging_diseases/strategy/Strategy/en/
48. Beatty M, Stone A, Fitzsimons D, Hanna J, Lam S, Vong S et
al. Best Practices in Dengue Surveillance: A Report from the Asia-
Pacific and Americas Dengue Prevention Boards. PLoS Neglected
Tropical Diseases. 2010;4(11):e890.
49. Malavige GN, Fernando S, Fernando DJ, Seneviratne SL.
Dengue viral infections. Postgrad Med J. 2004;80(948):588-601.
50. Rodriguez T. Dengvaxia Most Effective in High-Transmission
Areas [Internet]. Infectious Disease Advisor. 2016 [cited 3 April
2017]. Available from: http://www.infectiousdiseaseadvisor.com/
vector-borne-illnesses/dengvaxia-effective-in-high-transmissionareas/article/579948/
51. Aguiar M, Stollenwerk N, Halstead S. The Impact of the Newly
Licensed Dengue Vaccine in Endemic Countries. PLOS Neglected
Tropical Diseases. 2016;10(12):e0005179.
52. Questions and Answers on Dengue Vaccines [Internet].
Immunization, Vaccines and Biologicals. World Health Organization.
2017 [cited 11 August 2017]. Available from: http://www.who.int/
immunization/research/development/dengue_q_and_a/en
53. Hadinegoro S, Arredondo-García J, Capeding M, Deseda
C, Chotpitayasunondh T, Dietze R et al. Efficacy and Long-Term
Safety of a Dengue Vaccine in Regions of Endemic Disease.
New England Journal of Medicine [Internet]. 2015 [cited 3 April
2017];373(13):1195-1206. Available from: http://www.nejm.org/doi/
full/10.1056/NEJMoa1506223#t=article
54. Flasche S, Jit M, Rodríguez-Barraquer I, Coudeville L, Recker
M, Koelle K et al. The Long-Term Safety, Public Health Impact, and
Cost-Effectiveness of Routine Vaccination with a Recombinant,
Live-Attenuated Dengue Vaccine (Dengvaxia): A Model Comparison
Study. PLOS Medicine. 2016;13(11):e1002181.
55. Background Paper on Dengue Vaccines [Internet]. 1st ed.
SAGE Working Group on Dengue Vaccines and WHO Secretariat;
2016 [cited 3 April 2017]. Available from: http://www.who.int/
immunization/sage/meetings/2016/april/1_Background_Paper_
Dengue_Vaccines_2016_03_17.pdf
56. Masahiro U, Sengebau-Kinzio M, Nakamura K, Ridep E,
Watanabe M, Takano T. Household risk factors associated with
dengue-like illness, Republic of Palau, 2000-2001. BioScience
Trends. 2007;1(1):33 - 37.
57. Noel M. Dengue fever larval control in New Caledonia:
assessment of a door-to-door health educators program. Pacific
Health Surveillance and Response. 2005;12(2):39 - 44.
58. Morrow GBowen K. Accounting for health in climate change
policies: a case study of Fiji. Global Health Action. 2014;7(1):23550.
59. Burkot T, Handzel T, Schmaedick M, Tufa J, Roberts J,
Graves P. Productivity of natural and artificial containers for Aedes
polynesiensis and Aedes aegypti in four American Samoan villages.
Medical and Veterinary Entomology. 2007;21(1):22-29.
60. Chang M, Christophel E, Gopinath D, Abdur R. Challenges and
future perspective for dengue vector control in the Western Pacific
Region. Western Pacific Surveillance and Response. 2011;2(2):1 - 7.
61. McGraw EA, O’Neill SL. Beyond insecticides: new thinking on
an ancient problem. Nat Rev Microbiol. 2013 Mar;11(3):181-93.
62. Zug R, Koehncke A, Hammerstein P. Epidemiology in
evolutionary time: the case of Wolbachia horizontal transmission
between arthropod host species. J Evol Biol. 2012 Nov;25(11):2149-
60.
63. Xi Z, Khoo CC, Dobson SL. Wolbachia establishment and
invasion in an Aedes aegypti laboratory population. Science. 2005
Oct;310(5746):326-8.
64. Walker T, Johnson PH, Moreira LA, Iturbe-Ormaetxe I, Frentiu
FD, McMeniman CJ, et al. The wMel Wolbachia strain blocks dengue
and invades caged Aedes aegypti populations. Nature. 2011
Aug;476:450-3.
65. Frentiu FD, Zakir T, Walker T, Popovici J, Pyke AT, van der
Hurk A, et al. Limited Dengue Virus Replication in Field-Collected
Aedes aegypti Mosquitoes Infected with Wolbachia. PLoS Negl Trop
Dis. 2014 Feb;8(2):e2688.
66. Dyck VA, Hendrichs J, Robinson AS, editors. Sterile Insect
Technique: Principles and Practice in Area-Wide Integrated Pest
Management. Dordrecht: Springer; 2005. 787 p.
67. Soper FL. The elimination of urban yellow fever in the
Americas through the eradication of Aedes aegypti. Am J Public
Health Nations Health. 1963 Jan;53(1):7-16.
68. Phuc HK, Andreasen MH, Burton RS, Vass C, Epton MJ, Pape
G, et al. Late-acting dominant lethal genetic systems and mosquito
control. BMC Biol. 2007 Mar;5:11.
69. Kourí G, Guzmán MG, Bravo J. Hemorrhagic dengue in Cuba:
history of an epidemic. Bull Pan Am Health Organ. 1986;20(1):24-30.
70. Ooi EE, Goh KT, Gubler DJ. Dengue prevention and 35 years
of vector control in Singapore. Emerg Infect Dis. 2006 Jun;12(6):887-
93.
71. Disaster relief and emergency fund enables dengue outbreak
response [Internet]. Fédération internationale des Sociétés de la
Croix-Rouge. 2014 [cited 26 February 2017]. Available from: http://
www.ifrc.org/fr/nouvelles/nouvelles/common/disaster-relief-andemergency-fund-enables-dengue-outbreak-response-65371/
43

Family, Unity and Success - Australian
Indigenous Doctors’ Association (AIDA) 2017
[Conference report]
Narawi Foley Boscott
Narawi completed a Bachelor of Science (Biomed) at the University of
Queensland and is currently completing a Doctor of Medicine as well as
a Graduate Certificate in Business Leadership. Narawi is pssionate about
Badtjala culture and aspiring to improve Indigenous and mental health.
Hunter Valley
The Australian Indigenous Doctors’ Association
(AIDA) celebrated 20 years strong by holding their annual
conference for 2017 in the Hunter Valley, traditionally
owned by the Wonnarua people. This four-day long intensive
collaboration of keynote speakers, engaging workshops as
well as invaluable cultural and networking events created
a leading platform to connect and be inspired. The AIDA
2017 conference focussed on “family, unity and success”
with the overarching theme of supporting and connecting
Aboriginal and Torres Strait Islander medical students and
doctors to ultimately improve the health of Indigenous people
in Australia.[1] This conference has grown to not only bring
Indigenous students and doctors together but also to provide
networking opportunities for associate members, medical
college representatives, other health professionals and key
invited guests, making it an important medical and political
event.
“...in the medical curriculum, where
education about Aboriginal and Torres
Strait Islander culture and cultural safety
is often poor, undervalued or realistically
done too late to change some attitudes
and beliefs.”
Family
This was the second AIDA conference I have attended as a
medical student. I believe many people would underestimate
the value of bringing together fellow Indigenous medical
students and doctors from across Australia. However, this
sense of belonging and knowing you are not alone in medicine,
whether it be through sharing stories in the yarning circle
44

or networking in the lunch break, is why I believe the AIDA
conference and AIDA itself is so successful. Recently, AMSA
Blue Week highlighted conversations regarding the need to
do more about the mental health crisis amongst medical
students and doctors.[2] Research also shows that mental
health disorders are more prevalent amongst Indigenous
Australians than their non-Indigenous counterparts [3] and it
is well documented that good social support is protective for
mental illness.[4] This highlights the importance for Aboriginal
and Torres Strait Islander medical students and doctors, in
particular, to have a strong support network throughout their
medical journey. AIDA provides a support network as a familylike
organisation, its members backing each other as they
embark on their medical careers and embrace the enormous
task of improving Indigenous health.
Unity
So what do we know about Indigenous health? There is
still a lot to do, but as an attendee of the AIDA conference, I
was surrounded by people who are already are, or are soon
to be, making a real impact on many people’s lives. However,
the media continues to portray a narrative that there are
only a few well-educated Aboriginal or Torres Strait Islander
people. Australia’s history of Aboriginal and Torres Strait
Islander people is still poorly taught in schools. Not only this
but key Aboriginal and Torres Strait Islander people in the
past who have formed a better path for our people are either
unheard of or undervalued in our society.[5] This is reflected
in the medical curriculum, where education about Aboriginal
and Torres Strait Islander culture and cultural safety is often
poor, undervalued or realistically done too late to change
some attitudes and beliefs.[6]
broader society, particularly in how we value Aboriginal and
Torres Strait Islander lives, challenge racism and become
more culturally aware. At this year’s AIDA conference,
it was encouraging to see many of the medical college
representatives understand the need for more Indigenous
doctors, and the need for cultural change to challenge racism
and improve cultural awareness within their own colleges.
Medicare exclusions for prisoners is a key issue that
highlights systemic racism and contributes to health
disparities. Currently, prisoners in Australia are excluded
from Medicare and the Pharmaceutical Benefits Scheme
subsidies. This limited access to good healthcare is
shortening life expectancy and decreasing the quality of life
of many people who are incarcerated.[11] Aboriginal and
Torres Strait Islander people are over-represented in prisons
and are 13 times more likely to be incarcerated.[12] This is
not closing the gap but in fact, widening the existing chasm in
health disparities.[13]
The beautiful but complex aspect to Aboriginal and Torres
Strait Islander people and culture is that there are many
communities, languages and cultural protocols; in improving
Indigenous health there is no “one size fits all” approach. The
best outcomes at a grass-roots level are when a community
is meaningfully involved, a lengthy but essential strategy to
drive improvements to Indigenous health.[14] Targeting the
social determinants of health are also key, however tackling
systemic racism, the lack in cultural awareness and creating
a cultural change in society to value Aboriginal and Torres
Strait Islander lives should be our focus for enduring change.
All medical students and medical schools in Australia
The question then arises: is the problem really about the
lack of teaching about Aboriginal and Torres Strait Islander
culture, when racism (both institutional and interpersonal) is
known to be associated with poorer health and poorer health
outcomes?[7] Should the curriculum entail teachings on
racism, both identifying it and stopping it? This conference
asked whether it is the job of Indigenous people to educate
non-Indigenous people on racism itself. The term “hidden
curriculum” – the values and attitudes that medical students
see around them – highlights the importance of lecturers,
tutors, administrators and academics in showing strong
leadership and changing the culture of our universities to
stop racism and strongly value Aboriginal and Torres Strait
Islander culture and health.[8]
It is not just universities that need to step up. The United
Nations (UN) recently described Australia’s progress in
Closing the Gap as “woefully inadequate”.[9] Hearing this
in a room full of people who are driving positive change
and having real impacts on lives can be very disheartening,
especially when Aboriginal and Torres Strait Islander people
make up only 2.8% of Australia’s population.[10] However,
this highlights the importance for all Australians to unite to
make Indigenous health an absolute priority amongst many
key stakeholders. There needs to be a cultural change in
Painted stethoscope
45

should start talking about the idea that you are not clinically
competent until you are culturally competent. This is
imperative to reduce existing health disparities and eradicate
diseases still present in remote Indigenous communities.
AIDA and their supporters are ready to save and improve
Aboriginal and Torres Strait Islander peoples lives, but
everyone should also feel a sense of responsibility to unite to
change the narrative from “woeful” to making real and lasting
change.
Success
One of the most anticipated events of the conference
every year is the stethoscope ceremony. This ceremony is
where newly graduated Indigenous medical students and
newly qualified Indigenous fellows are recognised for their
hard work, sleepless nights, sacrifice and often added
weight of responsibility by being presented with a handpainted
stethoscope. This creates mentorship at AIDA and
inspiration that success is possible and very achievable as
an Indigenous medical student and graduate.
The other most anticipated event (for me anyway) is the
cultural excursion on the last day. I had very high expectations
after last year, living dangerously and tasting a particular
species of ant that tasted like citrus. However, I survived
that last year, and can tell you that I thoroughly enjoyed the
trip this year when people of the Wonnarua nation took us
to Biame cave, the site of a significant piece of rock art in
the Hunter Valley. These opportunities to have culture and
knowledge shared are invaluable. What I also learnt was
about how the traditional owners had worked with the non-
Indigenous property owners on which this significant site sits
in order to protect it, and make it accessible for those who
wish to visit and appreciate its significance - thousands of
“All medical students and medical schools
in Australia should start talking about the
idea that you are not clinically competent
until you are culturally competent.
years of culture and knowledge. The Wonnarua people also
believe there are many other significant sites around that
area. They hope that by setting this as precedent, not only
can they work with other property owners in the region, but
this can be applied to other significant sites across Australia.
So, if you, your family or your friends own a property with an
Indigenous site on it, or if you are unsure, please be in contact
with your local Indigenous community because there may
be thousands of important sites nationwide that need to be
protected for generations to come.
When talking about medicine today, we often think of just
the mind and body, but for many Indigenous people, there
is an element of the spirit. It is also important to recognise
that before colonisation, traditional healers or Ngangkari
looked after our people, probably with the same care and
dedication we hope to have as good doctors one day. These
Ngangkari included the spirit in healing; some are still around
today treating Indigenous people. So from an Indigenous
medical student’s perspective, in a society faced with racism
and disparity, perhaps we should put the humanity back into
medical school and not just hope, but work hard to create
a better world and health outcomes for this nation’s first
peoples.
Conflict of Interest
None declared
Correspondance
narawi.kefb@gmail.com
References
1. Australian Indigenous Doctors’ Association. AIDA Conference
2017 [Internet].[cited 2017 Oct 1]
Available from: https://www.aida.org.au/conference/
2. AMSA mental health. About the Campaign. [Internet]. [cited
2017 Oct 1].
Available from: http://mentalhealth.amsa.org.au/about-thecampaign/
3. Jorm A, Bourchier S, Cvetkovski S, Stewart G. Mental health
of Indigenous Australians: a review of findings from community
surveys. Med J Aust. 2012 196 (2):118-121.
4. Ozbay F, Johnson D, Dimoulas E, Morgan C, Charney D,
Southwick S. Social Support and Resilience to Stress. Psychiatry
(Edgmont). 2007 May 4(5):35-40.
5. NITV. Do our teachers care enough about Indigenous
Australia to bring it into the classroom? [Internet]. 2017 May 9
[updated 2017 May 9; cited 2017 Oct 1].
Available from: http://www.sbs.com.au/nitv/article/2017/05/09/
do-our-teachers-care-enough-about-indigenous-australia-bring-itclassroom
6. Durey A. Reducing racism in Aboriginal health care in
Australia: where does cultural education fit? Australian and New
Zealand Journal of Public Health. 2010 July 34(1):87-92.
7. Larson A, Gillies M, Howard P, Coffin J. It’s enough to make
you sick: the impact of racism on the health of Aboriginal Australians.
Australian and New Zealand Journal of Public Health. 2007 August
31(4):322-229.
8. Mahood S. Medical education-Beware the hidden curriculum.
Can Fam Physician. 2011 September 57(9):983-985.
9. Brennan, B. Australia’s progress on Closing the Gap ‘woefully
inadequate’, UN says. [Internet]. ABC News. 2017 September 11
[cited 2017 Oct 2].
Available from: http://www.abc.net.au/news/2017-09-11/closingthe-gap-progress-woeful-un-says/8892980
10. Australian Bureau of Statistics. Census: Aboriginal
and Torres Strait Islander population. [Internet]. 2017
June 27 [updated 2017 June 26; cited 2017 Oct 2]
Available from: http://www.abs.gov.au/ausstats/abs@.nsf/
46

Four perspectives on
the World Congress on public health
[Conference report]
Michael Au, Ka Man Li, Helena
Qian and Michael Wu
“Leadership is the capacity to translate vision into reality”
– Warren Bennis
The World Congress on Public Health (WCPH) is held every
2-4 years and organised by the World Federation of Public
Health Associations (WFPHA). Attracting between 2000-
4000 delegates from over 80 countries, the main objective of
this international forum was to engage diverse voices, ideas,
vision and actions of committed professionals and citizens
to strengthen and transform the global public health effort
and influence decision makers.[1] With a comprehensive
academic program, field trips, World Leadership Dialogues,
satellite events and meetings, and a glitzy social program,
this is truly the ultimate conference for public health inclined
peers.
To apply, there was a simple online questionnaire and
requirement to volunteer at least 20 hours throughout the
conference. As this meant volunteering for four hours per day,
I wasn’t able to attend all the academic workshops/sessions.
I mainly worked with the media department whereby I sent
interesting quotes from plenary sessions to the team for
Twitter content. I also had the opportunity to directly converse
with speakers in a relaxed setting, after their interview with
the media team.
We evaluate the experiences of attending the WCPH,
the benefits of meeting like-minded individuals, the sense
of optimism in the face of challenge and the problems on
financial supports in four different perspectives: a volunteer,
a presenter, a medical student and a young researcher.
A Volunteer’s Perspective - Helena Qian
Helena is a third year medical student at the University
of Newcastle with a keen interest in improving global health
and aiding underserved communities. She hopes to work with
WHO and MSF in the future as a collaborative researcher,
advocate, field doctor and volunteer.
“When ‘I’ is replaced with ‘We’, even ‘Illness’ becomes
‘Wellness’.” - Malcolm X
As someone passionate about improving public health,
I noticed a curriculum gap in which public health was only
briefly touched upon. WCPH was the perfect meeting of
likeminded individuals, leaders and global health enthusiasts
from which I could gain a holistic understanding of public
health from a grassroots standpoint to a global perspective.
With a registration fee of $770 for students (excluding
accommodation and flights) and being on a uni student
budget, I opted to attend the conference for free as a
volunteer.
Despite the vast array of expertise and interests,
discussion points centred around the confluence of global
environmental degradation, differing political agendas,
civil unrest and widening inequities in health outcomes.
Interestingly, despite proven health detriments from excess
alcohol, tobacco and sugar consumption, Prof. Mike Daube
stated, ‘Where engagement has occurred, it has invariably
been counterproductive.’ Hence, a significant barrier
preventing implementation of effective public health policies
are the industry groups who place private profits over the
health of their consumers. As Dr Bronwyn King eloquently
encapsulated, “60% of the tobacco industry involves child
labour - is there no baseline standard below which we will
sink to raise money?” Where negotiations with industry have
failed, focus has shifted to the consumer. Exposing the fund
managers who invest in these corporations and highlighting
that indirect health and environmental costs rest with
taxpayers, whereas revenue stays with manufacturers, have
resulted in approximately $5 billion AUD being withdrawn
from investment in the tobacco industry alone.[2]
47

Ultimately, the conference epitomised the power of public
health to draw connections to unseen patterns of disease,
highlighted hidden societal inequalities and served as a
platform for marginalised or underserved populations to have
a say. Backed by epidemiology and evidence based medicine,
public health brings ugly truths to the forefront of discussion
and ‘has a duty to speak truth to power’.
I’m immensely grateful to have attended as a volunteer and
to have met such an inspiring network of public health leaders
and fellow peers. As a student, I highly recommend attending
as a volunteer, especially as you gain unprecedented access
to event organisers and plenary speakers. Hope to see you at
the 16th WCPH in Rome 2020!
A Delegate’s Perspective - Michael Wu
Michael is a second year medical student and current Chair
of GlobalHOME at the University of Sydney with a burning
passion for health that disregards borders. Like Helena, he
dreams of working all over the world with MSF. His heroes include
inspirational figures such as Dr Catherine Hamlin. He also enjoys
sunsets and hummus.
The most palpable feeling one senses at a gathering of
minds tackling the most complex social health issues in the
world is that of positivity. Despite the clear adversity, there is
a strong belief that we have the tools and allies needed to
succeed in our agendas.
As anyone that is interested in optimising health outcomes
and promoting medical equity, the words “World Congress
of Public Health” instantly caught my attention when I first
heard them. The WCPH was a melting pot of inspiration,
edgy research and health reform superstars from all over the
world. This gathering does not come cheap but it also comes
only once every 2-4 years and can be anywhere in the world.
It was an opportunity I couldn’t miss.
To pay for my privilege to be a fly on the wall I sought
the assistance of the University. Unfortunately, the Sydney
Medical Program only sets aside funds for conferences if you
are a presenter, however, the Sydney University Postgraduate
Association was more than happy to hear me out. All I had
to do was attend a general meeting, provide background
information on the event and my interest and how this can
benefit their interests then prepare an “ask”. They saw fit
to offer me a grant for $480 to subsidise my registration in
exchange for sharing what I learnt with their Women’s Officer
and Environmental Officer.
This year, the University of Sydney’s Global Health
Society - GlobalHOME - committed to numerous key areas
of interest, including climate change and the impact on
Healthcare. The plenaries for the WCPH not only had this,
but also talks about Female Genital Mutilation, First Nations
people, Non-Communicable Disease and Tobacco Control.
These were talks dedicated to some of the most difficult
healthcare issues today, and WCPH would see some of the
greatest minds gather to discuss them. With Plain Packaging
2.0, we may start seeing cigarettes marked along their length
with the cost to your life expectancy. There was research
on the resiliency of health care systems in warzones. One
researcher working on his PhD had just returned from Eritrea
to add to his pool of data from nine other countries into which
he had ventured during active fighting.
As a student, it is a little daunting to attend a professional
conference out of your direct field but all you need is an
interest and passion. I made many connections and took
home plenty of key messages. I would encourage anyone
looking to attend a professional conference to do so
and to not be fazed by a lack of scholarship availability. It
would be worthwhile approaching your student council or
representative organisation and present to them to secure a
bursary of your own making.
A Presenter’s Perspective - Michael Au
Michael is a fourth year medical student at James Cook
University. He is committed towards the promotion of human rights,
social justice, and health equity. His interests lie in refugee and
maternal health, health systems and the social determinants of
health. He is currently completing research investigating refugee
health systems in Far North Queensland.
Although there is much to celebrate in public health, Dr
Margaret Chan at the conference described “new challenges
of unprecedented complexities” facing the world in the areas
of antibiotic resistance, obesity and chronic diseases. These
issues are intertwined with social, political and cultural issues
which make them increasingly difficult to address.
The status quo is not enough and there is still so much to be
achieved in public health. However, many students, including
myself, fall into the trap of complacency towards the state
of affairs in global health. As Australian students, we view
the rest of the world through the lens of a developed country,
distorted by daily privileges which we take for granted. The
solution? A continual pursuit for truth and information with a
high degree of scientific scepticism. This was just one of the
few gems I gathered from this conference.
With the support of the Royal Australasian College of
Physicians (RACP), I was fortunate to be given full registration
and travel assistance to attend the WCPH as a John Snow
Scholar. The scholarship gave me the opportunity to present
research which I had completed as a medical student, entitled
48

“HIV/HCV Prevention in Australian Incarcerated Populations:
A Review into Preventative Practices and Outcomes”. My
review highlighted the growing disparity in health outcomes
between prison populations and the community due to a
lack of preventative programs in Australian prisons against
infectious blood-borne diseases. I encourage all medical
students to consider applying for the John Snow Scholarship.
[3]
Attending this conference gave me the opportunity to
meet with leading academics in my area of research. In
addition to bringing together academics from across the
globe, both government and private sectors were closely
involved. It was my great pleasure to meet with the Australian
Capital Territory (ACT) Chief Health Officer who was leading
the reform in needle-syringe programs as well as other
academics prominent within the field of my research topic. I
found this most peculiar and warming, that an event like this
is able to bring people together from different parts of the
world, addressing a certain issue and to share, foster and
inspire other like-minded individuals.
Many medical students would have had experience
in attending AMSA Global Health and AMSA National
Convention events. The WCPH differs to AMSA events in that
it is a professional research intensive conference. These
events demarcate the knowledge frontier in public health
in a setting that aims to create professional networks and
expanding partnerships.
A Young Researcher’s Perspective - Ka Man Li
Ka Man is a final year Biomedical Science student at
the University of Melbourne with a strong devotion to furnish
approaches for current health concerns: healthy ageing and
preventive cardiology. She aims to serve as a part of WHO
and WFPHA to optimise global health in the nearest future.
“Pioneering spirit should continue, not to conquer the
planet or space... but rather to improve the quality of life.” –
Bertrand Piccard
As a young researcher, I always dreamt about either
standing behind the podium presenting my novel research
findings in front of experts in the field, or seeing my name on
publications. On the 4th of April this year, my dream finally
came true.
It all began an hour before a regular Monday meeting with
my supervisor. With little progression in my thesis, I did not
want to be a disappointment thus I googled an upcoming
conference related to my research field. I submitted an
abstract in the spur of the moment to this conference. Months
later, I got accepted as an orator for my study entitled, “The
Effect of Physical Activity, Body Mass Index on Cardiovascular
Risk in Australian Older Women”. I was overwhelmed by a
cocktail of excitement and anxiety.
Weeks before the conference commenced, I spent
countless days and nights working on my results for the
presentation, enduring many failures along the way. Numerous
times, I had to go back and forth changing the inclusion and
exclusion criteria for my literature review, refining the rationale
and interpreting my statistical regressions. However, with
the support and encouragements from my supervisor and
colleagues, I finally finished my results for the presentation.
As soon as I arrived at the venue of WCPH, my first
international conference, all my doubts, insecurities and
anxieties suddenly vanished. I was impressed by the scale,
the conference production value and the number of people
participating! It was a pleasure to meet with a diverse group
of delegates from different professional fields across
the globe. We were able to share personal experiences,
discuss typical research mistakes and exchange knowledge
about improving global health. One of the most memorable
highlights was meeting with leading academics, including Dr
Michael Moore, President of the World Federation of Public
Health Associations (WFPHA) and the CEO of Public Health
Association of Australia. Not only did he inspire me with his
persistence and belief in research but he also expanded my
vision for certain health issues with different perspectives.
Ultimately, WCPH was a life-changing conference. I was
delighted to achieve my dream at such an early stage of my
research career, presenting formally at one of the biggest
international conferences. WCPH has certainly reignited my
unwavering passion for public health research despite all the
challenges. It has given me an opportunity to engage, learn
and foster ideas with many like-minded individuals.
Although funding is not always available for research
students, conferences like WCPH are worth the cost! As Mr
Greg Hunt, MP, stated at the opening ceremony, we need
more frontier researchers to contribute to and enhance
quality of life. We, as tomorrow’s researchers, ought to raise
our voices to develop a comprehensive vision to take action
and improve global health nationally and globally.
Acknowledgements
Sydney University Postgraduate Representative Association
(Michael Wu)
Royal Australasian College of Physicians (RACP) (Ka Man Li)
Photo Credit
Helena Qian, Michael Wu, Michael Au, Ka Man Li
Conflicts of interest
None declared
Correspondance
helena.qian@uon.edu.au
References
1. WCPH About [Internet] Retrieved on 28th August 2017; Last
Updated 2017. Available from: http://www.wcph2017.com/about.php
2. WCPH Program Handbook. Proceedings of the World Congress
of Public Health; 2017 Apr 3-7; Melbourne, AU. 2017.
3. John Snow Scholarship Information website [Internet]
Retrieved on 10th September 2017; Last Updated 2017. Available
from: https://www.racp.edu.au/about/racp-foundation-awards/
division-faculty-chapter-regional-awards/australasian-faculty-ofpublic-health-medicine/john-snow-scholarship
49

Welfare cuts to refugees, AMSA Global Health
Crossing Borders National Managers
[Commentary]
Sibella Breidahl
and Jasmin Sekhon
Crossing Borders For Health is AMSA Global Health’s project that aims to advocate for
refugees and people seeking asylum. With arms covering Education, Advocacy and
Projects we aim to give students a functional understand of the refugee crisis, with a
focus on the Australian context, as well as contributing to the advocacy based around
creating a fair and fast processing system for people seeking asylum in Australia. Jasmin
and Sib are Crossing Border’s 2017 National Project Managers
We live in a society founded on the values of fairness,
reciprocity and freedom. Whether you call it a scallop
or a potato cake, you’re a millennial or older than Phillip
Ruddock, across lines of politics and race, these values
hold true.
We would all like to think that in our moment of
need we would be supported by our
community. Daily across Facebook and
the media, there are countless examples
of people proudly going above and
beyond for members of their community,
even for complete strangers. The
#sofaforlondon movement in the wake
of the London Bridge attack earlier this
year is a perfect example of this. People
posted on social media offering beds
(and salt and vinegar chips) to strangers who were left
stranded in the attacks.[1] Examples of this exist at
home as well, like the overwhelming response after the
Victorian bushfires in the last decade. We are great at
jumping into action when people need help. Why then,
are Australians so happy to eschew these values when
We are great at jumping into
action when people need
help. Why then, are Australians
so happy to eschew these
values when considering the
question of refugees?
considering the question of refugees?
Many social and economic factors inform the health
and wellbeing of humans. Housing insecurity, job hunting,
lack of access to proper medical care, limited education
pathways, lack of transport. These things pile up. Not
only do refugees face these stresses with no supportive
community or family, but also after years
of trying to get to Australia, often fleeing
horrific wars, genocides and famines.[2]
At the time of their greatest need, the
government resolves that the best thing
to do it to lock them up and throw away
the key.
The government decided in late
August to cut welfare payments to 100
of the 400 people seeking asylum in Australia that have
come to the mainland from regional processing centres
for medical treatment.[3] They plan to extend the cuts to
the other 300 people in this group in the coming months,
including pregnant women, 37 babies and 90 children
who attend school in Australia. This means they will stop
50

eceiving the paltry $200 a fortnight they have to support
their family, and will also be kicked out of supported
accommodation. With a name that would not be out of
place in an Orwell novel, the “Final Departure bridging E
visa” which stipulates these conditions, was given to 100
people with no notice.
It is deeply concerning that
post-arrival factors have a
worse impact on the outcomes
for children seeking asylum,
than the trauma of the wartorn
countries they come from
As a young, qualified person with an acceptable grasp
of the English Language and a good knowledge of the
workings of Australian society, I know how hard it can be
to find a job. These people who have been transferred to
Australia for serious medical illness must find a way to
support themselves in just three weeks, with the possibility
of being deported at any time, a prospect sure to turn
off any employer. To add insult to injury, the government
has also stuck by its policy that those over 18 years old
cannot access education or training programs, giving
them even less opportunity to find jobs. This has huge
implications for those at school. Why bother applying
yourself and working hard, just to be barred from further
education and face a desperate future?
Being transferred to Australia in the first place is no
mean feat, as we have seen in several cases, such of
that of Hamid Kazhei, who died on Manus Island of sepsis
from a cut in his foot because the government would
not transfer him to the mainland to get the attention
he needed. Or the multiple pregnant mothers with preeclampsia
who have been refused transfer and have no
access to obstetric care. This shows that the group in
question who did make it to Australia are extraordinarily
resilient and are in genuine need of care.
There is strong evidence to show that reduction in
funding for welfare has major effects on the health of
newcomers. Eroding economic and social conditions
negatively impacts on health by reducing access to
healthcare, deterioration in mental health and increases
domestic violence. [4]
The government has already made people seeking
asylum vulnerable, through damaging policies that
incorporate unnecessarily long processing times, keep
people in detention under inhospitable conditions, offer
few options for family reunification, deny full work rights
and withhold social services. This new policy will further
exacerbate the disadvantage that these people currently
endure.
It is deeply concerning that post-arrival factors have
a worse impact on the outcomes for children seeking
asylum, than the trauma of the war-torn countries they
come from.[1] A recent study published in the Journal
of Paediatrics and Child Health showed that childrens’
environment after arriving in Australia had more impact
on their physical health and wellbeing than the process
of getting to Australia and the traumas they experienced
before arriving.[5] Irresponsible policies like the recent
welfare cuts contribute strongly to this observation. The
government even went as far as threatening children in
their letter about the Bridging E visa, writing to parents
“Please remind your children that they will also be
required to abide by Australian values and laws. Breaking
Australian laws may result in their removal from the
community.”[3]
Refugees and people seeking
asylum are starting from a point of
compromise. It is our obligation as a
caring community that values equity
to springboard them into starting their
lives in Australia
The Government is pushing the financial burden to
support asylum seekers on community and not-for-profit
organisations, straining their already limited resources.
Refugees and people seeking asylum are starting from
a point of compromise. It is our obligation as a caring
community that values equity to springboard them
into starting their lives in Australia, rather than holding
them back or providing a flimsy safety net. It’s time to
say enough is enough and stop them bullying the most
vulnerable members of our society.
Conflicts of interes
None declared
Correspondance
jasmin.sekhon@amsa.org.au
sibella.harebreidahl@amsa.org.au
References
1. The Guardian staff and Press Association (2017).
#sofaforlondon: residents open their doors in wake of London
Bridge attack. The Guardian.
2. Marmot, M., Wilkinson R. (2003). Social Determinants
of Health, The Solid Facts. [online] The World Health
Organisation. Available at: https://books.google.com.au/
51

Start where you are, use what you
have, do what you can
-
Adelaide Global Health Conference 2017 Closing Address
AMSA Global Health Chair 2017
Liz Bennett
Good afternoon, wonderful GHC delegates. I’m Liz,
the Chair of AMSA Global Health and a final year medical
student at Flinders. As some of you would have heard
yesterday, my experiences in global health have taken me
from Adelaide, to Tennant Creek, to Oxford, to Geneva,
and to Tanzania, but GHC has always held a special
place in my heart and attending my first GHC was one of
the first steps on my global health journey.
I wanted to start by taking some time to reflect
on my time with AMSA Global Health this year. AMSA
Global Health is a team of 22 people from around the
country who work year round to advocate for, represent
and educate medical students like you on global health
issues. We focus on refugee and asylum seeker health,
climate health, sexual and reproductive health and most
recently non-communicable diseases.
There have been so many incredible moments this
year, from watching Sib, one of our Crossing Borders
For Health National Project managers, shine in her first
radio interview on refugee and asylum seeker health; to
watching Georgia, our Vice Chair Operations seamlessly
put the Council agenda together; to reading the amazing
divestment action plan for AMSA put together by the
Code Green National Project Managers, the Belles; to
seeing Carrie publish the first copy of Vector, our student
written, peer-reviewed global health journal, in two years
and then watch her guard the hard, print copies with her
life! I’ve participated in AMSA Global Health meetings
from Byron Bay, from Alice Springs, Darwin, Geneva and
most recently using dodgy airport internet in Tanzania,
and every single one has been a joy.
I would like to thank my AMSA Global Health team for
all of the amazing work they have done this year. It has
been a privilege to work with each and everyone one of
you and it has been incredible to watch your passion grow
into tangible products that have benefited so many.
At GHC, we are given the chance to learn how
phenomenal and passionate individuals - who are
often our idols - are making change. We are inspired,
challenged and empowered to then go forth and change
ourselves. I still remember sitting in plenary hall in Hobart
at my first GHC in 2013, listening to Julian Burnside talk
about his work in refugee and asylum seeker advocacy.
It was one of the first times I actually heard about the
impacts of immigration detention and I started crying
because I had never heard someone speak so candidly
52

about its devastating mental health effects. I could not
believe that this was happening in our country and that
our government was knowingly subjecting vulnerable
people to institutionalised torture. After a small period of
feeling hopeless, I began to get angry. It was this seed of
anger that has fuelled my passion for health inequalities
more broadly since then and I think this is a reason why I
am up here today.
But it is not enough to be
inspired. There is too much
to be done. We do not have
the luxury of apathy and you
cannot afford to waste time
thinking that you are too small
to make a difference.
However, if you had told me then that four years from
now, I would have been able to learn about global health
research with the George Institute in Oxford, I would have
been fortunate enough to spend 6 weeks being inspired
by global health babe, Sandro Demaio at the WHO in
Geneva, and that I would eventually publish an article with
Julian Burnside in the Lancet calling for immediate action
on refugee and asylum seeker health, I would not have
believed you. But it all started at GHC.
have the luxury of apathy and you cannot afford to waste
time thinking that you are too small to make a difference.
I encourage all of you to leave here and be productive
with the seed of inspiration that has been planted this
week. Continue to challenge yourself to make change and
always foster inquisitiveness and love of global health.
Ensure that you it, watch it grow and share its fruit with
those around you. This might be something as simple as
starting a conversation with someone using some of the
knowledge you gained, it could be putting pen to paper
and recording your ideas to share with others, it could be
joining a local advocacy group doing great work that you
are passionate about in your community, or it could be
joining an organisation like AMSA Global Health.
Start where you are, use what you have and do what
you can.
Photo credit
Karl Asmussen, Vienna Tran
Correspondance
liz.bennett@amsa.org.au
And so I would to thank Holly and her amazing team
for this fantastic event. Since that first GHC in Hobart,
this conference has gone from strength to strength and it
would not be possible without individuals like you.
This conference has given us the ability to challenge
ourselves in many different areas. We have been
provided with an opportunity to realise our strengths, as
well as our faults and imperfections. But it is not enough
to be inspired. There is too much to be done. We do not
53

Where to now?
-
Vector Journal & GHC Writing Competition
Helena Qian
Helena is a 3rd year medical student at the University of Newcastle with a keen
interest in improving global health and aiding underserved communities. She hopes
to work with WHO and MSF in the future as a collaborative researcher, advocate,
field doctor and volunteer.
What: “We are resolved to free the human race within
this generation from the tyranny of poverty and want,
and to heal and secure our planet for the present and for
future generations.” – The 2030 Agenda for Sustainable
Development
Society is at a critical juncture in world history
whereby a fragile balance exists between global health,
effects of modern-life, social constructs, politics and
economy.[1] The 2003 SARS epidemic encapsulates
how unprecedented population growth and adverse
living conditions have facilitated cross-species shift of
organisms.[1] Despite incredible medical advances, our
exponential increase in knowledge has not matched
public health progress as seen with the re-emergence of
polio in conflict-affected areas.[2]
Why: “If we see injustice, why can’t we make a change
right now?” – Mr Kon Karapanagiotidis GHC 2017
From conversing with Dr Stewart Condon, poor
application of knowledge due to differing political/
financial agendas have largely been to blame. These
stem from a failure of stakeholders/society to appreciate
the ‘complex links between social and economic aspects’
[1] of disease and address health at a world-population
level.
Contrary to popular belief, there is no shortage of
resources to improve global health,[3] only a lack of moral
imagination and political will to change long-standing,
inefficient healthcare systems and implement strategies
to broaden attitudes towards health.
Where to now? “The world is coming to recognise
more and more that problems in one country reverberate
in another...this is why it is so important to make the most
of our collective strengths.” - Ban Ki Moon
As privileged medical students with access to
platforms that engage our community, we can challenge
the complacency of those who don’t fully comprehend
the magnitude of impact every individual has on others
less fortunate. As future doctors, we should endeavour
to couple excellent care of individual patients to public
health programs that more efficiently disseminates
information and healthcare.
Although the way forward is challenging, it’s not
impossible with positive steps such as the creation of the
Coalition for Epidemic Preparedness Innovations (CEPI)
aiming to efficiently develop new vaccines to prevent
epidemics.
“It is because it is so dark that we need to burn the
brightest right now.”- Mr Kon Karapanagiotidis GHC 2017
Conflicts of Interest
None declared
Correspondance
helena.qian@uon.edu.au
References
1. Solomon R Benatar Global Health: Where to Now?
Retrieved 2017, August 19; Last Updated Unknown; Global
Health Governance, 2009;11;2 Available from:
2. Akil L, Ahmad HA. The recent outbreaks and
reemergence of poliovirus in war and conflict-affected areas.
Retrieved 2017, August 19; Last Updated 2016; International
journal of infectious diseases : IJID : official publication of the
International Society for Infectious Diseases. 2016;49:40-46.
doi:10.1016/j.ijid.2016.05.025.
3. Benatar, Daar, and Singer, “Global health ethics: the
rationale for mutual caring”; Benatar, Gill and Bakker, “Making
progress in global health: the need for new paradigms.”
Retrieved 2017, August 21; Last Updated Unknown
Moving forward, societal introspection are shifting
from a narrow, monetised view of global health to a multifaceted
appreciation for an interdependent world that
can drive forces for change. Greater emphasis should
be placed on collaboration to address health inequalities
and social determinants of health.
54

A Walk to Remember
[Book review]
Anna Marie Plant
Anna Marie Plant is a Medical student at the University of Sydney with a
strong interest in Global Health. She wishes to pursue a career in surgery
with a humanitarian focus and work for an organisation such as Médecins
Sans Frontières (MSF) to address the global shortage of safe surgical care,
especially in orthopaedics and trauma.
Walking Free
by A/Prof Munjed Al Muderis with
Patrick Weaver.
p 336. Allen & Unwin. $22.99
Despite our common motivations and
dedication to learning, the journey of each
medical student is unique. Despite managing
intense study loads, we probably cannot
imagine the added stress of living under a
brutal dictatorship, as was the experience of
Associate Professor Munjed Al Muderis. He
began his Medical studies at Basra University
in southern Iraq, near the Kuwaiti border that
former Iraqi President Saddam Hussein’s
forces had invaded a month prior. It was clear
from the outset that A/Prof Al Muderis’ journey
was never going to be straightforward.
awoken the following morning to the sound
of planes overhead and explosions nearby;
it was the 17th of January 1991 and the
commencement of Operation Desert Storm.
After he tended to civilian casualties at his
teaching hospital, he made the journey along
the war-ravaged Western highway, and passed
the Imam Ali Air Base that was under active
airstrikes by the US-led coalition, to Baghdad.
Al Muderis’ gripping vignette ensures that one
will never again complain about long flights or
drives to visit family.
Fast forward and the young Dr Al Muderis
found himself in one of the worst imaginable
situations: he had to choose between honouring
the Hippocratic Oath by refusing to remove the
ears of army deserters, or facing death at the
hands of Saddam’s military police. For most
of us this is a nightmare situation but sadly it
is the reality for some healthcare workers in
unstable geopolitical environments.
“the young Dr Al Muderis found himself
in one of the worst imaginable situations:
he had to choose between honouring the
Hippocratic Oath by refusing to remove
the ears of army deserters, or facing
death at the hands of Saddam’s military
police”
Midway through his first year of medical
school, his parents called one evening and
implored him to return home to safety. He was
After the journey to Australia, his stay in
Curtin Detention Centre would prove another
55

major hurdle. As detainee 982 (names were
replaced by numbers), his experience was the
rule, not the exception: extended periods of
solitary confinement, a general lack of privacy,
and navigating the complex web of rumours and
tensions that a confined environment instigated
between detainees. Detainees were constantly
reminded that their stay was indefinite and they
may never be resettled in Australia, but could
return to their country of origin at any time.
Al Muderis has presented the events of
his life as actions and reactions, rather than
delving into whether his experiences had any
long term psychological toll, however in writing
your own story you afford to keep some cards
close to your chest. Walking Free is the journey
of someone who achieved their dreams against
the odds of complex, challenging and evolving
geopolitical circumstances. It gives a face and
story to those on the other side of the fence:
“Al Muderis has presented the events
of his life as actions and reactions, rather
than delving into whether his experiences
had any long term psychological toll”
The story only briefly covered Al Muderis’ rise
through the medical ranks in Australia, most
likely because the day-to-day experiences
of surgical training are seemingly mundane
in comparison to the preceding journey.
Nevertheless, a more in-depth discussion of his
pioneering use of osseointegration surgery in
Australia would have been appreciated.
Despite the seemingly unbelievable events
of Walking Free, there are some commonalities
about life that hold true irrespective of personal
context. Marriage and a newborn child midway
through medical school was never an easy
undertaking but religious differences and
constant interference from both families
may ensure any union is doomed. There is
the sobering reminder that a bond and later
marriage forged through a treacherous boat
journey and stay in detention could be broken
by the strain of long working hours and constant
relocations associated with a surgical career.
My favourite anecdotes involve the
savviness of Mrs Al Muderis. She managed the
family finances during wartime and economic
sanctions, she provided USD $22 000 in cash
to her son upon hearing his need to flee during a
time in which owning US dollars in Iraqi banks was
prohibited, and organised legal representation
during his stay in Australian detention centres.
When family is involved, mothers will always find
a way.
locked up, anonymous individuals only seen
in glimpses of news reports as the ‘dangerous
other’; individuals that are every bit as human
as us, but who have been dealt a very different
hand in life.
As medical students, it can be easy to
become entangled in the inevitable drama and
competition that surrounds us, and lose sight
of why we are pursuing this goal. Walking Free
is a humbling reminder that everything can
change in the blink of an eye and that no matter
how tortuous the journey becomes, there is
something to be learnt from every step of the
way.
Conflicts of interest
The author of this book review declares that
they have no conflict of interest.
Correspondance
apla9692@uni.sydney.edu.au
56

57