Vector Volume 11 Issue 1 - 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 

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 designs by Lucy Yang (University of New South Wales) 

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: The Sky’s No Limit 1 

Commentary 

Rise of Trump/Fall of Health 2 

Owen Burton 

Anti-vaccination: Separating Fact from Fiction 5 

Elissa Zhang 

Climate Change and Vector-Borne Disease in Kiribati 8 

Erica Longhurst 

Features 

Humanity Lost? 11 

Patrick Walker 

Redefining Women’s Health: A Noncommunicable Diseases Perspective 14 

Charlotte O’Leary 

Healthcare in Conflict Zones 18 

Michael Wu 

Surgery: Luxury or Necessity? 22 

Maryam Ali Khan (Pakistan), Zineb Bentounsi (Morocco), Nayan Bhindi (Australia), Helena Franco (Australia), Tebian 

Hassanein Ahmed Ali (Sudan), Katayoun Seyedmadani (Grenada/USA), Ruby Vassar (Grenada), Dominique Vervoort 

(Belgium) 

Beyond the Horizon and Back Again: Interview with Professor David Hilmers 26 

Ashley Wilson-Smith 

Reviews 

PrEP-related health promotion for Aboriginal and Torres Strait Islander Gay and Bisexual Men 29 

Alec Hope 

Mental Illness Following Disasters in Low Income Countries 32 

Rose Brazilek 

Factors that Contribute to the Reduced Rates of Cervical Cancer Screening in 

Australian Migrant Women - a Literature Review 36 

Archana Nagendiram 

Medical Electives in Resource-poor Settings: Are We Doing More Harm Than Good? 40 

Gabrielle Georgiou 

Conference reports 

IFMSA - 5 letters with one big mission! Australian Medical Students attend the IFMSA 66th 

General Assembly in Montenegro 44 

Aysha Abu-sharifa, Stormie de Groot, Julie Graham, Justine Thomson 

Changing Climate, Changing Perspectives: iDEA Conference Report 47 

Isobelle Woodruff 

ii

Editor’s Note: The Sky’s No Limit 

Of the many things that come to mind when one thinks 

about global health, an astronaut is probably not high on the 

list. The front cover of this first issue of Vector for 2017 is 

not what we would conventionally expect of a global health 

journal. And yet, that is precisely the message that this issue 

conveys – the limitless diversity that global health has come 

to represent. We are living in an increasingly globalised world, 

with greater wealth and inequality we have ever encountered. 

We have made remarkable progress over the past few 

decades on the frontier of global health, including increased 

vaccination and access to treatment for diseases such as 

HIV. However, the agenda is now shifting to focus on new and 

emerging challenges. 

Undoubtedly, healthcare in a global context is intrinsically 

connected to the political, social and cultural phenomena 

that define today’s world. The rise to power of the United 

States President Donald Trump raises serious questions 

and concerns about the future of global health, with his 

controversial approaches and perspectives towards climate 

change, refugees and migrants, as well as sexual and 

reproductive health. Owen Burton (p 2) provides a thoughtprovoking 

commentary on these issues, and urges Australia 

to consider our future potential role in leading an alternative 

direction rather than following the direction set by the US. 

War and conflict, political stability and human rights 

also intersect with global health issues, as we see with the 

distressing increase in targeted attacks on health care 

facilities, Michael Wu (p 18) offers an insightful perspective 

into the situation of medical neutrality in conflict zones. In 

addition to man-made crises, natural disasters also pose a 

threat to human health and health care systems, with mental 

health implications a particular concern deserving attention, 

as discussed by Rose Brazilek (p 32). 

Climate change is the greatest challenge we are facing 

in the global health arena. Personal experiences and 

commentary are provided by Erica Longhurst (p 8). 

Noncommunicable diseases (NCDs) account for a 

substantial proportion of the global burden of disease. We 

are reminded by Charlotte O’Leary (p 14) that we need 

to question and redefine the approach we take towards 

this issue, to ensure that women’s health is not limited to 

reproductive health concerns, but a holistic approach over 

the entire life course, including addressing the risk factors 

and burden of NCDs specific to women and girls. 

Yet whilst our focus often turns to issues “abroad”, there 

is much to be addressed in global health on a local level. 

Health promotion amongst key populations in Australia is a 

particular topic of interest. A comprehensive review article by 

Alec Hope (p 29) describes issues regarding the promotion 

of HIV pre-exposure prophylaxis amongst Aboriginal gay and 

bisexual men in Australia. Migrant women in Australia also 

have lower rates of cervical cancer screening; the factors 

and interventions to address this issue are explored in a 

review article by Archana Nargendiram (p 36). 

The recent health policy “No Jab No Play / No Jab No 

Pay” also raises the issue of vaccination scepticism and 

conscientious objection, a concerning phenomenon in 

Australia as well as worldwide. A commentary by Elissa 

Zhang (p 5) provides an interesting overview of historical 

events like the Cutter Incident (involving the polio vaccine) 

and common concerns held by ‘anti-vaxxers’. 

With so much happening in global health, it is 

understandable for the general public, and particularly young 

people, to feel disenfranchised or disempowered. We even 

become desensitised and apathetic to the problems; such as 

conflict, mass displacement and natural disasters; that we 

are constantly exposed to in the media. Patrick Walker calls 

on us to remember the human side to the tragedies that we 

see, but also to promote tolerance and understanding with 

people who hold different views to our own (p 11). 

An interview by Ashley Wilson-Smith with NASA astronaut, 

paediatrician and internist Professor David Hilmers (p 26) 

provides a window into his vast experiences in resourcepoor 

settings, including recently in the Ebola crisis, and the 

interview reinforces that global health is not always what we 

expect it to be. Professor Hilmers is also one of our Advisory 

Board members, a new initiative aimed at strengthening the 

academic standard and longevity of Vector Journal. 

There is a growing community of medical students who 

share a passion for global health. (Indeed, they are attending 

conferences around the world, including at Doctors for the 

Environment Australia (Belle Woody, p47) and with the IFMSA 

in Montenegro (p44)!) Unlike other medical specialities that 

have a clear career pathway, global health is a blank canvass. 

It is hard to define, and that lends a huge amount of potential 

– global health can be anything that you want it to be. There 

is “no limit” in that sense! 

I believe that the contents of this issue speak to the 

diversity of global health. Not only does it bring attention 

to some of the greatest challenges, it also celebrates the 

developments in research, collaboration and policies that 

pave the way towards new and creative solutions. We hope 

this issue engages you, inspires you, and challenges your 

ideas and assumptions about global health. I am incredibly 

grateful to the Vector Committee, to all of our authors and 

contributors, to the Advisory Board, AMSA Global Health and 

many other supporters. 

Dear Reader, let Vector be a platform for you to launch 

beyond the horizon into global health. 

Carrie Lee, Vector Editor-in-Chief 2017 

Correspondance: carie.lee@amsa.org.au 

1

Rise of Trump/Fall of Health 

[Commentary] 

Owen Burton 

Owen Burton holds degrees of Bachelor of Biomedical Science (Griffith University) 

and Masters of Orthoptics (University of Technology, Sydney) 

As Donald Trump took the stage declaring 

victory as the 45th President of the United 

States and the Leader of the Free World, I had 

a sudden chilling realisation. This man, who 

has spent his entire life ignoring or actively 

working against the dangers of climate change, 

progressive social policy and a centralised 

state control healthcare system, now sits at 

the head of the American government, which 

sets the trends in policy and action in the 

Western world. 

His often-repeated goal during campaigning 

was to “repeal and replace” Obamacare by 

relaxing legislation which prevents exploitation 

of the injured by private 

insurance interests, and 

removing funding for vital 

infrastructure in hospitals and 

speciality clinics, as well as 

sexual health and Planned 

Parenthood programmes. 

Although he has, so far, been 

unsuccessful in repealing 

Obamacare, he has not given up his crusade 

against basic healthcare provisions. 

Under Trump’s direct guidance, Tom Price, 

head of the Department of Health and Human 

Resources, continues to reduce requirements 

for insurance companies to provide essential 

benefits, and works towards completely 

dismantling systems related to women’s or 

sexual health. Such a removal of support and 

shift away from women is concerning, as it 

appears to indicate the return of deep-seated 

sexism within governmental institutions which 

sets an example for the wider society. 

These cuts will jeopardise the health 

of the world’s most at-risk individuals 

by removing access to education 

and preventative measures against 

sexually transmitted diseases, as well 

as all facets of maternal healthcare. 

While Trump has proven time and time 

again that he has little regard for females, this 

blatant attack seems like an extreme first step. 

People have been protesting the numerous 

unconstitutional and unethical executive 

orders streaming from the desk of the White 

House through large organised protests, rallies 

at offices of local governmental officials 

and online petitions. It is vital, however, that 

this momentum does not weaken: accepting 

this situation as the new ‘normal’ cannot be 

allowed to happen. Having to fight constantly 

is exhausting but essential. Without significant 

resistance, it is likely that Trump will be able 

push many of these bills through a Republicandominated 

congress and into 

law. 

Trump’s executive order to 

freeze funding and support for 

global aid serves to reinstate 

and expand Reagan’s 1984 

ban on United States (US) 

foreign aid. All $9.5 billion 

USD of American global health funding will 

be restricted from being available to any nongovernment 

organisations providing or even 

discussing abortion with patients.[1, 2] These 

cuts will jeopardise the health of the world’s 

most at-risk individuals by removing access to 

education and preventative measures against 

sexually transmitted diseases, as well as all 

facets of maternal healthcare. The World 

Health Organization estimated that a total of 

225 million women in developing countries 

were not using contraception, mainly due to 

lack of access and education.[3] With the 

implementation of this gag, it is expected that 

these numbers will rise significantly. 

2

Trump has made it clear that he is committed 

to the promises he made going into the 

election – promises which have the potential to 

jeopardise global health. The next step is likely 

to be severe cuts or the removal of foreign aid 

funding entirely, as Trump has expressed on 

Slashing America’s global aid 

support will only result in detriment for 

those people already suffering from 

the consequences of poor support 

for health services; a rise in disease, 

poverty and death are to be expected 

if this policy is to be implemented. 

multiple occasions that he has no intention of 

being “president to the world”. By internalising 

focus, Trump aims to disconnect America from 

the rest of the world – a process that has 

started with reduction and removal of aid and 

is predicted to continue with taxing of overseas 

goods. 

The impact this will have on global health 

programs is not to be underestimated. Slashing 

America’s global aid support will only result in 

detriment for those people already suffering 

from the consequences of poor support for 

health services; a rise in disease, poverty and 

death are to be expected if this policy is to be 

implemented. 

and taking a strong stand on healthcare and 

foreign aid, Australia could become a rally point 

for other nations – a model for them to work by 

and therefore improve the lives of millions of 

people who have already, and will be, affected 

by the rise of Trump. 

Acknowledgements 

None 

Conflict of Interest 

None declared 

Correspondence 

oburton101@gmail.com 

References 

1. Filipovic J. The Global Gag Rule: America’s Deadly 

Export. Foreign Policy. 2017 March; 20. 

2. Office of the Press Secretary, White House. 

White House. [Online].; 2017 [cited 2017 May 10. 

Available from: https://www.whitehouse.gov/the-pressoffice/2017/01/23/presidential-memorandum-regardingmexico-city-policy. 

3. Singh S, Darroch J, Ashford L. Adding It Up: 

The Costs and Benefits of Investing in Sexual and 

Reproductive Health 2014. Guttmacher Institute; 2014. 

Australia has an opportunity, and a 

responsibility here to intervene. As a country 

with the wealth and resources to help, we would 

be passively condoning Trump’s gag policy if 

we do not aim to lessen its blow on developing 

nations. By increasing our international aid 

and presence, as well as encouraging other 

countries to do so, we can hopefully avoid the 

rise of neoliberalist nationalism we have seen 

in America, and help prevent its consequences 

to global health. 

Most importantly, Australia needs to stand 

up against America on this issue. It is time for 

Australia to take the lead. By changing direction 

3

4

Anti-vaccination: Separating Fact 

from Fiction 

[Commentary] 

Elissa Zhang 

Elissa is a 4th year medical student at UNSW. She currently conducts research 

on parental attitudes towards vaccine policies and media portrayals of vaccine 

safety at the UNSW School of Public Health and Community Medicine. 

Vaccines are indubitably one of the great 

successes of public health, on par with clean 

water and basic sanitation. They have saved 

millions of lives, and even eradicated infectious 

diseases such as smallpox.[1] 

Yet, regardless of these achievements, the 

legitimacy and safety of vaccinations are still 

questioned. Earlier this year Australian One 

Nation Senator Pauline Hanson urged parents to 

take a non-existent “vaccine-reaction test”,[2] 

and United States (US) President Donald Trump 

called for a commission into vaccine safety. 

[3] Furthermore, the recent implementation 

of stricter childhood vaccination policies (No 

Reasons behind vaccination hesitancy 

For as long as vaccines have been around, 

there have been those who oppose them. 

Vaccine opposition began in early 1800s in 

Europe with the first vaccination mandates. 

Scientists, doctors, and members of the public 

questioned the scientific basis of vaccines, 

even citing that they would disturb with God’s 

“natural control over the balance between 

the blessed and the damned”.[5] The modern 

manifestation of vaccine objection is 

simply another iteration of this longstanding 

phenomenon.. 

Jab No Pay; No Jab No Play) in Australia has 

raised contentious ethical issues regarding 

consent and balancing medical paternalism 

and parental autonomy in the provision of 

healthcare to children.[4] 

Ironically, the great success of vaccinations 

in dramatically reducing, and even eradicating 

disease is contributing to their own downfall. 

As diseases like measles and polio are no 

longer endemic in Australia, parents no longer 

directly face the harms of these highly virulent 

and contagious diseases. Consequently, they 

5

may perceive the risks from vaccinations to be 

greater than the likelihood of contracting the 

very diseases they prevent.[5] 

In fact, surveys of Australian parents show 

that the primary reason for vaccine hesitancy 

or objection is concerns about their safety[6] 

and a third of parents believe children are 

over-vaccinated. Newer vaccines, like the 

HPV vaccine, can be perceived to have 

a lower risk-benefit ratio, as they protect 

against diseases that are less prevalent or 

virulent. Older vaccines also face doubts, as 

the diseases they prevent are less common 

or even eliminated in the Australia, such as 

measles. Furthermore, concerns about adverse 

reactions to vaccination are growing. This could 

be attributed to the fact that such reactions 

are perceived to be more common than the 

diseases that they prevent. 

Common misconceptions regarding vaccines 

Rare but severe adverse reactions to 

some vaccinations attract great public 

interest, and give rise to misconceptions or 

over-estimations regarding their harms. For 

instance, the 1955 Cutter Incident in the USA 

involved administration of 380,000 doses of 

incompletely inactivated polio vaccinations to 

healthy children, which resulted in 40,000 cases 

of abortive polio (a minor form that does not 

involve the central nervous system), 51 cases 

of permanent paralysis and five deaths. It also 

started a polio epidemic, leaving even more 

people in the community affected.[7] 

This event severely undermined public 

confidence in the safety of vaccinations, even 

after it prompted the instigation much safer 

and stricter regulation of vaccines.[7] Incidents 

such as this undermine trust in vaccine safety, 

and these fears must be addressed in the 

community. 

Commonly, anti-vaxxers also claim that while 

they are not against vaccinations themselves, 

they oppose the adjuvants and preservatives 

that are potentially harmful, like thiomersal. 

However, studies have not been able to identify 

any harmful effects related to thiomersal, and 

even so, it was removed from all Australian 

childhood vaccines.[8] 

One of the most infamous controversies 

surrounding vaccine safety was Andrew 

Wakefield’s retracted 1998 paper that linked 

the Measles, Mumps and Rubella (MMR) 

vaccine to autism and bowel disease. His study 

was severely flawed, involving a sample of only 

12 children, and Wakefield was deregistered 

and discredited. In comparison, a Danish 

retrospective cohort study investigated over 

500,000 children who received the MMR vaccine 

and proved that there was no association 

between the vaccine and autism.[9] Despite 

this, many of the general public still believe in 

the association between the MMR vaccine and 

autism as a consequence of Wakefield’s study. 

Vaccine objection in the context of Australian 

vaccination policies 

As of January 2016, the nationwide legislation 

called “No Jab No Pay” has been put into 

effect, removing conscientious objection from 

exemption criteria to immunisation requirements 

for Centrelink childcare payments worth up to 

$19,000. A press release by then Prime Minister 

Tony Abbott and Health Minister Scott Morrison 

stated that “the choice made by families not 

to immunise their children is not supported by 

public policy or medical research nor should 

such action be supported by taxpayers in the 

form of child care payments”.[10] 

In contrast, public health experts believe that 

this policy is may be misplaced in its aims to 

reduce conscientious objection to vaccination, 

rather than addressing the more prominent 

barriers of access to services, logistical 

issues, and missed vaccination opportunities. 

[11] A policy such as this could also threaten 

the validity of a patient’s informed consent, 

which is outlined in the Australian Immunisation 

Handbook as being “given voluntarily in the 

absence of undue pressure, coercion or 

manipulation”.[12] This has generated a fresh 

6

debate into the ethics of mandating vaccines 

through paternalistic policy. 


None declared 

Statistics released in July 2016 show that 

following the implementation of this policy, 

148,000 incompletely vaccinated children had 

caught up, including 5,738 children of parents 

with previous conscientious objections.[13] 

Implications as medical professionals 

Public attitudes towards 

vaccinations are complex, as 

they are affected by a wide 

range of sources, including the 

media, personal experiences, 

and health providers. A 

variety of strategies should 

be implemented to influence 

such attitudes. For instance, 

willingness to vaccinate could 

be encouraged by focusing on improving 

awareness of the risks of vaccine preventable 

diseases, rather than discrediting or refuting 

myths about vaccine dangers. An intervention 

based on this strategy showed that higher risk 

perception of diseases resulted in an increased 

willingness to vaccinate.[14] It was also shown 

that rates of conscientious objection were 

reduced in areas with more administrative 

barriers to obtaining one. 

As future health professionals, we need 

to develop skills to practise evidence-based 

medicine. We need to be able to formulate our 

opinions based on verified facts, before helping 

parents to make informed decisions about 

vaccinations. We too can also be influenced by 

the vast amount of facts and misinformation 

disseminated about vaccinations in the media. 

Thus, it is our responsibility to stay up-to-date 

with the latest literature and separate fact from 

fiction, in order to provide the best care for our 

patients. 


Supervisor Prof. Raina MacIntyre, UNSW 

r.macintyre@unsw.edu.au 


elissa.j.zhang@gmail.com 

References 

As of January 2016, the 

nationwide legislation called “No 

Jab No Pay” has been put into 

effect, removing conscientious 

objection from exemption criteria 

to immunisation requirements for 

Centrelink childcare payments 

worth up to $19,000. 

1. Greenwood B. The contribution of vaccination to 

global health: past, present and future. Philos Trans 

R Soc Lond B Biol Sci. 2014;369(1645):20130433. 

Available from: https://www.ncbi.nlm.nih.gov/pmc/ 

articles/PMC4024226/ DOI: 10.1098/ 

rstb.2013.0433 

2. Australian Broadcasting 

Corporation. Pauline Hanson joins 

Insiders [Internet]. Sydney NSW: 

Australian Broadcasting Corporation; 

2017 [cited 2017 May 29]. Available 

from: http://www.abc.net.au/insiders/ 

content/2016/s4630647.htm 

3. Wadman M. Robert F. Kenndey Jr. 

says a ‘vaccine safety’ commission 

is still in the works. Science [Internet]. 

2017 Feb [cited 2017 May 29]. Available from: http:// 

www.sciencemag.org/news/2017/02/robert-f-kennedy-jrsays-vaccine-safety-commission-still-works 

4. National Centre for Immunisation Research & 

Surveillance [Internet]. Westmead NSW: NCIRS; 2016. No 

jab no play, no jab no pay policies; 2016 [cited 2017 May 

29]; [all screens]. Available from: http://www.ncirs.edu. 

au/consumer-resources/no-jab-no-play-no-jab-no-paypolicies/ 

5. Bond L, Nolan T. Making sense of perceptions of 

risk of diseases and vaccinations: a qualitative study 

combining models of health beliefs, decision-making and 

risk perception. BMC Public Health. 2011;11:943. 

6. Rhodes A. Vaccination: perspectives of Australian 

parents [Internet]. Melbourne VIC: The Royal Children’s 

Hospital Melbourne; 2017 [cited 2017 May 29]. 6 p. 

Available from: https://www.childhealthpoll.org.au/wpcontent/uploads/2015/10/ACHP-Poll6_Detailed-report_ 

FINAL.pdf 

7. Offit PA. The Cutter incident, 50 years later. N Engl J 

Med. 2005;352(14):1411-2. 

8. National Centre for Immunisation Research & 

Surveillance. Thiomersal FactSheet [Internet]. Westmead 

NSW: NCIRS; 2009 [cited 2017 May 29]. 5 p. Available 

from: http://www.ncirs.edu.au/assets/provider_resources/ 

fact-sheets/thiomersal-fact-sheet.pdf 

9. Madsen KM, Hviid A, Vestergaard M, Schendel D, 

Wohlfahrt J, Thorsen P, et al. A population-based study of 

measles, mumps, and rubella vaccination and autism. N 

Engl J Med. 2002;347(19):1477-82. 

10. Abbott T, Morrison S. No jab – no play and no pay 

for child care [Internet]. Canberra ACT: Parliament of 

Australia; 2015. 2 p. Available from: http://parlinfo.aph. 

gov.au/parlInfo/search/display/display. 

7

Climate Change and Vector-Borne 

Disease in Kiribati 

[Commentary] 

Erica Longhurst 

Erica Longhurst is a third year medical student at the University of New South Wales, passionate 

about environmental health, and who is a big fan of the great outdoors! Her loves are travelling 

and learning about people. She is studying in Griffith NSW this year, on clinical placement with my 

uni. She’s also super passionate about everything that’s in this edition of Vector! 

In February 2016, I went on a New Colombo 

Plan-sponsored climate change research trip 

to Kiribati, a nation of low-lying atolls in the 

Pacific Ocean. The islands of Kiribati are on 

the equator halfway between Australia and 

Hawaii. One of the most important things 

that I learnt was how being sustainable is 

not that difficult at all, and that the people of 

Kiribati are absolute professionals at living in 

harmony with their environment. We travelled 

to Kiribati to research the social, economic 

and environmental effects of climate change. 

However, this trip also taught us much about 

ourselves and the society that we live in, 

Australia. It was an opportunity to see how 

those who contribute nothing to global pollution 

are suffering from the effects of climate 

change. 

There is a large focus in the international 

community on the environmental implications of 

climate change. Whilst this is highly significant, 

the impact of climate change on the health of 

local communities also needs to be brought to 

attention. When I think of this impact on local 

people, Kiribati is the first place that comes 

to mind. Climate change is responsible for 

an array of health issues, primarily the rise 

in communicable diseases as a result of the 

climate change-induced El Nino Southern 

Oscillation (ENSO) effect.[1] Vector-borne 

diseases such as malaria and dengue fever 

are particularly relevant. Increase in average 

global temperatures due to raised levels of 

greenhouse gases essentially accommodate 

these epidemics.[2] Without firstly responding 

to the health issues that these populations 

face as a result of climate change, many of the 

other issues cannot be addressed. In Kiribati, 

it is crucial to take measures to avoid future 

health consequences such as communicable 

diseases, as these people are so susceptible 

to the effects of climate change. 

8

The people of Kiribati are said to be the 

most vulnerable to the implications of climate 

change because of the close proximity of 

the inhabitants to the coastal regions of their 

islands. The ENSO effect is characterised by 

irregular warming of the eastern equatorial 

Pacific Ocean, and is responsible for raising 

average temperatures and inducing higher 

rainfall in the Asia Pacific region. Kiribati itself 

is only two metres above sea level, and so 

faces challenges in this domain. This is a very 

significant issue for cooler regions where there 

is limited experience or resistance to vectorborne 

infectious diseases.[3] 

Vector-borne diseases have many factors at 

play, such as host resistance, the environment, 

urbanisation and the pathogens themselves. 

The severity and prevalence of vector-borne 

diseases depends heavily on the climate, and 

thus directly correlates with the ENSO climate 

cycles. Temperature, rainfall and humidity 

are especially important concerns for vectorborne 

diseases.[4] According to the ‘The Sting 

of Climate Change’ report, ‘warmer conditions 

allow the mosquitoes and the malaria parasite 

itself to develop and grow more quickly, while 

wetter conditions let mosquitoes live longer and 

breed more prolifically’.[5] There is an overall 

increase in the potential for disease transmission 

due to the change in the ecology of vectors. This 

is characterised by quicker mosquito breeding 

cycle (thus, higher concentrations), increased 

biting rates, and shortened pathogen incubation 

periods.[6] If rainfall is excessive, pooled water 

can form, which creates breeding sites for 

mosquito larvae. There are many factors that 

operate in these scenarios, and so there is no 

one direct link between climate and mosquito 

populations. 

For both dengue and malaria, some of the 

most effective control measures to reduce 

the burden are long-lasting insecticidal bednets, 

indoor residual spraying with insecticides, 

seasonal malaria chemo-prevention, 

intermittent preventive treatment for infants and 

during pregnancy, prompt diagnostic testing, 

and treatment of confirmed cases with effective 

anti-malarial medicines.[7] These measures 

have dramatically lowered malaria disease 

burden in many Pacific Islander settings over 

the years. Thus, prevention is limited to vectorcontrol 

measures, which are very difficult to 

monitor. 

Visiting Kiribati gave me insight into the reality 

of climate change and its current impacts 

on health. It is clear that there is a distinct 

connection between climate change and 

vector-borne diseases. This poses particular 

challenges for developing nations where 

consequences of climate change are most 

pronounced. My experiences in Kiribati showed 

us raw, personal stories, and we strongly believe 

it is imperative to take action immediately. 


None 


None declared 


e.longhurst1012@gmail.com 

References 

1. Reiter P. Climate change and mosquito-borne 

disease. Environmental health perspectives; 2011. 141 p. 

121 

2. Ebi KL, Lewis ND, Corvalan C. Climate variability 

and change and their potential health effects in small 

island states: information for adaptation planning in the 

health sector. Environmental Health Perspectives; 2006, 

1957-1963 p. 

3. Haines A, McMichael AJ, Epstein PR. Environment 

and health: 2. Global climate change and health. 

Canadian Medical Association Journal; 2006, 729-734 p. 

4. Woodruff R, Whetton P, Hennessy K, Nicholls N, 

Hales S, Woodward A, Kjellstrom, T, Human health and 

climate change in Oceania: a risk assessment. Canberra: 

Commonwealth Department of Health and Ageing; 2003. 

5. Perry M. Malaria and dengue the sting in 

climate change. Reuters; 2008. Available from: 

http://www.reuters.com/article/us-climate-diseaseidUSTRE4AJ2RQ20081120 

6. Bezirtzoglou C, Dekas K, Charvalos E. Climate 

changes, environment and infection: Facts, scenarios 

and growing awareness from the public health community 

within Europe. Anaerobe; 2011, 2 p. 

7. Githeko AK, Lindsay SW, Confalonieri UE, Patz JA. 

Climate change and vector-borne diseases: a regional 

analysis. Bulletin of the World Health Organization; 2000. 

1136-1147 p. 

9

REFUGEE AND ASYLUM SEEKER UPDATE 

MARCH 2017 

I MPORTANT UPDATE 

• The Immigration Department reduced the deadline asylum seekers must apply for protection visas from 1 year to 

60 days. 1 

• Affects thousands of asylum seekers. 1 

• Those who don’t make the deadline may have their claim overturned giving them no right to work or medicare 1 

• These applications are up to 60 pages long with complex medical terms in English, requiring legal advice for 

completion, overloading already saturated legal services 1 

• IHMS, contracted to provide primary health care + 

mental health services on Manus Island and Nauru has 

been found to be not registered by the PNG 

medical board. 2 

- Therefore, 103 staff working at the centre 

have been employed illegally. 2 

• Recent Dengue outbreak on Nauru (late Feb). 3 

Infecting 70 people on Nauru including 10 refugee and 

asylum seekers. 

- Unconfirmed reports up to 8 asylum seeker 

medevaced to Australia mainland for 

treatment. 3 

• Young male asylum seeker on Manus Island flown to 

Australia for treatment 9th Feb following long 

standing series of doctors referring the man to get a 

pacemaker since August 2016. 4 

- The man collapsed Feb 1 and was finally 

transferred. This is another example, just like 

that of Faysal Ahmed, of complaints being 

ignored for a long time 4 

• Amnesty International released a 

report labelling Australia’s offshore detention 

policy as inhuman and abusive 5 

o 

o 

Highlights governments refusal to 

honour offer from NZ to resettle 150 

refugees and asylum seekers 5 

Treatment of these people involves 

systematic neglect and cruelty 

designed to inflict suffering 5 

1 

Hart, C. (2017, February 26). Asylum seekers’ applications doomed to fail after visa deadline changes, says refugee support service. ABC news. Retrieved from 

www.abc.net.au/news/2017-02-26/asylum-seekers-issued-with-new-deadline-for-visa-applications/8304766 

2 

Armstrong, K. (2017, March 3). Manus Island health provider ‘operating illegally for three years’: report. SBS news. Retrieved from 

http://www.sbs.com.au/news/article/2017/03/02/manus-island-health-provider-operating-illegally-three-years-report 

3 

Riman, I. (2017, February 28). A physical attack and a Dengue-fever outbreak cause fear among Nauru detainees. SBS news. Retrieved from 

http://www.sbs.com.au/yourlanguage/arabic/en/article/2017/02/28/physical-attack-and-dengue-fever-outbreak-cause-fear-among-nauru-detainees 

4 

Booth, A. (2017, February 12). Manus Island asylum seeker with cardiac condition flown to Australia. SBS news. Retrieved from 

http://www.sbs.com.au/news/article/2017/02/17/manus-island-asylum-seeker-cardiac-condition-flown-australia 

5 

Jama, H. (2017, February 23). Amnesty critical of Australia’s asylum seeker policy. SBS news. Retrieved from 

http://www.sbs.com.au/yourlanguage/somali/en/content/amnesty-critical-australias-asylum-seeker-policy 

6 

Feng, L. (2017, March 8). Hungary toughens laws on asylum seekers again. SBS news. Retrieved from: 

http://www.sbs.com.au/news/article/2017/03/08/hungary-toughens-laws-asylum-seekers-again 

7 

Picture: Deacon, L. (2017, February 10). Migrants entering Hungary to be detained in shipping containers on border. Retrieved from 

http://www.breitbart.com/london/2017/02/10/migrants-entering-hungary-detained-shipping-containers-border/ 

10

Humanity Lost? 

[Feature article] 

This article was originally published in the Doctus Project (February 2017) 

Patrick Walker 

Patrick is a medical student at Monash University, and the Editor in Chief of non-profit health 

journalism organisation the Doctus Project. He is also the Global Health Policy Officer for the 

Australian Medical Students’ Association, attended the World Health Assembly recently in 

Geneva, and late last year completed a policy internship at the Grattan Institute. Health-wise, his 

interests lie mainly in global health and health policy, and outside of the classroom (or hospital) 

he’s either reading a novel, writing about something new, or sitting at the piano crunching out a 

tune or two. This year he is completing a Bachelor of Medical Science (Hons) with the Centre 

for International Child Health and the Royal Children’s Hospital, looking at oxygen systems and 

provision of care in low-resource settings. Looking forward, perhaps this line of work might form the 

basis of a career, though there’s plenty of time for that to change. 

‘We started the revolution holding roses. 

Hoping for support from the international 

community. Years passed. The roses turned 

into guns. But the hope for support continues. 

Still, neither roses nor hope helped.’ 

- Abdulazez Dukhan, Syrian refugee 

Trump, with a simple and powerful message: 

he wanted to be heard. He wasn’t asking for an 

end to the conflict in his ‘beloved Syria’. He was 

simply asking for the West – and its perceived 

leader, Trump – to acknowledge the human 

side of the war. He was asking for humanity in 

the West’s response to his story. 

Abdulazez Dukhan is one of 4.5 million 

people who have fled Syria since the current 

conflict began in 2011. He is one of the 

countless people whose lives have been 

destroyed beyond recognition; one of the 

countless people forced to leave everything 

behind, in search of a safe place to live. 

In January, Abdulazez penned a moving 

letter to the new American president, Donald 

‘Your words matter for us,’ he writes. ‘You 

might be able to change our future ‘Dear future 

president, we hope that someone can hear our 

words. We hope that you do.’ 

Sadly, his plea has largely fallen on deaf 

ears. 

11

Just two weeks after Dukhan’s letter was 

published by Al Jazeera, Trump signed an 

executive order banning people from seven 

predominantly Muslim countries, including Syria, 

from entering the United States (US) for 90 

days. The order also placed a blanket ban on 

all refugees for 120 days, and Syrian refugees 

indefinitely. 

of the highest number of forcibly displaced 

persons since World War II and unfathomable 

atrocities occurring throughout the Middle 

East, northern Africa and many other parts of 

the world. For many people – most notably the 

young and highly educated – these events were 

taken to be a clear marker of racism and an 

unwillingness to accept difference. 

But they were also each the result of a free, 

democratic vote. They reflected the view of the 

majority. Further, to pass them off as simply 

racist, or a blip in the global political agenda, 

would be naive and counter-productive. 

The ban is currently suspended thanks to a 

federal judge temporarily blocking the executive 

order, but Trump’s message can be heard loud 

and clear. His response to the Syrian War and 

the current refugee crisis is to look the other 

way; to close the doors to those most in need 

of help. 

When I first watched the video of Abdulazez 

Dukhan’s letter to Trump, I was brought to tears. 

Dukhan’s poignant words brought the horrors he 

had endured suddenly to life. For a moment, I felt 

I was able to gain a tiny glimpse into the harsh 

reality of life for the millions of Syrians living in 

a conflict zone. 

Perhaps this should not come as too much of 

a surprise. Trump’s protectionism and stance on 

immigration are neither novel nor unexpected. 

Rather, they can be viewed as a symptom of 

a broader rise in nationalism, in response to a 

global refugee crisis that continues to worsen. 

2016 was a year of many things, but 

prominent among them were nationalism, 

division, and an increasingly powerful global 

Right. Brexit and the rise of an assortment of 

right-wing parties defined politics in Europe. 

Across the Atlantic, Trump was elected to the 

Oval Office on a fervent anti-establishment and 

pro-US, protectionist agenda. Back home in 

Australia, we saw the re-emergence of Pauline 

Hanson and her far-right, anti-immigration One 

Nation party. 

All these events occurred in the context 

This visceral response is by no means 

unusual or unexpected. It is the same as the 

West’s response to the ‘boy in the ambulance’ 

12

(five year-old Omran Daqneesh, injured by a 

blast in Aleppo in August last year) or to horrific 

images of the dead body of three year-old Aylan 

Kurdi washed up on a Turkish shore. 

It is human nature to feel outrage at injustice 

when it is put in front of us. It is not, however, 

human nature to react the same way to atrocities 

removed from one’s own existence and social 

or political sphere. Without these images and 

videos that become – for better or for worse – 

perverse icons of death and destruction, it is all 

too easy for us to simply turn away. 

This tendency means we often lose sight of 

the human side of tragic events to which we find 

ourselves unable to relate. This is exactly what 

we have seen in our politicians and our leaders. 

And it is in many cases exactly what we have 

seen in ourselves. Instead of compassion and 

unity, we have responded to horrors such as 

those going on in Syria with disaffection and, at 

times, apathy. Instead of reaching out to those in 

need, we have instead turned inwards, creating 

division and, on the other end, despair. 

The unprecedented political phenomenon of 

2016 is perhaps best encapsulated by social 

psychologist Jonathan Haidt. In a remarkably 

insightful and prescient essay entitled ‘When 

and why nationalism beats globalism’, Haidt 

unpacks the rise in nationalism we have seen 

in the past year, and tries to answer the simple 

question: ‘What on earth is going on in the 

Western democracies?’ 

By resisting change and immigration, Haidt 

argues that nationalists are not, as many 

believe, being selfish or somehow morally 

inferior to those embracing change. Far from 

it. Rather than inciting discrimination, he writes, 

they are working to preserve their nation and 

culture. The division between nations that can 

arise from this attitude is a by-product, rather 

than an intended consequence. 

The way to tackle this, then, is not to label 

nationalist or anti-immigration sentiment as 

‘racism pure and simple’. As Haidt notes, ‘If we 

want to understand the recent rise of right-wing 

populist movements, then ‘racism’ can’t be the 

stopping point; it must be the beginning of the 

inquiry.’ 

Rather than labelling the majorities who 

voted for Brexit, Trump or Hanson as racist or 

ignorant, we as a society need to understand 

their motives, and why they have turned to the 

Right for answers. We need to understand why 

so many of us are seemingly willing to turn a 

blind eye to horrors occurring outside of our 

immediate vicinity. We need to understand why 

we have lost compassion in our response to the 

plight of Syria. 

2017 can be different from the division we 

saw in 2016, but only if we resist the urge to vilify 

the ‘Other’, regardless of who that ‘Other’ is – a 

Muslim refugee, a status quo conservative, a 

member of the educated elite, or a right-wing 

authoritarian. 

Instead, creating a space of mutual 

understanding between people of differing 

opinions may help bridge the gap that has 

formed between the Right and the Left; the 

Nationalists and the Globalists; the Educated 

and the Uneducated; the East and the West. 

By doing this, we will start on the path towards 

finding an adequate response to Dukhan’s 

plea to Trump. And, somewhere along the way, 

maybe we will find that humanity that seems to 

have gone missing. 

Photo credit 

Abdulazez Dukhan 


Doctus Project 


None declared 


patrick.walker@amsa.org.au 

13

Redefining Women’s Health: 

A Noncommunicable Diseases Perspective 

[Feature Article] 

Charlotte O’Leary 

Charlotte has completed 4 years of medical school at Monash University. She is currently undertaking 

a Bachelor of Medical Science (Honours) at the Uehiro Centre for Practical Ethics at the University of 

Oxford. Charlotte undertook a 3-month internship at the World Health Organization in early 2017 in the 

Global Coordination Mechanism for the prevention and control of noncommunicable diseases (NCDs). 

Noncommunicable diseases (NCDs) – 

mainly cardiovascular diseases, cancers, 

chronic respiratory diseases and diabetes – 

represent a major challenge for sustainable 

development in the twenty-first century. In 2015, 

NCDs were responsible for 39.5 million (70%) 

of the world’s deaths, with more than 40% (16 

million) dying prematurely, or before the age of 

70.[1] NCDs affect people of all ages in high, 

middle and low-income countries. In particular, 

women and girls face unique challenges in 

the growing NCD epidemic 

due to pervasive gender 

inequality, disempowerment and 

discrimination. Without specific 

attention to the needs of women 

and adolescent girls, the impact 

of NCDs threatens to unravel the 

fragile health gains made over 

the past decades and undermine future efforts 

to ensure gender equity and healthy lives for all. 

The problem 

Gender inequality and NCDs 

NCDs have been the 

leading causes of death 

among women globally for the 

past three decades, and now, 

NCDs account for nearly 65% 

of female deaths worldwide. 

Nearly two thirds of illiterate people in the 

world are women, and this ratio has remained 

unchanged for two decades.[2] Consequently, 

women have had fewer opportunities to improve 

their health literacy and equip themselves with 

transferable skills that will enable them to be 

advocates for their own health. 

Women face unique challenges accessing 

healthcare due to their lower socioeconomic, 

political and legal status compared 

to men. The critical importance of 

prevention and early diagnosis of 

NCDs requires regular contact with 

the healthcare system. In some 

cultures, the health of a woman 

is often seen as secondary to the 

health of a man, and she may be 

denied access to healthcare when resources 

are limited. Even when given the choice, 

women are more likely than men to invest their 

money in the health of their children and other 

family members, rather than prioritising their 

own health. 

NCDs have been the leading causes of 

death among women globally for the past three 

decades, and now, NCDs account for nearly 

65% of female deaths worldwide. Pervasive 

gender inequality particularly affects the health 

of women and girls, influencing their ability to 

improve their health literacy, access healthcare 

services, achieve economic empowerment 

and financial security and live with NCDs free 

from stigma and discrimination. 

Many women may experience financial 

vulnerability due to high out-of-pocket 

healthcare costs. Lower access to formal paid 

employment may deny women the social and 

financial securities required to insure them 

against poor health. 

Additionally, women are too frequently 

viewed as commodities, and women living 

with a chronic disease may face alienation 

14

and discrimination. This is often due to the 

emphasis in certain social or cultural settings 

on a woman’s suitability for marriage and 

childbearing, which may be affected by chronic 

diseases. 

The caring burden 

Beyond their personal experiences with 

NCDs, women are indirectly affected by the 

increase in the burden of chronic diseases due 

to their traditional role as carers in families and 

communities. In a survey of 10,000 women from 

around the world, half the women were caring 

for a family member with an NCD, with one in five 

realising their own economic opportunities were 

diminished as a result.[3] Another study from the 

United States revealed that women make 80% 

of the health care decisions for their families, 

yet often go without health care coverage 

themselves.[4] Caregiving responsibilities can 

threaten or disrupt the education of adolescent 

girls, and often impacts women in their most 

productive years. Paid work decreases 

because of the burden of caring for people 

living with NCDs and reduces the economic 

contribution of women. This loss of productivity 

is felt by the whole society. The large amount of 

unpaid work undertaken by women in the family 

and community at all levels of society is highly 

under-appreciated. 

Vulnerability to NCD risk factors 

Women are uniquely vulnerable to the four 

major risk factors for NCDs, namely physical 

inactivity, poor nutrition, tobacco use and 

excessive alcohol intake. Improved social 

status and economic empowerment has 

contributed to an alarming increase in cigarette 

smoking amongst women and girls. The World 

Health Organization (WHO) estimates that the 

proportion of female smokers will rise from 12% 

in 2010 to 20% in 2025. Deaths attributable 

to tobacco use amongst women are also 

projected to increase from 1.5 to 2.5 million from 

2004 to 2030.[5] Women’s increasing social and 

economic status, especially in low and middleincome 

countries, has made them a prime target 

for the tobacco industry. This is especially true 

in Asia where regulation of tobacco advertising 

is lacking. Aside from the immoral promotion of 

health-harming products, the objectification of 

women is entrenched in tobacco advertising. 

Women’s bodies are exploited for the sale of 

cigarettes to men, whilst simultaneously and 

paradoxically, a message of health and beauty 

through tobacco consumption is conveyed to 

women and girls.[5] 

A similar trend is seen in alcohol consumption, 

with female alcohol consumption now rivalling 

male consumption, closing a historic divide. 

[6] Women and girls around the world are less 

likely to be physically active than boys and men 

due to sociocultural, economic and physical 

limitations imposed on them. In many cultures, 

women are largely responsible for food 

preparation. As a consequence, women often 

eat least and last in the family, compromising 

their nutrition. Additionally, inhalation of indoor 

cooking fuels is a well-known risk factor for 

chronic respiratory disorders, and this risk is 

borne disproportionately by women.[7] The list 

goes on. 

The way forward 

So how might we move forward at this 

critical time to ensure that we are effectively 

addressing the unique needs of women in 

the NCD epidemic? This problem is evidently 

complex and multifaceted. Presented here are 

some possible approaches, to firstly broaden 

our understanding of women’s health to include 

NCDs, and secondly to ensure that women are 

empowered and engaged in their own health. 

Defining women’s health 

One important step forward is to adopt a 

broader and more holistic definition of women’s 

health. Historically, the field of women’s 

health has focused on reproductive health, 

and consequently, considerable gains have 

been made in reducing maternal and newborn 

mortality and morbidity. While these gains are 

positive and important, it is equally important 

that the definition of women’s health not be 

confined to reproductive health. As Norton et al. 

15

posit in Women’s Health: A New Global Agenda, 

the currently narrow approach to women’s 

health firstly limits opportunities to effectively 

improve the health of the maximum number of 

women, and secondly, discriminates against 

women who do not have children.[8] 

In recent years, many international advocacy 

efforts have thus been made to expand this 

definition, and encompass a more holistic view 

of the health challenges faced by women. Such 

focus areas include, but are not limited to: the 

burden of NCDs in women, including mental 

health; the caring roles of women; and sexual 

and interpersonal violence. Additionally, the 

health of women must be considered across 

the whole life course. A reproductive focus 

risks excluding pre-adolescent girls 

and older women, all of whom face 

unique challenges in navigating 

their health in a climate of gender 

inequity. Indeed, women who have 

been through menopause have 

substantially increased risk of 

NCDs. Thus a focus on older women 

should be an integral of a life course 

approach to women’s health. 

Integrating NCDs into other health programs 

There are great opportunities to capitalise on 

existing healthcare services to better address 

the needs of women in the NCD epidemic. There 

is enormous opportunity to expand existing 

reproductive, communicable disease (such 

as HIV and tuberculosis) and sexual health 

services to incorporate NCDs. In particular, 

maternal and reproductive healthcare services 

are targeted at women, allowing healthcare 

to be delivered in an environment that is 

acceptable to, and accessible by, women and 

adolescent girls. Given the unique challenges 

faced by women in the NCD epidemic, these 

existing services can be broadened to include 

health promotion activities around NCD risk 

factors, early diagnosis and screening services 

(including breast and cervical cancer screening) 

and referral and treatment services. This will 

ensure that women are empowered to improve 

the health of themselves, their families and 

The impact of educating 

women has multigenerational 

effects due to their central 

position in the community, so 

improving women’s engagement 

with health promotion is a high 

yield intervention. 

communities. One such approach might be 

to follow up women with gestational diabetes 

after birth and to provide screening checks and 

education around good nutrition for mothers 

and children in order to prevent the development 

of diabetes. There is growing evidence for the 

feasibility and effectiveness of health system 

integration to prevent and control NCDs. [9,10] 

Women in medical research 

There is scope for the broader scientific and 

research community to ensure that women are 

equally represented in medical research. It is 

increasingly apparent that NCDs do not affect 

men and women equally. Women who smoke 

have a 25% greater relative risk of ischaemic 

heart disease than men who 

smoke.[11] Women suffer 

worse cardiovascular disease 

as a consequence of type 2 

diabetes than men,[12] and 

women with type 1 diabetes 

have a roughly 40% greater risk 

of all-cause mortality than men. 

[13] However, taking a focused 

biomedical approach is not 

sufficient to address the burden of NCDs in 

women. Medical research must also consider 

the social and cultural effects of gender 

inequity in order to fully appreciate the health 

outcomes of women with NCDs. Increasing 

attention to gender-disaggregated of research 

data has been recognised in the Sustainable 

Development Goals as an important tool for 

discovering these important gender disparities 

in illness.[14] 

Engaging women at every level 

Lastly, increasing female participation in 

decision-making will ensure the challenges 

faced by women are reflected in policies 

for health and sustainable development. 

Participation happens at every level. In local 

communities, women are attuned to the needs of 

other people, and as evident above, make many 

of the health related decisions in the community. 

There is a huge opportunity to harness their 

strength and knowledge to be a driving force 

16

for the prevention of NCDs. The impact of 

educating women has multigenerational effects 

due to their central position in the community, 

so improving women’s engagement with health 

promotion is a high yield intervention. There must 

be a concerted global effort to remove barriers 

to female participation in politics and high-level 

decision-making. Until this is achieved, it will 

be challenging to ensure that the multifaceted 

effects of gender inequity are accounted for in 

national and international policy. 

Conclusion 

Noncommunicable diseases are one of the 

biggest threats to health in an increasingly 

globalised world. Addressing gender inequity 

will be a necessary component of the solution. 

The health of women concerns everyone, and is 

far more than an economic, political or cultural 

issue. Ultimately, ensuring every woman and 

girl has the right to access the utmost level of 

health and wellbeing is an issue of human rights 

and justice. 


None 


None declared 


charlotte.a.oleary@gmail.com 

2014;25(4):1507-13. 

5. World Health Organization. Gender, women, and 

the tobacco epidemic. World Health Organization; 2010. 

6. Slade T, Chapman C, Swift W, et al Birth cohort 

trends in the global epidemiology of alcohol use and 

alcohol-related harms in men and women: systematic 

review and metaregression BMJ Open 2016;6:e011827. 

doi: 10.1136/bmjopen-2016-011827 

7. World Health Organization. Household air pollution 

and health [Internet]. Geneva: World Health Organization. 

2017 [cited 27 May 2017]. Available from: http://www.who. 

int/mediacentre/factsheets/fs292/en/ 

8. Peters SA, Woodward M, Jha V, Kennedy S, Norton 

R. Women’s health: a new global agenda. BMJ Global 

Health. 2016 Nov 1;1(3):e000080. 

9. Chamie G, Kwarisiima D, Clark TD, Kabami J, Jain 

V, Geng E, Petersen ML, Thirumurthy H, Kamya MR, Havlir 

DV, Charlebois ED. Leveraging rapid community-based 

HIV testing campaigns for non-communicable diseases 

in rural Uganda. PloS one. 2012 Aug 20;7(8):e43400. 

10. Janssens B, Van Damme W, Raleigh B, Gupta J, 

Khem S, Soy Ty K, Vun MC, Ford N, Zachariah R. Offering 

integrated care for HIV/AIDS, diabetes and hypertension 

within chronic disease clinics in Cambodia. Bulletin of the 

World Health Organization. 2007 Nov;85(11):880-5. 

11. Huxley RR, Woodward M. Cigarette smoking as a 

risk factor for coronary heart disease in women compared 

with men: a systematic review and meta-analysis of 

prospective cohort studies 

12. Woodward M, Peters SA, Huxley RR . Diabetes and 

the female disadvantage. Women’s Health (Lond Engl). 

2015; 11: 833-839. 

13. Huxley RR, Peters SA, Mishra GD, Woodward M. 

Risk of all-cause mortality and vascular events in women 

versus men with type 1 diabetes: a systematic review and 

meta-analysis. The Lancet Diabetes & Endocrinology. 

2015 Mar 31;3(3):198-206. 

14. United Nations. Transforming our world: the 2030 

Agenda for Sustainable Development. Geneva: United 

Nations. 25 Sept 2015. 

References 

1. World Health Organization. NCD mortality and 

morbidity [Internet]. Geneva: World Health Organization. 

2017 [cited 27 May 2017]. Available from: http://www.who. 

int/gho/ncd/mortality_morbidity/en/ 

2. The World’s Women 2015. 2015. United Nations 

Statistics Division [Internet]. Accessed from: https:// 

unstats.un.org/unsd/gender/chapter3/chapter3.html 

3. Insights from 10,000 women on the impact of 

NCDs [Internet]. Arogya World. 2014. Accessed from: 

http://arogyaworld.org/wp-content/uploads/2014/12/ 

Arogya-Full-Report-For-Web.pdf 

4. Matoff-Stepp S, Applebaum B, Pooler J, Kavanagh 

E. Women as health care decision-makers: Implications 

for health care coverage in the United States. 

Journal of health care for the poor and underserved. 

17

Healthcare in Conflict Zones 


Michael Wu 

Michael Wu graduated with a B.Pharm from the University of Sydney in 2012 with a major 

from the Clinical Excellence Commission focusing on IV to Oral Switch Therapy. Since then, my 

passions have grown from Infectious Diseases to just about everything. It’s a problem. I’d like to 

work all over the world at some stage, whether in Trauma or Ophthalmology. 

Introduction 

Medical neutrality in war-ravaged areas 

is the cornerstone of healthcare provision in 

conflict zones. However, weaponisation of 

healthcare – the deliberate destruction or 

removal of access to healthcare as a means 

of hamstringing opponents – has emerged as 

a concerning and common practice in modern 

military engagements. Medical neutrality was 

formalised in 1864 with the inception of the First 

Geneva Convention, which sought to establish 

a permanent ‘neutral’ agency that would deliver 

medical aid and services to sick and wounded 

combatants.[1] There was consensus amongst 

governments that armed conflict, no matter 

how violent, must maintain some semblance 

of compassion and humanity. This recognition 

was at the core of the message the Geneva 

Convention sent; that a line must be drawn 

in war and conflict. Recent years have seen 

military forces and governments ignore this 

sentiment, with clear violations of the Geneva 

Convention, from deliberate bombings and 

executions of doctors, nurses, pharmacists, 

medical students, and pharmacy students 

in Syria and Somalia, for example. Indeed, it 

would appear that many countries are either 

implicated in, or turn a blind eye to, atrocities 

resulting from violations of the Geneva 

Convention. 

Dr Kathleen Thomas has experienced 

this degeneration in the standard of warfare 

first-hand. Her story has become a landmark 

in this field. As an Australian doctor, she was 

responsible for an Intensive Care Unit at a 

Medecins Sans Frontieres (MSF) hospital in 

Kunduz, Afghanistan, when it was bombed by 

an American AC130 gunship in October, 2015. 

MSF had released the GPS coordinates of their 

hospital to American forces in the region days 

prior; their location was known. Repeated air 

strikes resulted in 42 fatalities, including 12 

staff, 24 patients and 4 caretakers, with dozens 

more wounded. MSF maintains that the attack 

was deliberate and has called for independent 

investigations by multiple bodies.[2] One must 

question why American forces, or indeed 

any government, would condone the attack 

of healthcare facilities. Similarly, however, 

it is important to realise that from a military 

perspective, this weaponisation of healthcare 

makes sense: it removes a valuable resource 

to guerrilla forces, that of neutral healthcare. 

Healthcare and conflict in Syria 

Syria is now the most dangerous nation in 

the world according to the Global Peace Index. 

[3] The Syrian civil war has left much of the 

country’s population displaced since beginning 

in 2011. As early as March that year, the country 

saw its first documented execution of a doctor. 

Subsequently, the attrition of healthcare in 

Syria has been the result of direct and violent 

attacks on health workers, as well as a mass 

exodus of health workers fleeing persecution. 

These direct attacks are mostly carried out by 

pro-government forces, and have manifested 

as “attacks on health facilities, executions, 

imprisonment or threat of imprisonment, 

unlawful disappearance (i.e. kidnapping), 

abduction, and torture sometimes leading to 

18

death” [4]. According to data from Physicians 

for Human Rights, 796 health workers were 

killed between March 2011 and December 

2016. Of these deaths, shelling and bombing 

accounted for just over 

half (55%), followed by 

shooting (23%), torture 

(13%), and execution 

(8%).[5] In addition to 

health worker fatalities, 

military forces have also 

targeted health facilities. 

This escalated in late September 2015, when 

Russia intervened militarily to provide support 

for the Syrian government, with 2016 data 

showing an 89% increase in verified attacks 

on healthcare facilities. The Syrian Network 

for Human Rights documented “289 attacks on 

medical facilities, ambulances and Syrian Arab 

Red Crescent bases, 96% of which were by 

Syrian or Russian forces”.[6] In contrast to the 

attacks in Afghanistan, such as that of the MSF 

Hospital in Kunduz, these documented attacks 

became so blatant that the United Nations (UN) 

Security Council condemned them in Resolution 

2286 on May 2016.[7] 

In 2009, Syria had 29,927 

doctors,[8] a figure that has fallen 

by 15,000 due to persecution and 

war, as reported by Physicians for 

Human Rights in 2015.[9] 

In 2009, Syria had 29,927 doctors,[8] a figure 

that has fallen by 15,000 due to persecution 

and war, as reported by Physicians for Human 

Rights in 2015.[9] This vacuum of physicians 

has led to the development of gaps 

and deficits in the skills and numbers of 

healthcare personnel available to serve 

the civilian population, which is already 

under duress from open conflict and 

aerial bombings. However, a deeper look 

at this gap reveals a disparity between 

government controlled areas and nongovernment 

controlled areas. In 2015, the 

non-government controlled region of Eastern 

Aleppo had a doctor-to-patient ratio of 1:7000; 

just 5 years prior, the ratio was 1:800. Research 

from The Syrian Centre for Policy Research has 

demonstrated a gross disparity in healthcare 

cover, with 31% of Syrians living in areas with 

insufficient health workers and 27% living 

in areas with a complete absence of health 

workers.[4] 

Many medical students in Syria have 

abandoned their studies, either because there 

are no longer doctors to teach them, or because 

there is such an urgent need to replace missing 

health workers that students are required to 

provide care. This has amplified the 

potential for suboptimal outcomes, 

with inexperienced doctors and 

medical students forced to practice 

outside of their scope of proficiency, 

increasing the risk of complications 

for patients. Indeed, surgical 

complications and infections have 

become more common, potentially reflecting 

shortcomings in medical training.[4] 

Responses to healthcare weaponisation 

In the face of these atrocities, what is there 

to do? In keeping with observations regarding 

healthcare in conflict zones, particularly in the 

context of healthcare weaponisation, health 

policy released by The Lancet and American 

University of Beirut (AUB) Commission 

has explored priorities for maintaining and 

promoting healthcare despite the challenges 

of conflict. Strengthening accountability with 

respect to the protection of health workers has 

been noted as the key priority in combating the 

surge in violence towards health workers and 

facilities. Multiple nations and key advocates, 

such as the UN Secretary General and the UN 

Strengthening accountability 

with respect to the protection of 

health workers has been noted as 

the key priority in combating the 

surge in violence towards health 

workers and facilities. 

High Commissioner of 

Human Rights, have 

supported and referred 

numerous war crimes 

from the Syrian conflict 

to the International 

Criminal Court. These 

attempts have been 

obstructed by Russia and China, two of the five 

permanent members of the UN Security Council. 

Indeed, the UN Security Council has issued 

multiple resolutions demanding humanitarian 

access and condemning chemical warfare, the 

latter of which is particularly pertinent given 

recent chemical attacks in Syria. However, 

these resolutions have resounded emptily 

due to political and diplomatic obstruction. 

Fouad et al., publishing under the Lancet/AUB 

Commission, suggest that responsibility falls 

to the civic society and medical community 

19

to bring governments and warring factions 

to account, and to end war crimes against 

both health workers and civilians. Groups in 

the Netherlands, Belgium, Spain, France, and 

Sweden have already had some success in 

bringing the agenda of health workers in conflict 

zones to peace negotiations.[4] 

Other recommendations include supporting 

health workers in conflict zones with resources, 

and reinforcing their capacity to deliver a wide 

range of services beyond trauma management. 

The Syrian conflict has highlighted the shortand 

long-term complexities of healthcare in 

conflict zones, and it is not feasible to allow 

other domains of care, such as maternal and 

neonatal care, to suffer as a consequence 

of conflict, or to allow vaccine-preventable 

endemics to resurge, as has happened in 

Nigeria. 

Institutions, including 

military organisations, 

should actively encourage 

and promote the concept 

of medical neutrality, and 

work to minimise disruption 

to healthcare services. 

It must also be realised 

that promoting global solidarity with health 

workers will help to develop an environment 

within which protection in times of conflict is 

more readily achieved. Initiatives such as the 

Safeguarding Health in Conflict Coalition and 

the Red Cross’ Health Care in Danger Project 

should be developed further to prevent targeting 

of health workers, or at least to facilitate early 

mobilisation and response to violence against 

health workers and facilities. 

Finally, but perhaps most importantly, 

more research on health workers in conflict 

is required, with an emphasis on developing 

understanding across multiple nations and 

conflict zones, given the heterogeneity in 

warfare and its effects on healthcare. Such 

data will allow governments and organisations 

to draw precedence for future conflicts, and will 

lend weight to arguments advocating for the 

protection of health workers and the civilian 

populations they serve. 

Conclusion 

Finally, but perhaps most importantly, 

more research on health workers in 

conflict is required, with an emphasis 

on developing understanding across 

multiple nations and conflict zones, 

given the heterogeneity in warfare and 

its effects on healthcare. 

Fighting against this paradigm shift away 

from medical neutrality is an arduous and 

daunting task. Even with strong backing from 

top UN position holders and many governments, 

offending parties still roam free of retribution 

and accountability. Despite feeling like a 

David vs. Goliath battle, the fate of healthcare 

in conflict relies upon the empathic and 

moral consideration of medical neutrality, a 

responsibility which belongs to every health 

worker, medical student, and civilian. 

“The standard you walk past is the standard 

that you accept” – General David John Hurley 

(AC). 

References 


None 


None declared 

Correspondance 

miwu5665@uni.sydney.edu.au 

1. Shaw M. Geneva Conventions. In: Encyclopaedia 

Britannica [Internet]. Chicago: Encyclopaedia Britannica 

Inc; 2004. Available from: https://www.britannica.com/ 

event/Geneva-Conventions. (Accessed March 30th 

2017) 

2. Thomas K. What was lost in the Kunduz Hospital 

Attack [Internet]. Medecins Sans Frontieres; 2016. 

Available from: https://www.msf.org.au/article/storiespatients-staff/what-was-lost-kunduz-hospital-attack. 

(Accessed March 30th 2017) 

3. Institute for Economics & Peace. Global Peace 

Index 2016 Report. IEP Report 39. 2016. Available from: 

http://visionofhumanity.org/app/uploads/2017/02/GPI- 

2016-Report_2.pdf. (Accessed March 30th 2017) 

4. Fouad F, Sparrow A, Tarakji A, Alameddine M, 

El-Jardali F, Coutts A, et al. Health workers and the 

weaponisation of health care in Syria: a preliminary 

inquiry for The Lancet –American University of Beirut 

Commission on Syria. Lancet. 2017. DOI: http://dx.doi. 

org/10.1016/ S0140-6736(17)30741-9 

5. Anatomy of a Crisis: A Map of Attacks on Health 

Care in Syria [Internet]. Physicians for Human Rights. 

Available from: https://s3.amazonaws.com/PHR_syria_ 

20

map/findings.pdf (Accessed 30th March, 2017). 

6. Reports on vital facilities attacked August 2014 

through December 2016 [Internet]. Syrian Network for 

Human Rights. Available from: http://sn4hr.org/blog/ 

category/report/monthly-reports/vital-facilities-monthlyreports/ 

(Accessed 30th March 2017) 

7. United Nations. Security Council adopts resolution 

2286 (2016), strongly condemning attacks against 

medical facilities, personnel in conflict situations 

[Internet]. 2016. Available from: https://www.un.org/press/ 

en/2016/sc12347.doc.htm (Accessed 30th March 2017) 

8. Annual Report, 2009. Ministry of Health Syria; 

2009. Available from: http://www.moh.gov.sy/Default. 

aspx?tabid=251&language=en-US (Accessed 30th 

March, 2017) 

9. Kupferman S. Syria’s neighbors must let doctors 

practice [Internet]. Physicians for Human Rights. 2016. 

Available from: http://physiciansforhumanrights.org/ 

press/press-releases/syrias-neighbors-must-letdoctors-practice.html 

(Accessed 30th March 6, 2017) 

21

Surgery: Luxury or Necessity? 


Maryam Ali Khan (Pakistan), Zineb Bentounsi (Morocco), Nayan Bhindi (Australia), 

Helena Franco (Australia), Tebian Hassanein Ahmed Ali (Sudan), 

Katayoun Seyedmadani (Grenada/USA), Ruby Vassar (Grenada), Dominique 

Vervoort (Belgium) -InciSioN international team members 

InciSioN, the International Student Surgical Network, is a student-led organisation of 

medical students and young doctors from around the globe with one shared passion, 

Global Surgery. InciSioN embodies the aim of educating about, advocating for, and 

performing research in Global Surgery. Among the 33 members of InciSioN, we share 23 

countries spanning over 12 time zones, in 5 continents, and speak over 15 languages. 

The seminal report published by the Lancet 

Commission on Global Surgery (LCoGS) in 

April 2015 highlighted that an estimated 5 

billion people continue to lack access to 

safe and affordable surgical and anaesthetic 

care when required.[1] Often, surgical care is 

associated with costly procedures and stateof-the-art 

equipment. While that might be true 

for a subset of procedures, there are many 

lifesaving procedures that are considered 

basic public health needs and can be 

performed cost-effectively with a simpler set 

of equipment. Through domains of research, 

education and advocacy, the relatively recent 

movement of Global Surgery endeavours to 

address and alleviate these vast disparities in 

surgical equity, particularly in low and middleincome 

countries (LMICs). Here, we would like 

to evaluate surgical care on a global scale 

from a basic public health standpoint. 

Basic surgical care and safe surgery 

Surgery is defined by the World Health 

Organization (WHO) as “any procedure 

occurring in the operating room involving the 

incision, excision, manipulation or suturing of 

tissue that usually requires regional or general 

anaesthesia or profound sedation to control 

pain”.[2] Surgery is rendered across all disease 

categories, and is an indispensable component 

of health care. Essential surgical care is a 

distinct concept, meaning surgery necessary 

to prevent imminent death or disability. Without 

access to essential surgical care, readily 

treatable diseases can pose serious threats to 

health. 

Safe surgery involves avoiding complications 

or adverse events that can arise before, 

during and after surgical procedures. Thus, 

safety measures are implemented before 

anaesthesia, before incision, during surgery 

and in the provision of post-operative care. 

The WHO estimates that every year almost 

7 million surgical patients suffer significant 

complications, most commonly including 

infection, bleeding and various complications of 

anaesthesia. More than half of these adverse 

events are preventable. In view of this, the WHO 

has implemented Guidelines for Safe Surgery 

(2009) to define core safety standards, with 10 

essential objectives that can be implemented 

in any country and any surgical setting. These 

serve to reinforce the standardisation of safe 

practices, particularly in developing countries. 

Cost of basic surgical care 

Access to safe anaesthesia and surgery, 

or lack thereof, has a considerable economic 

impact on both patients and society. 

22

Without sufficient public funding or health 

insurance, access to surgical services depends 

on the ability of patients and their family to pay. 

[3] High death rates for surgically treatable 

conditions in LMICs are often due the financial 

barriers of accessing surgical care. Thus 

affordability, and not necessarily availability, of 

treatment is a major focus. 

Surgically treatable causes of disease 

account for 28-32% of the global burden of 

disease; yet five billion people do not have 

access to the surgical care they need.[4] There 

is a common misconception that surgical 

treatment of these conditions is expensive and 

not cost-effective. Beyond the 

incredible impact certain basic 

surgeries, including caesarean 

sections and hernia repairs, can 

have on an individual’s quality of 

life, their overall monetary cost 

over time is comparable to other 

global health initiatives. 

The cost per DALY averted for basic surgeries 

is low in LMICs, in both small and large hospitals. 

Examples include emergency caesarean 

sections ($18 USD), elective inguinal hernia 

repair ($12.88 USD), and cleft lip repair ($15.44 

USD).[5] In contrast, other widely implemented 

public health initiatives can cost much more: 

oral rehydration therapy can cost over $1,000 

USD per DALY averted, and HIV HAART therapy 

can cost over $900 USD per DALY averted.[5] 

Beyond economic measures, lack of access 

to treatment of surgically treatable diseases 

has a major impact on the lives of patients, their 

families, and their communities. A condition as 

easily addressed as a strangulated hernia can 

be life-threatening to an otherwise healthy adult. 

Such a loss of life or work productivity can have 

devastating impacts not only on the patient, but 

also on those who financially depend on them. 

Surgery in low and middle income countries 

In the past, the impact of surgical diseases 

has been vastly underestimated by global 

Surgically treatable causes 

of disease account for 28- 

32% of the global burden of 

disease; yet five billion people 

do not have access to the 

surgical care they need.[4] 

health experts, leading to its absence in the 

Sustainable Development Goals (SDGs). 

However, since the establishment of the LCoGS 

in 2015, there has been a shift in this paradigm. 

With 16.9 million annual deaths (32.9% of all 

deaths) attributed to surgical conditions, the 

total burden far outweighs that of tuberculosis 

(TB), HIV/AIDS and malaria combined.[4] This 

is because easily treatable surgical diseases 

such as open fractures and obstructed labour 

cause significant morbidity and mortality due to 

lack of access to safe surgical care. 

The LCoGS sheds light on the startling 

paucity of surgeries performed in LMICs. It 

found that a disproportionately 

low number of surgeries are 

performed in LMICs compared 

to the population size. A third of 

the world’s poorest population 

resides in LMICs, and yet only 

6% of all surgical procedures 

worldwide are performed in 

these countries.[4] An additional 

143 million surgical procedures are required 

annually to overcome this present need. 

Failure to address such basic health and 

surgical needs can potentially endanger the 

economic progress of these countries. This 

is particularly pertinent given the growing 

population and problem of uneven healthcare 

access in LMICs. Each year, 33 million individuals 

worldwide face immense expenditures due to 

out-of-pocket payment of medical and surgical 

costs, which can push them into poverty.[4] The 

LCoGS found that workforce losses attributable 

to surgical conditions reduce GDP growth by up 

to 2%, particularly affecting growing nations. If 

no further is taken to address surgical needs in 

LMICs, it is estimated that the global economic 

loss in terms of international GDP could soar up 

to $12.3 trillion USD from 2015 to 2030.[4] 

These figures are alarming, and it is of 

utmost importance to recognise that these are 

not merely numbers and statistics, but that they 

represent real people affected every day. What 

must be stressed is that although the costs of 

23

providing surgery are high, investing in surgical 

services in LMICs is affordable, saves lives, 

and promotes economic growth.[4] To improve 

the current conditions, there is a great need 

to gather data, identify gaps in data regarding 

surgical access, funding and resources, and 

monitor progress. 

Global surgery in action 

Advocacy in recent years has demonstrated 

new potential for advancements in global surgery. 

Since its establishment in 2015, the LCoGS has 

been ground-breaking in demonstrating the 

many opportunities for improvements in global 

health and global surgery over the next 15 years 

and beyond. 

Progress has also been made in surgical 

safety. For instance, the sustained use of 

the “WHO Surgical Safety Checklist” led to 

continued improvements in surgical processes 

and reductions in 30-day surgical complications 

in Moldova, a LMIC, almost 2 years after 

its implementation.[6] Such improvements 

were seen despite the absence of continued 

oversight by the research team, demonstrating 

the important role that local leaders play in 

the success of quality improvement initiatives, 

especially in resource-limited settings. 

Moreover, opportunities to address health 

inequity and reset the global health agenda 

have arisen. These include global commitments 

to achieve Universal Health Coverage and the 

establishment of the Sustainable Development 

Goals. Realisation of the various goals to end 

poverty, ensure health for all, and promote 

sustainable economic growth, will be more 

achievable by ensuring delivery of safe, 

affordable and timely surgical care.[1] 

However, more improvements can still 

be made to further the provision of surgery 

worldwide. Currently, a global fund for surgery 

does not exist, and only a few foundations 

are willing to support surgery. Indeed, it took 

decades of advocacy to demonstrate the huge 

disease burden of other global health issues 

such as HIV/AIDs, tuberculosis and malaria, 

and then to develop funding mechanisms for 

them. With surgeons and leaders in global 

health advocating for patients in LMICs, we can 

hope to push for financial support in the coming 

years in order to improve the infrastructure and 

access to safe surgical care. 

In order to improve training and facilitate 

sharing of resources, there should also be further 

collaboration between hospitals in high income 

countries and LMICs (“twinning programs”). 

[3] However, donor hospitals, surgeons, and all 

those involved in efforts to redistribute surgical 

supplies need to exercise due diligence by 

ensuring that their partner institutions, including 

hospitals, clinics and medical schools, commit 

to reaching the poorest populations. Additionally, 

it is important to integrate vertical surgical 

programs into broader efforts to improve public 

health. In doing so, several important questions 

need to be raised: how effectively are the 

partner institutions providing care? Are they 

meeting broader goals of public health and 

global health equity?[3,7,8] 

Finally, professional interest groups starting 

at the level of medical students and residents 

can foster interest and educate others about 

surgery in a global healthcare setting. One 

such entity is the International Student Surgical 

Network (InciSioN). This international team of 

medical students and young doctors, began as 

a small working group within the International 

Federation of Medical Student Associations 

(IFMSA) in 2014. Since its initiation, members of 

InciSioN have been passionately active in global 

surgery research, advocacy and education. 

Conclusion 

Considering the significant economic and 

disease burden of lack of access to safe 

surgical care, surgery is truly a necessity and 

not a luxury. Put simply, essential surgical care 

should be made accessible and available 

to everyone in the public sector. Whilst the 

challenges are huge, progress in global surgery 

can be made with patience, determination and 

24

devotion to the cause. There is much hope that, 

through international movements led by various 

organisations, and with involvement of medical 

students, doctors, and leaders in global health, 

the landscape of safe surgical care will change. 

As members of InciSioN international team, we 

dream of a world where no life is lost due to lack 

of access to safe surgery and anaesthesia. 

References 

1. Lancet Commission on Global Surgery. Global 

surgery 2030 report overview [Internet]. 2015. Available 

from: https://www.surgeons.org/media/21831010/ 

Lancet-Commission-Policy-Briefs.pdf 

2. World Health Organization. WHO guidelines for 

safe surgery 2009 [Internet]. World Health Organisation; 

2009. Available from: http://apps.who.int/iris/ 

bitstream/10665/44185/1/9789241598552_eng.pdf 

3. Farmer PE, Kim JY. Surgery and global health: a 

view from beyond the OR. World J Surg [Internet]. 2008 

Mar [cited 2017 May 28];32(4):533-536. Available from: 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2267857/ 

pdf/ DOI: 10.1007/s00268-008-9525-9 

4. Meara, JG, Leather AJM, Hagander L, Alkire BC, 

Alonso N, Ameh EA et al. Global surgery 2030: evidence 

and solutions for achieving health, welfare, and economic 

development. Lancet [Internet]. 2015 Apr [cited 2017 May 

28];386:569-624. Available from: http://www.thelancet. 

com/pdfs/journals/lancet/PIIS0140-6736(15)60160-X. 

pdf DOI: 10.1016/S0140-6736(15)60160-X 

5. Grimes, CE, Henry JA, Maraka J, Mkandawire NC, 

Cotton M. Cost-effectiveness of surgery in low- and 

middle-income countries: a systematic review. World J 

Surg [Internet]. 2013 Oct [cited 2017 May 28];38:252- 

263. Available from: http://www.brighamandwomens. 

org/Research/labs/CenterforSurgeryandPublicHealth/ 

Documents/AGSF/2014/December/Grimes%20 

CE%20CE%20of%20Surgery%20in%20LMICs%20 

systematic%20review%20WJS%202014.pdf DOI: 

10.1007/s00268-013-2243-y 

6. Kim RY, Kwakye G, Kwok AC, Baltaga R, Ciobanu G, 

Merry AF et al. Sustainability and long-term effectiveness 

of the WHO surgical safety checklist combined with pulse 

oximetry in a resource-limited setting. JAMA Surg [Internet]. 

2015 Mar [cited 2017 May 28];150(5):473-479. Available 

from: http://jamanetwork.com/journals/jamasurgery/ 

fullarticle/2207940 DOI: 10.1001/jamasurg.2014.3848. 

7. Walton DA, Farmer PE, Lambert W, Leandre F, 

Koenig SP, Mukherjee JS. Integrated HIV prevention and 

care strengthens primary health care: lessons from rural 

Haiti. J Public Health Policy. 2004;25(2):137-158. 

8. Farmer P. From “marvelous momentum” to health 

care for all. Foreign Affairs. 2007 Mar;86(2):155-161. 

25

Beyond the horizon and back again 

Interview with Professor David Hilmers 


Ashley Wilson-Smith 

Prelude 

The globalisation of medicine, particularly 

within the last 50 years, has presented both 

students and practitioners with an exciting - 

yet staggering - amount of career and lifestyle 

pathways. Be it working with Medecins Sans 

Frontieres (MSF) in Africa; coordinating a WHO 

response to a new, virulent disease; or servicing 

rural-remote populations in outback Australia; 

the variety of work within medicine is nothing 

short of astounding. 

Early life and background 

Speaking with Professor David Hilmers of 

the Baylor College of Medicine, this becomes 

abundantly clear. With rich and varied 

occupational and academic experience, 

Hilmers’ pathway into medicine is as fascinating 

as his career has been since graduation. After 

growing up in a small town in Iowa, Hilmers 

moved from undergraduate study to flight 

school, the United States Marines – during the 

Vietnam War, no less – and eventually graduate 

school. Here, he studied electrical engineering 

and mathematics, giving him a tremendous 

grounding in scientific practice. Whilst he 

expressed a desire to practice medicine 

from as early as childhood, Hilmers was 

serendipitously given opportunities that initially 

drove him more towards working with N.A.S.A 

than working in medicine, as astounding as 

that may seem. Contextually, the United States 

space program was still maturing following 

the peak of the Cold War, with Hilmers’ career 

progression perfectly aligning with the 1980’s 

selection period. 

In space on IML-1 just before starting medical school 

Moving into N.A.S.A (and eventually, 

medicine) 

Whilst stationed in Japan on his third tour 

overseas, Hilmers heard that the Marines were 

offering forward candidates for consideration 

to the astronaut program. Given that his 

background was textbook in terms of the 

desired skillsets - flight/military experience, 

engineering and mathematics - he placed 

himself forward. One level after another, he 

cleared selection and eventually found himself 

as an astronaut-in-training, something which 

he considered entirely surprising. After a period 

of intense long-term preparation, training and 

eventually four on-orbit expeditions later, 

Hilmers decided that it was finally time to study 

medicine. Whilst it would have been incredible 

to hear more about this journey to N.A.S.A, 

it is his work following his time in space that 

really exemplifies the multifaceted nature of 

medicine and global health. 

26

Medical career and global health research 

experience 

After graduation and specialisation in 

Medicine/Paediatrics at the Baylor College of 

Medicine, Houston, Hilmers’ career branched out 

across all realms of medicine. Encompassing 

on-the- ground experience in disease outbreak 

areas, applying his engineering knowledge within 

a medical context, working with large soft-drink 

distributors (Coca Cola) and then finally more 

traditional faculty and hospital work, Hilmers’ 

practice has been anything but conventional. 

Discussing all he has done in retrospect, he 

did find it amusing that his background mirrors 

his life outlook; a “little bit of variety” being his 

exact words. 

The Smart Pod 

A notable outcome following Hilmers’ 

return from Liberia, however, was his ensuing 

attachment to a research team who were in 

the process of developing a rapidly deployable 

‘Emergency Smart Pod’ [1]. This pod is an on-site, 

versatile management centre and laboratory, 

with revolutionary potential with regards to 

disease outbreak and disaster response. Given 

his background, Hilmers was able to provide 

highly practical, ongoing advice; this came in the 

form of refining and redesigning early iterations, 

and increasing functionality and practicality. 

The pod, as it stands now, is a feat of modern 

science and engineering; touting high-tech 

computer systems with language and literacy 

programs, screening facilities, crowd control 

and Ebola-level handling capabilities. Hilmers 

humorously likened it to a space module. The 

pods are similar to shipping containers in size, 

but far lighter and more durable. In fact, they are 

built entirely from recyclable materials that can 

withstand extremes both hot and cold, and can 

be integrated with one another should the need 

arise. Clearly, the ability to treat, screen and 

mitigate disaster on-site will strengthen frontline 

medical workers domestically and abroad. 

Coca Cola and micronutrient deficiencies 

AIDS patient in Romania 

Starting his global health journey by touring 

overseas to Africa with the Baylor AIDS initiative, 

Hilmers subsequently went on to see AIDSravaged 

Eastern Europe post-collapse of the 

Soviet Union, and more recently was the Chief 

Physician of an Ebola treatment unit in Liberia 

during the outbreak. Whilst acknowledging 

the saddening reality of AIDS treatment and 

outcomes in the early days, Hilmers remarked 

that the experience was immensely educational 

and worthwhile. Indeed, it inspired him to 

continue his work with AIDS sufferers in local 

Houston. 

In terms of more typical research, Hilmers 

has been involved in a number of studies on 

health inequalities, with some interesting pieces 

focussing on effective delivery of micronutrients 

to nutrient-deficient communities. This work 

interestingly includes working with Coca Cola, 

given their not-so-surprising ability to source 

fresh, clean water for their drinks in even the 

most remote locations. The importance of this 

becomes clear with a bit of thought; considering 

Coca Cola’s highly efficient sourcing and 

distribution system, there is an opportunity to 

integrate fortified beverages into their product 

line. This has enabled access to otherwise 

inaccessible communities overseas, and 

disadvantaged communities domestically. This 

was notable, given the medical community’s 

overwhelming condemnation of Coca Cola’s 

27

soft-drinks in day-to-day practice. It’s a case 

that speaks to the astounding intricacy of global 

health work, and the manner with which problems 

can be solved in the most unconventional of 

ways. 

Life experience and medicine - how does 

everything relate? 

One of the things that became apparent 

to me regarding Hilmers’ work is an ability 

to extract the positive attributes needed in 

previous work, and apply them to his current 

setting. He credits his military training with giving 

him a “coolness under fire”, his engineering 

and mathematics background with a logical 

thought process, and finally his N.A.S.A flight 

experience with a systematic, step-by-step 

approach to problem solving - all experiences 

that have shown themselves to be invaluable. 

Therein lies a lesson for all students: take on 

board every opportunity to grow your skillset, 

as it will lend itself in ways that may not yet 

seem apparent This is, in fact, one of Hilmers’ 

central advocacy arguments for continued 

work on the International Space Station, 

that space exploration and experimentation 

confers benefits to medical practice that are 

not foreseeable, and vice versa. For example, 

treatments that are developed to deal with the 

marked muscle atrophy, bone loss and vision 

impairment associated with long-term space 

travel, can then be applied to everyday medical 

practice. 

Going forward - individual practitioners and 

the profession 

So, what advice did Hilmers have for future 

medical practitioners as we move into our 

practicing years? Principally, it is important to 

work in a practice or organisation that allows 

you to follow your passion. Be that working solely 

within the W.H.O or Medecins Sans Frontieres, 

or perhaps academia with concurrent research 

and clinical duties, there is a balance that every 

person needs to figure out for themselves. 

Indeed, Australia is unique in the tremendous 

scope of medical opportunities available. 

Depending on your location, you can experience 

tropical disease in the far north states, noncommunicable 

disease in the mid-states, and 

the reality of disadvantaged communities 

in rural-remote locations. This does beg the 

question as to whether global health lends 

itself more to international health, as it seems 

to be viewed traditionally, or universal well-being 

within your own context or circumstance. There 

are no borders, rules or regulations as to what 

constitutes “global health”, only the limits of our 

imagination and creativity. Regardless, if you 

want to work in global health, the first step is 

finding an area of medicine you have a burning 

passion for – the rest will follow as natural 

sequelae. 

Ebola protective gear 

As the mid-century approaches, the threat 

of climate change, antibiotic resistance and 

the management of ethical conundrums – such 

as gene editing and healthcare equity – are 

all very real problems that our generation will 

have to face. It was saddening to hear Hilmers 

recall scenes of polluted, diverted or dammed 

lakes from space, of burning forests and haze 

hovering over cities, but that is the reality we 

live in. It does, therefore, imply that we hold at 

least part of the solution to the problems we 

face. In what form the specific solution will 

take, however, only time can tell. It is, however, 

abundantly clear that in going forward we 

should learn from leaders like Professor David 

Hilmers, whose experience is entirely unique 

and profound. 

28

PrEP-related health promotion for 

Aboriginal and Torres Strait Islander 

gay and bisexual men 

[Review] 

Alec Hope 

Alec is a 4th year medical student at the University of New South Wales who is conducting qualitative research into the health 

promotion of PrEP to Aboriginal and Torres Strait Islander gay and bisexual men. Alec’s research interests include immunology, 

sexual health, and health inequality. He is looking forward to completing his last two years of medical school in Wagga Wagga. 

Abstract 

Aboriginal and Torres Strait Islander peoples experience significantly poorer health 

compared to the general Australian population. This health inequality is highlighted in 

comparisons between Indigenous and non-Indigenous sexual health. Pre-exposure 

prophylaxis (PrEP) is a new HIV prevention technology that protects gay and bisexual 

men. Social, economic, cultural and historical barriers may exist that prevent Aboriginal 

and Torres Strait Islander gay and bisexual men from accessing PrEP, and therefore widen 

the sexual health inequality that already exists. 

Introduction 

Aboriginal and Torres Strait Islander (hereafter 

‘Indigenous’) peoples living in Australia have significantly 

poorer health than non-Indigenous Australians,[1] inextricably 

linked to a history of disempowerment and oppression through 

colonialism.[2, 3] Indigenous Australians are often identified 

as a priority population for public health interventions due to 

their generally lower health status.[4] Discrepancies between 

Indigenous and non-Indigenous sexual health have been recontextualised 

as a human rights issue to draw awareness 

and urgency to the matter of inequity of sexual health 

between Indigenous and non-Indigenous Australians.[5] 

HIV and Indigenous Australians 

Human immunodeficiency virus (HIV) is a retroviral 

infection that is both blood-borne and sexually transmissible. 

HIV exhibits epidemiological differences between Indigenous 

and non-Indigenous Australians. Sexual contact between 

men is responsible for 75% of HIV notifications for non- 

Indigenous Australians, compared to only 

51% of HIV notifications amongst Indigenous peoples. 

[6] Twenty-one percent of Indigenous HIV notifications are 

attributable to injecting drug use and 16% to heterosexual 

contact.[6,7] Worryingly, since 2011, the age-standardised 

rate of Indigenous HIV notifications has been steadily rising 

despite nationwide slowing of HIV notifications in the general 

population.[8] In 2015, the age-standardised rate of new HIV 

notifications in Indigenous people was more than double 

that of non-Indigenous people (6.8 per 100,000 vs 3.1 per 

100,000).[6] 

Men who have sex with men (MSM) are at elevated risk 

of becoming infected with HIV compared to the general 

population. It is unclear how many Indigenous Australians 

identify as gay or bisexual, and many Indigenous MSM may 

not identify as gay or bisexual, sometimes due to stigma.[9] A 

survey of Indigenous youth aged 16 to 29 found 6% of male 

respondents identified as gay, 2% as bisexual, and a small 

but significant number as transgender.[10] 

Indigenous gay and bisexual men (GBM) and other MSM 

may be at increased risk of contracting HIV compared to 

non-Indigenous GBM. Indigenous peoples experience higher 

rates of sexually transmitted infections (STIs), namely 

gonorrhoea and chlamydia, particularly in remote areas. 

[6] The presence of an STI predisposes individuals to HIV 

infection.[7] Furthermore, Indigenous GBM report higher rates 

of risky sexual behaviours compared to non-Indigenous 

GBM.[11, 12] Rates of unprotected anal intercourse with 

casual partners are higher in Indigenous GBM compared 

to non-Indigenous, a known risk factor for HIV infection. 

[13] Likewise, illicit drug use before or during group sex 

was reported at higher rates in Indigenous GBM compared 

to non-Indigenous GBM.[11, 14] Coupled with the worrying 

epidemiological pattern of HIV notifications among injecting 

drug users and heterosexual people, these elevated rates 

of risk factors among Indigenous people could increase the 

risk of HIV transmission for Australia’s Indigenous peoples. 

[11] Indeed, steady increases in Indigenous HIV notifications 

and an elevated age-standardised rate of Indigenous HIV 

notifications are causes for concern (Figure 1).[6] 

A pill a day to prevent HIV 

Antiretroviral (ARV) medications have been used since 

the 1990s as an effective treatment for HIV. More recently, 

at-risk individuals have used ARVs as an effective HIV 

29

prevention method.[15] At-risk individuals can take one pill 

daily containing two antiretroviral medications, preventing 

replication of the virus within the body so that viral exposure 

is not seroconverted, thus preventing HIV infection.[16] 

Randomised control trials have found that ARVs taken as 

pre-exposure prophylaxis (PrEP) can prevent 40-99% of HIV 

infections when taken more than four times a week.[17-21] 

PrEP implementation trials are currently being run in New 

South Wales, Queensland, Victoria, South Australia, and 

the Australian Capital Territory. These trials are supported 

and funded by state health departments, allowing free or 

heavily discounted access to expensive drugs that cannot 

be accessed as PrEP via the Australian Pharmaceutical 

Benefits Scheme (PBS).[22] 

In New South Wales, the Kirby Institute runs the Expanded 

PrEP Implementation in Communities (EPIC) trial in 

conjunction with NSW Health. After a year of recruitment, over 

5000 at-risk individuals have been enrolled and given access 

to PrEP. Most of these participants are GBM, identified as 

being at high risk of HIV exposure.[13] This represents a major 

expansion from a small pilot study to a large demonstration 

trial. 

Are Indigenous gay and bisexual men accessing PrEP? 

Studies in the United States (US) have found that identified 

priority populations, including Black (African-American) men 

who have sex with men, may have difficulty in accessing PrEP 

compared to the general population. This may be due to lack 

of awareness about PrEP,[23] stigma,[24] poor healthcare 

coverage,[3] or lack of culturally-appropriate services 

providing access.[25] Indeed, Black men who have sex with 

men in the US were successfully recruited, engaged and 

retained in PrEP programs that employed “culturally-tailored 

techniques”.[26] 

Research shows that in order to target interventions 

like PrEP to Indigenous communities, culturally-appropriate 

services owned and governed by the community are in the 

best position to deliver positive health outcomes.[27-29] 

Likewise, health promotion materials should be designed and 

produced by the community for the community, and should 

avoid blocks of text and overly technical terminology.[30] 

Therefore, Aboriginal community-controlled health services 

(ACCHSs) may be best placed to help promote and educate 

PrEP to at-risk members of the community, facilitating 

referral to specialised sexual health clinics for assessment 

and preventative methods that may or may not include 

PrEP. ACCHSs provide holistic care, and are well equipped 

to focus on prevention and primary healthcare.[31] ACCHSs 

are considered manifestations of self-determination and 

autonomy for Indigenous communities.[29, 32] 

Self-determination in Indigenous Australian health 

services 

The United Nations has identified ACCHSs as best 

practice models of self-determination,[29] and the United 

Nations Declaration on the Rights of Indigenous Peoples 

advocates for the right of all peoples, especially Indigenous, 

to be able to “freely determine their political status and freely 

pursue their economic, social and cultural development”. 

[33] However, self-determination in healthcare alone cannot 

improve health outcomes. Secure, long-term funding coupled 

with equitable partnerships between Aboriginal communitycontrolled 

and mainstream health services is required to 

address the gap between Indigenous and non-Indigenous 

health.[29, 32] Facilitating community empowerment reduces 

the rates of HIV and STIs in female sex workers (FSWs) 

in low- and middle-income countries.[34, 35] Community 

empowerment in Australian FSWs during the initial years of 

the HIV epidemic was essential in enshrining effective HIV 

prevention focused on universal condom use among FSWs. 

[36] This case study could be applicable to the Indigenous 

population, and similar community empowerment in the 

form of well-funded ACCHSs may allow the gap between 

Indigenous and non-Indigenous health. 

Furthermore, Aboriginal Sexual Health Workers administer 

culturally-appropriate health services throughout Australia, 

increasing the involvement of Indigenous people in the 

healthcare workforce.[28, 37] However, Indigenous peoples 

need to be consulted and involved in the decision-making 

process and not just in the delivery of health services.[38, 39] 

Conclusion 

PrEP is touted as a crucial part of the HIV eradication 

strategy throughout the world. However, efforts to prevent HIV 

transmission may be hampered by a failure to engage priority 

populations, including Aboriginal and Torres Strait Islander 

Australians. PrEP implementation projects such as EPIC need 

to ensure adequate coverage of at-risk Indigenous peoples 

through culturally-appropriate health promotion and security 

of access to medication. This would be facilitated through 

the involvement of Indigenous Australians in the decisionmaking 

process. Further research will explore PrEP-related 

health promotion to Indigenous peoples and communities, 

and attempt to identify any gaps or facilitators. 

Figure 1. The age-standardised rate 

of new HIV notifications by Indigenous 

status.[8] 

30


Dr Bridget Haire, The Kirby Institute 

b.haire@unsw.edu.au 


None declared 


alecjulianhope@gmail.com 

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of and intentions to adopt HIV pre-exposure prophylaxis among black men 

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Relevant Clinical Trial for PrEP. 2016 International Aids Conference; 20 July 

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(STRIVE) study protocol: A cluster randomised controlled trial comparing 

‘usual practice’ STI care to enhanced care in remote primary health care 

services in Australia. BMC Infectious Diseases. 2013;13(1). 

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an Aboriginal community and cultural framework; lessons from NSW. N S W 

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BM, et al. Community mobilization, empowerment and HIV prevention among 

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P, Win KT, et al. A community empowerment approach to the HIV response 

among sex workers: effectiveness, challenges, and considerations for 

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I. Problems, Solutions and Actions: Addressing Barriers in Acute Hospital 

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31

Mental illness following disasters in 

Low Income Countries 

[Review] 

Rose Brazilek 

Rose Brazilek is a PhD candidate studying through the Australian Centre for Blood Disease 

at the Alfred Hospital. She has a keen interest in translational medical research and blood 

disorders. In the future, she hopes to specialise in haematology with a special interest in 

thrombosis and haemostasis. 

Abstract 

Disasters test the capacity of health infrastructure to act in a well-coordinated and adaptable manner, due to the unique 

nature of each event. While immediate provision of healthcare focuses on the physical consequences, the long term mental 

health ramifications of such events are often forgotten, and services are ill-equipped to deal with the mental illnesses 

arising from them. The inherent challenges to the public health response are compounded by the limitations experienced 

by Low to Middle Income Countries (LMIC). These countries may lack the fiscal resources to fund such interventions and 

have unstable socio-political environments, which may further complicate disaster response. It is by consideration of these 

limitations, risk factors specific to such countries, and cultural sensitivity then that effective, long-standing mental health 

interventions can be implemented. This paper will review the predisposing factors to mental illness development following 

disaster, particularly in respect to at-risk subpopulations, the impact of socio-political climate and low GDP on disaster 

response, and the development of effective, culturally-specific interventions. The intersection between low national GDP 

and poor mental health infrastructure often translates to poorer mental health outcomes following disaster. Women, 

people of low educational status and low income are especially predisposed to development of mental illness. Common 

mental health disorders include Post Traumatic Stress Disorder, depression and anxiety 

Introduction 

In Low and Middle Income Countries (LMIC), mental 

health care considerations of disaster survivors have taken 

a proverbial back seat, as the establishment of basic needs 

take priority.[1] Unfortunately, overwhelming evidence of 

causality between natural disasters and mental health issues 

has confirmed that provision of culture-specific mental 

health care is an integral part of the public health response 

following massive loss of life and injury to minimise longterm 

recovery ramifications, and a lack of these services 

negatively impacts survivors.[2] 

Psychosocial and mental health support programmes 

are increasingly being recognised as a crucial component 

of the humanitarian response to disasters.[3] However, 

disaster response coordination is notoriously complicated 

with numerous factors to consider, and lack of funding 

and resources in low income countries further limits health 

responses.[4] This paper will examine the predisposing 

factors to the development of mental illness in those affected 

by disaster in LMIC, and suggests potential preventative 

actions. 

Common mental health disorders arising from disasters 

Poor mental health in the immediate aftermath following 

disasters is to be expected in most survivors, the degree 

of suffering is affected by the nature of the experience, 

support networks, coping skills and the community response. 

[4] This suffering includes distress –situations in which the 

individual feels anger, fear, sadness or shame – emotional 

dysregulation, or emotional numbing, however these typically 

resolve without long-term consequences.[5] It is when they 

are sustained, and impact on daily functioning, that they 

are defined as a ‘mental illness’. The most common of 

these are the anxiety disorders, particularly Post Traumatic 

Stress Disorder (PTSD), in which the individual experiences 

heightened arousal, avoidance of triggers, and flashback 

episodes.[5] Other mood disorders commonly experienced 

include abnormal grief reactions and depression. 

Due to the decreased utilisation of health services, 

particularly mental health services around the world and 

especially in Low to Middle Income Countries (LMIC), 

individuals may attempt to self-medicate with alcohol 

and other substances.[4] This may lead to substance use 

disorders as a way to deal with stressors, by avoiding or 

displacing difficult emotions associated with disasters. This 

is especially common in patients with a history of substance 

use disorder in remission, as relapse is common following 

stressful events. 

Somatisation disorders also show increased incidence 

following disasters; a way for survivors to express emotional 

distress.[2] They are more likely to occur in individuals 

with other concurrent mental health diagnoses, such as 

PTSD. Various cultures approach emotional distress as 

irrational, and thus there are a number of culture-specific 

disorders that manifest in this way.[3] These include Latah, 

32

a condition originating in Southeast Asia in which individuals 

have an abnormal startle reaction; Koro, significant anxiety 

surrounding recession of genitalia; or Susto, a cultural 

variation of panic attacks originating in Latin America.[6] 

Knowledge and sensitivity surrounding these diagnoses 

may dramatically increase utilisation and efficacy of mental 

health programs in disaster areas. 

Predisposing factors to mental health disorder diagnosis 

There is a complex interplay between social dynamics 

and mental health diagnoses, and alteration for cultural 

context is an important consideration for any mental health 

intervention to be effective. Disasters have the potential to 

have a greater impact than initially considered because of 

the fear regarding the loss of long-held traditions that define 

the culture and community of those affected.[7] 

Gender 

Of people impacted by disaster in LMIC, females have 

been shown to have a higher overall likelihood of developing 

mental health disorders, particularly depression.[8, 9] 

Recognition of the specific cultural challenges that females 

face following a disaster may reduce the impact of events 

on their recovery. Females in LMIC often occupy roles of 

household responsibility, and women may therefore feel guilty 

regarding their lack of ability to tend to basic domestic tasks. 

Practical consideration may also mitigate some impact of 

the trauma; though shelters often offer gender-segregated 

areas, nursing mothers may be reluctant to feed in public 

spaces. Women may suffer additional mental strain or sexual 

harassment if they are obliged to use public toilet services, 

or if they are seen in wet clothing in traditionally modest 

countries. These considerations must be kept in mind for 

established relief facilities to be effective, particularly in the 

case of foreign aid provision. 

Low income 

The correlation between low income in LMIC and increased 

propensity towards poor mental health may be explained 

by the ‘reserve capacity model’.[5] This model states that 

as individuals have increasing background worries – for 

instance uncertainty regarding income and food shortages 

– their capacity to deal with additional stressors, as in the 

case of disaster, diminishes accordingly. It is well established 

that those of low Socio-Economic Status (SES) have poorer 

mental health, and often have the least access to services, 

either because lack of funding or locational difficulties.[10] 

Recognising low SES as a risk factor for the development 

of mental illness following disaster may allow more targeted 

relief efforts to be initiated. 

Formal education 

Education and financial stability may also influence 

recovery and disease development.[10] One of the key 

areas preventing development of LMIC is the lack of 

formal education of its citizens. This may also influence 

coping capacity following a disaster. On a practical level, 

educated individuals have an increased ability to cope 

with documentation demands, applications and resource 

seeking. This accordingly reduces the stress and impact 

of coping following disasters. Similarly, financial status may 

impact individuals at every stage of disasters. Those with 

lower incomes may have poorer quality of life and less safe 

dwellings, and are thus most predisposed to damage in the 

event of disasters.[11] Additionally, poor financial reserves 

may make it difficult to repair houses, and thus affects 

post-disaster recovery as well as the reserve capacity of 

individuals. 

At-risk subpopulations 

Children 

Children are amongst the most vulnerable groups to 

disasters.[12] Negative long-term effects on paediatric 

wellbeing include increased incidence of PTSD, depression, 

and life dissatisfaction. Children may lose one or both parents 

due to disasters, potentially leaving them without a primary 

caregiver in areas with inadequate infrastructure such as 

education to meet their needs. 

Such events have been showed to have a deleterious 

impact on school performance, particularly in young males. 

[13] In countries where education level has a direct correlation 

with lifetime health quality, lack of access to education may 

drastically alter an individual’s life course, as well as the 

overall poverty level of the affected country. Schools, if still 

operational, may provide invaluable facilities for mental 

health support for students following natural disaster events 

in LMIC. Schools provide a relatively stable environment for 

observation and continued support, and they may bring a 

sense of normalcy back to areas ravaged by disaster.[14] 

Aid workers 

A specific challenge is to assess and care for the first 

responders and aid workers who assist in relief work following 

a disaster. All rescue workers have a higher risk of chronic 

distress following exposure to an incident; although several 

elements, such as years of experience, perceived locus of 

control and social support; may mitigate development of 

disease.[15] These factors are important as responders 

are often foreign aid workers, operating without existing 

infrastructure and in unfamiliar environments devoid of a 

support network. Though they are often briefed beforehand 

and may receive training to prevent long-term mental health 

consequences, such workers are often volunteers with 

minimal experience. There is also some degree of stoicism 

amongst these volunteers, as their degree of suffering is 

judged to be far less than that of the people they are assisting. 

Specific considerations in LMIC 

The impact of disasters in LMIC appears to be far greater, 

in part due to the fragility of their existing infrastructure, and 

the lack of significant financial reserves to rebuild and support 

affected communities.[3] It is expected that encroaching 

urbanisation and industrialisation of developing counties will 

33

increase the incidence of disasters – both man-made and 

natural – and that developing countries will be most affected 

in terms of number and severity. It has been shown that the 

risk of PTSD also rises proportionate to increase in severity 

and frequency of such events.[15] 

Several factors worsen the impact of disasters. Houses 

are often of inferior build quality, which reduces the ability 

to withstand severe forces.[7] Slums and communities 

experiencing poverty are also likely to be built in disasterprone 

areas such as flood plains because their inhabitants 

are unable to obtain property in safer areas. 

In the immediate aftermath of these events, LMIC may 

struggle to adequately treat the problems of their citizens 

due to limited training and capacity of healthcare and 

aid professionals.[10] The World Health Organization has 

recognised the role of unskilled aid workers in assessing 

mental health conditions and have devised a framework to 

use in these circumstances.[16] Untrained or poorly-organised 

humanitarian aid and destruction of primary infrastructure 

may also constitute secondary stressors following natural 

disasters and may compound the initial trauma of the 

event. Improper, or lack of, information dissemination may 

lead to anxiety and depression about food distribution, with 

negatively impacts on community wellbeing.[3] 

Determinants of effectiveness of public health responses 

One of the difficulties surrounding mental health disaster 

response is the changeable nature of the assistance 

required. Systems required in the immediate aftermath to aid 

those dealing with loss, physical impairment and adaptation 

to a different way of life are vastly different as some people 

return to their original occupations and homes.[3] Pre-disaster 

planning should involve a multidisciplinary team of healthcare 

professionals, infrastructure experts and politicians to create 

lasting policies that are effective and easily implemented. 

Disparities in the availability, accessibility and quality of 

mental healthcare due to ethnicity are well-documented. This 

may be due to language barriers, fears regarding insurance 

and monetary constraints, geographical difficulties 

(especially in rural communities), mental health stigma and 

lack of education.[7] Addressing these barriers may increase 

uptake of such services and reduce the incidence of mental 

health-related decrease in quality of life for those most at 

risk. 

Solutions include the validation and normalisation of 

distress reactions, so individuals feel they are experiencing 

legitimate reactions, rather than moments of weakness. 

[7] It is important to recognise the role of communities and 

to establish programs which value interdependence rather 

than independence in such situations. Promoting community 

action and initiatives will increase community resilience and 

realisation of the true impact of shared events. 

Cultural competence and sensitivity in foreign aid workers 

is essential to effective integration of support services, 

as well as the recognition that cultural competence is an 

ongoing learning process rather than an end-state.[16] It 

is important to identify the causes of potential stigma and 

mistrust in order to properly engage minorities in healthcare. 

Rituals and traditions from the cultures of those affected may 

also be utilised and integrated into care solutions, thus using 

innovative interventions to circumvent such difficulties. Finally, 

it is critical that aid workers and all stakeholders advocate, 

facilitate and conduct research into the incidence of mental 

illness and effective treatment solutions for mental illness in 

affected populations to increase efficacy of interventions in 

the future.[1] 

Disaster-derived mental illness: a contemporary 

perspective 

Disasters today are often man-made, as in the case of 

conflict. There is scarce research into the impact of such 

political conflict in LMIC. Of the research exists, it has been 

shown that women and people with a past history of mental 

illness have the greatest risk of developing mental disorders 

post-event.[17] Higher levels of constant political terror – 

measured on a scale that stratified countries according 

to the frequency of politically-motivated crises – directly 

correlated with higher rates of PTSD and depression.[18] 

Resource limitation directly impacts on the quality and 

quantity of care provided because LMIC must allocate fiscal 

resources frugally. They often chose to apportion money 

only to the most severely-affected populations, where the 

greatest benefit would be attained. This, in addition to the 

deterioration of healthcare services in wartime, culminates 

in a dearth of services for all but the most severely affected. 

The current global political climate, with the rise of 

nationalism and the unprecedented numbers of people 

displaced by conflict worldwide, also raise a number of 

considerations with respect to disaster preparedness. 

[19] There are more people displaced by conflict than ever 

before, seeking relocation in countries with greater stability 

and economic opportunity. The mental health of refugees 

is also influenced by the circumstances in the country of 

their resettlement. For example, a study of Latino and Asian 

refugees arriving in America found that those who experienced 

discrimination, unemployment or who experienced uncertainty 

due to unpredictable health insurance had lower self-rated 

mental health.[19] These post-settlement factors had a 

greater impact on their mental health than pre-settlement 

trauma, including war-related trauma.[19] This reflects the 

detrimental effect of hostile attitudes from the host country 

towards displaced individuals, and should be considered in 

the provision of mental health services for these affected 

communities. 

The impact of political instability on disaster responses 

in LMIC was also demonstrated following the earthquake in 

Nepal’s Gorkha region. Nepal has a GDP of only $20 billion 

USD, and an extremely limited capacity to fund disaster 

relief operations. Political instability and slow constitutional 

development following abolition of the region’s monarchy has 

prevented ratification of rigorous governance surrounding 

disaster prevention efforts, such as building codes, which 

may have reduced the impact of such an event. 

34

Conclusion 

Considerations regarding the provision of mental health 

support to people in LMIC following disasters rely on a complex 

interplay between existing culture, socio-political climate 

and financial constraints hindering relief and prevention 

efforts. This review has identified that potential avenues for 

improvement of mental health services in disaster responses 

include: identification of most at-risk subpopulations 

including low SES; active integration of cultural sensitivity in 

in the provision of mental health support; and measures to 

address barriers in uptake of care. Though further research 

is needed into the impacts of disaster in LMIC, governments 

must actively engage in policy development before these 

events occur and learn from previous experiences to protect 

their citizens from long-term mental health implications of 

disasters. 

14. Thapa K. Mental Health in Post-Earthquake Nepal. Nepal Journal of 

Epidemiology.5(4):520-1. 

15. Marmar CR, Weiss DS, Metzler TJ, Delucchi KL, Best SR, Wentworth 

KA. Longitudinal Course and Predictors of Continuing Distress Following 

Critical Incident Exposure in Emergency Services Personnel. The Journal of 

Nervous and Mental Disease.187(1):15-22. 

16. Zhang Y, Baik SH. Race/Ethnicity, disability, and medication 

adherence among medicare beneficiaries with heart failure. Journal of 

general internal medicine. 2014;29(4):602-7. 

17. Ostadtaghizadeh A, Soleimani SV, Ardalan A. Health Consequences 

and Management of Explosive Events. Health in Emergencies and Disasters 

Quarterly.1(2):71-8. 

18. Charlson FJ SZ, Degenhardt L, Chey T, Silove D, Marnane C. Conflict 

in Libya on Population Mental Health: PTSD and Depression Prevalence and 

Mental Health Service Requirements. PLoS ONE.7(7):e40593. 

19. Kim I. Beyond Trauma: Post-resettlement Factors and Mental Health 

Outcomes Among Latino and Asian Refugees in the United States. Journal 

of Immigrant and Minority Health.18(4):740-8. 


None 


None declared 


rose.brazilek1@monash.edu 

References 

1. Galea S, Brewin CR, Gruber M, Jones RT, King DW, King LA, et al. 

Exposure to hurricane-related stressors and mental illness after Hurricane 

Katrina. Archives of general psychiatry. 2007;64(12):1427-34. 

2. Treatment CfSA. Trauma-Informed Care in Behavioral Health 

Services. 2014. US. 

3. McFarlane AC, Williams R. Mental health services required after 

disasters: learning from the lasting effects of disasters. Depression research 

and treatment.1:970194. 

4. Norris FH, Friedman MJ, Watson PJ. 60,000 disaster victims speak: 

Part II. Summary and implications of the disaster mental health research. 

Psychiatry: Interpersonal and biological processes. 2002;65(3):240-60. 

5. Gallo LC, Bogart LM, Vranceanu AM, Matthews KA. Socioeconomic 

status, resources, psychological experiences, and emotional responses: 

a test of the reserve capacity model. Journal of personality and social 

psychology.88(2):386-99. 

6. Fergusson DM, Horwood LJ, Boden JM, Mulder RT. Impact of a major 

disaster on the mental health of a well-studied cohort. JAMA psychiatry. 

2014;71(9):1025-31. 

7. Norris FH, Alegria M. Mental health care for ethnic minority individuals 

and communities in the aftermath of disasters and mass violence. CNS 

spectrums. 2005;10(2):132-40. 

8. Kar N, Bastia BK. Post-traumatic stress disorder, depression and 

generalised anxiety disorder in adolescents after a natural disaster: a 

study of comorbidity. Clinical Practice and Epidemiology in Mental Health. 

2006;2(1):1-7. 

9. Nahar N, Blomstedt Y, Wu B, Kandarina I, Trisnantoro L, Kinsman 

J. Increasing the provision of mental health care for vulnerable, disasteraffected 

people in Bangladesh. BMC public health.14:708. 

10. Lima BR, Pai S, Santacruz H, Lozano J. Psychiatric disorders among 

poor victims following a major disaster: Armero, Colombia. J Nerv Ment 

Dis.179(7):420-7. 

11. Sathyanarayana Rao TS. Managing Impact of Natural Disasters : 

Some Mental Health Issues. Indian Journal of Psychiatry.46(4):289-92. 

12. Catani C, Jacob N, Schauer E, Kohila M, Neuner F. Family violence, 

war, and natural disasters: A study of the effect of extreme stress on 

children’s mental health in Sri Lanka. BMC Psychiatry. 2008;8(1):1-10. 

13. Kar N, Jagadisha, Murali N. Post-traumatic stress disorder in children 

following disaster. Kerala Journal of Psychiatry. 2001;16. 

35

Factors that contribute to the reduced rates 

of cervical cancer screening in Australian 

migrant women - a literature review 

[Review] 

Archana Nagendiram 

Archana is a fourth year medical student from James Cook University with interests in 

global health and women’s health. 

Abstract 

AIM: This literature review presents factors that have led to decreased cervical cancer screening rates in Australian 

migrant women. It also evaluates past interventions that have been implemented to solve this issue in screening. 

METHODS: A wide range of peer reviewed articles from databases such as CINAHL and SCOPUS were analysed to 

determine factors that have led to migrant women having a lower cervical cancer screening rate in comparison to 

the general Australian population. This review also analysed the reference lists from these articles. 

RESULTS: The factors that have led to this reduction in screening rates include cultural differences, limited acculturation, 

modesty, and logistical issues. Specific cultural issues such as female genital mutilation and the use of Ayurvedic 

medicine in certain ethnic groups may also contribute. There have been interventions aimed at increasing screening 

rates, including ethnic media campaigns and education of health professionals, such as doctors and nurses who 

work in these communities. However, their effectiveness is uncertain due to a lack of evaluation after implementation. 

CONCLUSION: Whilst research has provided a basic understanding of the reasons that have contributed to 

the difference in screening between these two populations, there have been insufficient strategies applied to 

remedy it. Moreover, there has been inadequate appraisal of current interventions and discussion of the cultural 

appropriateness of current programs. 

Introduction 

This year, the Australian government has renewed the 

National Cervical Cancer Screening Program (NCSP) to 

incorporate updated screening protocols in accordance 

to new research. Hence, it is important to assess the value 

of the previous screening protocols in underscreened 

populations such as Australia’s migrant women. From 2012- 

2013, 58.2% of the target population partook in the NCSP 

and since the introduction of organised cervical cancer 

screening in Australia, cervical cancer mortality has fallen 

by 44% (95% CI 0.51-0.62).[1,2,3] Whilst migrant women 

have benefited from screening, the results have not been 

as favourable in comparison to the general population. The 

incidence of cervical cancer is higher in migrant women from 

countries with higher incidence of cervical cancer, including 

Sub-Saharan Africa, Central America, South East Asia and 

Melanesia.[1] 

Consequently, this paper will examine relevant literature 

since the current NCSP’s introduction in 1991. It will analyse 

the factors that have caused lower screening rates in 

migrants, at the level of both the individual and the health 

system. It will also analyse past and future interventions that 

may reduce these disparities evident in the rates of cervical 

cancer screening in Australian migrant women. 

Methods 

This literature review used various online databases to 

source information. It concentrated on articles that surveyed 

Australian migrant women, however some larger international 

studies were also used to provide global context. CINAHL 

was searched with keywords “cervical cancer AND migrant 

women”, and SCOPUS was searched with the key words 

“cervical cancer AND migrant AND Australia”. Only peer 

reviewed journal articles were used, and opinion papers were 

excluded in the search. Relevant articles since 1991 were 

analysed, from the implementation of the NCSP in Australia. 

Additionally, reference lists of relevant articles were examined 

using similar inclusion criteria. 

What is a pap smear? 

Pap smears are the recommended primary screening tool 

for cervical cancer by the NCSP. During the procedure, the 

doctor collects a cytological sample from the ectocervical 

and endocervical canal of the uterus, which is then analysed to 

see if any pre-cancerous or cancerous changes are present. 

If a cytological abnormality is identified, the patient will then 

be referred for colposcopy.[4] Pap smears are routinely 

used in general practice and account for approximately 1.7 

of 100 consultations.[5] Disease incidence and burden is 

reduced in Australia through organised screening for cervical 

36

cancer. A key strategy lies in general practitioners instigating 

accessible screening, recall systems and opportunistic 

screening in their practice.[6] 

Factors that prevent regular screening 

Lack of Knowledge 

Prior to living in Australia, many migrant women from 

developing countries had never heard of cervical cancer 

screening or understood the risk factors associated with the 

disease.[7] This is the result of a lack of organised screening 

programs in countries such as Ghana and Vietnam, as their 

health systems lack the appropriate human resources and 

infrastructure to support such programs.[8,9,10] Hence, 

Australian general practitioners are key in providing health 

education to new migrant women about the NCSP. A 

qualitative study of 21 West African women in Australia 

showed that they became informed about pap smears via 

public health campaigns and from antenatal care during 

pregnancy in Australia. After this initial point of contact, they 

had their first pap smear after their pregnancy and then 

received reminders every two years.[8] Although migrant 

women of reproductive age were educated through these 

campaigns, post-menopausal women who have a greater 

risk of cancer with age were neglected.[11] 

Even with health education on cervical cancer, it appears 

that migrant women still have a misconstrued understanding 

about the NCSP or why they require a pap smear.[8,12] 

The surveyed West African migrant women believed that 

they did not require a pap smear without a family history of 

cervical cancer.[8] Thai and Chinese migrant women also 

had misconceptions about the risk factors of cervical cancer 

which included promiscuous behaviour, karma or having a 

sexual partner who had unhygienic genitalia.[7,13] Some 

Chinese migrant women did not understand the role of pap 

smears as a screening tool and none of the surveyed women 

were aware of the role of Human Papillomavirus (HPV) 

in cervical cancer.[7] Furthermore, these migrant women 

believed they did not require a pap smear as they were 

asymptomatic, had no family history and only had one sexual 

partner.[7,8] 

Cultural Factors 

Language is a common barrier for women from non-English 

speaking backgrounds (NESB). Migrant women have a strong 

preference to see a doctor who speaks their native language, 

regardless of their English proficiency, as it allows for clearer 

articulation of their concerns, particularly regarding intimate 

procedures.[7] However, a study of migrant women from NESB 

portrayed that 75.1% of the surveyed women would prefer 

female health providers to male practitioners to conduct their 

pap smear, and only 36.4% would travel a large distance 

to see a doctor who spoke their own language.[14] Another 

study of Thai immigrant women analysed that 61% would 

prefer a female general practitioner to perform the pap smear 

due to embarrassment.[13] This implied that modesty was 

important to migrant women from a NESB, especially as the 

newer migrant population often were from very conservative 

cultures in the discussion of sexual and reproductive health 

is surrounded by stigma.[8] Additionally, cultural beliefs about 

maintaining purity may also affect cervical cancer screening, 

with Assyrian migrants believing that unmarried women 

should not have pap smears as premarital sex is prohibited. 

[15] Throughout the literature, it appears that migrant women 

feel vulnerable and embarrassed during their pap smears 

and would ideally prefer a female doctor who spoke their 

language to assist them.[7,8,12] 

Moreover, there are factors that are culturally specific, such 

as female genital mutilation (FGM) and the use of Ayurvedic 

medicine. Approximately 130 million females worldwide have 

experienced FGM, mainly in Asia, the Middle East and Africa. 

[16] Migrant women with FGM may not wish to undergo pap 

smears due to pain, both physical and psychological, and 

the reminder of the initial traumatic experience.[8] Ayurvedic 

medicine is practised throughout Asia. A study of Thai women 

in Brisbane showed these women saw a variety of alternative 

medical practitioners; including naturopaths, chiropractors, 

herbalists and traditional Chinese healers; both in Australia 

and Thailand.[13] As these women would often rely on these 

traditional methods for medical care, they were less likely 

to present to their general practitioner for ailments and thus 

have a reduced chance of undertaking opportunistic cervical 

cancer screening. 

Finally, the time since migration to Australia is directly 

proportional to a woman’s probability of having regular pap 

smears.[7] As acculturation occurs, the individuals becomes 

more integrated into the Australian community and start to 

adopt health preventative behaviours.[13] Single migrants or 

those who are married to other migrants took the longest time 

to adjust to the health system. On the other hand, migrants 

who married an Australian or had a catalytic health event, 

such as the birth of a child, had a faster trajectory to health 

acculturation.[12] 

Other Factors 

Various factors further contribute to the lower participation 

of migrant women in cervical cancer screening. Several 

migrant women from Asia and the Middle East hold a fatalistic 

view of health and believe that screening is superfluous, as 

they have no control over their destiny.[19] Migrant women 

from Yugoslavian and West African communities describe 

their fear of their results and do not wish to start looking for 

problems that did not exist.[8,20] Similar to women in the 

general population, Chinese Australian women describe how 

previous negative experiences have deterred them from 

having regular pap smears.[7] Additionally, they may simply 

forget or have logistical barriers that prevent regular pap 

smears, such as lack of transportation or childcare.[7,20] 

Interventions 

From 2002 to 2011, the Australian Research Council 

(ARC) spent 7.8% of their funding for people-related research 

on the migrant population; insufficient considering migrants 

comprise over a quarter of the Australian population. 

[21,22] Moreover, the lack of funding for migrant research 

37

does not allow for the provision of strongly evidencebased 

interventions into migrant health, especially as data 

is not available as to the amount of ARC funding allocated 

specifically to cervical cancer screening.[22] Nonetheless, 

using available Australian data supplemented with some 

international publications, the following conclusions can be 

drawn about the effectiveness of past interventions and 

discussion of what is required for future success. 

Educational Campaigns 

Migrant women state that they largely receive information 

about cervical cancer from health professionals and public 

media campaigns. Therefore, the lack of awareness about 

pap smears must be targeted in both health and community 

settings; through general practice, migrant resource centres 

and community centres.[8] General practitioners play a key role 

in advocating for cervical cancer screening in consultations 

and through reminder letters, as migrant women who have 

never had a pap smear may not be comfortable asking for 

the test.[7,8,23] Similarly, the use of nurses in community, 

refugees health, women’s health, and child and family health 

is key in facilitating discussions regarding cancer screening 

amongst the migrant population.[8] 

The Ethnic Communities Council of Queensland (ECCG) 

created the Pilot Cancer Screening Education Program 

(PCSEP) which identified cervical cancer screening levels in 

various migrant populations before and after their program. 

In this program, 76% of participants participated in cervical 

cancer screening and this increased to 91% after the PCSEP. 

[24] Yet as this result was not statistically significant, we 

cannot confirm that this target program would be successful 

in increasing cervical cancer screening rates in migrant 

populations. 

Cultural Sensitivity 

As cultural factors play a key role in the decreased 

screening rate amongst migrant women, it is essential for 

Australian doctors to undertake cultural sensitivity training. 

This may improve understanding of factors affecting women 

from certain cultures such as modesty and fatalistic views of 

health.[7] This will allow health practitioners to appropriately 

tailor their consultations and the way that they promote 

cervical cancer screening with their migrant patients. 

There may also be reduced rates of cancer screening 

referrals from migrant doctors to patients of their own 

nationality. A study of Korean American doctors showed 

that there were reduced referral rates of colorectal cancer 

screening for their Korean patients. This was because they 

understood the cultural sensitivities surrounding cancer 

screening and perceived that compliance would be lower 

amongst their Korean patients.[25] It is key for doctors 

providing carer to patients of the same nationality to undergo 

training in cancer screening. The significance of bilingual 

health practitioners cannot be underestimated, as migrants 

prefer to see practitioners of the same nationality.[7,23] In 

the Vietnamese community, information sessions for bilingual 

practitioners about cervical cancer has been documented, 

but the effectiveness of this intervention has not been 

assessed.[23] 

Use of ethnic media 

Previous interventions have used ethnic media as a health 

promotion strategy to increase cervical cancer screening in 

various migrant populations.[23,26] Between 1991 and 1994, 

Pap Test Victoria conducted three sets of interventions in 

ethnic media outlets for over 12 migrant groups including 

Vietnamese, Chinese, Arabic and Turkish populations. 

During these interventions, the respective ethnic media 

outlets conducted live interviews, paid announcements and 

competitions with prizes. These three interventions led to an 

increase in screening compliance by 6.7% (95% CI 4.4-9.2). 

[26] As ethnic media can be utilised for health promotion and 

appears to be an effective method of increasing screening 

uptake, funding should be allocated for a nationwide ethnic 

media campaign on cervical screening. 

Conclusion 

Lower rates of cervical cancer screening in migrant 

women is a multifaceted issue. Factors contributing to these 

lower rates include lack of knowledge, cultural differences, 

limited acculturation and logistical issues. While research has 

been undertaken to understand the cause of the decreased 

participation of migrant women in regular pap smears, there 

have not been sufficient evidence-based interventions to 

address the issue. Although the government has redesigned 

the NCSP to reflect current medical research, there has 

been little evaluation of the cultural appropriateness of the 

current NCSP and the effectiveness of previous interventions 

to increase participation amongst the migrant population. 

The renewal of the NCSP should parallel the increased 

number of research projects that occurred during its initial 

implementation, as this is necessary to provide updated 

information on cervical cancer screening to migrant 

women. This will then allow for the application of evidencebased 

interventions to increase pap smear rates in this 

underscreened population. 


None 


None declared 

References 

1. Aminisani N, Armstrong BK, Egger S, Canfell K. Impact of 

organised cervical cancer screening on cervical cancer incidence and 

mortality in migrant women in Asutralia. BMC Cancer. 2012;12(1):491-501. 

2. Australian Institute of Health and Welfare. Cerivcal screening in 

Australia 2012-2013. [Internet]. 2015 [updated 2015 May 1; cited 2017 

May 20]. Available from: http://www.aihw.gov.au/WorkArea/DownloadAsset. 

aspx?id=60129550872. 

3. Simonella L, Canfell K. The impact of a two- versus three-yearly 

cervical screening interval recommendation on cervical cancer incidence 

and mortality: an analysis of trends in Australia, New Zealand, and England. 

Cancer Causes Control. 2013;24(9):1727-1736. doi: 10.1007/s10552-013- 

0250-9. 

4. Shader RI. The PAP test and the pap smear. Clin Ther. 

38

2015;37(1):1-3. doi: 10.1016/j.clinthera.2014.12.002. 

5. Australian Institute of Health and Welfare. General practice 

activity in 2009-10. [Internet]. 2010 [updated 2010 Dec 8;cited 2017 May 5]. 

Available from: http://www.aihw.gov.au/publication-detail/?id=6442472433. 

6. Munro A, Pavicic H, Leung Y, Westoby V, Steel N, Semmens J et al. 

The role of general practitioners in the continued success of the National 

Cervical Screening Program. Aust Fam Physician. 2014;43(5):293-296. 

7. Kwok C, White K, Roydhouse JK. Chinese-Australian women’s 

knowledge, facilitators and barriers related to cervical cancer screening: 

a qualitative study. J Immigr Minor Health. 2011;13(6):1076-1083. doi: 

10.1007/s10903-011-9491-4. 

8. Ogunsiji O, Wilkes L, Peters K, Jackson D. Knowledge, attitudes 

and usage of cancer screening among West African migrant women. J Clin 

Nurs. 2013;22(7-8):1026-1033. doi: 10.1111/jocn.12063. 

9. Sankaranarayanan R, Nessa A, Esmy PO, Dangou JM. Visual 

inspection methods for cervical cancer prevention. Best Pract Res Clin 

Obstet Gynaecol. 2012;26(2):221-232. doi: 10.1016/j.bpobgyn.2011.08.003. 

10. Lesjak M, Hua M, Ward J. Cervical screening among immiagrant 

VIetnamese women seen in general practice: current rates, predictors 

and potential recruitment strategies. Aust NZ J Public Health. 1999; 23(2): 

168-173. 

11. White MC, Holman DM, Boehm JE, Peipins LA, Grossman M, 

Henley SJ. Age and cancer risk: a potentially modifiable relationship. Am J 

Prev Med. 2014;46(3 Suppl 1):S7-15. doi: 10.1016/j.amepre.2013.10.029. 

12. Terry D, Ali M, Le Q. Asian migrants’ lived experience and 

acculturation to Western health care in rural Tasmania. Aust J Rural Health. 

2011;19(6):318-323. doi: 10.1111/j.1440-1584.2011.01229.x. 

13. Jirojwong S, Manderson L. Beliefs and Behaviors About 

Pap and Breast Self-Examination Among Thai Immigrant Women in 

Brisbane, Australia. Women & Health. 2001;33(3-4):53-73. doi: 10.1300/ 

J013v33n03_04. 

14. Henderson S, Kendall E, See L. The effectiveness of culturally 

appropriate interventions to manage or prevent chronic disease in culturally 

and linguistically diverse communities: a systematic literature review. 

Health Soc Care Community. 2011;19(3):225-249. doi: 10.1111/j.1365- 

2524.2010.00972.x. 

15. Ussher JM, Rhyder-Obid M, Perz J, Rae M, Wong TWK, Newman 

P. Purity, Privacy and Procreation: Constructions and Experiences of Sexual 

and Reproductive Health in Assyrian and Karen Women Living in Australia. 

Sexuality & Culture. 2012;16(4):467-485. doi: 10.1007/s12119-012-9133-6. 

16. Allen B, Oshikanlu R. Female Genital Mutilation: A practical guide 

for health visitors and school nurses. Community Pract. 2015;88(12):30-33. 

17. Taylor RJ, Mamoon HA, MOrrell SL, Wain GV. Cervical Screening 

in Migrants to Australia. Aust NZ J Public Health. 2001; 25(1): 55-61. 

18. Wain G, Morrell S, Taylor R, Mamoon H, Bodkin N. Variation 

in cervical cancer screening by region, socio-economic, migrant and 

Indigenous status in women in New South Wales. Gynecol. Oncol. 2001; 

41(3): 320-325. 

19. Aminisani N, Armstrong BK, Canfell K. Cervical cancer screening 

in Middle Eastern and Asian migrants to Australia: a record linkage study. 

Cancer Epidemiol. 2012;36(6):e394-400. doi: 10.1016/j.canep.2012.08.009. 

20. Fernbach M. Exploration of factors linked with high cervical 

cancer rates in women from the former Yugoslavia in Victoria, Australia. 

Ethn Health. 2002;7(3):209-220. doi: 10.1080/1355785022000042033. 

21. ABS. 3412.0 - Migration, Australia (2013-2014). website. http:// 

www.abs.gov.au/ausstats/abs@.nsf/mf/3412.0. Published 2015. 

22. Renzaho A, Polonsky M, Mellor D, Cyril S. Addressing migrationrelated 

social and health inequalities in Australia: call for research funding 

priorities to recognise the needs of migrant populations. Aust Health Rev. 

Jul 13 2015. doi: 10.1071/AH14132. 

23. Cheek J, Fuller J, Gilchrist S, Maddock A, Ballantyne A. 

Vietnamese women and pap smears: issues in promotion. Aust NZ J Public 

Health. 1999. 

24. Cullerton K, Gallegos D, Ashley E, et al. Cancer screening 

education: can it change knowledge and attitudes among culturally and 

linguistically diverse communities in Queensland, Australia? Health Promot 

J Austr. Jun 29 2016. doi: 10.1071/HE15116. 

25. Jo AM, Maxwell AE, Rick AJ, Cha J, Bastani R. Why are Korean 

American physicians reluctant to recommend colorectal cancer screening 

to Korean American patients? Exploratory interview findings. J Immigr Minor 

Health. Aug 2009;11(4):302-309. doi: 10.1007/s10903-008-9165-z. 

26. Mitchell H, Hirst S, Mitchell JA, Staples M, Torcello N. Effect of 

ethnic media on cervical cancer screening rates. Aust N Z J Public Health. 

1997; 21(2). 265-267. 

39

Medical electives in resource-poor settings: 

Are we doing more harm than good? 

[Review] 

Gabrielle Georgiou 

Gabrielle is a final-year medical student (VI) at the University of New South 

Wales. She has a particular interest in global health and medical education. 

Abstract 

Medical students from around the world desire ever-increasing global health experiences and education, 

particularly from international medical electives. However, while elective experiences offer a number of 

potential benefits for students and sending institutions alike, recent evidence suggests that significant 

practical, social and ethical challenges may result, specifically in resource-poor settings. Ideally, there 

should be an opportunity for students to engage with elements of a global health program or some form 

of pre-departure training prior to undertaking a medical elective, with the aim being to engage with social 

determinants of health, and aspects of service learning. Furthermore, additional research is required to 

ensure that medical electives do not detract in any way from the pursuit of global health equity and the 

provision of care in these locations. 

Introduction 

Interest in international medical electives is burgeoning, 

with medical students from around the world desiring global 

health content in their curricula,[1] and greater discovery 

traversing international socio-cultural borders.[2-8] In the 

United States, for example, of ninety-six medical schools 

surveyed, 87% reported availability of international clinical 

electives, 45% offered preclinical research abroad, and 

61% offered international opportunities over school holidays. 

[9] Here in Australia, international health is often explored in 

medical schools through compulsory elective terms, which 

typically occur over a period of 6-8 weeks and may take 

place in developing countries.[1] 

Medical electives may involve experiences in developing 

nations with pronounced inequities in health and socioeconomic 

development.[1, 10] Such electives have been 

described in the literature with various terms - from 

‘international medical experiences’, ‘global health programs’, 

‘medical electives’, and ‘global health experiences’, to the 

use of other, more controversial definitions, such as “medical 

voluntourism”, “fly-by medical care”, or “duffel-bag medicine”. 

[6] While elective experiences offer potential benefits for 

medical students and sending institutions alike, recent 

evidence suggests the potential for significant practical and 

ethical challenges, exacerbating global health inequities.[2-4, 

7, 8, 11-14] 

Motivations 

Certain factors appear to influence student involvement 

in medical electives. These include altruistic intent, curiosity, 

having a sense of adventure and hopes of language 

development, as well as the allure of the opportunity to 

experience medical practice outside the scope of one’s 

normal hospital and community setting.[15] Other benefits 

which may result from experiencing a medical elective include 

the prospect of improving clinical skills, enabling personal 

transformation,[12] increasing tropical medicine knowledge, 

gaining cross-cultural competency, and improving overall 

confidence, independence and resourcefulness levels.[5] 

Benefits 

Electives may offer an ideal setting for students to engage 

with preventative health measures that are utilised around 

the world.[9] Students can develop a greater understanding 

of effective resource management and public health 

strategy implementation, improve their awareness of the 

social determinants of health, and improve their competency 

as global health advocates.[5] There is also evidence that 

students’ increase their willingness to assist underserved 

populations and levels of social responsibility when they 

experience medicine in another country, particularly in the 

developing world.[9, 16] 

International medical experiences are also said to 

facilitate the process of service learning- that is, a structured 

learning style incorporating community service, experiential 

learning, as well as adequate preparation and reflection.[9, 

17] Consciousness-raising, self-efficacy, and networking 

capability, are three notable outcomes which may be 

facilitated by this service learning style.[14] 

Institutions hosting medical students may also benefit 

through improved international partnerships, promoting 

40

a potential workforce of international health workers in 

the future, reciprocal training opportunities for local staff 

and students to work abroad, equipment donation, and/or 

potential financial compensation.[5] 

Concerns 

Nonetheless, medical electives have the potential to 

cause serious ethical breaches, particularly those resulting 

from a medical student practising medicine beyond their 

level of competency.[4] There have been growing concerns 

that students are utilising elective opportunities to practise 

skills, enhance their resumes, and to travel to ‘exotic’ places, 

which can result in vulnerable communities serving as a 

means for students to merely fulfill selfish ends, as opposed 

to students serving to address the needs of the community. 

[7, 14, 16] Some have argued that electives in resource-poor 

settings are being used as a glorified form of tourism, with 

no known sustainable benefits for the receiving community. 

[13] Furthermore, any form of pre-departure training or global 

health education as a pre-requisite for such an elective is 

often missing, limited, or narrow in focus.[15] 

For the student specifically, there may be health risks 

involved, substantial costs assumed, the potential for 

cultural shock, and the likelihood of experiencing ethicallychallenging 

situations, which may include pressure to exceed 

the student’s role, and also perform procedures without 

adequate supervision.[5] There may be uncertainty about 

how best to contribute, working beyond the student’s scope 

of practice, navigating through unknown medical cultures, 

and leaving a subsequent gap in care provision when the 

student returns home. There are various other issues which 

may result, including failure to obtain truly informed consent 

due to language, cultural or other barriers, lack of adequate 

medical knowledge, and a lack of cultural awareness, which 

can all potentially lead to patient harm.[5] 

In the case of elective work in Honduras, for example, 

medical tourism is considered harmful, entrenching 

paternalism and inequitable relationships.[14] It is argued that 

while educational and social benefits may potentially occur, 

they are not natural consequences of these international 

experiences, but instead, examples of practical outcomes 

which must be nurtured and developed through significant 

education, reflection, and long-term relationship building.[14] 

Recommendations 

Healthcare practitioners may provide effective input 

during a short-term medical elective only if they have 

adequate knowledge, skills and ethical preparation prior to 

their departure.[18] There must be a shift in focus from the illprepared 

student who faces significant ethical dilemmas in 

global health on an international medical elective, to greater 

provision of support by teachers and institutions, prior to such 

an experience, given they ultimately have a responsibility to 

provide global health training and awareness of potential 

challenges.[4, 15, 19, 20] 

Students should be given pre-departure training, which 

may involve reflecting upon potential ethical challenges 

and discussing issues regarding resource shortages and 

other cultural or professional differences.[17] There should 

be an opportunity for students to engage with elements of a 

global health program prior to their undertaking of a medical 

elective, with the deliberate aim being to engage with social 

determinants of health.[7, 12, 13, 15] This may encourage 

students to question social inequities and shift the experience 

of a medical elective into a period of transformative learning. 

[19] This may in turn contribute to social change within the 

medical realm - which is a vital need for improving global 

health.[15] 

Further, student-led groups, databases and/or forums 

could be utilised to facilitate conversation, mentoring 

opportunities, and more personalised pre-departure training. 

Discussion amongst students who have been on an elective 

previously may allow for reflection upon these experiences 

and any challenges faced, as well as the sharing of 

knowledge with future cohorts who have not yet undertaken 

their placements. 

A global health curriculum would ideally examine ethical 

issues associated with working with vulnerable populations, 

and incorporate potential health and personal safety 

challenges associated with working in resource-poor 

environments.[3, 4, 20, 21] Experiential data suggests that 

ethical dilemmas are often part of medical electives and 

that, in most cases, medical students are not adequately 

trained to negotiate their way through ethically-troublesome 

situations.[19] There is a clear necessity for training so 

that students are able to recognise when to ‘say no’ during 

such experiences, and are able to learn from challenging 

situations.[3, 4, 16] 

The Working Group on Ethics Guidelines for Global 

Health Training (WEIGHT) has developed a set of guidelines 

regarding ethical issues and best practice for global health 

training. It simultaneously encourages efforts to continuously 

assess and evaluate the potential benefits and harms of 

programs being undertaken worldwide.[2] Trainees must 

understand their personal responsibility during a global 

health experience, to ensure it is a primarily positive one, and 

to recognise that their actions and behaviours can have farreaching 

long-term implications.[2] 

Evidence suggests that one of the most effective ways 

of teaching skills relating to global health - such as ethical 

and cultural competency - is through service learning.[17] 

Service learning incorporation relies on increased academic 

programming, fostering sustainable hospital partnerships, 

and encouraging mentorship and reflection for students 

involved, prior to, during and after their elective experiences. 

[21] Reflecting on the purpose of their volunteer experience, 

as well as their capacities and goals, will inform a more 

culturally-appropriate provision of care abroad, and will 

allow the student to recognise that good intentions alone 

are not necessarily sufficient preparation or justification for 

volunteering or working overseas.[20] Thus, the application 

of a simulation-based approach to global health ethics 

education prior to an elective may be useful in dealing with 

41

the tensions which exist between service learning and the 

respect of patient rights and well-being.[17] 

Social justice-oriented approaches to service learning, 

coupled with active critical reflection, also serve viable 

pedagogical approaches for learning the health advocate 

role.[10] This means that students should be able to better 

recognise and address relevant ethical and professional 

issues, with a greater understanding and appreciation 

of altruism, social justice, autonomy, and integrity as a 

result.[10] When a student does undertake an elective in a 

developing country, such experience leads to higher levels 

of community health knowledge on return, a greater sense 

of what it means to be vulnerable, a heightened awareness 

of the social determinants of health, and an appreciation 

of the importance of socially responsible approaches for 

community engagement and health advocacy.[10] 

Another important consideration is to enable bi-directional 

flow of medical students through formal partnerships between 

university institutions. This can facilitate more positive 

elective experiences through sustainable relationships and 

effective involvement in medical care, as well as encouraging 

an international medical workforce in the future.[5] Along 

with fostering such connections, skills building in crosscultural 

effectiveness, long-term sustainability planning, and 

local capacity building may help to produce more effective 

overseas opportunities with meaningful outcomes.[7] 

Discussion 

Overall, there is a clear need for individuals who wish to 

undertake medical electives in the future to reflect upon 

ethical and best practice guidelines prior to departure,[2] and 

to subsequently decide whether the experience is right for 

them.[12] It would also be of benefit to engage in conversation 

with previous cohorts about their elective experiences, 

enabling a baseline understanding of any challenges that lie 

ahead. Pre-departure, students should aim to gain as much 

contextual knowledge as possible in relation to their host 

country, including the language, the specific local needs, 

the details of the participating institution and the work being 

carried out. Students must recognise the possible ethical 

consequences of the work being done, and appreciate the 

potential impact they might have during such an experience. 

[12, 16] 

By incorporating a greater emphasis on learning and on 

reflection prior to, during, and after an international medical 

elective experience, students will be better placed to question 

their values, assumptions, and beliefs to help mitigate 

the potential harms which their placement may cause. 

[15] Students must actively question themselves and their 

surroundings, consider the ways in which healthcare is being 

delivered, and engage with potential ethical dilemmas and 

broader social, political and economic concerns underlying 

their medical provision, without necessarily being engaged 

in the direct provision of medical care.[11] Indeed, practising 

beyond one’s capabilities as a medical student is central 

to the potential harm which may result during an overseas 

elective in a resource-poor environment, particularly when 

this is coupled with a lack of adequate supervision. 

Education and planning are essential in minimising harm 

to host communities. It is necessary to have well-defined 

objectives and structured clinical experiences in place for 

students while abroad, which may be promoted by institutions 

and educators through mandatory global health education to 

ensure medical electives are carried out to the highest ethical 

standards.[8, 19] At all stages, electives must be completed 

in a way that acknowledges any underlying power balances, 

ethical challenges, and resource differentials to provide 

community-led efforts which are focused on sustainable 

development and community health gains.[7] 

There is an undeniable need for more global health 

Global Health Programs Abroad 

1. University of Saskatchewan, Canada: the ‘Making the Links’ program provides an opportunity for 

undergraduate medical students to participate in a local student-led inner-city clinic, a Northern Aboriginal 

community health initiative and a long-standing service-learning project in Mozambique over two years. This 

includes the provision of a supplementary clinical curriculum, guided and facilitated reflections, as well as a 

complementary global health course and language courses.[15] 

2. University of British Columbia, Canada: ‘First, Do No Harm: Global Health Initiatives, Ethics and Social 

Responsibility’ is a piloted series of interactive workshops.[16] Participants analyse case studies exploring 

different ethical dilemmas. Results have indicated that this approach to learning and reflection is necessary 

before participating in a global health initiative, and that problem-based learning is effective in teaching 

students to engage in the process of identifying and addressing ethical issues.[16] 

3. University of Arizona, United States: a four-week immersion program undertaken by students prior to an 

overseas placement covers a range of international health topics. 

42

education to be incorporated into the curriculum for medical 

students around the world, with rubrics containing detailed 

expectations and outcomes that are applicable to global 

health experiences.[21] Educators have a responsibility 

to their students to facilitate the development of skills in 

cultural competency, compassion, and public health, as well 

as encouraging them to understand the potential ethical 

challenges they may encounter.[9] 

Additional qualitative research is required to ensure that 

the expectations, attitudes, and experiences of healthcare 

institutions accepting elective students are clearly 

understood. Recognising the benefits and concerns of 

elective programs in resource-poor settings in greater depth 

will ensure that electives do not detract in any way from the 

pursuit of global health equity and the provision of care in 

these locations.[6] 


None 

13. Snyder J, Dharamsi S, Crooks VA. Fly-by medical care: conceptualizing 

the global and local social responsibilities of medical tourists and physician 

voluntourists. Globalization and health. 2011;7(1):1. 

14. McLennan S. Medical voluntourism in Honduras: ‘Helping’ the poor? 

Progress in Development Studies. 2014;14(2):163-79. 

15. Hanson L, Harms S, Plamondon K. Undergraduate International 

Medical Electives: Some Ethical and Pedagogical Considerations. Journal of 

Studies in International Education. 2011;15(2):171-85. 

16. Dharamsi S, OseiTwum JA, Whiteman M. Socially responsible 

approaches to international electives and global health outreach. Medical 

education. 2011;45(5):530-1. 

17. Logar T, Le P, Harrison JD, Glass M. Teaching Corner: “First Do 

No Harm”: Teaching Global Health Ethics to Medical Trainees Through 

Experiential Learning. Journal of Bioethical Inquiry. 2015;12(1):69-78. 

18. Asgary R, Junck E. New trends of short-term humanitarian medical 

volunteerism: professional and ethical considerations. Journal of medical 

ethics. 2013;39(10):625-31. 

19. Petrosoniak A, McCarthy A, Varpio L. International health electives: 

thematic results of student and professional interviews. Medical Education. 

2010;44(7):683-9. 

20. McCall D, Iltis AS, editors. Health Care Voluntourism: Addressing 

Ethical Concerns of Undergraduate Student Participation in Global Health 

Volunteer Work2014: Springer. 

21. Stoltenberg M, Rumas N, Parsi K. Global health and service learning: 

lessons learned at US medical schools. Medical education online. 2012;17. 


None declared 


gabbygeorgiou@gmail.com 

References 

1. Fox GJ, Thompson JE, Bourke VC, Moloney G. Medical students, 

medical schools and international health. Medical Journal of Australia. 

2007;187(9):536. 

2. Crump JA, Sugarman J, the Working Group on Ethics Guidelines for 

Global Health T. Ethics and Best Practice Guidelines for Training Experiences 

in Global Health. The American Journal of Tropical Medicine and Hygiene. 

2010;83(6):1178-82. 

3. Banatvala N, Doyal L. Knowing when to say” no” on the student 

elective; students going on electives abroad need clinical guidelines. British 

Medical Journal. 1998;316(7142):1404-6. 

4. Shah S, Wu T. The medical student global health experience: 

professionalism and ethical implications. Journal of medical ethics. 

2008;34(5):375-8. 

5. Bozinoff N, Dorman KP, Kerr D, Roebbelen E, Rogers E, Hunter A, et 

al. Toward reciprocity: host supervisor perspectives on international medical 

electives. Medical education. 2014;48(4):397-404. 

6. DeCamp M, Enumah S, O’Neill D, Sugarman J. Perceptions of a 

short-term medical programme in the Dominican Republic: voices of care 

recipients. Global public health. 2014;9(4):411-25. 

7. Melby MK, Loh LC, Evert J, Prater C, Lin H, Khan OA. Beyond Medical 

“Missions” to Impact-Driven Short-Term Experiences in Global Health 

(STEGHs): Ethical Principles to Optimize Community Benefit and Learner 

Experience. Academic Medicine. 9000;Publish Ahead of Print. 

8. Ketheeswaran P. Good intentions with unknown consequences: 

understanding short term medical missions: SCHOOL OF MEDICINE Thesis 

GOOD INTENTIONS WITH UNKNOWN CONSEQUENCES: UNDERSTANDING 

SHORT TERM MEDICAL MISSIONS by PAVINARMATHA KETHEESWARAN 

BS, University of Florida; 2015. 

9. Ackerman LK. The Ethics of Short-Term International Health 

Electives in Developing Countries. Annals of Behavioral Science and Medical 

Education. 2015;16(2):40-3. 

10. Dharamsi S, Richards M, Louie D, Murray D, Berland A, Whitfield M, 

et al. Enhancing medical students’ conceptions of the CanMEDS Health 

Advocate Role through international service-learning and critical reflection: 

A phenomenological study. Medical Teacher. 2010;32(12):977-82. 

11. Wallace LJ. Does Pre-Medical ‘Voluntourism’Improve the Health of 

Communities Abroad? Journal of Global Health Perspectives. 2012;1:1-5. 

12. Citrin DM. “Paul Farmer Made Me Do It”: A Qualitative Study of Short- 

Term Medical Volunteer Work in Remote Nepal: University of Washington; 

2011. 

43

IFMSA - 5 letters with one big mission! 

Australian Medical Students attend the IFMSA 

66th General Assembly in Montenegro 

[Conference report] 

Aysha Abu-sharifa (University of Notre Dame Fremantle), Stormie de Groot 

(University of New England), Julie Graham (James Cook University), Justine 

Thomson (University of Wollongong) 

The International Federation of Medical 

Students Associations, or IFMSA, was founded 

in 1951 in response to the overwhelming global 

challenges following World War II. Committed 

to the ideals of the Alma Ata Declaration 

and “Health for All” (2007), the founders 

believed that medical students should not 

be passive bystanders, but rather, use their 

ability to create lasting and meaningful change 

through collaboration and innovation. Today, 

the organisation represents over 1.3 million 

medical students from over 122 countries 

worldwide, with the Australian Medical 

Students’ Association (AMSA) having been part 

of the organisation for many years. 

The IFMSA is involved in a wide range of 

global health advocacy, public health, primary 

health and clinical health projects. This 

encompasses training arms, medical student 

exchange programs and collaborative public 

health projects. There are several standing 

committees working within specific areas of 

global health, including Public Health (SCOPH), 

Sexual and Reproductive Health (SCORA), 

Medical Education (SCOME), Human Rights 

and Peace (SCORP) and Professional and 

Research Exchanges (SCOPE/SCORE). 

The IFMSA is also divided into regions which 

allow for effective collaboration across 

geographically similar areas, such as the Asia 

Pacific Region, of which AMSA is a member. The 

IFMSA offers the opportunity for all Australian 

medical students, through AMSA, to be involved 

in student activities on an international scale. 

Most recently, AMSA sent a team of 14 

Australian delegates to attend the IFMSA’s 66th 

General Assembly (GA) in Budva, Montenegro, 

from March 2-8, 2017. The team was led by 

Julie Graham, AMSA Global Health’s Vice Chair 

International and acting IFMSA Australian 

President, along with Liz Bennett, AMSA Global 

Health’s Chair. The General Assembly is likened 

to an international version of an AMSA Council 

in which policies are discussed and debated, 

changes to operational processes are made, 

new member states are voted in and prepared 

statements are read. Most of these processes 

take place in plenary sessions, where Julie and 

Liz represented Australia on issues relating to 

medical education and general global health. 

Charlotte O’Leary presents youth declaration on 

NCDs 

Along with the plenary sessions, each 

standing committee also conducts their own 

parallel SCORA sessions for members. The 

Australian members were divided between 

many of these half-day standing sessions, 

which allowed the Australian team members 

to think about being part of the global health 

community and how IFMSA projects could open 

many doors on this level. Other key components 

of the program include joint sessions between 

standing committees, National Member 

Organisation meetings and plenaries, where 

delegates participate as guests to support and 

advise the delegation leaders. 

44

This year’s GA was marked by several 

significant achievements by the Australian 

team. Most notably Australian student 

Charlotte O’Leary was responsible for the Non- 

Communicable Disease (NCD) Youth Caucus, 

which lead to the creation and adoption by the 

IFMSA of the “Budva Youth Declaration: A Call 

to Action on Non-communicable Diseases”. 

Charlotte has just completed a 3-month 

internship at the World Health Organization 

(WHO) in Geneva and was appointed by the 

IFMSA to organise and moderate the NCDthemed 

events. AMSA Global Health Chair, 

Liz Bennett, was also one of the panellists 

amongst many prestigious speakers and 

discussed the linkage between nutrition, food 

systems, and NCDs. The Youth Caucus formed 

the key components of the themed events on 

NCDs. It was opened at the IFMSA GA opening 

ceremony by Dr Bente Mikkelsen, Head of the 

WHO Commission on NCDs, and was followed 

by two panel discussions. 

Prerna Diksha 

AMSA was also represented at the IFMSA 

GA Activities Fair, where over 150 projects 

worldwide were featured and discussed with 

delegates. Three Australian projects were 

presented, including Project Burans, presented 

by Prerna Diksha of Melbourne University, 

Crossing Borders, a National Project of AMSA 

Global Health, presented by Aysha Abu-sharifa, 

and AMSA’s Newcastle NewGHC presented 

by Adelaide Pratt (Logistics Convenor, AMSA 

2016 Newcastle Global Health Conference). 

Project Burans is a philanthropic mental health 

initiative of the Emmanuel Hospital Association, 

the largest non-governmental provider of 

healthcare in India. It won second place for 

founder Prerna Diksha and other members of 

Melbourne University, out of almost 150 other 

entries! 

Participation in both policy writing and 

review represents a significant opportunity for 

involvement in any IFMSA GA. Julie Graham, 

delegation leader, was a member of the Policy 

commission team for the IFMSA Rural Health 

Policy, along with 2 other international team 

members. This policy received input from 

around the world prior to the GA, including 

ample suggestions from Australian medical 

students. The Rural Health Policy was one of 

12 propositions that were successfully passed 

during the plenary policy session. 

The Pre GA provides a great opportunity to 

work with and get to know a smaller proportion 

of students attending the GA. Medical science 

student, Stormie de Groot attended a Pre-GA 

workshop, “Transforming Our World by 2030: 

Reaching the Sustainable Development Goals 

(SDGs)”, which focused on how and why the 

SDGs were developed, their purpose, and how 

medical students could work towards achieving 

them. 

“It was insightful and humbling to 

see the work that was already being 

achieved by National Medical student 

Organisations (NMOs) around the world, 

amongst various social, cultural and 

political contexts. Overall, it challenged 

all of us to adopt the SDG framework 

into our existing AMSA Global Health 

Projects and beyond through our AMSA 

Sustainable Development Policy (2016).” 

-Stormie de Groot, University of New England. 

The activities of the Sexual and Reproductive 

Health stream within the IFMSA represent 

a key area for involvement for Australian 

medical students, many of whom are engaged, 

interested and skilled in this field. Justine 

Thomson, Education Officer for AMSA Global 

45

Health, was involved in presenting a session 

within the SCORA streams on Comprehensive 

Sexuality Education. 

“As a health and physical education 

teacher prior to medical school, I enjoyed 

the opportunity to take part in the General 

Assembly and share my knowledge in 

[sexual health]. My experiences within the 

general SCORA sessions were excellent 

and the guest speakers were highlights, 

particularly Dr Lale Say from the 

Department of Reproductive Health and 

Research, WHO, speaking on Female 

Genital Mutilation, and new guidelines in 

this space.” 

-Justine Thomson, University of Wollongong. 

Dr Elijah Painsil, from the Yale School of 

Medicine, also presented a keynote address 

around the challenges of children and 

adolescents living with HIV. 

In addition to the significant academic 

opportunities, the IFMSA General Assembly 

allowed the Australian team members to 

grow and develop on a personal level through 

their interactions with other delegates. It 

was not hard for the team to truly believe the 

foundational philosophy of the IFMSA: that with 

collaboration and partnership, it is possible 

to have an impact on health challenges of 

the world. For delegation member Aysha 

Abu-sharifa, the highlight was the personal 

interactions with other delegates, and being 

challenged by various cultural perspectives on 

polarising issues. The Human Rights and Peace 

stream offered insights into human rights law 

versus humanitarian law, health inequalities in 

an intersectional context, and the effects of 

discrimination on the paediatric population. 

“[Another] highlight this year was the Activities 

Fair where projects ranged from medical 

students mentoring orphans in Baghdad, to signlanguage 

proficiency training for healthcare 

workers in Athens, to the advocacy of nondiscriminatory 

health care for sex workers in the 

Netherlands.” Aysha Abu-sharifa, University of 

Notre Dame Freemantle. 

The March General Assembly in Montenegro 

was an encouraging reminder of the need for 

global collaboration from Australian medical 

students. This year’s delegates agreed that 

not only is there a lot to learn from like-minded 

students, but there is also a great deal to 

contribute. The IFMSA conference is only one 

of the many platforms in which individuals can 

get involved. 

Act now: 

• Join the mailing lists of the IFMSA to learn 

about all the great opportunities (www.ifmsa. 

org) 

• Email julie.graham@amsa.org.au to found 

out more about getting involved with AMSA’s 

international opportunities, including IFMSA 

exchanges. 

Photo credit 

Jasper Lin & Jessica Yang 


None 


None declared 


julie.graham@amsa.org.au 

References: 

1. Baum F. Classics in Social Medicine; Health for 

All Now! Reviving the spirit of Alma Ata in the twenty first 

century: An Introduction to the Alma Ata declaration. 

Social Medicine. 2007;2(1):34-41. 

Upcoming events: 

1. IFMSA August General Assembly in Tanzania: 

Pre GA 28 July-1 August; GA 1-7 August; Post GA 

7-10 August 

2. IFMSA Asia Pacific Regional Meeting (APRM) 

in Japan: Pre- September 15-17; APRM September 

17-21 

46

Changing Climate, Changing Perspectives: 

iDEA Conference Report 

[Conference report] 

Isobelle Woodruff 

Isobelle is a third year Doctor of Medicine student at UNDS, currently completing her 

clinical years in Melbourne. She is also the AMSA Code Green Co-National Project 

Manager and is passionate about empowering people to mitigate the health effects of 

climate change. Her other areas of interest include mental health and wellbeing, nutrition 

and behavioural change strategies. 

The iDEA conference is an annual national 

conference of Doctors for the Environment 

Australia (DEA). Run over two days with over 35 

world-renowned speakers; engaging breakout 

workshops; and entertaining social nights 

with gourmet, ethically-sourced food; iDEA 

is the centrepiece of environmental health 

education and inspiration. iDEA unites medical 

professionals and students from around 

Australia “with one common goal – to address 

the human health impacts of the environment 

and climate change”,[1] with a 2017 theme of 

“Global Problems, Local Solutions”. 

effects of climate change; droughts, bushfires, 

allergies, asthma”. Similarly, Dr Simon Judkins, 

President-Elect of the Australian College of 

Emergency Medicine, asserted that “climate 

change means that we are seeing bigger 

and more frequent large scale disasters, and 

emergency physicians are front and centre 

when it comes to responding to those events”. 

Global Problems 

Throughout the weekend, I was reminded of 

why our changing climate is indeed “the biggest 

global health threat of the 21st century”,[2] 

affecting health both directly and indirectly. 

The widely cited 2009 paper “A Commission 

on Climate Change” in The Lancet outlines 

the direct effects of climate change to be, 

namely; increased heat stress, floods, drought 

and increased frequency of intense storms.[2] 

In a panel of College Presidents at iDEA17, 

Dr Bastian Seidel, President of the Royal 

Australian College of General Practitioners, 

outlined the direct impacts of climate change 

on human health through referencing his 

everyday experiences as a general practitioner; 

“General Practitioners (GPs) are true climate 

change witnesses. As a GP in Southern 

Tasmania, there is not a single day that 

patients don’t come in and tell me about the 

L to R: Dr Scot Ma (ANZCA), Prof John Middleton (UK 

FPH), Dr Simon Judkins (ACEM), Dr Bastian Seidel (RACGP), 

Dr Kym Jenkins (RANZCP) 

In addition to the direct impacts of climate 

change on human health, there are also 

subtler, insidious, indirect effects. Some of 

these include air pollution, the spread of 

vector-borne diseases, food insecurity and 

under-nutrition, displacement and an increase 

in mental illness.[2] Dr Helen Szoke, CEO of 

Oxfam, directed our attention to the recent 

WHO report on pollution and child health, a 

landmark study which found that more than 1 

in 4 deaths of children under 5 years of age 

are attributed to unhealthy environments. 

Additionally, climate change could drive 122 

47

million more people into extreme poverty by 

2030 through its impact on increasing vectorborne 

diseases, food insecurity, increasing the 

number of climate refugees and respiratory 

disease through air pollution.[3] 

Dr Alessandro Demaio, Medical Doctor for 

the World Health Organization (WHO) and cofounder 

of NCD-Free, addressed the connection 

between obesity and climate change. This is a 

potentially hidden link, but one not to be ignored: 

if food waste were a country, it would be the 

third largest CO2 emitter.[4] He emphasised 

the importance of collaboration on global 

issues such as obesity and climate change, 

“when it comes to NCDs and climate change, 

opportunities for co-mitigation are profound and 

unprecedented. Inaction cannot be an option.” 

He urged us to think laterally on 

the topic – both issues have 

similar causes and solutions, 

so how can we address them 

together through lobbying, policy 

change and targeted public 

health strategies? 

Local Solutions 

In the face of impending “climate chaos”, 

as it was colloquially referred to throughout 

the conference, it is easy to feel overwhelmed 

by the reality of climate change. Despite this, 

the speakers provided messages of hope and 

inspired action and empowerment through local 

solutions. 

Coming from a refreshingly non-medical 

perspective, Tim Buckley, one of Australia’s top 

financial energy analysts, provided an overview 

of the progress our neighbours in India and 

China are making in the renewable energy 

market [5]. He outlined the importance of 

knowing your audience – the motivation behind 

these nations’ transition to renewables wasn’t 

for health reasons, but economic reasons in 

India (considering renewables cost 80% of 

what it costs to import fuel) and populationdriven 

air quality concerns in China. Buckley 

highlighted the financial stability and success 

What makes climate change so 

difficult to comprehend is the lack 

of a clear, single perpetrator; it 

doesn’t have a face. 

these nations have had since leading the way in 

renewables and why it makes economic sense 

for Australia to follow suit.[6] Focusing the light 

on Australian shores, Dr Roger Dargaville from 

the Melbourne Energy Institute outlined the 

need for robust policy and strategic direction for 

the Australian energy market, if we are to move 

towards renewables and avoid further energy 

demand issues like the recent South Australian 

energy crises. 

Changing Perspectives and Summary 

I took away a bigger picture of how we 

conceptualise climate change, and left thinking 

that we need to change our perspective to 

achieve true change. What makes climate 

change so difficult to comprehend is the lack 

of a clear, single perpetrator; 

it doesn’t have a face. Without 

oversimplifying complex issues, 

it is clear that, for example, when 

we want to blame someone for 

the obesity epidemic we think 

of big corporate companies like 

Coco Cola or McDonalds. When we want to 

blame someone for displaced people and mass 

migrations, we think of war and governments. 

With climate change, it isn’t as easy to play 

the blame game. We can’t easily point the finger 

at someone or something and say “this is the 

reason why; this is the cause”. Because we can’t 

readily shift the blame onto something easily 

identifiable, it makes the issue less tangible 

and more challenging to connect with. There is 

nowhere to direct the anger and frustration at 

the catastrophic changes we are seeing around 

us, the natural response is to either disconnect 

with the issue, or to feel overwhelmed with 

despair and subsequently be driven to inaction. 

In truth, we should be pointing the finger at 

is ourselves. As was made abundantly clear 

at the conference and in countless articles 

and reviews presented by the wider scientific 

community, the evidence overwhelmingly 

indicates that climate change is largely human 

driven, and thus we must take responsibility.[7] 

48

Yes, we are a large part of the cause. But if 

I learned anything over the weekend, it is that 

we can also drive the solution. In the words of 

Dr Helen Szoke, “the mission that you sign up 

to when you become a doctor means that you 

have a responsibility to assist humanity climate 

change is a big part of that.” There needs to be 

a shift of focus from the negative outcomes of 

climate change, towards the positive ways we 

as doctors, we have an obligation to talk and 

act on climate change”. 

Photo credit 

Mack Lee 


None 


None declared 


isobelle.woodruff@amsa.org.au 

References 

iDEA17 delegates 

can address it. We need to stop seeing it as 

an issue and start seeing it as a potential for 

change and act in the infinite ways the speakers 

outlined at iDEA. While it is the biggest threat to 

our species and planet, climate change could 

also be “the greatest global health opportunity 

of the 21st century”.[8] 

The evening before the conference 

commenced, I was honored to hear from human 

rights lawyer Julian Burnside AO QC, who 

eloquently stated; “to remain silent is as much 

a political act as to speak out”. This simple idea 

is as applicable to climate change and human 

health as ever; the health impacts of climate 

change are direct and indirect, immediate and 

long term, both overt and subtle. We must have 

a global perspective on the issue, but also the 

willingness to act locally to create sustainable 

and tangible change to protect the health of our 

planet and our people. It is our responsibility as 

informed, ethically-minded health professionals 

to act now. In the words of Dr Stephen Parnis, ex- 

AMA Vice President “prevention and mitigation 

is always better than reaction and recovery – 

1. Doctors for the Environment Australia. iDEA17 Conference 

DEA2017 [Available from: https://www.dea.org.au/ 

idea2017/. 

2. The Lancet. A Commission on climate change. The 

Lancet. 2009;373(9676):1659. 

3. Inheriting a sustainable world? Atlas on children’s 

health and the environment. Geneva: World Health 

Organisation, 2017. 

4. Food and Agriculture Organization of the United 

Nations. Food wastage footprint; impacts on natural 

resources (summary report). Natural Resources 

Management and Environment Department, United 

Nations, 2013. 

5. Buckley T. IEEFA Update: China Is Now Three Years 

Past Coal. IEEFA, 2017 Feburary 28, 2017. Report No. 

6. Tan JAMH. Economics: Manufacture renewables to 

build energy security. Nature. 2014;513(7517). 

7. McMichael AJ. Globalization, Climate Change, and 

Human Health. The New England Journal of Medicine. 

2013;386:1335-43. 

8. Nick Watts et al. Health and climate change: 

policy responses to protect public health. The Lancet. 

2015;386(10006):1861 - 914. 

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Vector Volume 11 Issue 2 

Submission Callouts July-August 2017 

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Cover image reproduced with 

permission from Dr Hilmers 

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Vector Volume 11 Issue 1 - 2017

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