Vector Issue 12 - 2011

vector
www.ghn.amsa.org.au
Issue 12 Febuary 2011
The Official Student Publication of the AMSA Global Health Network
the
Millennium Development Goals
issue

THANKS TO ALL OUR SPONSORS

contents
4 EDITORIAL
5
8
Reflections on the 63rd UN DPI-NGO Conference
GLOBAL HEALTH IN THE NEWS: AN UPDATE
Feature articles
12
14
18
20
26
28
30
32
34
36
MDGs not only for Developing Nations
Tipping the Scales
One Step on a Long Path to Much More
The Pains of Labour
Nets, Condoms and Drugs
Going Environmental
Why can’t we just all get along?
Global health, Sustainability and Doctors
Student Selective - Welcome to Samoa
Global Health Conference 2010 Report
a Window into Global Health
A series of powerful photos that visualise and
encapsulate the MDGs
Vector: The Official Student Publication of the AMSA
Global Health Network
GHN Publicity Officer Alyssa Fitzpatrick
Editor in Chief Saion Chatterjee
Co Editors Maheshie Dayawansa
Katherine O’Shea
Design & Layout Annjaleen (Anjie) Hansa
Web master Rungrueng (Tommy)
Kovitwanichkanont
Editorial enquiries:
Email vectormag@gmail.com
GHN enquiries:
ghn.publicity@gmail.com
or visit www.ghn.amsa.org.au
We welcome your written submissions, letters
and photos on any global health issue or topic.
Please limit submissions to 500 words or less.
Cover Photography Hiep Pham
Graphics Ralph Bergmann

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4
A
young child in Ethiopia aspires to become
a doctor, engineer, or teacher one day. She
dreams of earning an income, owning a house
and providing her children with a life she could
never have. But this seems like a futile dream. Her
family is unable to provide her with an education,
as school fees would consume more than one quarter
of her family’s income. Despite her parents’ wholehearted
efforts to send her to school, the reality of
their situation means that she will be entrenched in
the perpetual cycle that has encompassed her family;
editorialcould still
a nomadic life underpinned by the daily struggle to
survive.
On the other side of town, another child can no
longer endure the darkness, waiting for daylight to
arrive so she can get ready for school. She lives in
a small one room abode, abutted by replicas of her
home. Her mother leaves early in the morning to
work in the mill and returns in the late hours of
night. The child must cook and clean for herself,
and make the arduous journey to school every day.
School for her, however, is a secure and nurturing
setting, where she can come early and often stay
late, and is lovingly equipped with the tools to lead a
better life by her teachers.
Education in Sub-Saharan Africa has prevailed as
a ray of hope, in the midst of proliferating political
warfare, and the truculence of disease and inequality.
The 2 nd Millennium Development Goal - to ensure
that, by 2015, children everywhere, boys and girls
alike, will be able to complete a full course of
primary schooling - has been a key focus in the
vector FEB 2011
s a i o n
chatterjee
editor in chief
m o n a s h
university
countries of Sub-Saharan Africa and Southern Asia.
Education has been identified by experts as the most
sustainable and expeditious means of economic and
social development and to alleviate poverty. With
education, employment opportunities are broadened,
income levels are increased and maternal and child
health is improved.
Countries such as Burundi, the Democratic Republic
of the Congo, Ethiopia, Ghana, Kenya, Malawi,
Mozambique, Tanzania and Uganda have abolished
school fees, which has led to a surge in enrolment: in
Ghana, for example, public school enrolment in the
most deprived districts and nationwide soared from
4.2 million to 5.4 million between 2004 and 2005 1 .
In Kenya, enrolment of primary school children
increased dramatically with 1.2 million extra
children in school in 2003 alone; by 2004, the number
had climbed to 7.2 million, of which 84 percent were
of primary school age 1 . Despite this, the 2nd goal is
not on course to reach its target of universal primary
education by 2015. Currently, 56 million children
be out of school in 2015 and
girls will still lag behind boys in school
enrolment and attendance 2 .
As the 63rd UN DPI-NGO conference
occurred in Melbourne late last year,
with a large medical student contingent from
around Australia putting in their two cents, this
issue canvasses the progress and potential pitfalls
concerning the Millennium Development Goals
(MDGs). The MDGS are a series of resolutions
setting a hard target of 2015 to achieve a range of
specific quality-of-life benchmarks agreed to by 192
countries and 23 international organizations. We
can all play our part to ameliorate our globalised
world, whether it be through grass roots action,
supporting non-governmental organisations
though activism and participation, or influencing
health care in developing nations via research and
student placements. Medical students must show
leadership when it comes to issues such as universal
primary education, as factors like this will play an
unprecedented role in the burden of disease and
quality of life people face, particularly in developing
nations, in the years to come.
1. United Nations Development Programme. Achieve universal primary education (Success stories) [Internet]. 2007
[updated 2007 Nov 1; cited 2010 Aug 7]. Available from: http://www.mdgmonitor.org/story.cfm?goal=2/
2. UNICEF. Press release [Internet]. 2010 [updated 2010 May 17; cited 2010 Aug 7]. Available from: http://www.unicef.
org/media/media_53659.html/

arthur
cheung
university of
queensland
ADVANCE global health ACHIEVE the MDGs
reflections on the 63 rd UN
DPI-NGO Conference
From 30 th August to 1 st September 2010,
Melbourne hosted the largest United Nations
conference in Australia’s history. It was the
third time the UN Department of Public Information
Non-Governmental Organisation (UN DPI-NGO)
Conference was held outside the UN headquarters
in New York, and the first time it was held in the
Southern Hemisphere.
The theme for the 63rd UN DPI-NGO Conference was
global health and achievement of the Millennium
Development Goals (MDGs): eradicate extreme
poverty and hunger, achieve universal primary
education, promote gender equality, reduce child
mortality, improve maternal health, combat
communicable diseases, ensure environmental
sustainability, and access to essential medicines.
With a large contingent of Australian youth in
delegations including those from the World Medical
Association and the International Federation of
Medical Students’ Associations, it promised to be a
great boost to the level of global health engagement
in Australia.
Reflecting on the conference brought mixed feelings.
There is a common belief that we must remain
positive about our experiences, to the extent that it
makes us uncomfortable to criticise that which needs
critique. Regardless, I shall give my honest thoughts
on the conference and its proceedings.
There are three main reasons why a productive
conference was vital. The first is that while we sat
in the Melbourne Convention and Exhibition Centre,
people continued to die of preventable causes in
the world outside. So any diversion of the attention
of the world’s NGO leadership must be for a good
reason. The second is that it is extremely rare for
such a diverse and comprehensive range of NGOs to
come together for the express purpose of
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6
idea sharing, collaboration and co-ordination. We
therefore must make maximal use of such immense
potential to secure the future of our world through
successful pursuit of the MDGs, a duty all the more
important in light of the UN General Assembly
Summit on the MDGs that was held later in 2010.
The third is the many youth who were present at the
conference, who hoped to experience an inspirational
and informative conference, and to gain a glimpse
into the world and NGO community they will inherit.
However, I was both dismayed and frustrated at
the lack of direction, co-operative spirit, forward
movement and learning in the majority of the
plenary roundtable discussions. Many delegates
distracted the conference with questions and
comments that showed a disregard of the topics at
hand, the dire nature of the problems we are trying
to address, and where their contribution sat within
the larger picture of global health efforts as a whole.
To ask a roundtable of world leaders in the MDG
campaign to comment on whether the conference
should be held with Esperanto as the official
language is inappropriate. To ask off-topic predrafted
questions merely to practice public speaking
or to assert your NGO’s presence at the conference
is inappropriate. To have speakers misunderstand
the few questions that were on topic due to lack of
interpreters is farcical.
It was great that there were so many new NGOs,
youth, and others less experienced in global health
at the conference. However, we must let the more
experienced NGOs/WHO/UN have productive
discussion. Pushing of individual agendas only serves
to undermine meaningful discussion of the relevant
topics and stall progress on the overall objectives.
If this is the state of world affairs, it seems our
generation has a lot to fix.
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‘‘
To ask a roundtable
of world leaders in
the MDG campaign to
comment on whether
the conference
should be held with
Esperanto as the
official language is
inappropriate
‘‘
It should be recognised that perhaps it was a
unique set of circumstances that resulted in a less
productive UN DPI-NGO conference than is usual.
The uncertain political situation in Australia postelection
prevented a number of high-profile UN
officials and Australian politicians from attending.
This undoubtedly led to a lack of clear leadership and
vision, and a lesser sense of urgency and importance
that productive discussion need take place.
So did I regret attending the conference? No. There
were undoubtedly some exceptional delegates
present, and the conversations which resulted (on
topics from the mundane to philosophical, from
policy issues ranging from Indigenous health and
access to essential medicines to reproductive health
education) was undoubtedly of great benefit to
the delegates personally, and therefore also to the
people their organisations help. The time allowed
for networking was certainly a useful insight into
the breadth of global health activities, from the
Global Alliance for Vaccines and Immunisation,
to the work of the Burnet Institute based in
Melbourne. The growing recognition that addressing
non-communicable diseases and climate change is
fundamental to achieving the MDGs is a positive step.
The consistent advocacy for strengthening health
systems over running vertical aid programs focussed
on specific diseases was great to see. The observation
that everyone wants to coordinate, but no one wants

to be coordinated, is a poignant indictment and call
for action. To hear Che Guevara’s daughter speak of
the Cuban health and medical education system was
inspirational, if not embarrassing when she suggested
that Cuba train Indigenous doctors free of charge
so that they may return to benefit our communities
in Australia. If the plenaries reached that level
of discussion, it would be a hugely productive
conference indeed!
The point made here is that good process is important
to good outcome. Our activities must have clarity
of purpose, and strong leadership to steer discussion
and ensure we stay on task. Should I be criticised for
criticising the conference? As was emphasised at the
6th Annual Nossal Institute for Global Health Forum
held immediately after the UN DPI-NGO Conference,
evaluation is a crucial aspect of running aid. The
appropriate response to a fear of donors withdrawing
support due to deficiencies identified by evaluation
of aid programmes (or, similarly, voter support for
government initiatives) is not to neglect critique.
It is to educate donors that evaluation is vital to
improving and following evidence for better practice.
Indeed, improvement, not the outcome per se, should
be the framework under which we measure success.
What of the MDGs, and our strategy beyond 2015?
A few observations were especially influential:
you cannot save the most vulnerable infants and
children without first ensuring the health of their
mothers; educating a boy educates an individual,
‘‘
The observation
that everyone wants
to coordinate, but
no one wants to be
coordinated, is a
poignant indictment
and call for action.
‘‘
while educating a girl educates a family; the MDGs
are donor driven and over-sell the significance of
international aid (aid does not progress the MDGs
when funds flow to developed-world contractors
rather than building local capacity); the MDGs focus
on aggregate measures and averages and are poor
indicators of equity; the MDGs do not cover all issues
important to global health; and prevention is not
only better than cure, but is also cheaper.
The MDGs should not be an end-point in and of
themselves, but a benchmark for measuring the
success of initiatives that develop local capacity.
The MDGs are merely a communication tool used in
assessing progress on our commitment to health as a
universal human right. It is important to remember
that the MDGs are both a moral imperative, and
achievable.
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1. the battle
against AIDS
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The AIDS pandemic is almost 30 years old. Sixty million
people have been infected with HIV. However, since
the pandemic peaked in 1999, safer-sex education and
widespread condom use have brought down the number
of new infections by 19 percent, according to a state-ofthe-pandemic
report just issued by UNAIDS, the United
Nations agency charged with leading the fight against
AIDS.
child
health
8
mil
maternal
health
358 ,
000
HIV/
AIDs
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estimated
number of
children
under five
who die every
year
estimated
number of
women who
die each year
in pregnancy
and childbirth
67 %
of HIV
infections
are in sub-
Saharan
Africa
2. second hand
smoking
3. TB test
A new speedier test for
tuberculosis has been
endorsed by the World
Health Organization. The
test will shorten diagnosis
time from months to a few
hours. Currently TB spreads
and kills faster than it can be
diagnosed.
More than 600 000 deaths per year
worldwide are caused by second-hand
smoke (SHS) - this is more than 1%
of all deaths. 165 000 of these deaths
are among children.
what’s
been
global
health in
the news
- a quick
overview

http://www.good.is/post/which-countries-are-making-the-most-progress-on-the-millenium-development-goals/
h
a
p
p
e
n
i
n
g
Countries around the world are working hard to achieve the Millennium Development Goals
(MDGs). The Overseas Development Institute’s Millennium Development Goals Report
Card: Measuring Progress Across Countries, recently ranked the countries that have made
significant progress on key targets of the first, fourth, and fifth goals. The rankings are in
terms of absolute progress toward the targets, meaning that countries that have improved by
the largest margins (from first measurement), regardless of initial conditions (and distance
from the targets).
4. needle for
meningitis
‘Tis the season for meningitis in Sub-
Saharan Africa. Starting December
and running through June, the seasonal
drought will once again put more than
450 million people across Burkina Faso,
Mali, Niger, Chad, Sudan, and Ethiopia
at risk of developing meningitis.
But this year, doctors have a new
weapon in their fight; a new vaccine
that works against the group A
meningitis strain that causes more
than 8 out of 10 cases on the continent.
Moreover, it costs less than 50 cents a
dose.
5. Cancun
clinches
a climate
consensus
For the first time the pledges by
developing and developed nations
to cut pollution have been brought
under a UN agreement, despite
vigorous opposition from Bolivia.
A multi-billion dollar Green
Climate Fund was established
for poorer countries to deal with
climate change and progress was
made on deforestation and clean
energy technology.
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aWindow
intoGlobal
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Goal 1: Eradicate extreme poverty and hunger
Miguel Angel Leonardo, 6, licks clean a spoonful of Incaparina, a
powdered supplement distributed by food-aid organizations to
prevent malnutrition in infants and children. Even so, Guatemala has
the highest rate of chronic malnutrition in the western hemisphere,
and continues to have the highest rate of chronic malnutrition,
according to a report from United States Agency for International
Development.
photo by
jeremiah stanley
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Why should Australia be interested in the
Millennium Development Goals (MDGs)?
Despite the fact that focus is indeed on
developing nations, Aboriginal & Torres Straight
Islander (ATSI) communites have health statistics
comparable to poorer countries. So there is much
that is relevant especially with our poor track record
in improving ATSI health and, not only that, when
this country is faced with an unsustainable health
system there is much to be learnt from some of the
successes of the approach.
The initiative was launched in September 2000,
building upon a decade of major United Nations
conferences and summits where world leaders came
together at the United Nations Headquarters in
New York to adopt the United Nations Millennium
Declaration, committing their nations to a new
global partnership to reduce extreme poverty. It is
important to note the time for planning and gaining
a commitment compared to how long this country
takes to plan and implement health interventions. A
series of time-bound targets were set with a deadline
of 2015. Such long term planning and goals are
impossible in Australia thanks to our electoral cycle
and the short term funding of health projects.
The eight goals were assessed for progress and
further resources were allocated to countries that
were clearly not going to achieve their goals without
extra support.
Australia set the National Health Goals and Targets
in 1994 1 ]. What happened to them? We seemed
to have moved to measuring activity leaving the
question open as to whether the activity promotes
the health of all Australians.
This is the appeal of the MDGs in that they are
focussed on populations as opposed to individuals.
This is consistent with the well known aphorism
of Dr Geoffrey Rose 2 , ‘... a preventive measure that
brings large benefits to the community offers little
to each participating individual.’ In Australia the
focus is on the customer with a disease and no cost is
spared to bring the benefits of the latest technology
to bring a cure or to palliate. This has led to inverse
care law being alive and well in that the provision
of cutting-edge health services is located where the
need is least 3,4 .
Many strategies included in the MDG approach
are synonymous with the social determinants of
health, ten of which were identified by Wilkinson
and expatriate Professor Sir Michael Marmot (visit
http://www.who.int/social_determinants/en/). He
also emphasised the importance more recently of
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MDGs not only for
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Dr Bret Hart, Head of Public Health Unit , Nort

the need for interventions to be proportionate to the
degree of disadvantage, and hence applied in some
degree to all people, rather than applied solely to the
most disadvantaged 5 .
The impact of comparatively modest interventions
can be seen by reviewing some of the strategies
employed so far in reaching the MDGs. For example
the first goal is to ‘halve, between 1990 and 2015, the
proportion of people whose income is less than one
dollar a day’. Imagine the impact of developing a
program that doubles a person’s income to two dollars
a day. Now reflect on the difference an extra dollar
a day would make to you. This prompts another law
to be considered: the law of diminishing returns.
Applied to Australian health the law suggests that
the more we reach health actualisation (apologies to
Maslow and his hierarchy of needs), the more the cost
to achieve a marginal gain in personal health and no
improvement in population health - in fact there is
the potential for a net loss because of the opportunity
cost associated with the provision of boutique health
services as opposed to providing basic health care to
those who need it most.
Another lesson for us is that when global threats
to health become more manifest during this
decisive decade, there is the need to emulate the
multidimensional approach to ensure that the
factors that determine health are enhanced and
strengthened. Many of these factors included in
the MDGs are summarized in a recent extension of
the Dahlgren and Whitehead model to include the
environmental influences on health [6,7 .
The challenges for health systems across the world
are great but, ironically, it is the developed world
where the dominance of tertiary services has led to
an exponential and unsustainable increase in costs.
Thanks to the MDGs we are likely to see enormous
health gains from investing in the determinants of
health and in primary health services and hopefully
the Australian medical leaders of the future will
take note of where they need to focus their efforts
to achieve the greatest impact on the health of
Australians.
1. National health goals and targets: summary of draft reports. Canberra: Department of Human Services and Health;
1994
2. Rose G. The strategy of preventative medicine. Oxford University Press; 1992.
3. Hart JT. The inverse care law. The Lancet 1971 Feb 27; 1(7696):405-12.
4. O’Dea JF, Kilham RJ. The inverse care law is alive and well in general practice (Editorial). Med J Aust 2002; 177:78-
79.
5. Health equity: an election manifesto? (Editorial). The Lancet 2010; 375(9714):525.
6. Dahlgren G, Whitehead M. Tackling inequalities: a review of policy initiatives. Tackling inequalities in health: an
agenda for action. London: King’s Fund Institute; 1995
7. Barton HAGM. A health map for the local human habitat. J R Soc Promot Health 2006; 126(6): 252-261.
developing nations
h Metropolitan Area Health Service, WA.
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3 MDG
promote gender equality & empower women
Tipping
www.ghn.amsa.org.au
1. UNDP. Goal 3: promote gender equality and empower women. [Internet]
2010 [updated 2010; cited 2010 November 18]; Available from: http://www.
undp.org/mdg/goal3.shtml.
2. UN. The Millennium Development Goals Report. New York; 2010
3. UNSD. Millennium Development Goals: Gender equality and women’s
empowerment progress chart 2010. New York; 2010.
4. UNDP. Keeping the promise: united to achieve the Millennium
Development Goals. United Nations 2010 MDG Summit; New York.
KEY FACTS
MDG 3 seeks to promote gender
equality and empower women. The
empowerment of women has been
linked to long term financial and social
stability in communities across the
globe. This is reflected in the 2000
Millennium Declaration, which states
that the empowerment of women is
an “effective way to combat poverty,
hunger and disease and to stimulate
development that is truly sustainable 1 .”
The achievement of the MDG is
reflected in three key indicators,
including the ratio of girls to boys
in primary, secondary and tertiary
education, the proportion of women
employed in the non-agricultural
sector, and the share of seats held by
women in the national parliament 1 .
The 2010 MDG Review Summit, held in New York in
September, held a spotlight on the progress made
towards achieving equality for and the empowerment
of women. It provided a chance to reflect on what
has been achieved thus far, and the barriers which
remain towards achieving the full political, financial
and social involvement of women on the world stage.
Equality for women, however, is more than just an end
in itself. Kofi Annan, former Secretary-General of
the United Nations, stresses that it is a precondition
for meeting the challenge of reducing poverty,
promoting sustainable development and building
good governance.”In short, not much will happen until
women have the chance to be equal on the playing
field.
Since 2000, documented progress has been made in
achieving the third Millennium Development Goal,
as reflected in greater gender parity in primary
education in some nations. While the greatest
advances have been made in Southern Asia, Sub-
Saharan Africa, Western and Northern Africa have
also documented improvement in female participation
in the education sector 1 . Sadly, in Oceania, which in
conjunction with Sub-Saharan Africa and Western
Africa, has the poorest record of gender equity, there
has been a slight reduction in parity in enrolment
in primary education 1 . Similarly, the percentage
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of women who share in employment in the nonagricultural
sector remains at worryingly low levels
in many African and South Asian nations 2 .
Long-held cultural views of the secondary role of
women in society provide a major barrier to the
active participation of women in educational,
financial and employment sectors. Drought, food
shortages, conflict, failure to register births, child
labour and the rise of HIV/AIDS further cripple
progress by impeding school involvement and
denying girls the opportunity to gain an education 1 .
Beyond immediate crises, however, women are
unable to achieve equal participation in society
in the absence of appropriate infrastructure to
unable to break the cycle of poverty and become
active participants in the labour market 3 . Where
women are denied an education, they are unable to
make choices about the use of contraception, key to
controlling the spread of HIV/AIDS and in enabling
women to choose the timing of their children 3 . And
where women are not empowered to become active
decision makers, their needs continue to be unheard
and unaddressed.
alyssa fitzpatrick
university of adelaide
support their ongoing development. For example,
in communities where water is not available by
pipeline, girls are twice as likely as boys to be
required to collect water, completing multiple
long-distance trips and sacrificing time that could
otherwise be used for education and employment. 3
Women’s economic involvement provides a conduit
for improved livelihoods for themselves and their
families, and improved health and educational
opportunities for the children 3 . Where women are
denied ownership and control of resources, they are
‘‘
investing in women
‘‘
and girls has a
multiplier effect on
productivity, effiency
and sustained
economic growth
review summit 2010
The 2010 Review Summit reiterated its
commitment to promoting women’s social and
economic involvement, stressing that investing
in women and girls has a multiplier effect on
productivity, efficiency and sustained economic
growth” and thus that a focus on women is key
to ensuring continued progress and meaningful
improvements in quality of life 4 . The 2010 Review
Summit placed an emphasis on the continuing need
to target gender equality through the launch of
the Gender Equality and Women’s Empowerment
Progress Chart. Highlighting the promising increase
in aid directed at improving parity in women’s
involvement in recent years, it nonetheless called
for further contributions to address this core
concern 3 . However, the Summit also emphasised
the need to ensure good sanitation and nutrition,
and to combat HIV/AIDS, to facilitate women’s
empowerment. It additionally reiterated the
reciprocal dependency of achieving MDG 3 and
realisation of the other core targets embodied in
the Millennium Development Goals to achieve
improvements in quality of life for all. At the
heart of it, however, is the deep understanding that
without equal opportunity for women, there will
be continued barriers to achieving long-lasting and
meaningful development.
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Goal 4: Reduce child mortality rate
Reducing child mortality is
not as simple as increasing
immunisation rates. A burn
like this one can mean a life
of disability, and increased
susceptibility to other
diseases. It's important to
recognise the importance
that rehabilitation also plays
in helping those children
who have suffered a serious
illness or injury to remain
free of further problems.
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photo by
Zhi Lin Kang

aWindowintoGlobalHealth
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educe child mortality
ONEStep
university of
melbourne
on a long path
towards much
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4 MDG • growth monitored
The story of what is today global or international
child health had its beginnings in the aftermath
of the violence of World War II. Much as the War
abolished and redefined borders, the boundaries
of responsibility for the world’s children were
to progressively expand. The United Nations
International Children’s Emergency Fund (UNICEF)
was created in 1946 by the United Nations General
Assembly to provide relief to children affected by
World War II; and this heralded an approach that
called for international collaboration to improve the
health of children.
The 4th Millennium Development Goal, to reduce the
rate of child deaths (expressed as deaths per 1000 live
births) in each country by 2/3 of what it was in 1990 by
2015, is a continuation of approaches adopted over the
last three decades. The idea is that most child deaths
are preventable. Despite advancement in the science
of medicine, pharmaceuticals and technology, the
major killers of children are still pneumonia, malaria,
malnutrition, diarrhoeal diseases, and complications
of birth or infections of the newborn. In the 1980s,
UNICEF introduced the GOBI initiative, focussing on
trying to ensure every child has their basic needs of
medical care.
more
GOBI initiative(198o):
• oral rehydration solution
access if diarrhoeal
disease occurs
• breast feeding
• immunisation
This had remarkable results, and emphasised
an important lesson: what needs to be done is
already known, and the majority of child deaths
can be averted by focussing on a few simple,
highly effective interventions, and doing them
well.
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It would be simplistic to assume that
MDG 4 is sufficient for improving
child health. We know that health is
much more than preventing deaths.
Children need a safe environment to
prosper in, a future and the chance to
become what they aspire to, without
being hindered by race, gender or place
of birth. If we achieve MDG 4 – which
would be the case for most countries
in Latin America and some countries
in South East Asia – that would be
encouraging, but still not enough.
Today, the greatest determinant of
a child’s future is the country they
are born in. Addressing this inequity
requires more than reducing death
rates.
it can target high density areas, and
neglect scattered rural communities.
Such details will never be reflected by
one national figure for child mortality.
And then there is sustainability, and
the effect that global support for
particular areas can have on the health
system. Generous external donors can
identify HIV and malaria as a problem,
and fund initiatives to address these
at a scale that engulfs other ongoing
health programs. And hence, the
bigger picture can become clouded
with multiple, well funded diseasespecific
programs that are highly
dependent on external support and
management.
The Millennium Development Goals
are a remarkable step forward. But
we do need to be cognisant of their
constraints. What is the problem with
focussing on reducing national death
rates? The most obvious problem is
data. Most developing countries do
not have vital registration systems,
i.e., no population records of births
and deaths. Therefore, indicators,
like child mortality, are calculated
using indirect methods, such as
surveying a representative sample
(much like political opinion polls).
The inaccuracies in these methods are
obvious when we compare mortality
rate estimates from say WHO and
UNICEF, which can be significantly
different depending on the methods
used to derive the estimate.
The more worrying problem is equity.
Within every society, there are the rich
and poor; the privileged and underserved.
But within the under-served,
there is a continuum. A country can
reduce its mortality rates by targeting
a large population of marginally
disadvantaged groups, neglecting
smaller populations of extremely
disadvantaged minority groups. Or
annual
number
of child
deaths
has
dropped
from
12.5
million
in 1990 to
8 million
in 2009
There is much to be hopeful about.
For one, the annual number of child
deaths has dropped from 12.5 million
in 1990 to 8 million in 2009. We are in
an era of increasing global awareness
to the plight of people in every corner
of the globe, and increasing interest
by health professionals in engaging
in global health. The science of just
how to reduce child deaths, support
the development of health systems
and work towards health is gradually
improving. However, it is important to
always emphasise that MDG 4 is the
right step on a long path towards much
more.
1.UN. Summit on the Millennium Development Goals. [Online]. 2010 [accessed 1st
November 2010]. Available from: URL http://www.un.org/millenniumgoals/
2.UNICEF. The State of the World’s Children. New York: United Nations Children’s
Fund; 1984
3.UNICEF. Progress for children: MDG4. [Online]. 2007 [accessed 1st November 2010].
Available from: URL:http://www.unicef.org/progressforchildren/2007n6/index_41799.
html
4.You D, Jones G, Hill K, Wardlaw T, Chopra M. Levels and trends in child mortality,
1990-2009. The Lancet. 2010; 376(9745):931-33
www.ghn.amsa.org.au
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19

5 MDG
improve maternal health
KEY FACTS
MDG 5 focuses on
maternal health and has
two targets. The first is to
reduce by ¾ between 1990
and 2015 the Maternal
Mortality Ratio (MMR),
defined as the number of
deaths of women who
are pregnant, giving birth,
or up to 42 days postpartum,
per 100,000 live
births 1 . The second is to
achieve universal access to
reproductive health care.
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the Pains of
Labour
samantha
sundercombet
university of sydney
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Progress to date:
MDG5 is the worst performing MDG 2 . Since 1980,
the world MMR has declined 1.3 percent (CI 1.0-1.5)
annually to 251 deaths/100,000 live births in 2008 3 .
Similarly, there has been a 1.5 percent annual decline
in the gross number of deaths, from 526,300 to 342
900 (CI 302 100-394 300) 3 . These figures are smaller
than the 3 percent annual decline necessary to meet
the MDG5 target between 1990 and 2015.
Over half the maternal deaths in 2008 occurred
in just 6 countries: India, Nigeria, Pakistan,
Afghanistan, Ethiopia and the Democratic Republic
of the Congo. Afghanistan has the highest MMR, at
1575/100,000 3 ]. For comparison, Australia’s MMR is
5/100,000 3 .
‘‘
MDG 5 is the
worst performing
millenium
Access to modern contraception is an effective
primary prevention strategy against unsafe abortion,
which causes 8 maternal deaths an hour [9 , and
maternal mortality generally 10 . Modern contraceptive
use has increased in all regions 11] , however remains
so low that 76 million unintended pregnancies occur
each year 12 : 41 percent of pregnancies globally are
unwanted and 22 percent result in induced abortion 13 .
Access to safe, legal abortion has been shown to
reduce abortion mortality 10 .
‘‘
development goal
World Global Monitoring Report 2010
Maternal mortality progress from 1980-2008 3
Reasons for high maternal mortality:
The most common immediate causes of maternal
death are post-partum haemorrhage, sepsis,
hypertensive disorders, unsafe abortion, and
obstructed labour 4 . The majority of deaths occur
around labour, delivery, and 5-48 hours post-partum 5 .
Broader socio-economic factors contributing
to maternal deaths include poverty 6 , which is
improving 2 , disempowerment of women, and HIV 3, 5 .
Solutions:
Ensuring access to skilled attendance at delivery, and
emergency obstetric care for birth complications,
can potentially prevent 250,000 maternal deaths per
year 7 . A strategy where women deliver their children
in a health facility attended by midwives, with other
attendants such as doctors available if complications
arise, is the ‘best bet’ for reducing maternal
mortality 8 .
In India, a scheme where women are given cash
incentives to deliver their babies at health facilities
has increased the number of in-facility births 14 . If
adopted globally, this scheme could reduce maternal
deaths due to poverty.
Women are gradually becoming more empowered.
Girls were attending primary school at the same
rate as boys in almost 2/3 of developing countries by
2005 2 ]. Educated women marry later, have greater
decision-making power in households, and have
fewer, healthier and better-nourished children 15 .
Furthermore, more women than before are able to
earn income through access to small business loans,
known as microfinance.
Maternal mortality progress from 1980-2008 3
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Results from the UN MDG summit:
At the UN MDG Summit 20-22 September 2010
the Global Strategy for Women’s and Children’s
Health was launched 16 . This document encourages
governments, NGOs, universities, health workers,
philanthropists and business partners to join forces
to integrate and scale-up interventions and services
proven to work. It emphasizes supporting country-led
health plans, delivering packages of integrated care
and building capacity in health workforces.
More investment is needed to meet MDG5 - US
26 billion dollars in 2011. More than 40 million
dollars was pledged at the summit. If implemented
successfully, the strategy will provide access to
modern contraception for 43 million more women,
and enable 19 million more women to deliver their
children safely, with a skilled birth attendant by 2015.
This will prevent 33 million unwanted pregnancies,
and save 570,000 women who would have otherwise
died of birth or pregnancy complications.
The 6 countries in which half the
maternal deaths in 2008 occurred, with
number of national maternal deaths (in
1000s) 3 68.3%
15.4%
18.2%
20%
36.7%
20.1%
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22
[1.] United Nations General Assembly. United Nations Millennium Declaration. A/RES/55/2. New York: United
Nations, 2000
[2.] World Bank. Global Monitoring Report 2010. The MDGs after the Crisis. Available: http://web.worldbank.org/
WBSITE/EXTERNAL/EXTDEC/EXTGLOBALMONITOR/EXTGLOMONREP2010/0,,contentMDK:22529228~pagePK:64
168445~piPK:64168309~theSitePK:6911226,00.html
[3.] Hogan MC, Foreman JK, Naghavi M, Ahn SY, Wang M, Makela SM et al. Maternal mortality for 181 countries, 1980-
2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet. 2010; 375:1609-1623
[4.] Potts M, Hemmerling A. The worldwide burden of postpartum haemorrhage: Policy development where inaction is
lethal. Int J of Gyn and Obst. 2006; 94(2):S116-S121
[5.] Ronsmans C, Graham WJ. Maternal mortality: who when, where and why. Lancet. 2006; 368: 1189-1200
[6. World Health Organisation statistical information system. World Health Statistics 2008. Available: http://www.
who.int/whosis/whostat/2008/en/index.html
[7.] Save the Children. Women on the front lines of health care: state of the world’s mothers 2010. 2010 IS BN 1-888393-
22-X
[8.] Campbell OR, Graham WJ. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006;
368:1284-1299
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[9.] Singh S, Wulf D, Hussaid R, Bankole A, Sedgh G. Abortion worldwide: a decade of uneven progress. New York:
Guttmacher Institute. 2009
[10.] Haddad LB, Nour NM. Unsafe abortion: unnecessary maternal mortality. Rev Obst and Gyn. 2009; 2(2): 122-126
[11.] United Nations. The Millennium Development Goals Report 2010. Available: http://www.un.org/millenniumgoals/
pdf/MDG%20Report%202010%20En%20r15%20-low%20res%2020100615%20-.pdf
[12.] United Nations Population Fund. State of the World Population on Climate Change, Population, and Women. 2009.
Cited in Save the Children. State of the World’s Mothers Report 2010.
[13.] The Alan Guttmacher Institute. Sharing responsibility women, society and abortion worldwide. New York. 1999.
Cited in Campbell and Graham 2006
[14.] Lim SS, Dandona L, Hoisington JA, James SL, Hogan MC, Gakidou E. India’s Janani Suraksha Yojana, a conditional
cash transfer programme to increase births in health facilities: an impact evaluation. Lancet. 2010; 375:2009-23
[15.] UNESCO. Reaching the Marginalised: EFA Global Monitoring Report. 2010
[16.] UN Secretary General Ban Ki Moon. Global Strategy for Women’s and Children’s Health. 2010. Available: http://
www.who.int/pmnch/topics/maternal/20100914_gswch_en.pdf

aWindowintoGlobalHealth
Goal 3: Empowering women and promoting gender equality
Empowering women means ensuring they
have the same opportunities in education,
employment and politics as do their male
counterparts. It means giving them a voice.
In Bangladesh, the Female Secondary
School Stipend programme has provided
money directly to girls and their families
to cover tuition and other costs, ensuring
many more girls bear the radiant smile of
this lady.
photo by
sophie white
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aWindowintoGlobalHealth
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24
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Goal 6:
Combat HIV/AIDS,
malaria, and other
diseases
The sheer number of
people in this picture is a
powerful reminder of the
difficulties of controlling
communicable diseases.
In India, tuberculosis kills
an estimated 330,000
people per year, but
there is hope! Since 1997,
the Revised National
Tuberculosis Control
Programme has provided
treatment to more than
11 million patients and
saved more than two
million lives.
photo by
tim whittick &
penny brussen
www.ghn.amsa.org.au
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2
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26
6 MDG
Up to 2 million people die from AIDS related
illnesses every year, many of whom are in
southern Africa (38%). Increased access to
antiretroviral drugs in poorer countries means this is
decreasing; however over 5,000 people still die each
day from AIDS. Running a close second in global
mortality is tuberculosis, responsible for 1.8 million
deaths in 2008, about 500,000 of whom were HIVpositive.
90 per cent of malaria deaths also occur
in Africa, where it accounts for a fifth of childhood
mortality (equivalent to the death of one child in the
world every 45 seconds) 1-3 . [ ]
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combat HIV/AIDS, malaria and other diseases
Challenges to achieving the targets
1
Education and knowledge of HIV is unacceptably low
Knowledge about HIV and its modes of transmission
is the first step to preventing its spread. However,
less than a third of young men and one fifth of
young women in developing countries have received
education about the illness. Condom use also remains
low globally, especially among developing countries.
With many young people in Africa unaware of the
risks and modes of transmission for HIV, the UN’s
goal on comprehensive HIV knowledge of 95 per cent
of people in developing countries is still far from
being achieved 1,2,4 . []
Antiretroviral treatment has expanded but HIV
prevalence rates continue to rise
When antiretroviral therapy was launched in 2003,
only 400,000 people were able to access it. By the
end of 2009, more than five million people were
receiving treatment. However, for every two people
starting HIV treatment each year, five new people
are infected. Access to antiretroviral therapy needs
to be expanded for pregnant women, as most of
the 2 million children younger than 15 living with
HIV were infected by vertical transmission (in the
womb, at birth or via breastfeeding). In 2008 alone,
over 60,000 HIV infections among at-risk babies
were prevented because their HIV-positive mothers
received treatment. However, less than 50 per cent
of HIV-positive expectant mothers currently receive
treatment 1,2,5,6 . []
3
HIV/AIDS is becoming a chronic disease in many
countries
The survival rate of HIV/AIDS is growing in many
countries due to the increasing availability of
antiretroviral drugs in the developing world. As
a result, HIV/AIDS is being transformed into a
chronic disease, with a model of care that also needs
to transform to focus on multidisciplinary models,
continuity of care, long-term adherence support, and
social support 1,4,7 . []
4
HIV/AIDS may not just affect poorer populations
Contrary to evidence for other infectious diseases,
HIV may be more prevalent amongst higher-income
demographic populations than previously thought.
In a large study looking at eight African countries,
wealthier men and women had a higher prevalence
of HIV than poorer ones and were at least as likely
as poorer adults to be infected. If this is in fact a
common pattern, a broader approach needs to be
taken in the prevention of HIV/AIDS in developing
countries 8 . []
What is being done worldwide?
The UN is coordinating global efforts to achieve
these targets in reducing communicable and largely
preventable deaths. Several UN programs aim
to prevent these diseases and enhance access of
treatments according to the following strategies:
•Increase technical support for HIV/AIDS
• The Joint United Nations Programme on HIV/
AIDS (UNAIDS) coordinates the resources of ten
organisations assisting developing countries with
technical support in the implementation of their
national AIDS plans [1 .]
•Prevent mother-to-child transmission of HIV/AIDS
• The UN Children’s Fund (UNICEF), the World
Health Organisation (WHO), the UN Population
Fund (UNFPA) and UNAIDS have assisted countries
to develop and implement programmes aimed at
preventing vertical transmission of HIV, including
training, funding and technical expertise [1,2 .]

SNAPSHOT
33 million people are
currently living with HIV
worldwide. Two thirds of
these are in Africa (mostly
women) and this number
continues to grow, despite a
decrease in new infections
(as those infected with HIV
are now surviving longer).
There are also 11 million
people currently suffering
from tuberculosis, and a
staggering 240 million cases
of reported malaria in 2008 1,2 .
nets
condoms &
drugs
minh nguyen
flinders university
Widespread HIV/AIDS prevention and care programs
• The UN Development Programme (UNDP) has
engaged over three million people in prevention
activities over the last five years. In Burkina Faso,
an African country in West Africa, this programme
provided regular support to nearly 36,000 people
living with HIV, including home visits, meals and
assistance to set up small-scale enterprises 1,2,5-7 . [
Increasing access of mosquito nets to prevent malaria
• Global production of mosquito nets has increased
500% since 2004 to 150 million nets in 2009. Nearly
200 million nets were delivered to African countries
between 2007 and 2009. However, nearly 350 million
are needed to achieve universal coverage and this
effort needs to be intensified 1,2,9 .]
•
The first scoping study, on HIV prevention initiatives
targeting men who have sex with men in Asia and
the Pacific (with a focus on Vietnam Cambodia Burma
Philippines and PNG), was completed in 2009. A
second study on greater involvement of people living
with HIV was completed in November 2009 and the
final study on HIV legal and policy frameworks was
completed in March 2010. Initial responses to the
recommendations include 3 million dollars of funding
over three years (2009-12) to support programs for
men who have sex with men in Indonesia, PNG
and Burma, and 1.5 million dollars over three years
(2009-12) to PNG and the Solomon Islands for legal
and policy development activities. Further work on
incorporating recommendations from these studies
into longer-term HIV programming is underway 10 .]
Australia’s role in achieving MDG 6
The Australian Government has a focussed strategy
aimed at helping partner countries address MDG6.
The main focus for Australia’s support to the global
HIV/AIDS effort is based in the Asia Pacific region.
In Africa, Australian support is channelled through
the Global Fund and UNAIDS. Currently,
AusAID, Australia’s aid program, has focussed its
global research efforts into three areas:
• HIV prevention for men who have sex with Men;
• greater involvement of people living with HIV;
• and legal and policy enabling environments for
effective HIV responses.
1.United Nations. 2010. The millennium development goals report 2010. New York: United Nations.
2.UN Development Programme (UNDP). 2010. What Will It Take to Achieve the Millennium Development Goals? An
International Assessment 2010. New York: United Nations.
3.WHO. 2009. Global Tuberculosis Control: A Short Update to the 2009 Report. Available from http://whqlibdoc.who.
int/publications/2009/9789241598866_eng.pdf (accessed 13 November 2010).
4.Center for Global Development. 2004. Millions Saved: Proven Successes in Global Health. CGD Brief. October 2004,
3:3.
5.MARCO. 2009. Five-Year Evaluation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, Synthesis of Study
Areas 1, 2 and 3, Marco International Incorporation.
6.Nunn, A. S., da Fonseca, E. M., Bastos, F. I. and S. Gruskin. 2009. AIDS Treatment in Brazil: Impacts and Challenges.
Health Affairs, vol. 28, no. 4, pp. 1103-1113.
7.Janssens, B., et al. 2007. Offering integrated care for HIV/AIDS, diabetes, and hypertension within chronic disease
clinics in Cambodia. Bull WHO, Vol. 85, pp. 880-885.
8.Mishra, V. et al. 2007. A study of the association of HIV infection with wealth in sub-Saharan Africa. DHS Working
Papers.
9.WHO. 2007. WHO Releases New Guidance on Insecticide-treated Mosquito Nets: Recent Data from Kenya “Ends the
Debate” About How to Deliver the Nets. Available from http://www.who.int/mediacentre/news/releases/2007/pr43/
en/index.html (accessed 20 November 2010)
10.AUSAID [homepage]. 2010. HIV/AIDS: Australia's response. Available from http://www.ausaid.gov.au/keyaid/
hivaids/default.cfm (accessed 22 November 2010)
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28
7 MDG
Millennium development goal (MDG) seven
is to ensure environmental sustainability 1 .
To help us understand how this is defined,
the goal is broken down into several ‘targets’.
The targets pertain to things like optimising the
percentage of land area covered by forest, protecting
biodiversity, improving the efficiency of energy use,
reducing per capita CO 2
emissions and consumption
of ozone depleting chlorofluorocarbons, improving
population access to clean water and sanitation,
and access to adequate housing for the most
impoverished. The achievement of these targets
would not only improve the health of our ecosystem
but also directly improve human health and assist
ensure environmental sustainability
in the mitigation of climate change. We can assist
in making MDG reality by applying these global
targets to the local communities in which we
participate. Perhaps most appropriately, as future
health professionals, we should consider the ways in
which we can assist the health sector to acknowledge
the ecological footprint of its business, and duly take
steps to rectify this blight.
‘‘
‘‘
scientific consensus that, as a consequence of human
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our nation has made
minimal progress in
lifting its ecological
game
In the ten years since then Australian-PM John
Howard was signatory to the United Nations
Millennium Declaration in the year 2000, our
nation has made minimal progress in lifting its
ecological game. This is despite knowing that there is
activities, the earth’s climate is warming. During the
twentieth century Australia’s average surface air
temperature has increased by 0.7 0 C and rainfall has
substantially reduced 2 . The rise has been attributed
to our reliance on the combustion of fossil fuels for
energy generation and transport and the concomitant
rise in atmospheric concentrations of carbon dioxide
and other greenhouse gases 3 . Disheartingly, we are
locked in to a further warming of at least 0.2-1.0 0 C
by the year 2100 2 , however much larger rises are
likely to be in store if we are unable to dramatically
reduce greenhouse gas emissions in the next decade 2 .
In addition to this, extreme weather events such as
tropical cyclones, heat waves, and floods will become
more frequent. In this way climate change will have
detrimental impacts on the environment, economy,
and public health.
Rich countries such as Australia are better placed
than many other nations to be able to fund climate
mitigation and adaptation strategies. Mitigation is
essentially primary prevention to contain a rise in
surface air temperature through cuts to greenhouse
gas emissions, whilst adaptation is a form of
secondary prevention to allow us to live with the
inevitable changes in weather patterns; tertiary
prevention is tantamount to disaster response to the
predicted increase in extreme climate events. As in
medicine primary prevention, although unpopular, is
a much more cost-effective approach than having to
deal with a series of emergencies.
It is in this context that the Australian healthcare
system is gradually adopting a triple-bottom line
approach to evaluation, thereby moving away from an
arcane system that treated environmental impacts as
an ‘externality’ with little mandate or incentive for
hospitals, universities and other large institutions
to reduce their carbon footprint . By targeting waste,
staff and patient transport and utility (water, energy)
consumption some such facilities are starting to
make moves. Actions are starting to pop up - ride
to work days, waste reduction programs - all
contributing to the broader tapestry of sustainabilitypromotion.
With the knowledge that there is no health, or
economy, without the environment many current and
future health professionals such as ourselves realise
that to concern for population health necessitates
taking action to ensure environmental sustainability.
Thus to take care of the the environment is not
merely a case of “doing the right thing, it is also an
opportunity to make cost savings, experience health
co-benefits and mitigate some effects of climate
change.

PLAY A
PART AND
MAKE A
DIFFERENCE
Understand the threats
by educating yourself and
your colleagues 1about the
links between ill health,
environmental degradation, and
climate change and mitigation
strategies such as promotion of
active transport and increasing
teleconferencing to reduce
unnecessary car and plane
travel.
Campaign for the
integration
4
of
education on climate
change into the
medical curriculum
at your university.
Help to build networks of like-minded
people within your university, hospital
or community by joining the your local
green group, student 2division of Doctors
for the Environment Australia (www.dea.
org.au) and/or the climate code green
project for Australian medical students
(www.codegreensite.com). Consider
participating in the national gathering for
medical students on climate change and
other environmental health issues called
‘iDEA’ which will be held in Sydney over
the weekend of April 29-May1, 2011.
Environ
GOING
liz o’brein
university of
notre dame
west australian
student member
for doctors for
the environment
australia (DEA)
Advocate local and national
policies to improve health both
now and for 3future generations.
Educate those in positions of power
(e.g. local politicians, hospital
administrators, academics) about
the health risks of climate change
through meetings, articles in
public forums such as your medical
school paper and suggest ways
they can incentivise sustainable
practice.
1. United Nations. 2007. Millennium development goal seven: ensure environmental sustainability. United Nations
Development programme. Accessed online October 18, 2010 at http://www.un.org/millenniumgoals/environ.shtml
2. Preston BL, Jones RN. 2006. Climate Change Impacts on Australia and the Benefits of Early Action to Reduce Global
Greenhouse Gas Emissions. A consultancy report for the Australian Business Roundtable on Climate Change. CSIRO.
Canberra, Australian Capital Territory. Accessed online on October 18, 2010 at http://www.csiro.au/resources/pfbg.
html
3. Intergovernmental Panel on Climate Change. Climate change 2007: the physical science basis—summary for policy
makers. Accessed online October 18, 2010 at: http://www.ipcc.ch/publications_and_data/ar4/wg1/en/contents.html
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29

MDG
develop a global partnership for development
w h y
can’t
WE
just
All
get
What’s it all about? What’s it supposed
to do? And can’t we all just get along!?
Perhaps the most varied, and least
understood of the UN MDGs, this
MDG is designed to tie the other seven
together, by taking steps towards
strengthening trade, political and
health systems.
?
along
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30
nick watts
university
of western
austraila
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key goals
1. Raise the commitment of Official
Development Assistance (ODA) to 0.7% of
the Gross National Income (GNI) of donor
countries.
2. Develop an equitable finance system, by
allowing the Least Developed Countries
(LDC) access to markets of developed
countries, and through tariff reductions
benefiting these countries.
3. Ensure that in an increasingly globalised
world, we address the needs of the LDCs
and Small Island Developing States (SIDS)
4. Manage the heavy debts of low income
countries (think Live-Aid… kind of).
5. Provide access to essential medicines, life
saving drugs through a variety of patent and
trade-related mechanisms.
6. Set in place structures which allow
the spread of new Information and
Communication Technologies (ICTs) –
internet & mobile phones – to the global
South.
Ten years in, where do we stand? Well, only 1
billion of the world’s 6.88 billion have access
to the internet, debt levels (whilst still high)
are falling rapidly, and ODA stands at roughly 0.34%
of GNI of developed countries, a little under half way
towards the 0.7% we’re aiming for.
Australia (one of the lucky few who has kept a budget
surplus throughout the recession) has recently
committed to increase our ODA to 0.5% of our GNI by
2015, falling significantly short of our 1970 promise
(renewed in 2002 Monterrey Consensus). Meanwhile,
the UK - a country which is literally hemorrhaging
from the results of the global financial crisis - is well
on track to achieve their commitments.
Achieving these targets will require partnership…
in fact… it requires “global partnerships for
development. We’ll need all countries (of high and
low incomes) to work with behemoths such as the
Bretton Woods trio (the International Monetary
Fund, the World Bank and the World Trade
Organisation), three bodies charged with managing
the trade and finances of the world. We’ll need
unprecedented Public Private Partnerships (PPP)
between governments and privatised pharmaceutical
companies and ICT companies to ensure global
access to essential communication technologies
and medicines. We’ll need donor countries to work
together to coordinate their aid, ensuring that
evidence based assistance is delivered to the parts
of the world where it is needed most. We’ll need
non-governmental and organisations (NGO) such as
Médecins Sans Frontiéres (MSF) and Oxfam to assist
with aid coordination and distribution. But most of
all, we’ll need a partnership between civil society,
a roar from the public, telling the governments of
the world that there is support for action on poverty,
‘allowing’ them to act.
Each and every partnership takes us one step closer
not only to achieving MDG 8, but to the eradication of
extreme poverty. After all:
“It is not in the United Nations that the Millennium
Development Goals will be achieved. They have to be
achieved in each of its Member States, by the joint
efforts of their governments and people”
- Kofi Annan, Former UN Secretary General
1. United Nations Development Programme. MDG Monitor. Geneva2010 [26 Oct 2010]; Available from: http://www.
mdgmonitor.org/.
2. Australian Agency for International Development (AusAID). Australian Partners. Canberra2010 [26 Oct 2010];
Available from: http://www.ausaid.gov.au/.
3. UK Department for International Development (UKDFID). Governance and Social Development Resource Centre.
London2010 [26 Oct 2010]; Available from: http://www.dfid.gov.uk.
4. UN MDG. Millennium Development Goals - 2015. New York2010 [26 Oct 2010]; Available from: http://www.un.org/
millenniumgoals/global.shtml.
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Introduction
The world’s first major conference on the global
environment was held in Stockholm, in 1972.
At that time few doctors seemed aware or
concerned about the global environmental dimension
to inequality 1 , though the medical profession had
by then a long history of working to promote health
in low income settings [2 , exemplified by Albert
Schweitzer, who divided his time between Europe
and the hospital he had established in French
Equatorial Africa.
In 2009, as the world anticipated the biggest
climate change summit since Kyoto in 1997, the
issue of climate change appeared to almost head
the international agenda. The health literature also
published many papers on this issue [3-5] . Yet, since
then, developed nations including France, the U.S.
and Australia have retreated from the rhetoric which
briefly raised hopes of leadership from the rich
world. This is not because of any weakening in the
evidence or scientific consensus, but a possibly fatal
weakening in the political support. The current year
has been the hottest on record, and the drought in
Russia and the Ukraine (during July to August 2010)
has triggered the sharpest rise in grain prices seen in
30 years [6 . Speculation is undoubtedly a major cause
of this rise, but the market is likely sensing and
reflecting increasing global concern and volatility.
This heat wave is consistent with climate change.
Health effects of
climate change:
primary, secondary
and tertiary
The list of health conditions associated with climate
change can seem bewildering; from the fairly obvious
to the obscure, such as gastroenteritis caused by
Vibrio Parahaemolyticus [7] . One way to categorise
these diverse manifestations is by grouping the most
obvious effects as ‘primary’ and less obvious effects
as ‘secondary’. Primary effects include heat waves,
heat stress, and the physical impacts from extreme
weather effects such as storms and fires. The latter
group includes ecologically mediated vector borne
diseases, such as malaria, and other communicable
diseases whose epidemiology will be altered by
climatic and associated ecological variation, from
plague [8] to hantaviruses 9] .Many more details of these
effects are available elsewhere [10] .
There is one more level of effect that must be
considered, here called ‘tertiary’ 10, 11 .Ultimately,
these effects should cause the greatest anxiety, to
society and therefore to health. Yet, among the vast
literature concerning climate change very little
discusses the likely impact upon global health from
the bleak social and physical conditions to which
much of the world appears to now be heading. It
perhaps takes courage rather than imagination to
contemplate a nuclear-armed world in which sea
level has risen by a metre, and where the grain yield
in South Asia has declined by 18 to 22% 12 , ven though
global health,
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doctors
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colin david butler
national centre for epidemiology
and population health,
australian national university

several hundred million additional South Asians
are then predicted to be alive. Yet such conditions,
interwoven with many other difficulties, are likely to
occur within 70 years.
THE FUTURE
Beyond the health literature, frank discussion of the
likely conditions in which humanity will live in 2100
is also rare, and where it exists, it is generally biased
towards the optimistic [13 . Official socio-economic
forecasts and scenarios are excessively hopeful,
perhaps because humans cannot bear too much pain,
or perhaps because authorities are concerned that
bleak forecasts will become self-fulfilling. However,
in addition, a good deal of woolly thinking, ‘group
think’ and frank denial is occurring, evidenced, for
example, by the way the global financial crisis caught
governments and their elite economic advisers by
surprise. This disconnect between prediction and
reality likely extends to the size of oil supplies [14 and
to other critical limits to growth [15 .
Irrespective of the reasons for this optimism [13 the
health consequences of future global climate change
are likely to be severely underestimated, without
consideration of tertiary effects. Such effects are
likely to exceed the other impacts, even if combined,
perhaps by one or even two orders of magnitude.
Apprehension of these tertiary effects, though poorly
articulated, appears to be a rational explanation
not only for many concerns expressed by youth
about the future 16 , but also for the level of concern
about climate change in both the health and wider
literature.
Linking the global
climate and global
health inequality
crises
That humanity appears to be nearing an abyss
might surprise some readers. However, another
immense problem has co-existed with our increasing
prosperity, since at least World War II 17 . This is
the problem of apparently intractable Third World
poverty, and of the resultant health gap between
privileged and poor populations. In fact, the parallel
problems of global health inequality and of our
trajectory towards dangerous climate change can
each be considered as manifestations of an intelligent
species, a clothes-wearing primate, who is not quite
as smart as s/he thinks. History is replete with
civilisations that have collapsed 18, 19 . Even before
humans had developed cities violent conflict among
humans has been documented, from the end of the
Pleistocene 20 .
Although there it is legitimate to be troubled by the
future, hope should not be lost. Humanity has faced
great stress before. Seventy years ago the Allies
fought a bitter war against the Japanese and Nazi
Germany. A quarter century after that, many fears
were expressed concerning impending famine in
the 1970s 21 . [ In both the early 1960s and again in the
1980s, great fear was held about a nuclear war. So
far, we have escaped these fates. If humanity is to
traverse this future it will do so in part because of
the contribution of doctors, together with many other
actors and new ways of social organisation 22 .
1. Boyden S. The environment and human health. The Medical Journal of Australia. 1972;116:1229-34.
2. King M, editor. Medical Care in Developing Countries. A Primer on the Medicine of Poverty and a Symposium from
Makerere. Nairobi: Oxford University Press; 1966.
3. McMichael AJ, Neira M, Heymann DL. World Health Assembly 2008: climate change and health. The Lancet.
2008;371:1895-6.
4. Lim V, Stubbs JW, Nahar N, Amarasena N, Chaudry ZU, Weng SCK, et al. Politicians must heed health effects of
climate change. The Lancet. 2009;374:973.
5. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the health effects of climate change. The
Lancet. 2009;373:1693–733.
6. Williams S. Parched Russia warns on harvest, wheat prices surge. Sydney Morning Herald. 2010.
7. McLaughlin JB, DePaola A, Bopp CA, Martinek KA, Napolilli NP, Allison CG, et al. Outbreak of Vibrio
parahaemolyticus Gastroenteritis Associated with Alaskan Oysters. New England Journal of Medicine. 2005;353:1463-9.
8. Stenseth NC, Stenseth NC, Samia NI, Viljugrein H, Kausrud KL, Begon M, et al. Plague dynamics are driven by
climate variation. Proceedings of the National Academy of Science (USA). 2006;103:13110-5.
9. Klempa B. Hantaviruses and climate change. Clinical Microbiology and Infection. 2009;15(6):518-23.
10. Butler CD, Harley D. Primary, secondary and tertiary effects of the eco-climate crisis: the medical response. Post
Graduate Medical Journal. 2010;86:230-4.
11. Butler CD, Corvalán CF, Koren HS. Human health, well-being and global ecological scenarios. Ecosystems.
2005;8(2):153-62.
12. Tubiello FN, Fischer G. Reducing climate change impacts on agriculture: Global and regional effects of mitigation,
2000–2080. Technological Forecasting & Social Change. 2007;74:1030–56.
13. Butler CD. Peering into the fog: ecologic change, human affairs and the future (commentary). EcoHealth. 2005;2:17-
21.
14. Kerr R. Splitting the Difference Between Oil Pessimists and Optimists. Science. 2009;326:1048.
15. Hall CAS, John W. Day J. Revisiting the limits to growth after peak oil. American Scientist. 2009;97:230-7.
16. Eckersley R. What's wrong with the official future? In: Hassan G, editor. After Blair: Politics After the New Labour
Decade. London: Wishart; 2006. p. 172-84.
17. Butler CD. Inequality, global change and the sustainability of civilisation. Global Change and Human Health.
2000;1(2):156-72.
18. Diamond J. Collapse: How Societies Choose to Fail or Succeed. London: Allen Lane; 2005.
19. Tainter JA. The Collapse of Complex Societies. Cambridge: Cambridge University Press; 1988.
20. Bowles S. Did Warfare Among Ancestral Hunter-Gatherers Affect the Evolution of Human Social Behaviors?
Science. 2009;324:1293-8.
21. Ehrlich PR. The Population Bomb. London: Ballantyne; 1968.
22. Walker B, Barrett S, Polasky S, Galaz V, Folke C, Engström G, et al. Looming global-scale failures and missing
institutions. Science. 2009;325:1345-6.
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Student Electives
a world of experience
whitney
d o w n e s
monash university
welcome to
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SAMOA
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I
recently undertook my medical elective at Tupua
Tamasese Meole Hospital in Apia, Samoa, in the
Obstetrics and Gynaecology Department. I was
involved in providing ante- and post-natal care, as
well as assisting in deliveries.
My first day on the labour ward, I was confronted
by a thoroughfare occupied by at least 15
pregnant bellies, each attached to a woman either
uncomfortably waddling up and down the corridor
or leaning against a vacant doorway, labour pains
acknowledged only through the cessation of
movement. I entered a delivery room (a 4 x 2m space
with room for a bed and a bench for equipment) to
find a woman lying prone with legs apart in the timehonoured
position of birthing, husband pushing the
crown of her head as if he could somehow increase
the force of his wife’s straining uterus, midwife
shouting encouragement in the usually dulcet tones
of the Samoan language, and two Austrian doctors
watching the perineum in anticipation, chatting in
German as the baby calmly crowned. In minutes, a
boy was delivered (their 5th, the husband informed
us), syntocinon administered and 3rd stage of labour
apparently in progress. Fundal massage to assist
placental delivery raised an interesting question, was
there perhaps a second baby, explaining the prolonged
3rd stage?
Calm turned to chaos as I was ordered to get the
consultant, the parents worryingly understanding the
frantic tones but not the English or the German, as
the midwife performed a completely unsterile vaginal
examination in order to determine presentation of
the latest surprise. The consultant calmly entered
the room, delivered the second baby breech, and
left after satisfying himself that both babies would
survive, with just a cursory nod to the bewildered
parents. The Austrian doctors turned to me and said,
‘Welcome to Samoa!’
My experience of Samoa continued in a similar
fashion. Questions posed on ward rounds highlighted
the dichotomy of ideal management versus that in
developing countries, ‘How would you manage this
condition, but how can we best manage it here?’
Antenatal clinics were conducted in an old ward
room, curtains dividing the ‘cubicles’ and providing
the illusion of privacy. The corridors are full of
women waiting to see either midwives or doctors,
most heavily pregnant but often on their first visit,
with only unsure dates or late obstetrics scans to
provide a rough estimate of due dates. Five doctors
attempt to sift through the patients, assessing fundal
height and blood pressure with one tape measure and
one sphygmomanometer shared between them. The
pitter-patter of foetal hearts is barely heard amongst
the electronic whine of a Doppler probe struggling to
operate on failing batteries. Any procedures are done
with the supposed protection of XL gloves, which
are probably a greater risk than help. Women in
labour rooms who have been pushing past the limit
of normal labour wait anxiously for one of the two
cardiotocograph machines to be available for foetal
monitoring. In these labour rooms, meconium liquor
is often the first and only sign of foetal distress.
However, despite the apparent lack of equipment, the
hospital has surprisingly few maternal or neonatal
deaths. The staff, used to not having equipment
available, work incredibly well within the imposed
limits, and the women accept the basic conditions
in which they are required to labour. Delivery is
perhaps returned to its natural state, with the
parents not focused on ‘pethidine versus nitrous
oxide’, ‘Coldplay versus Mozart’, but on having a
healthy child. Having said this, I definitely missed
the comfort of a reassuring CTG or maternal blood
pressure, and learnt the hard way when I delivered
a floppy baby and was chastised by the doctors for
letting the delivery carry on too long, that if I was
in the room with a midwife, I was assumed to be in
control.
My experience of Samoa was a welcome insight
into the world of medicine in developing countries,
of a beautifully strong culture and of people who
are rich in ways we in the ‘developed’ world do not
place enough value on. I look forward to my return,
perhaps in a more senior medical role.
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global health conference 2010 report
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alexandra
f r a i n
& l u k e
hamilton
co-convenors
global health
conference
executives
The enthusiasm and inspiration of over 430
medical students from Australia and the
Asia-Pacific region intersected in Hobart from
July 1 to 4th, for the 6th Annual Australian Medical
Students’ Association Global Health Conference.
The theme was ‘Small Steps, Big Picture’, with a
focus on empowering students with knowledge about
issues that impact on health around the world, whilst
equipping them with practical skills to get involved
in advocacy and activism at a grassroots level.
Delegates were addressed by Dr Helen Caldicott
on the medical implications of nuclear power, by
Reverend Tim Costello on child and maternal health,
and by Professors Tony McMichael and Colin Butler
on Climate Change and Health, just to name a few.
The stream program provided delegates with an
overview on issues such as water quality and access,
refugee health, sexual health, Indigenous health and
resource allocation. With over 66 speakers and tutors,
it is impossible to convey the amount of information
that was packed in to four days at the University of
Tasmania, and even more impossible to describe the
intangible benefits of having 430 motivated students
in one place, with one growing global conscience.
As well as being addressed by some of the most well
respected figures in global health in Australia, some
of the most profound learning came from our peers.
Ten students from developing nations joined us
through the AusAID International Seminar Support
Scheme, and we were enlightened by what they could
share about health in their countries. Workshops
were also run by students, for students, through the
AMSA Training New Trainers and Think Global
initiatives. These programs allowed delegates to
develop skills in leadership, advocacy and project
management.
The conference was also very lucky, with the support
of the University of Tasmania, SecondBite, Scolorest
and the Salvation Army, to be able to contribute to
the local community through a food rescue after
lunch each day. Delegates were so inspired by this
that many of them returned breakfast foods for
distribution after the conference as well.
We certainly learned that the issues facing the health
of the world are undoubtedly huge, and require action
of a similar magnitude. We were powerfully urged
by Nick Bearlin-Allardice in the closing address of
the AMSA GHC to remember that it is not enough to
simply attend a conference. There is so much work
to be done in the realm of global health, as evidenced
by the array of topics covered over the four days of
the conference. If you are interested in putting the
passion and excitement generated at the AMSA GHC
to good use, please consider joining the Global Health
Group at your university, or joining an advocacy group
like World Vision, Oaktree, RESULTS, the Global
Poverty Project or the Doctors for the Environment
Australia. We hope that the AMSA Global Health
Conference will be the springboard for many people,
including you, into making a real, tangible difference
in global health.
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