Vector Issue 10 - 2009

vector
The Official Student Publication of the AMSA Global Health Network
www.ghn.amsa.org.au
Issue 10 November 2009
Non-communicable
diseases edition
Stroke and Heart Disease Impacts
the Developing World
GHN Update
Global Health
Conference 2009
Talking with the
Indian Consul General
Medical student experiences
from PNG and Cambodia
Also inside: Creative stories from the medical profession on global health issues!

contents
issue 10 november 2009
3 Editor’s Note
11
9
4 What Lurks in the Shadows: noncommunicable
disease in the
developing world
5 Heart Disease and Stroke Threaten
Developing World
6 Tipping the Scales: the ‘expansion’
of the global community
8 Smoking and Tobacco’s Impact
on the Developing World: the
worlds top health priority
9 A Conversation with the Indian
Consul General
10 The Nageri Misiion
11 Mental Health Crisis in China
12 Medicine and Mosquitoes: a
medical student’s month in
Papua New Guinea
13 Stories from Cambodia
14 Global Health In The News
www.ghn.amsa.org.au
16 13
the
non-communicable
diseases
edition
2 vector november 2009
Global Health Network Update
15 Welcome to the GHN
15 A Year in the GHN: Looking back
and Looking Forwards
16 The Global Health Conference:
Challenging the world after
Brisbane
17 Global Health Series - University
of Sydney
17 Student Involvement - Helping
VSAP to help others
Creative Pieces
18 The Boy who Jumped off the
Bridge
19 Noor
20 at a Glance: India

editor’s
note
“
Kruthika Narayan
Vikram Joshi
Rami Subhi
The golden arches of McDonalds
have become a ubiquitous metaphor
for globalisation; previously in
the economic sense, but perhaps
now as a symbol of the global epidemic of
‘lifestyle’ diseases. There is an inherent irony
in that the very symbols of prosperity and
growth have become emblems for illness, in
the developed world with growing incidence
of chronic non-communicable diseases
(NCDs).
The picture is both similar and different
in the less developed world. Instead of representing
the dangers of excess, the rampant
increase in NCDs in less-developed countries
Non-communicable diseases, with their precursors of
high cholesterol, hypertension and obesity, are overwhelming
the developing world much faster than the
developed
reflects the deficiencies of stretched health
systems traditionally geared towards relief
of acute illness in handling the immense
burdens of chronic disease. It also highlights
the effects of environmental exploitation
limiting access to fresh healthy foods, and
the dire struggle of the growing populations
of the urban poor for whom chronic disease
is yet another force perpetuating the vicious
cycle of poverty.
Non-communicable diseases, with their
precursors of high cholesterol, hypertension
and obesity, are overwhelming the developing
world much faster than the developed.
Added to this are high rates of smoking and
the long standing struggle against chronic
infections.
The World Health Organisation estimates
that NCDs, including cardiovascular disease,
diabetes, cancer and respiratory diseases,
are responsible for over half of all deaths and
46% of the global disease burden.
Health issues in the developing world
have thus far concentrated on communicable
diseases; and rightly so, since many of these
are preventable and/or readily treatable. But
with the rise of NCDs including HIV/AIDS, an
emerging concern about the influence of climate
change and the environment on health
outcomes, and the appreciation
of the economic
implications of chronic
diseases particularly when
compounded with poverty
and failing health systems,
it is time to promote the
”
complexities of NCDs on the
global agenda.
In this issue of Vector,
we consider the impact of
non-communicable diseases in settings least
equipped to bear the burden of mortality,
morbidity and economic strain they impose.
The challenges are immense. The experience
of the Western World attests to the difficulty
in preventing and treating chronic disease; a
difficulty compounded by the resource limitations
of low income countries. The multifactorial
causes of NCDs require a shift in
attitude, not just in local government policies
but in the ethics of operation of industries,
corporations and nations, and a shift in the
perceptions of the global society as a whole.
Vector: The Official Student Publication of the AMSA Global
Health Network
GHN Publicity Officer
Editors
Design & Layout
Catherine Pendrey
Kruthika Nayaran
Vikram Joshi
Rami Subhi
Alexander Murphy
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 Photo: The locals in Papua New Guinea
// Image by Georgia Ritchie, Medical Student,
University of Sydney
november 2009 vector3
www.ghn.amsa.org.au

What lurks in the shadows:
non-communicable disease in the developing world
Words Fred Hersch, Medical student, University of Sydney
// Image by xymonau (sxc.hu)
www.ghn.amsa.org.au
1.Tunstall-Pedoe H. Preventing Chronic Diseases.
A Vital Investment: WHO Global Report. Geneva: World
Health Organization, 2005. pp 200. CHF 30.00. ISBN 92
4 1563001. Also published on http://www.who.int/chp/
chronic_disease_report/en. Int J Epidemiol. 2006 Jul 19.
2.AD Lopez CM, M Ezzati, DT Jamison and CJL
Murray, Editors. Global burden of disease and risk factorsnext
term, Oxford University Press, New York2006.
3.Gaziano TA. Economic burden and the costeffectiveness
of treatment of cardiovascular diseases in
Africa. Heart. 2008 Feb;94(2):140-4.
4.Leeder Sea. A Race Against Time: The Challenge
of Cardiovascular Disease in Developing Countries (New
York: Trustees of Columbia University)2004.
5.Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum
A, Lanas F, et al. Effect of potentially modifiable risk factors
associated with myocardial infarction in 52 countries
(the INTERHEART study): case-control study. Lancet.
2004 Sep 11-17;364(9438):937-52.
6.Steyn K, Sliwa K, Hawken S, Commerford P,
Onen C, Damasceno A, et al. Risk factors associated
with myocardial infarction in Africa: the INTERHEART
Africa study. Circulation. 2005 Dec 6;112(23):3554-61.
7.Thomas A. Gaziano KSR, Fred Paccaud, Susan
Horton, and Vivek Chaturvedi. 2006., editor. "Cardiovascular
Disease."2006.
8.Joshi R, Jan S, Wu Y, MacMahon S. Global
inequalities in access to cardiovascular health care:
our greatest challenge. J Am Coll Cardiol. 2008 Dec
2;52(23):1817-25.
9.Greenberg H, Raymond SU, Leeder SR.
When we think about
the global burden
of disease and the
plight of the poorest
of the poor our minds often
turn to the scourge of HIV/AIDS,
malaria and tuberculosis - after
all, that’s where all the attention
is. Yet in the shadows lurks
an uneasy truth: the rise of noncommunicable
disease (NCD).
Historically thought to be a disease
of the “developed world”, NCD is in fact
a worldwide pandemic of devastating
proportions. In 2005 alone there were an
estimated 35 million deaths from heart
disease, stroke, cancer and other chronic
diseases - approximately 50% (17.5 million)
due to cardiovascular disease(1). Of
these, 80% occurred in low- middle- income
countries– (LMIC) twice as many
deaths as from HIV, malaria and tuberculosis
combined(1, 2). Cardiovascular
disease (CVD), responsible for 30% of
the total deaths worldwide(1)1, is the
second leading cause of death in Africa,
and the leading cause of death in those
aged 30 or older(3). The fastest growing
region for CVD is in the African region
(27%) and it is estimated that over the
next 10 years the burden from NCD will
rise by 17% whilst those from communicable
diseases will fall by 3% which
translates to approximately 28 million
deaths due to NCD over that period(1).
The consequences of this are profound
and far-reaching. Consider this:
In contrast to our experience of NCD
Cardiovascular disease and global health: threat and
opportunity. Health Aff (Millwood). 2005 Jan-Jun;Suppl
Web Exclusives:W-5-31-W-5-41.
10.Gaziano TA. Reducing the growing burden of
cardiovascular disease in the developing world. Health
Aff (Millwood). 2007 Jan-Feb;26(1):13-24.
11.Beaglehole R, Ebrahim S, Reddy S, Voute J,
Leeder S. Prevention of chronic diseases: a call to action.
Lancet. 2007 Dec 22;370(9605):2152-7.
12.Lim SS, Gaziano TA, Gakidou E, Reddy KS,
Farzadfar F, Lozano R, et al. Prevention of cardiovascular
disease in high-risk individuals in low-income
and middle-income countries: health effects and costs.
Lancet. 2007 Dec 15;370(9604):2054-62.
13.Gaziano TA, Galea G, Reddy KS. Scaling up interventions
for chronic disease prevention: the evidence.
Lancet. 2007 Dec 8;370(9603):1939-46.
14.Beaglehole R, Epping-Jordan J, Patel V, Chopra
M, Ebrahim S, Kidd M, et al. Improving the prevention
and management of chronic disease in low-income and
middle-income countries: a priority for primary health
care. Lancet. 2008 Sep 13;372(9642):940-9.
15.Asaria P, Chisholm D, Mathers C, Ezzati M,
Beaglehole R. Chronic disease prevention: health
effects and financial costs of strategies to reduce salt
intake and control tobacco use. Lancet. 2007 Dec
15;370(9604):2044-53.
16.Gaziano TA, Opie LH, Weinstein MC. Cardiovascular
disease prevention with a multidrug regimen in the
developing world: a cost-effectiveness analysis. Lancet.
2006 Aug 19;368(9536):679-86.
being a disease of old age, in LMIC, it
is often men and women in their most
productive years (40‘s and 50‘s) who
are most affected(4). On a personal level
this is a tragedy for a family struggling
for survival. At a societal level this
lost productivity further compounds
the challenges of economic growth.
Inattention, rather than complexity
contributes to the lack of action to date.
A common set of known risk factors:
hypertension, elevated lipids, smoking,
obesity, sedentary lifestyles, and diabetes
accounts for about 80% of clinical
cardiovascular disease in every region of
the world(5, 6). As developing countries,
particularly those in sub-Saharan Africa
move to the next stage of the epidemiological
transition greater numbers
of people are being exposed to diseaseproducing
risk factors (2, 4, 7-11).
The challenges are vast yet not
insurmountable. We know from our
experience that prevention works and
there is a growing literature pointing
to opportunities for scaling up low
cost interventions. Tobacco control
measures and dietary interventions can
lead to small but significant changes in
large groups of people(12-15). Health
systems in LMIC traditionally oriented
towards communicable disease
will require re-orienting to address the
chronic nature of NCD(1, 8, 12-14, 16).
As we struggle towards goals such
as “health for all” it would be nice to
think that we can address the challenges
of disease in a linear fashion - communicable
then non-communicable.
The inconvenient truth in all of this is
that health, like life, is more complex
than that. It is time that we lift the
spotlight off to reveal the true picture of
the global burden of disease and direct
our efforts at addressing the health
needs of communities as a whole.
4 vector november 2009

Heart disease and stroke
threaten developing world
Words Stephen R. Leeder and Angela Beaton
Stephen Leeder is a Professor of
Public Health and Community Medicine
at the University of Sydney and Director
of the Menzies Centre for Health Policy.
He has a long history of involvement
in public health research, educational
development and policy. His research
interests as a clinical epidemiologist
have been mainly asthma and cardiovascular
disease. His interest in public
health was stimulated by spending 1968
in the highlands of Papua New Guinea.
Dr Angela Beaton is a Research Officer at
the Menzies Centre for Health Policy.
Heart attack and stroke,
thought to be typically
western diseases, are
fast becoming major
threats in developing countries.
Four times as many deaths in
mothers occur in most developing
countries than do childbirth and
HIV/AIDS: HIV/AIDS causes
three million deaths a year; stroke
and heart attack cause 17 million.
Yet heart disease and stroke have
attracted virtually no interest from
international agencies committed
to improving global health.
It is time for that to change.
Developing economies are seeing the
kind of devastation to their workforces
that Western countries experienced 50
years ago. Troubling as these patterns
are, they are but the first rumbles of the
storm. The worldwide shift of working
people from rural to city living has
paralleled rising levels of prosperity and
with it, greater consumption of food. A
worldwide epidemic of obesity, even
where under-nutrition persists in poorer
quarters, presages high levels of diabetes,
heart disease and stroke ahead.
Fortunately, we can prevent and treat
much heart disease and stroke. Treatment
of raised blood pressure and blood
lipids with drugs radically reduces risk
and smokers who quit halve their risk
of heart disease and stroke within two
years. The World Health Organization
has shown commendable leadership
in relation to global tobacco control
and now has its sights set on nutrition
and exercise. Governments can assist
by taxing tobacco and promoting good
lifestyle habits, ensuring that all citizens
have easy access to clinics, and plan
healthier cities. Poor urban environments
exacerbate physical and mental
illnesses, now a major burden of global
illness, at the expense of the economies
of developing countries and our planet.
To wait until heart disease and stroke
decimate workforces before we take the
global epidemic of heart disease and
stroke seriously, would be both a health
and economic tragedy. Heart disease and
stroke are already propelling families
into poverty in developing countries
as young breadwinners and mothers
die. Many developing countries have
yet to create programs to control these
diseases through long-term changes in
macroeconomic policies, and by providing
effective clinical care. Prevention
programs must be locally sustainable
for an indefinite future, and so developing
countries should be encouraged to
take the first step themselves, now.
There is a responsibility for Australian
medical students in advocating for
action. Medical professionals have an
important role in educating the public
and lobbying governments to take up the
challenge. Countries need the encouragement
that stronger vocal advocacy for
change can provide, to prod governments
and donors into action, and international
aid agencies should add to their agendas
efforts to work with developing countries
to contain these urgent and heavy threats
to global health, national prosperity
and family life in the developing world.
Commitment from the highest levels of
government in these countries is essential
for comprehensive heart disease and
stroke prevention. It will be important to
graduate medical practitioners that have
the capacity to deal with the consequences
of an increased burden of chronic
illness and an ageing population, and to
assist communities to help themselves.
november 2009 vector5
www.ghn.amsa.org.au

tipping the scales
the ‘expansion’ of the global community
Words Rhea Pserickis, Medical student, University of Tasmania
www.ghn.amsa.org.au
I
looked up from the desk and
watched as my next patient
walked in through the door.
She was a middle-aged
obese woman and beads of sweat
had formed along her forehead
in spite of the cooler weather. It
took her a while to shuffle in, navigate
the chair and find a comfortable
sitting position. I noticed her
heavy breathing. This patient was
presenting with back and knee
pain and had come in hoping for
some analgesia. As I continued the
consult, I pondered how to broach
the fact that her weight was
probably contributing to, if not
directly causing, her pain. Just
another obese patient with more
chronic disease. Right? Well, not
quite. The disparity is that this
patient wasn’t in Australia nor
was she a white Caucasian. I had
in fact been working at a mobile
clinic in remote Western Kenya,
and this was a native Kenyan;
more alarming, she was not the
first or last obese Kenyan I came
across during my time in Africa.
Once considered a problem only
in wealthy countries, the number of
overweight and obese individuals has
escalated in low and middle income
countries. As risk factors for cardiovascular
disease, type 2 diabetes, stroke
and other chronic diseases, the rising
prevalence of overweight and obesity in
less developed countries is a hallmark of
the now increasingly recognised ‘global
society’ (1). Furthermore, the morbidity
and mortality associated with these
chronic diseases are significantly higher
6 vector november 2009

Right: Influences on the energy equation in
developing countries (3). Below and facing
page: One can appreciate the irony in all this
when you see both the malnourished and
obese side by side in a Gambian hospital (2).
in less developed countries due to lack of
education and understanding, as well as
the age-old problem of resource insufficiency.
In sub-Saharan Africa case-specific
mortality rates for diabetes are more
than 10 times higher than in the UK (2).
The WHO indicates that globally,
greater than 75 percent of women over
the age of 30 are now overweight (1).
Estimates are similar for men. In the
Pacific islands of Nauru and Tonga nine
out of every 10 adults are overweight
(1). Obesity is even spreading rapidly
through many an African countryside,
along with its bevy of chronic disease
burden which is both devastating and
costly (2). Indeed, the existence of
obesity and malnourishment within the
one community presents an unintelligible
paradox (see figure 1) (3).
The increase in obesity in developing
nations is due to ‘a global shift
in diet towards increased energy, fat,
salt and sugar intake, and a trend
towards decreased physical activity
due to the sedentary nature of
modern work and transportation, and
increasing urbanisation.’ (1) The developing
world is now more than ever a
target of many food companies and less
developed countries present the largest
growth markets for soft drink producers
(4). Even where the Global Financial
Crisis has tainted the US and European
markets, consumption of soft drinks
has increased in countries as diverse as
Mexico, Egypt and China, encouraged
by aggressive marketing campaigns,
often aimed at children and youth (4).
It is estimated that by 2015, 1.5
billion individuals globally will be
overweight (1). At this point, non-communicable
diseases associated with the
overweight and obese will surpass malnutrition
as the leading cause of death in
low-income communities (5). The contribution
of chronic disease on the health
status of the global community may paint
a bleak picture, but it is our responsibility
to take action to combat it. And where
obesity is such a paradox to concurrent
poverty, malnutrition, environmental
instability and development, this responsibility
becomes even more urgent.
1.Anon. The World Health Organization warns of
the rising threat of heart disease and stroke as overweight
and obesity rapidly increase. (Media release).
Geneva: September 22 2005. Article retrieved online
on September 17 2009 from, http://www.who.int/
mediacentre/news/releases/2005/pr44/en/
2.Prentice A and Webb F. Obesity admist poverty.
Int J Epidemiology. 2006; 35:24-30
3.Witkowski TH. Food Marketing and obesity
in developing countries: analysis, ethics and public
policy. J Macromarketing. 2007; 27(2):126-137
4.Anon. Soft drinks and obesity: global threats
to diet and health. (online article). Retrieved online
on September 17 2009 from, http://www.dumpsoda.
org/health.pdf
5.Tanumihardjo SA, Anderson C, Kaufer-Horwitz
M, Bode L, Emenaker NJ, Haqq AM, Satia JA, Silver
HJ and Stadler DD. Poverty, obesity and malnutrition:
an international perspective recognising the paradox.
J Amer Dietetic Assoc. 2007; 107(11):1966-1972
november 2009 vector7
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Smoking and Tobacco’s Impact on the
Developing World: The World’s Top Health Priority
Words Cam Hollows, Medical student, University of Sydney
“In the 20th century, the tobacco epidemic killed 100 million people worldwide…
during the 21st century, it could kill One Billion.”
“Reversing this entirely preventable epidemic must now rank as a top priority for
public health and for political leaders in every country of the world.”
Dr Margaret Chan, WHO Director-General (1)
www.ghn.amsa.org.au
// Image by Vivekchugh (sxc.hu)
1. Organization WH. WHO Report on the Global
Tobacco Epidemic, 2008: the MPOWER package.
Geneva: World Health Organization2008 Contract No.:
ISBN 9789241596282.
2. The Global Fund to Fight AIDS TaM. The Global
Fund to Fight AIDS, Tuberculosis and Malaria: Annual
Report 2008. Vernier, Switzerland: The Global Fund to
Fight AIDS, Tuberculosis and Malaria2008 2008 Contract
No.: 92-9224-163-X (ISBN).
3. UNAIDS. UNAIDS Report on the global AIDS
epidemic: 2008. Geneva, Switzerland: UNAIDS2008
August 2008 Contract No.: 978 92 9 173711 6.
4. Organization WH. WHO Report 2009: Global
Tuberculosis Control Epidemiology,
Strategy, Financing. Geneva, Switzerland: World
Health Organization2009 Contract No.: 978 92 4 156380
2.
5. Organization WH. WHO 2008 World Malaria
Report. Geneva, Switzerland: World Health Organization2008
Contract No.: 978 92 4 156369 7.
6. Nations TU. The Millennium Development Goals
Report 2208. New York, USA: United Nations2008
August 2008 Contract No.: 9789211011739.
7. Chapman S. Public Health Advocacy and
Tobacco Control: Making Smoking History. Oxord:
Blackwell Books; 2007.
These statements are on
the opening page of the
World Health Organization
Report on the
Global Tobacco Epidemic, 2008.
Tobacco use is recognized as
harmful throughout the medical
profession. The links of smoking
with increased incidence of
cardio-vascular disease, peripheral
vascular disease, respiratory
diseases, many cancers, as well as
effects on reproductive health (to
name but a few) have also been
clearly established. Recently, new
data have made clear just how
harmful smoking is in a global
epidemiological sense and the
disproportionate impact it has on
health in developing countries.
Tobacco use currently kills around
5.4 million people every year. To put
this in perspective, in 2005 HIV/AIDS,
TB & Malaria (the diseases targeted
in Millennium Development Goal 6)
killed approximately 4.2 million together
(2-6). Whilst I am aware of the dangers
of impetus splitting, and I would
not for a second want to detract from
the importance of programs combating
these diseases (particularly having had
falciparum malaria myself!), the huge
impact of tobacco related disease cannot
be ignored. It is estimated that smoking
related deaths will rise to as much
as 8 million every year by 2030. These
mortality data are of course not the full
picture and as medical students our own
clinical experience should allow us to extrapolate
the burden of associate morbidities.
We should also pause for thought
as to the resource demands imposed by
smoking in already stretched systems.
Whilst the individual circumstance
is often tragic and coupled with physiological
and psychological addiction,
the reality is that diseases occurring
due to tobacco use are entirely preventable.
Tobacco is the only product on
the planet which if used according to
the manufacturer’s instructions kills
half of the people who use it (7).
The unfortunate reality for those
of us working in global health is that
over 80% of smoking related deaths
are occurring in the developing world
(1). But the burden goes further than
the morbidity, mortality and economic
impact. For the poor, money spent on
tobacco means money not spent on
basic necessities such as food, shelter,
education and health care. In one study
in Bangladesh low-income families
were spending as much as ten times on
tobacco as they were on their children’s
education (1). Given our awareness of
the importance of education in health
and sustainable development, and the
prevalence of extreme poverty, this sort
of study should chill us to the very core.
In Australia, tobacco control is a
public health success story. That our
rates of smoking are so low and rates of
tobacco related disease are dropping is
to be lauded (7). Most other countries
in the world are much worse off than
we are in terms of what they can spend
on tobacco control. Whether we are
interested in it or not, the problems of
tobacco related illness cannot be ignored;
the numbers and impacts are simply too
large. So where and when we can, we
must remember to add tobacco control to
our list of priorities as we try to address
the challenges of equitable and sustainable
health in the developing world.
8 vector november 2009

Many of you
may recognise
the
painting as
Van Gogh’s Wheatfields
with Crows. Each of you
will be struck by some aspect
of the painting and form your
own impression of it. What if you
were then told that this was Van
Gogh’s last painting before his
suicide? Given this key piece of
information, do your perceptions
then change? The flying birds
perhaps, are crows, harbingers
of death; the chaotic landscape a
reflection of his inner turmoil. In
reality, Wheatfields
is not
Van Gogh’s
last painting.
Does this fact
once again
completely alter
the perceptions
proceeding
from the
previous one?
This was the
eloquent example
with which
the Consul-
General of India,
Sydney, Mr
Amit Dasgupta,
commenced his
talk to medical
students at the University of Sydney. As
part of the Global Health Stream, the
Medical Faculty’s international health
curriculum, we had the valuable opportunity
of speaking with the Consul-General
on Thursday 17 September about health
issues in India. Prior to his appointment
in Sydney, Mr Dasgupta has held various
diplomatic positions across the world,
from Cairo to Kathmandu. His wide
experience is reflected in the numerous
books he has edited and written in both
fiction and non-fiction. Caught up as
we are in the world of medical facts, the
Consul-General’s talk was an important
eye-opener into the more philosophical
issues surrounding health policy.
a conversation with the
Indian Consul General
Words Kruthika Narayan, Medical student, University of Sydney
Van Gogh’s Wheatfields was a
poignant illustration of how essential
pieces of information shape the way
we perceive a situation and how these
perceptions may not always be correct.
As the Consul-General emphasised, this
is particularly important in addressing
the various issues of international health.
It highlights that a health model which
works in one developing country situation,
may not necessarily be transplanted
with equal effectiveness to another. In
India, as the Consul-General explained,
the diversity in language, culture and
customs within states, let alone between
them, makes the implementation of
health policy a complex issue, requiring
a different approach in each region.
The burgeoning of chronic disease
in India highlights the importance of
targeted health intervention programs.
According to 2009 WHO statistics,
the age–standardised mortality rate for
cardiovascular disease is 382/100 000
and studies suggest that chronic diseases,
particularly cardiovascular, are
fast becoming the main cause of mortality
in urban and rural populations. Not
to mention diabetes, the prevalence
of which was estimated to be greater
than 31 million in 2005 and growing.
The Consul-General spoke of some of
the health interventions implemented by
the Government to counter this increase
in chronic illness. Recognising that a
centralised approach to health policy
would be less effective, one strategy
has been to empower village councils or
‘Panchayats’, funded by, but not accountable
to, the Government. Composed
of local villagers and an elected leader,
these Panchayats have a better picture of
the cultural and social characteristics of
a region, and are in a position to know
what policies would be most suitable.
Another includes the health education
programs, run by the Central
Health Education Bureau, focusing on
the education of women and children
and taking into account the differences
in beliefs between regions.
These two strategies mentioned by
Mr Dasgupta reiterate that approach
is the key message. Health interventions
need to be tailored and not run
as an identical franchise from state
to state, or as the Consul General put
it, ‘McDonalised’. It comes back to
how we interpret the picture of chronic
disease in India, or in any country;
ensuring the individual characteristics
of that particular picture are what
shape our perceptions and actions.
november 2009 vector9
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www.ghn.amsa.org.au
The Nageri Mission
Words Jennifer Prince, MS Gen Surgery trainee, CMCH Vellore
Having been in Christian
Medical College
(CMC), a tertiary
hospital throughout
my training, I entered with a
sinking feeling into the Church of
South India (CSI) hospital Nageri,
located on the Andhra Pradesh-
Tamilnadu border in South India.
This was a part of a rural
service obligation. In contrast to
CMC's state-of-the art facilities,
the Nageri hospital was a single
storied building with a minimum
of amenities.. The hospital was
located 100km from Chennai, the
capital city of the state of Tamilnadu
and 70km from Tirupati, one
of the large pilgrimage centres of
the neighbouring state of Andhra
Pradesh. It was a cultural potpourri
of the two states yet, development
came slowly to this region.
The hospital itself was conceived
by Dr Fanny Gibbens, a missionary
doctor, and begun in the front yard of
her house. She was in a land of strangers
with just the will to serve the sick.
I find it hard to imagine the depth of
commitment that step would have asked
of her. A new building sprung up as
the workload increased and in a few
years, the hospital reached the zenith of
its development, with long queues of
outpatients stretching into the night and
inpatients awaiting their turn for admission
on the floor between the cots.
But with Dr Gibbens' death the
hospital joined the ranks of Mission
Hospitals started by committed individuals
but struggling to remain open.
The reasons were many- lack of doctors,
paramedical staff, equipment and
a committed leadership. And here
I was, fresh from Internship, full of
hopes, and plans and apprehension.
There was a small medical staff
at the hospital, including the Medical
Superintendent, a Paediatrician, an
auxiliary nurse midwife in charge of
obstetrics and a senior from medical
school. We catered to a patient profile
that varied from those who could not
afford a 5 day course of Amoxycillin for
their children, to affluent businessmen
presenting for follow up between their
regular reviews in private city hospitals.
As the days passed into months, the
other doctors left Nageri and my senior
and I were left to care for the hospital.
As a primary evaluation centre,
the spectrum of cases was wide, from
respiratory infections and viruses to the
common emergencies of traffic accidents
and poisonings. Organophosphorous pesticides
were readily available to the farming
community of Nageri and were the
poison of choice for suicidal attempts.
As we did not have access to monitoring
equipment like an ECG monitor or
a pulse oximeter, or to a ventilator, the
patients were given a gastric lavage and
atropine. If there was any suggestion
of respiratory compromise, the patient
would be intubated and taken
“
by relatives
to the nearest city. What
can I say? It was far from
the ideal in my head;
some made it and some
did not. But occasionally,
we were rewarded
in the form of a patient
who returned for follow up after being
on a ventilator for almost a fortnight.
We did have a functional Operating
Theatre. However, in the absence of
an Anaesthetist, most of the surgeries
we performed were those that could be
done under spinal or local anaesthesia.
On some days, the city hospitals
would oblige us with the services of an
Anaesthetist for more complex cases.
As I mentioned earlier, we had a
section of patients who were from an
affluent background. They often presented
with chronic illnesses such as
Diabetes Mellitus, Hypertension and
Obesity. In fact, infected trophic ulcers
constituted one of the most common
as well as dreaded complications of
poorly controlled Diabetes Mellitus
resulting in amputations and numerous
visits for wound care. The patients were
provided advice on lifestyle modification
and were offered the services of
the visiting Physician and an Ophthalmologist
whenever possible.
My favourite part was the weekly
outreach clinic in a selected village
around the hospital, aided by a Non-
Government Organisation. There was
a social worker who supervised four
female workers, each of whom collected
the Health Statistics from areas
around the hospital. Regular Medical and
Ophthalmology camps were a unique
feature of this programme, as well as
health education and preventive medicine.
We worked towards understanding
their beliefs and perceptions on health as
well as addressing some superstitions.
Notable examples of these included
the avoidance of food or water during
diarrhoea or that a febrile illness with
rash was due to divine visitation. These
clinics provided the ideal perspective
of a patient's illness, allowing us to see
firsthand his or her usual environment,
lifestyle and beliefs. I will treasure the
friendships that I have with many of the
families through these interactions.
What did I learn from my experience?
That what mattered most was
that you did the best you could with
the situation rather than looking at the
What can I say? It was far
from the ideal in my head;
some made it and some did not.
”
flaws. I learnt not to take resources for
granted: indeed the hardest problems
were the lack of resources and expertise.
Gloves and sutures were hard to come
by and are to be used carefully. In the
absence of a senior doctor, I learnt to do
what I could in a given situation, often
performing surgical procedures with an
open book for my guide. It did add to
my self confidence and I learnt to rely
on myself in the absence of supervision.
It was also a lesson in administration.
I hope to go back to Nageri after
my General Surgery training. We have
a new administrative team, operations
are being scheduled on a regular basis
and things are indeed looking up. The
Nageri hospital was started with the
vision of service to the ailing. What
this requires is consistent work, vision
and money. Sometimes I question
if one person will be able to make a
difference. But the reality is that there
is often only one person and he/she is
the one who makes the difference.
10 vector november 2009

Mental Health Crisis
in China
Words Ron Cheung
Medical student
University of Sydney
// Image by Ringoc2 (sxc.hu)
Mental health is
a substantially
underestimated
problem in China.
In a four province study, 63 000
people were screened in random
urban and rural sites. A trained
psychiatric nurse screened-out
those at high risk of mental illness,
or those with a pre-existing
diagnosis of a severe mental
illness. Those at moderate to low
risk were administered a Chinese
version of the Structured
Clinical Interview for (DSM)-IV
axis I disorders by a psychiatrist.
Importantly, clinicians who
spoke the local dialect and were
familiar with local expressions
and culture were selected, so
they could adapt questions in
order for patients to understand.
Seventeen percent (17%) of the
population had a form of mental illness
(this is 173 million people!). Eleven
percent (11%) of men had issues with
alcohol abuse: an increasing problem
that has thus far not received attention.
Of those with mental illness, 25% were
so severely disabled by it that they
were unable to work. Among all those
with mental illness, only 5% have ever
seen any mental health professional.
Unfortunately, China’s health care
system is plagued by systematic issues.
There are no mental health services in
rural areas. There is a stigma towards
mental illness and even though people
realize they have it, they refuse to seek
treatment. There is a lack of knowledge
- 60% of people interviewed had never
heard of the word depression, even
though they had full blown symptoms.
In China, GP’s do not offer mental
health services, only large psychiatric
wards in large hospitals do
so. It is not seen as part of a GP’s
duties to address mental health.
Closing the gap in mental illness
and services in China is challenging.
The culture of medicine will need to
be changed: barriers will need to be
overcome, medical school curriculums
redeveloped, effective reimbursement
patterns in hospitals introduced, and
the makeup of the health care workforce
that includes a consideration
of the mental health agenda.
november 2009 vector11
www.ghn.amsa.org.au

I
was fortunate enough to spend a month of my Christmas
holidays in Papua New Guinea (PNG). The people of PNG have
the lowest health status in the Pacific region. Despite this, life
in PNG is full and the people embrace it with all their might.
I was welcomed with huge smiles and all around kindness. I was
often invited back into people’s homes to meet their families and
be shown their village life.
MEDICINE
and
MOSQUITOES
a medical student’s
month in papua new
guinea
www.ghn.amsa.org.au
One particular day in the town of
Goroka, I was invited to a Christmas
party by the surgical team. For Christmas
the staff often prepare a ‘mumu’, a
traditional way of cooking in PNG where
a whole pig or goat is killed, wrapped in
banana leaves and cooked in the ground
with hot rocks. For this Christmas party
they had decided that they would prepare
a pig for the mumu. So they brought the
pig to the hospital, where it waited on the
first floor balcony until they could kill it
and prepare the mumu. The pig, however,
had other ideas and was last seen
running frantically around the hospital
grounds followed closely by the entire
theatre staff, leaving an empty theatre
and a rather bewildered looking surgeon.
I was later informed that pigs are highly
valued in PNG and are a symbol of
wealth and social standing. In fact they
12 vector november 2009
are so important that women will often
breastfeed the piglets when they are born.
Now after they had caught the pig
and it was prepared for the mumu I sat
down with the theatre staff and surgical
team to enjoy the feast. However, this
was not for long as the surgical resident
and myself were called to emergency to
assess a patient. Having been in PNG for
over 3 weeks I was not easily shocked
by anything I saw, but this still did shock
me! On entering the ED I was directed
to a young man sitting on the edge of a
bed with three arrows protruding from
his body. He had been shot four times
in total; the first arrow was in the ninth
intercostal space on the left, the second
entered the superficial tissue on his right
flank, the third was embedded in his
groin and the fourth he had removed
himself from his right triceps. Despite
Words and Photos
Georgia Ritchie
Medical student
University of Sydney
the wounds, he sat perfectly still and
appeared not to be in any pain. Despite
much effort the radiographer at the hospital
could not be contacted that evening
so the young man had to wait until morning
for his X-rays and surgery to remove
the arrows. This meant he had to sleep
on his front with three arrows protruding
form his body! When he eventually went
to surgery, it was found that the arrow
entering the chest had passed through the
spleen, the duodenum and the transverse
colon. After 7 hours of surgery, the arrow
was removed, the spleen saved and the
puncture wounds to the bowls closed and
he was sent to the ward for recovery.
I have a story about each day I
spent in PNG. Whether it is about the
amazing people I met or the interesting
medical cases I saw, I was constantly
in awe of the country. Although
at times a hard place to comprehend,
I feel that I understood by the end
of my trip and fell in love with the
PNG, its culture and the people.

Stories from
Cambodia
Behind these smiles are stories of great
sadness and tragedy
Words and Photos Nilru Vitharana
Medical student, University of Sydney
During my summer
holidays last year, I
spent a few weeks
volunteering at an
orphanage and medical clinic in
rural Cambodia in a town called
Neak Leung on the banks of the
Mekong River. Cambodia has
some of the worst health statistics
in the world – 1 in 7 children
will die before the age of 5.
The charity I visited was called
Damnok Toek, which means ‘a drop
of water’ in Khmer. Ironic, given
that the area is surrounded by flooded
rice paddy fields, and the houses
are built up on stilts to avoid the
floodwaters during rainy season.
Damnok Toek houses 60 orphans,
provides schooling for a further 150
children and has a social work program
and medical clinic. As you can see
from the photos, the children here are
all smiles, but behind these smiles are
stories of great sadness and tragedy.
Some of the children in the permanent
centre had been sold into child
prostitution and child labour in Thailand’s
notorious Pattaya district before
they were rescued, some are AIDS
orphans, some are mentally or physically
handicapped and thus abandoned
by their families who cannot afford
to take care of them, and others were
the victims of domestic violence.
The medical clinic here provides a
vital service for the rural poor. The government
healthcare system is expensive
($20 US for a consultation) and underresourced.
The poor,
many of whom earn
less than $1 a day,
simply cannot afford
it. In contrast, the
medical clinic costs
12 cents (including
medication). People
would travel several
hours to receive affordable
medical care.
I also spent much
of my time doing
social work in the
community. One day we went to followup
a child who hadn’t been turning up
to school, which surprised us because he
loved going to school and hadn’t missed
a day. When we arrived at his home we
discovered that his older brother had died
of AIDS, and now he had to stay at home
to take care of his younger brother. Stories
like his are a prime example of the
“cycle of poverty” – now he is likely to
miss out on the opportunity of education.
Living with a local family, I was
able to immerse myself in the language
and culture of the Khmer
people. Having fallen in love with the
people of Cambodia, I will be returning
this year to Damnok Toek.
november 2009 vector13
www.ghn.amsa.org.au

global health
in the news
Copenhagen Climate Change
Summit will be held in December
2009. For the health impacts
of climate change, refer
to the editorial published by the
Lancet and BMJ and University
College London in September
2009.
http://en.cop15.dk
World Diabetes Day
14th November 2009
WHO estimates that more than 180 million people worldwide have diabetes,
according to 2005 figures. This number is likely to more than double by
2030 without intervention. Almost 80% of diabetes deaths occur in low and
middle-income countries.
www.worlddiabetesday.org
HIV vaccine?
A trial of a vaccine to prevent infection
by HIV involving 16,000 participants
in Thailand this year has shown modest
results with 26% reduction in rates of
infection compared to placebo controls.
Refer to the October 20th 2009 issue of
the New England Journal of Medicine.
PNG’s Liquid Nitrogen Gas
(LNG) Project will officially open
in 2010, is expected to double the
country’s GDP, and will have a profound
impact on trade and health
in the Pacific region. Refer to a
series by Jo Chandler of The Age
published September this year.
www.ghn.amsa.org.au
Indonesia’s official death toll stands
at 650, with a 672 people missing, following
the devastation of the recent
earthquake. Damage to roads, disruption
to electrical power and sources of clean
water could make the situation much
worse in the coming weeks.
There is similar concern in Samoa
about the spread of infectious diseases,
such as causes of acute watery diarrhoea,
typhoid fever and dengue fever
following the Tsunami.
2nd November 2009 commemorates renewed efforts to promote pneumonia
on the global health agenda by 2011. Wear blue jeans on the 2nd of November
(signifying the 2 million deaths of children every year due to pneumonia) and support
this cause.
www.worldpneumoniaday.org
14 vector november 2009

global health network
update
Welcome to the GHN
A Year in the GHN:
Looking back and
looking forwards
Trung Nghia Ton
WakeUp! GHN Officer, University of Newcastle
AMSA GHN Chair 2009 - 2010
Tamara Vu
AMSA GHN Chair
2008-09
A very warm
welcome to you all on
behalf of the AMSA
Global Health Network
Committee! This issue
of Vector marks the start of yet another
Global Health Calendar year (kicked off by
a truly rousing Global Health Conference in
Brisbane).
We look forward to adding to the
monumental efforts of the GHN Committee
of 08/09 who have worked tirelessly to bring
together students from all over the country
to collaborate in common interests in global
health awareness and action. This culminated
in the very first GHN National project, the
Red Party concept, which raised national
funds and awareness for HIV/AIDS, and was
a huge success. This is a tangible example of
how our efforts at a local level can be part
of a global impact. Additionally, The GHN
began its first national advocacy movements,
further highlighting the GHN’s increasing
ability to inform, represent and advocate for
medical students in matters of global health.
I would like to extend heartfelt congratulations
and thanks to the outgoing
GHN Committee for their successes this last
12 months. It is without a doubt that their
efforts have made a real and tangible difference,
and has set up a national framework
for us to continue to grow and mature as an
organisation. Their efforts continue to reflect
on the new committee as they mentor us
through a very steep learning curve.
With much enthusiasm, the newly
elected GHN committee for 09/10 are getting
right onto the task. Realising this year’s GHN
National project, the South East Asian Libraries
Project, will be a challenging undertaking
but with the experience and motivation of
each global health group (GHG) we hope to
exploit the growing momentum and make
a longstanding impact by helping our fellow
medicos in the developing world (watch this
space!). We also hope to strengthen our
collective voices and to bring truly pressing
global health advocacy issues to the fore in
our chosen active advocacy campaigns, especially
in regards to the crucial Millennium
Development Goals, and the treatment of
refugees and asylum seekers.
The GHN remains an avenue for medical
students to bring ideas, issues and action to
a national level, but it is vitally important for
us all to look at developing our own Global
Health Groups (GHG) and individual initiatives
– there are so many opportunities available
to bring grass roots ideas and projects to
fruition and collaborate on a local, regional
and national level.
I invite you all to become active members
of your local GHG as they grow into dynamic
student organisations. It is incredibly exciting
to see the initiatives of GHGs around the
country in 09/10 and I look forward to working
with an exceptional and motivated GHN
Committee and witness medical students
making a real difference in our global community.
As the outgoing
Chair of the Global
Health Network (GHN),
I am delighted to
report on our successful
year of global health group development
and support; our wildly successful National
Project, the Red Party, which raised over
$88 022 for HIV/AIDS support and research;
and our advocacy working party, which
developed the Millennium Development
Goals policy that in February became
AMSA’s first-ever global health-based policy
document.
It’s been a great year for medical
students in global health, with new and
exciting work happening in global health
groups, in the GHN, at GHC09, and at AMSA
level. It has been my privilege to serve as
GHN Chair during the last twelve months.
Along with the other outgoing GHN Representatives
and officers, I am delighted to be
handing over the reigns to a new committee,
as I know Trung and his team will be
dedicated and enthusiastic in promoting
and supporting global health activities
around Australia. And, looking back on the
various global health events of the past
year, I look forward to seeing what the next
twelve months will bring.
november 2009 vector15
www.ghn.amsa.org.au

The Global Health Conference:
Challenging the world after Brisbane
Meg Scott Deputy Convenor GHC 2009
www.ghn.amsa.org.au
As I think back over the 4 days of the
Global Health Conference 2009 (GHC),
certain events and lessons I learned remind
me to do more with my life and challenge my
world!
Our biggest achievement, the event we
put the most blood, sweat and tears into
was challenge day. The 10 station, half-day
workshop challenged the delegates to work
through various situations one might come
up against in an overseas medical aid situation.
Delegates planned a refugee camp and
were marked on the appropriateness of their
toilet selection, as well as deciding how many
farms they would have. Groups got to try
talking their way into a prisoner of war camp
past cheeky guards, and the guards were
also marked on their ability to stick to their
guns. The triage station allowed the clinical
years delegates to shine, using their ability
to interpret vital signs to save many a paper
doll life. We made nutritional food packs, delivered
babies (and placentas) in emergency
situations, learned about the difficulties in
communicating with non-English speaking
patients, allocated sparse resources to those
who needed it the most, and perhaps most
importantly, enjoyed the Brisbane sunshine!
The inspiring opening plenary from Dr.
Sujit taught me a couple of things. One, if
you want to add prestige to a product, print
the label in English; if the people can’t read
it, they’ll want it more. Two, having nothing
is no excuse; start where you are and
the financial support will come. There is no
reason why one person can’t start making
a difference in the community. Personally,
I was amazed at how easy Dr. Sujit made it
all sound! Starting at a farm, negotiating the
use of a barn for a clinic, to shortly thereafter
running numerous hospitals and schools! He
definitely challenged my idea that one needs
money to make a difference.
Tania Major continued the unintended
theme to get out there and start doing, with
her challenging Australians’ attitudes towards
the Indigenous population. She spoke of her
work increasing awareness of Indigenous
issues, which she has been doing for the
majority of her life. She reminded us that
whether Indigenous or non-Indigenous, we
are all Australian, and we must look after
our own. We all know of the 17 year age
gap between the two populations, and the
barriers towards proper healthcare for those
in remote communities are not new. Tania
showed us that grassroots action is vital in
making a change. As Tania so eloquently
stated, “just fucking do it!”
Carolyn Hardy showed us what has been
done so far in combating HIV/AIDS, and we
are sadly nowhere near meeting the Millennium
Development Goal. Again we were
shown how to challenge the problems in
bringing healthcare to those who need it,
and how to overcome these obstacles. Carolyn
spoke of the potential for conducting HIV
tests remotely via mobile phone and picture
texts! With unbelievable solutions like this
in the works, I was reminded to look outside
the box for solutions to decade-old problems.
Dr. Nick Coatsworth gave me wanderlust
recounting his missions with MSF to such
places as Darfur and the Sudan. He also
spoke of getting in there and working at a
grassroots level and somehow managed to
make immunising hundreds of children a day
for 4 weeks straight sound exciting! He’s definitely
an inspiration for all medical students,
showing us that it is possible to have a life,
train in a specialty and work overseas all at
once.
Gabi Hollows, on behalf of the Fred
Hollows Foundation (FHF), taught us that
enthusiasm is enough; that having passion
for a cause will make things happen. She
also reminded us of the need for medical
aid in Australia. Sure, while the FHF now
have clinics and factories all over the world,
Fred Hollows’ work started in rural/remote
Australia, and Gabi reminded us we cannot
overlook our own country. Also, what struck
me from the Fred Hollows story was that one
persons’ passion and hard work can continue
indefinitely.
After all that energy spent learning
and inspiring, I wouldn’t have
thought anyone had enough energy
for a party, but boy, was I wrong!
Perhaps the memory burned into my
mind the most was the monkey dancing
with the genie, or was it seeing 2
sumo wrestlers trying to get onto a
bus? Check out the pictures on our
website to decide for yourself…
Thank you everyone for coming
to Brisbane, for participating so fully
in the program (both day and night!),
and for challenging yourself and your
peers to do more and be more. I look
forward to seeing you in Hobart for
GHC 2010 and hearing about how you
have challenged your world this year.
Left: The GHC is a ‘hands-on’ event.
Far left and above left: Dr Sujit inspires
the audience to make a difference. Images:
www.amsa.org.au/ghc09
16 vector november 2009

Student Involvement
Helping VSAP to help others
What is VSAP?
The Victorian Students’ Aid Program
(VSAP) is a student initiative run by medical
students at the University of Melbourne,
which delivers much needed equipment and
health resources to disadvantaged communities
globally.
Our vision is that all doctors worldwide
will have essential medical supplies and
equipment to treat their patients.
Recently, VSAP has elected to broaden its
scope and fulfil the role of being the University
of Melbourne’s global health group. This
financial year we will be taking on additional
projects as well as expanding into the areas
of education and advocacy.
Check out our website for more information
on: our Teddy Bear Hospital community
project, our Global Health Short Course being
held in collaboration with the Nossal Institute
for Global Health, and our Red Party fundraising
event that raises money for HIV/AIDS
research and awareness. One of our main,
ongoing projects is the Wishlist Project.
What is the Wishlist Project?
The Wishlist Project aims to contribute
to global health equity by sending
targeted aid to hospitals in
poorly resourced areas via medical
students completing their elective
placements there.
To ensure that we are supplying
appropriate and effective
equipment, the hospitals are asked
to compile a ‘wishlist’ of the supplies
and equipment that they require.
VSAP works with hospitals and medical
suppliers in Australia to fulfil these wishlists
and these donations are delivered with the
medical student when they leave for their
elective placement.
Since its inception in 2005, VSAP has
delivered over $30000 worth of equipment
and monetary donations to countries as
diverse as Guatemala, Tanzania, East Timor
and Vietnam.
How can you be involved?
Student involvement – Helping VSAP to help
others
We are always looking for travelling
students who can deliver donated supplies to
areas where health care professionals are in
need of medical supplies. We are also looking
for students to get involved in our various
projects. Please contact us by email.
Equipment and financial contributions for
Wishlists
VSAP relies on the generosity of sponsors
to obtain equipment to send to underresourced
communities. In the past, health
institutions have been the main contributors
of equipment particularly when they reorganise,
close down, have excess supplies,
or upgrade.
VSAP is also responsible for the logistics
of delivering donated supplies to destination
hospitals. Assistance with airfreight,
packaging, and transport would also be very
welcome.
We are always looking for sponsors of
medical equipment and supplies. If you
would like to donate, please contact us by
email.
Contact us
General enquiries:
vsap.aid@gmail.com
Sponsorship enquiries:
vsap.sponsorship@gmail.com
For more information, visit http://www.
vsap.org.au
Right: Sanka Amadoru delivering
supplies to Kibosho Hospital, Tanzania.
Far right: Alexandra Bryson
using a donated anaesthetic machine,
Papua New Guinea
Global Health Lecture Series - The University of Sydney
Nilru Vitharana, Acting Chair, USyd GlobalHOME [Global Health Group]
After attending the Global Health Conference, students from
globalHOME (Sydney University’s global health group) were inspired
to educate their fellow students about global health by developing
a lecture series to improve the global health awareness and skills of
medical students.
The 8-part lecture series will be delivered by leading experts
in the field, from doctors, public health personnel, and NGOs. The
topics to be covered include: aid and poverty, healthcare in conflict
settings, emergency response to natural disasters, tropical infectious
diseases, climate change and its impact on health, malnutrition and
indigenous health. This series will equip students with the necessary
clinical and public health skills to understand global health issues
that they may encounter whilst on elective or in their future careers.
The lecture series will feature case studies, scenarios, interactive
discussion and is designed to appeal to students from across all
years of the medical program. The lectures will be held on Tuesday
evenings in March and May. Students from other universities are
most welcome to attend. Please sign up to our Yahoo Group (http://
groups.yahoo.com/group/globalhome/) to join our mailing list and
keep up to date with details of our lecture series.
november 2009 vector17
www.ghn.amsa.org.au

creative
pieces
www.ghn.amsa.org.au
“It was in the news. He
jumped off the bridge last
qweek. He died.” My old
school friend told me in
tears on the phone. The sunlight
is so bright. I sit, feeling a little
nauseous. In that country, it is
the coldest time of the year. Did
he drown or freeze to death?
“Does anyone know why he killed
himself?” We used to go to the same
primary school. We were in the same
class although he was 3 years older
than the rest of the class. Kids used to
laugh at him, because his legs looked
funny. He had poliomyelitis. He would
never catch anyone after being teased. It
would only cause more laughs. And he
walked in the most awkward way, too.
“They said he was a psycho, he went
to see a shrink a few times.” The last
time I heard about him was last year.
He published an article on a famous
magazine, named “A sad river”. I can
just remember the words he used in
that book. That unbearable sense of
sorrow floods my heart even now.
“Was he depressed?” He never really
spoke to anyone. I supposed we were
all immature and didn’t want to hang
out with a kid who couldn’t play with
us. He dropped out of school after high
school. It was simply too far away. His
parents couldn’t afford anything after
paying for his expensive medications.
“Depression. Emm… Maybe. But it
is not a problem for poor people. People
have enough trouble paying for food,
it’s not at the top of their agenda.” It is
true. Who would pay money to see a
psychologist when that same money was
enough for a month’s worth of food.
He didn’t have a job as far as
I know. So many people who had
good legs were still unemployed.
The boy who
jumped off
the bridge
Words Mengying Su
Medical student, University of Tasmania
“Couldn’t he apply for government
support?”
“The government? Are you kidding?
I don’t think it is rich enough
to look after everyone here. The
hospital wouldn’t treat anyone who
can’t pay the bill up front.”
// Image by OmirOnia (sxc.hu)
Outside the window, children walk
across the street after school. They
are young, healthy and happy. Just
like how we were like. I feel sorry
for that boy. I wonder if it would be
any different if we were young today
or if he lived somewhere else.
18 vector november 2009

This morning, with
thanks to the Australian
Cricket Team, morale
seems particularly high
in Michael's Care Home, New
Delhi. The staff
and clients of the
AIDS hospice
and mini hospital,
squash up on the
old cast iron beds
of the main ward
and watch Australia
(32 for 3)
squirm live on TV.
Between overs,
one of the care workers disentangles
himself from the jubilant add break
highlights recap, and bounds up to
me with a piece of paper in his hand.
The paper, though of creamy, freshly
minted quality, is already softening
along the fold, a sign of being
read and re-read many times over.
We stand next to the bed of Noor, the
patient who I came today to visit, and
share the contents of the page. On this
day of victory, its contents make me cry.
Before that though, let
me tell you about Noor.
Noor is about 45. Tall. Muscled.
My earliest memory of Noor is
in the kitchen of 'Sahara', the heroin
rehabilitation centre to which Michael's
Care Home is attached. Long
hair in a ponytail, white singlet with
sweat crescents under the arms. Hoisting
kilo upon kilo of rice or hovering
above the perpetual dhal pot, bini (local
cigarette) smoke trailing from his lips
as he tossed in onions. A tomato.
He ran a slick kitchen. Vital, sunnywindowed
place. The sort of kitchen
you feel drawn to. I remember leaning
against the bench top, sipping water
and listening to Phantom of The Opera
on his radio in one ear and instalments
from his 15 year saga with the
Afghani Embassy in the other. Noor
was an Albanian refugee, somehow
made it through Afghanistan to India
where he wound up in heroin rehab.
Despite the smallness of the Sahara
kitchen, Noor never shooed me away.
He churned out three meals a day for
all present at mealtime, the aroma of
his cooking as reliable as the sun.
Brown and ambiguous, we made
jokes about 'The Noor Curry' then.
The details of how Noor went from
staff member at the men's rehab centre
to patient at Michael's Care Home are
foggy. It happened around Christmas
time. Alcohol was involved. A fall. Brain
haemorrhage. Emergency surgery.
NOOR
Words Cara Munro
Now a piece of his skull is missing
and a thick line of cable stitching
closes the place where his brain was
exposed. His long black hair is shorn
and the jagged greying crop makes
him look vulnerable as a lamb. Occasionally
his eyes respond to words.
The care workers have been trying
to help him walk. At night he sits
up and mutters a little in his first language.
The rest of the time his hands
are bandaged to the bed sides and he
sleeps. They tell me he needs further
surgery, but for now, rest and healing.
Michael's Care Home first came into
being in 1998 to care for those marginalised
by addiction and ostracised
from society by HIV. Public hospitals
in Delhi, were too scared to touch them.
So were their families. So, rather than
let people die on the path outside the
emergency departments (as was happening)
Michael's Care Home was born.
There still aren't many family
visitors to Michael's Care Home.
Blood relatives don't cook special
convalescent cuisine or send cards.
But a care force has been
formed to look after Noor.
Sporting tattoos and track marks
and the signature Sahara combed hair
and worn but washed clothes, they take
turns at occupying the uncomfortable
plastic chair at Noor's bedside, by day
and night, anticipating his every need.
His meals are prepared by an exclient
of the rehab centre (now the
hospice cook) and spoon fed to him by
a team of young men (all ex-injecting
drug users) who, having completed some
or all of their own rehabilitation, have
volunteered to be with Noor in his.
Noor, with no family to speak
of in India, has someone with
him 24 hours a day.
One of the volunteers, a handsome
and talented soccer player (also, along
with his brother, a refugee from Iran and
witness to his own father's execution) sits
with his patient by
night. He speaks in
Persian to Noor and
translates what little
anyone can offer in
encouragement.
Another, onetime
street child,
shaves Noor with
gentleness that cuts
directly to the heart.
And still another,
stands beside me
this morning, bashfully holding a clean
piece of paper on which his recently
written letter of reference is printed.
We read together slowly.
'Mr. Satish, 27 years old has been
working with us as a care worker from
2003–present. He is diligent, committed
and his performance is satisfactory in
every way ... We wish him every success
in future undertakings ...' It is signed
by Sahara 's Director of Medicine.
His hard yards in heroin rehab and
then as a volunteer care worker are
coming to an end and he has applied
for a job in a hospital outside Michael's
Care Home. He plans to continue to
live at Sahara and help out where he
can around the hospice, caring for
people such as Noor, but build a life
and a career in the world outside also.
In mixed Hindi and English.
'I just like to care for people.'
I feel the heat of tears rising. Satish
has never had a letter of reference before.
His job interview is at 10am tomorrow
morning. No doubt he'll be
sighted in a borrowed shirt and freshly
pressed pants, reference in hand.
The Cricket score is Australia 155
for 5. A roar erupts throughout Michael's
Care Home. Noor is sleeping.
'The world is full of suffering, it is
also full of overcoming it.' –Hellen Keller
Cara is a registered Division 1 nurse
who undertook the PHC Jamkhed Course
with the University of Melbourne in
2005. She has since lived and worked in
India in the area of HIV / Aids, heroin rehabilitation
and Public Health and in the
process of writing about many of these
experiences.
november 2009 vector19
www.ghn.amsa.org.au

at a glance
india
// Image by asifthebes (sxc.hu)
India has had significant economic growth in the
past decade from which the general health of the
population has benefitted in many ways. The following
summarises many of the facts regarding health in the
world’s second most populous nation.
Indicator
Date Preceding
Most Recent
Date
Target by 2015
Proportion of population below 37% (1990) 26% (2000) 18.5%
poverty line
Proportion of population undernourished
62% (1990) 53% (2000) 31%
as whole
Proportion of children undernourished
54% (1990) 47% (1998) 27%
Under five mortality rate (per 125 (1990) 98 (2000) 41
1000 births)
Maternal Mortality Rate (per 437 (1991) 407 (1998) 107
100 000 births)
Deaths due to AIDS 471 (2000) 1114 (2004) Arrest the spread of HIV.
The estimated adult prevalence
of AIDS in 2007 was
0.3%
Deaths due to TB (per 100 000) 56 (1999) 33 (2003) Reverse the number of
deaths due to TB
Deaths due to Malaria (per 100
000)
Healthcare investment (proportion
of GDP)
0.13 (1994) 0.09 (2004) Reverse the number of
deaths due to malaria
Approximately
3% (1990)
Approximately 5%
(2000)
Increased economic growth
is expected to reflect a
greater investment in
health care
Healthcare Staff
As of 2004, India had:
• 503 900 doctors
• 737 000 nurses
• 350 000 chemists
• 15 000 hospitals
India has a three tiered healthcare
system with 23 000 Primary Healthcare
Centres (urban), 137 000 subcentres
(semi-urban and rural) and
3000 community health care centres.
// Image by barunpatro (sxc.hu)
www.ghn.amsa.org.au
Adapted From:
Government of
India. (2005). Millennium
Development Goals India
Country Report 2005. New
Delhi: India.
Indian Council of
Medical Research. (2005).
Assessment of Burden of
Non-Communicable Diseases.
Ansari Nagar: India.
Issue
Ischaemic
Heart Disease
Urban
Weighted
average prevalence
/1000
(+20y.o.)
Rural
Weighted average
prevalence
/1000
(+20y.o.)
Total Number of
entire population
affected
64.37 25.27 18 600 984 (1998)
22 367 840 (2004)
Stroke 1.54 792 628 (1998)
930 985 (2004)
Consequences
Expected to be single greatest cause
of mortality in India by 2015.
Total number of DALYS attributable
to stroke approximately 6.37 million
in 2004
Diabetes 118.02 38.67 37 768 402 (2004) Rates of diabetes incidence are
expected to increase significantly
within the next two decades
Hypertension 164.20 157.44 Total contribution of hypertension in
combination with other risk factors,
as it occurs, would prove worse
outcomes than shown here.
20 vector november 2009