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JUNE 2019

EST 2006

Volume 13

Issue 1

June 2019

Food for thought

FOOD FOR THOUGHT Fighting malnutrition

84

ADVOCACY IN MEDICINE Offshore immigration 1

16

FOOD AND REMOTE AUSTRALIA Closing the gap 60


AJGH 2019 Volume 13 Issue 1

ADVISORY BOARD Consists of academic mentors who provide guidance for the present and future direction of Vector Journal

Dr Claudia Turner Consultant paediatrician and clinician scientist with the University of Oxford and chief executive officer of Angkor

Food for thought

Hospital for Children

Professor David Hilmers Professor in the Departments of Internal Medicine and Pediatrics, the Center for Global Initiatives, and the Center for

Ideas are akin to food.

Space Medicine at the Baylor College of Medicine.

Associate Professor Nicodemus Tedla Associate Professor in the School of Medical Sciences at the

We read to satiate our intellectual hunger.

University of New South Wales.

We converse to quench our thirst for knowledge.

Dr Nick Walsh Medical doctor and regional advisor for viral hepatitis at

We engage in meaty discussions about complex issues.

the Pan American Health Organization / World Health

We spoon feed information to our children.

Organization Regional Office for the Americas.

We regurgitate material from textbooks and bosses.

PEER REVIEWERS

Dr Amy Burraston Dr Bridget Haire Ms Elesa Crowley Dr Evie Kendal Ms Jenny García

EDITOR-IN-CHIEF

Koshy Mathew

SENIOR EDITORS

We dislike opinions that are shoved down our throats. We reject ideas that are half-baked. The mind can indeed be as hungry as the stomach. Please enjoy our first issue for the year as our chefs (authors) dish out some food for thought.

Nicholas Mattock Simran Dahiya

ASSOCIATE EDITORS

Marisse Sonido Stephanie Kirkby Sunjuri Sun Soph Moshegov David Motorniak Thomas Nguyen Steven Chung Kyrollos Hanna

PUBLICATION DIRECTOR Tara Kannan

PROMOTION DIRECTOR

Ishka De Silva Design and layout © 2019, AJGH Australian Medical Students’ Association Ltd, 42 Macquarie Street, Barton ACT 2600 ajgh@amsa.org,au ajgh.amsa.org.au Content © 2019, The Authors Cover design by Tara Kannan AJGH is the official student-run, peer-reviewed journal of AMSA Global Health. Responsibility for article content rests with the respective authors. Any views contained within articles are those of the authors and do not necessarily reflect the views of AJGH or the Australian Medical Students’ Association.

THE AJGH TEAM


REVIEWS

CONTENTS 4

Marisse Sonido

8 Food for thought: The role of ethical eating in mental health.

Preshita Pande

16

The role of advocacy in medicine

30

Venezuela’s public health crisis

37

Resistance: The rise and spread of AMR

FEATURES

Developing countries versus infectious diseases

Rohanna Stoddart

Caroline Lee

Jesse Schnall

43

Nuclear’s second wind

Tara Kannan

47 Climate change and the role of future health professionals

Jeevan Jangam

52 Domestic violence: The mourned, the outraged and the forgotten

Kyrollos Hanna

56

Pandora’s box: The benefits and burdens of compulsory mental health treatment in the community

60

Food and remote Australia: a ‘fresh’ perspective on closing the gap

REPORTS

Natalie S

Anna-Louise Bayfield

66 Case report: Fatal neonatal tetanus from rural Bangla desh

Madeline Fitzpatrick

70

Elective: What Australia can learn from the Cook Islands & New Zealand

74

UN Commission: Twenty first century woman

Helena Qian

EDU

Clinical challenge

80

RESEARCH

Alexander Johnson

84 Food for thought: Fighting malnutrition one meal at a time

Samuel Smith

Sharanya Mohan Heeral Thakkar


DEVELOPING COUNTRIES VERSUS INFECTIOUS DISEASES: The role of travel and vaccinations in global health

In February 2019, measles was reintroduced to Costa Rica by an unvaccinated child on holiday with his family. Until this incident, the country had been free of the disease since 2014. The boy and his family were quickly placed in quarantine and no further cases were reported. [3] This close call, however, is a grim reminder that travellers bringing VPDs to developing countries is a possible occurrence.

Marisse Sonido

Infections in travellers, especially those visiting high population areas, have the potential of spreading quickly and are often more difficult to control given the limited resources available. VPD spread in developing countries For several reasons, developing nations are more vulnerable to disease outbreaks and large epidemics. Several environmental factors - such as the reduced availability of sanitised water and a warmer climate - that are more common to developing countries make them more conducive to disease spread.[4] Health care infrastructure is often less equipped and accessible, hindering prompt intervention and an effective response against disease outbreaks.[5] On top of this, vaccination coverage in developing countries is generally reduced compared to developed countries, leading to reduced herd immunity against VPDs.[6] In 1999, it was estimated that vaccination rates in the most economically disadvantaged countries are about 26% lower than the global average.[7] Some of the reasons for this are as follows.

4

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e live in a society where international travel is commonplace. In 2012, it was estimated that 1035 million individuals travelled internationally.[1] Immunisation prior to travel is meant to prevent travellers from contracting vaccine-preventable diseases (VPDs) and becoming carriers when they return from overseas.[2] While the greatest risk of this is usually associated with visiting developing countries, where VPDs are usually more common, the reverse can also occur.


Even small declines in vaccine coverage could significantly pose a danger to public health.

Costs of vaccination The costs of vaccinating children in developing countries has been increasing in the last two decades. In 2001, it cost at least US$0.67 to immunise a child against the six diseases in the WHO immunisation schedule. In 2014, it cost at least US$32.09–45.59 to immunise a child against the twelve diseases in the immunisation schedule, indicating a price increase of almost 24-fold.[8]

Implications in the current global scene Largely due to the above factors, developing countries are particularly vulnerable to disease outbreaks. Infections in travellers, especially those visiting high population areas, have the potential of spreading quickly and are often more difficult to control given the limited resources available. As such, unvaccinated travellers threaten disease control in developing countries as potential vectors of VPDs.

This is because competition among suppliers for most vaccines is quite low, with few suppliers entering the vaccine market. Further, some newer vaccines (e.g., HPV, rotavirus) are only being supplied by one or two manufacturers.[8,9] While vaccine suppliers often use tiered pricing with consideration to a country’s economic status, they are often not transparent about their pricing policies, allowing them to increase the price of a vaccine to whatever a country’s market can tolerate.[8]

Recently, the anti-vaccine movement and vaccine hesitancy has become more vocal in the Western world.[15] Vaccine hesitancy is defined as a delay in the acceptance or refusal of vaccines despite their availability.[16] As vaccine hesitancy continues to grow, its potential to rapidly reduce vaccination coverage through voluntarily unvaccinated individuals is becoming a greater concern. In the USA in 2000, 19% of parents indicated they have concerns about vaccines, and this rose to 50% in 2009. Concurrently, there was also an increase in non-medical vaccine exemptions in those years.[17] In Germany and France, vaccination hesitancy was also identified as a main driver of a decline in vaccination rates.[18]

Logistical difficulties of vaccination transport Many vaccines are heat sensitive (e.g., inactivated poliovirus and MMR) and are required to be continuously kept at temperatures of 2–8 °C (i.e., cold chain.[10] The lack of access to physical infrastructure and poor transportation networks make it difficult and expensive to properly store and transport vaccines to many remote areas, reducing coverage and further increasing costs. The lack of trained health staff qualified to administer vaccinations and manage immunisation programs may also limit coverage in areas where there is no nearby health service.[11]

Even small declines in vaccine coverage could significantly pose a danger to public health. In a study, it was estimated that even a 5% reduction in measles, mumps and rubella (MMR) coverage could lead to a three-fold increase in annual measles cases.[19] Today, we are beginning to see the consequences of decreasing vaccination coverage. Between 2017 to 2018, the number of cases of measles has increased 48.1% globally.[20] Brazil accounts for a large part of this increase. While the country had no cases of measles recorded in 2017, 10,262 cases where recorded in 2018, illustrating how quickly such outbreaks can escalate after a disease is reintroduced to a developing nation.[20] A responsibility to developing nations Many individuals view vaccination as a choice made based on individual beliefs and preferences, with impacts only reaching as far as their own health or those of their immediate community. However, in the age of travel, such decisions can potentially have global consequences. In Australia, where vaccines are accessible and affordable, residents have an opportunity—and

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Distrust of vaccines There is an existing distrust of vaccinations in many developing countries. As in developed countries, one reason for this may be due to the growing anti-vaccine movement. In the Philippines, a 2017 controversy regarding the dengue fever vaccine rocked public confidence in the safety of vaccines,[12] leading measles immunisation rates in the country to fall from 75% in 2016 to 60% that year.[13] In some countries, such as in Nigeria and the Republic of Congo, a general distrust of the government’s motivations leads to misconceptions that vaccines are a means to harm the population. These concerns are often coupled with poor health literacy in these countries, which furthers misconceptions about vaccines.[14] 5


perhaps a responsibility - to interrupt the spread of VPDs by becoming vaccinated. Maintaining and improving national vaccination coverage in developed countries - particularly in travellers - protects developing nations that are more susceptible to outbreaks due to lack of resources and reduced access to vaccinations. This is herd immunity on an international scale and an impactful means of improving the global picture of health. Marisse is a fifth year UNSW medical student. Besides writing and research, she enjoys art, watching nature documentaries, and playing an unhealthy amount of board games. Conflicts of Interest None declared Correspondence marisse.sonido@amsa.org.au References 1. Mirzaian E, Amloian A, Makar F, Goad JA. Vaccine-preventable diseases in travelers. Current Treatment Options in Infectious Diseases. 2014 Mar 1;6(1):58-73. 2. Healthdirect Australia. Travel vaccinations [Internet]. Sydney NSW: Healthdirect Australia; 2018. Available from: https://www.healthdirect.gov.au/travel-vaccinations 3. Foster A. Fears unvaccinated French boy reintroduced measles to Costa Rica [Internet]. News Pty Limited; 2019. Available from: https://www.news.com.au/lifestyle/health/ health-problems/fears-unvaccinated-french-boy-reintroduced-measles-to-costa-rica/news-story/734c65944332ee8ff3a2898375a00e2e 4. World Health Organization. Environmental factors influencing the spread of communicable diseases [Internet]. The World Health Organization; 2019. Available from: https://www. who.int/environmental_health_emergencies/disease_outbreaks/communicabl e_diseases/en/ 5. Gupta I, Guin P. Communicable diseases in the South-East Asia Region of the World Health Organization: towards a more effective response. Bulletin of the World Health Organization. 2010;88:199-205. 6. Tulchinsky TH, Ginsberg GM, Abed Y, Angeles MT, Akukwe C, Bonn J. Measles control in developing and developed countries: the case for a two-dose policy. Bulletin of the World Health Organization. 1993;71(1):93. 7. United States General Accounting Office. Global Health: 6

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Factors contributing to low vaccination rates in developing countries [Internet]. Washington D.C.: United States General Accounting Office; 1999. Available from: https://www.gao.gov/ assets/230/228261.pdf 8. Médecins Sans Frontières. The right shot: Bringing down barriers to affordable and adapted vaccines [Internet]. Geneva: Médecins Sans Frontières; 2015. Available form: https:// www.msf.org.uk/sites/uk/files/msf_the_right_shot_report_2nded_2015.pdf 9. World Health Organization, UNICEF, World Bank. State of the world's vaccines and immunization (third edition). Geneva: World Health Organization; 2009. 10. Immunisation Unit, Health Protection NSW. Cold chain breaches [Internet]. NSW: NSW Health; 2019. Available from: https://www.health.nsw.gov.au/immunisation/Documents/ cold-chain-breaches.pdf 11. Institute of Medicine. Priorities for the national vaccine plan. Washington, DC: The National Academies Press; 2010. Available from: https://doi.org/10.17226/12796. 12. Fatima K, Syed NI. Dengvaxia controversy: impact on vaccine hesitancy. Journal of global health. 2018 Dec;8(2). 13. BBC News. Measles outbreak declared in Philippines. BBC; 2019. Available from: https://www.bbc.com/news/worldasia-47153817 14. Ozawa S, Stack ML. Public trust and vaccine acceptance-international perspectives. Human vaccines & immunotherapeutics. 2013 Aug 8;9(8):1774-8. 15. Hussain A, Ali S, Ahmed M, Hussain S. The anti-vaccination movement: A regression in modern medicine. Cureus. 2018 Jul;10(7). 16. World Health Organization. Addressing vaccine hesitancy [Internet]. World Health Organization; 2019. Available from: https://www.who.int/immunization/programmes_systems/ vaccine_hesitancy/en/ 17. Gowda C, Dempsey AF. The rise (and fall?) of parental vaccine hesitancy. Human vaccines & immunotherapeutics. 2013 Aug 8;9(8):1755-62. 18. Kieslich K. Addressing vaccination hesitancy in Europe: a case study in state–society relations. European journal of public health. 2018 Nov 1;28(suppl_3):30-3. 19. Lo NC, Hotez PJ. Public health and economic consequences of vaccine hesitancy for measles in the United States. JAMA Pediatr. 2017 Sep 1;171(9):887-92. 20. Avramova N. Measles cases at ‘alarmingly’ high levels around the world, UNICEF says [Internet]. Cable News Network; 2019. Available from: https://edition.cnn.com/2019/02/28/ health/global-measles-increase-unicef-intl/index.html


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AMSA Journal of Global Health

8


Abstract Aims: Mental health is a growing public health concern in both global and Australian contexts. More recently, the relationship between climate change and mental health has been examined. This review begins with a discussion of mental health in the context of climate change, followed by a critical analysis of the role of ethical consumerism and its associated impact on mental health. Methods: A comprehensive search of PubMed, Google Scholar and Medline was conducted using the search terms (‘climate change’ OR ‘global warming’) AND (‘ethical consumerism’ OR ‘green consumption’ OR ‘ethical eating’) AND (‘mental health’ OR ‘psychological distress’ OR ‘mental well-being’ OR ‘psychological well-being’). Further studies were identified via citation review.

FOOD FOR THOUGHT The role of ethical eating in mental health Preshita Pande

June 2019

Conclusions: Further investigation of the relationship between mental health and climate change is required, specifically with regards to psychoterratic syndromes and their associated impact on mental health. An analysis of the distribution of ethical consumerism and associated behaviours in an Australian population is required. The relationship between ethical eating and mental health in the context of long-term positive psychology interventions is worthy of further investigation.

Issue 1 Volume 13

Results: Current approaches to changes in mental health due to climate change focus on weaknesses in health; however, the emergence of positive psychology has begun to change this approach. This literature review focused on the emergence of ethical consumerism practises and their role in mental health through the framework of positive psychology. Food trends driven by environmental concern are promising for further understanding mental health in the context of climate change.

9


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raditionally, mental health was considered the absence of mental illness, however, in recent years, its definition has evolved into a continuum. This continuum takes into account the positive aspects of mental health, termed ‘psychological well-being’, and the negative aspects, termed ‘psychological distress’.[1] The World Health Organisation now defines mental health as a ‘state of well-being in which every individual realises his or her own potential, can cope with normal stresses of life, can work productively and fruitfully and is able to contribute to their respective community’.[2] ‘Mental illness’ is defined as a clinically diagnosable disorder that interferes with an individual’s emotional, cognitive or social functioning.[1]

Climate change and health Climate change is a globally recognized concern and has been labelled the greatest threat to humanity in the 21st century and a destructive reality that will leave irreversible effects for future generations. [8] It is defined as the long-term change in statistical distribution of weather patterns over extended periods of time.[9] Global warming, a result of climate change, is defined as a rise in the average temperature of the Earth’s atmosphere and oceans. [9] Anthropogenic factors such as fossil fuel usage, deforestation and livestock farming are currently the leading causes of global warming.[8]

Mental health has been worsening globally and within Australia.[3,4] The Lancet estimated the global burden of mental illness to account for 32.4% of years lived with disability (YLD) and 13% of disability adjusted life years (DALYs). They also suggested that current approaches have been underestimating the burden by more than a third, and that mental illness is the leading cause of global YLDs and second highest cause of DALYs.[5]

The relationship between the environment and human health has recently become a focus of the literature, with academic writings in this field tripling between 2007 and 2018.[8,10] The 2015 Lancet Health Commission on Health and Climate Change stated that the health impacts of climate change are catastrophic, and that tackling climate change is the ‘greatest global health opportunity’ of the 21st century. The commission also extensively mapped out the direct and indirect consequences of climate change, which have been increasing rapidly.[11] The current rate of climate change is imposing life-limiting consequences on the physical and mental health of the public on a global scale, with the World Health Organization (WHO) estimating 250,000 deaths per year between 2030 and 2050 as a result of climate change.[12]

In Australia, as of 2017, 45% of individuals aged 16-85 years experienced psychological distress, ranging from generalised anxiety and depression, to severe psychological distress. The same study suggested that poor mental health is currently the largest contributor to non-fatal disease burden and subsequent number of years of healthy life lost in Australia, accounting for 23.6% of all non-fatal disease, surpassing musculoskeletal and respiratory disorders. Furthermore, the main causes of non-fatal burden for those suffering mental illness were anxiety disorders (27%), depressive disorders (24%) and alcohol use disorders (11%).[6] The financial expense associated with mental illness has continued to rise, with the annual cost of depression in Australia now estimated to be $12.6 billion, excluding anxiety and other mental illnesses.[7]

Mental health and climate change Until recently, the focus of both research and public interest has been on the impact of climate change on physical health. However, in the last decade, there has been a growing body of research focusing primarily on both the direct and indirect impacts on mental health.[13]

Studies have demonstrated a relationship between an individual’s psychological well-being and their connection to nature, thus, when natural resources are threatened, it can act as a source of psychological distress to individuals.

There is evidence to support the direct impact of climate change on mental health; for example, studies have shown that individuals experiencing adversities, such as droughts or floods as a direct result of climate change, have shown symptoms of post-traumatic stress disorder, depression and aggression following the loss of people and property, financial burdens and dislocation from one’s community.[14,15] Similarly, less acute weather events, such as increased humidity, have previously been 10

AMSA Journal of Global Health

The socio-ecological factors contributing to mental health are complex and interact at a multitude of levels including individual, interpersonal, organisational and environmental. One such factor that is growing in public interest is climate change.

Background


associated with poorer concentration and increased fatigue, whilst increased temperatures have been associated with aggression and increased suicide risk.[16] The associated extremities with climate change are thus expected to be matched with these negative mental health outcomes.[16] Limitations to this literature include the relationship between heat, humidity and mental health being sensitive to locality or being confounded by research methods.[16] Psychoterratic Syndromes More recent studies have investigated the indirect and longer-term impacts of climate change on mental health. These have emerged as a result of the increased awareness of climate change as a threat as opposed to the direct experiences of climate change events. For example, Fritze et al. had suggested that as people’s understanding of climate change grows, their social, emotional, spiritual and mental wellbeing will be negatively influenced.[17] Studies have demonstrated a relationship between an individual’s psychological wellbeing and their connection to nature; thus, when natural resources are threatened, it can act as a source of psychological distress.[18] Psychological distresses caused as a result of climate change are collectively known as psychoterratic syndromes and are a new focus of research in the context of mental health and climate change.[19] Eco-anxiety and solastalgia are two specific emerg-

ing areas of research within psychoterratic syndromes. Eco-anxiety is defined as anxiety associated with the implications of climate change. Most individuals experiencing eco-anxiety identify the impact of climate change on their future as a primary source of concern.[20] Studies have reported anecdotal evidence of eco-anxiety causing symptoms such as panic attacks, loss of appetite, irritability, weakness and sleeplessness.[21] Other studies have suggested that the large increase of media coverage on climate change has led to individuals feeling overwhelmed, with consequent symptoms of anxiety and depression.[22,23] However, the studies discussed here lack empirical evidence, and the use of anecdotal evidence is susceptible to bias and a lack of reproducibility. Limitations to these studies are also evident through difficulties in distinguishing between normal and pathological anxiety and thus, it is possible that individuals predisposed to anxiety show heightened symptoms as a result of eco-anxiety. The term solastalgia was first used by Albrecht et al. after a study conducted in rural New South Wales that found that individuals exposed to persistent droughts showed psychological distress. [19] The same study simultaneously found that individuals exposed to large scale open cut mining presenting with psychological distress and feelings of helplessness and powerlessness. The term solastalgia was consequently defined as the existential distress caused to an individual as a result of recognizing that the place that one resides and is attached to is under immediate threat.[19] Individuals experiencing solastalgia have reported that losing their sense of place and home has led to distress, with these growing concerns about environmental health threats taking a toll on wellbeing.[24]

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Overall, it is difficult to distinguish between these emerging psychoterratic syndromes due to their overlapping symptomatology and subjective natures. As a result, the proportion of global mental health burden specifically attributed to these syndromes is also difficult to estimate. Ethical consumerism

Figure 1: Classification and interaction of ethical consumerism practises based on environmental, human or animal concerns 11

The deterioration of mental health as a consequence of climate change has led to a unique transformation in the Australian and global food market, with growing behavioural


tributor being sustainably sourced fish.[29] The majority of respondents (64%) stated that they had made food decisions based on environmental and animal welfare reasons.[29] The boycotting of unethical products has also become more common with an 85% increase in avoidance of products based on their environmental impact reported since 2016.[29] This report has also suggested that this ethical food market will continue to grow over the next 5 years based on current trends.[29] However, possible inaccuracies in this report could arise due to reliance on individuals recalling their own dietary habits, and thus may overestimate this trend. The Nielsen Global Report conducted a behaviour-based survey analysing 30,000 individuals across more than 100 countries in 2018 and found that 73% of respondents reported being willing to change eating behaviours to reduce an impact on the environment.[30] However, this report did not explore specific consumer trends, but rather perceptions and attitudes. Euromonitor International also released a global report showing an analysis of 26,000 products across 26 countries and has predicted an overall growth of 10% in the ethical food and beverage market from 2015-2020.[31] In 2015 it was estimated that 75% of the global ethical market was accounted for by environmentally-driven labels.[31] There has been limited replicated research since this report in 2016. A common limitation of these studies includes the inability to distinguish between ‘animal’, ‘environmental’ and ‘human’ reasons for ethical eating due to complex interaction and overlap (Figure 1).

These studies have shown that vegetarians typically enjoy a lower risk of these chronic conditions and hence, through successfully managing these conditions with plant-based diets, patients are expected to experience improved psychological wellbeing. The focus of this literature review is ethical consumerism practiced for environmental reasons within the context of climate change (Figure 1), which includes the adoption of plant-based diets, food miles, organic foods and minimisation of food waste, amongst others. However, as shown in Figure 1, these components are interrelated. Such practices have gained traction in recent decades as an alternative to mainstream food processes and practices, particularly in Western countries including Australia. This increasing demand is observed through the overall growth of the ethical food market and a substantial increase in products labelled ‘eco-friendly’, ‘sustainable’, ‘organic’ and ‘fair-trade’ in Australia, the UK and America.[25-27] While data on ethical consumerism is lacking in Australia outside of summative global reports, reports from the UK are outlined below, due to their similarities in consumerism trends.[25,28]

Positive emotion, engagement, relationships, meaning and accomplishment (PERMA) model of wellbeing and positive psychology Ethical eating and associated behaviours can be considered an element of improving mental health. This is a novel approach which can be illustrated using the theoretical framework of the PERMA model, constructed by Seligman in 2009 (Figure 2).[32] Seligman demonstrates the contribution of these 5 pillars to overall psychological wellbeing, with each having subjective importance and being defined independently of one another.[32] Theoretically, ethical eating practices draw from 3 pillars: engagement, as individuals vary their lifestyles based on adherence to an ethical perspective; meaning, as individuals believe eating practices have a connection to something greater than themselves such as the environment; and accomplishment, as individuals may feel their food choices have had an

The Ethical Consumer Market Report conducted across all retailers in the UK showed ethically labelled food and beverage products to have more than doubled between 2008 and 2018, with a growth of 16.3% in 2017-2018, with the largest con12

AMSA Journal of Global Health

trends towards ‘ethical consumerism’ practises. [26] A large proportion of this shift has been due to an increase in concern regarding the impact of production and consumption of products on climate change.[25] Ethical consumerism, also known as green consumerism, is an emerging type of consumer activism involving eating and drinking, such as veganism, and associated lifestyle behaviours, such as waste-free living or fair-trade consumption. This form of consumerism is driven by either the selection of products that meet ethical standards or the boycotting of products based on their failure to meet these standards.[26] These ethical standards are based broadly on the practice of ‘harm minimisation’ or ‘elimination’ regarding products that pose a threat to either animals, humans or the environment. More specific motivations behind ethical consumer practise include supporting animal welfare; fair treatment of workers to address the issues of economic justice and the inequitable distribution of wealth; or the promotion of individual health.


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impact beyond themselves, such as avoiding meat products for animal welfare reasons. Seligman’s proposal of positive psychology as a major component of the PERMA model also plays a key role in understanding how environmental ethical consumerism could be used to improve individual mental health. Positive psychology is an umbrella term that focuses on the sources of psychological well-being that enable individuals to thrive and function optimally.[33] Positive psychology has led to the pioneering of tools and techniques aimed at enhancing individual strengths and qualities and encouraging positive mental health and happiness.[34] This is practiced through positive Figure 2: Seligman’s PERMA Model of Well-Being - A scientific theory to happipsychology interventions (PPIs), ness a novel non-pharmacological approach towards improving mental and towards a more holistic approach. The PPIs health. This intervention focuses on positive emoused in the meta-analyses drew from the PERMA tions and improvements in quality of life, rather model, which has not yet been applied similarly to than focusing on resolving weaknesses in health. A ethical consumerism in existing literature, and may meta-analysis conducted in 2009 analysed the efwarrant further investigation to determine whether fects of 51 PPI-based studies, with results showing ethical consumerism serves as a form of PPI. that PPIs significantly enhanced well-being (mean r = 0.29) and reduced depressive symptoms (r = Ethical consumerism and mental health 0.31).[35] This study also showed that individual therapies proved more effective than group-based Although ethical consumerism as a PPI has not therapies, and that individuals who had the lowest been explored, the relationship between ethical well-being scores prior to the interventions showed consumerism and mental health directly has been the highest increase in well-being scores post-intersupported by many studies.[37-42] A systematic vention.[35] review conducted in 2018 showed plant-based diets to be associated with significant (p < 0.001) imAnother meta-analysis conducted in 2013 focused provements in emotional well-being and a reducspecifically on randomized controlled trial evidence tion in depressive symptoms.[37] Limitations of for PPIs and indicated less significant results than this study included a small sample size, and results the aforementioned study, with the mean effect size being highly dependent on participants’ recollecon psychological well-being equating to 0.2 and tion of dietary intake, suggesting potential inaccu0.23 on depressive symptoms.[36] These effect sizracies. Although only conducted in type 2 diabetic es varied greatly, with some also suggesting a negpatients, this research has considerable implicaative impact on psychological well-being; however, tions for plant-based diets in mental health. the underlying reasons for this were not explored. Furthermore, participants involved in longer-term A survey-based study specifically analysing the studies (up to 2 year follow-ups) indicated better mental health status of vegetarians reported sigpsychological well-being than those in short-term nificantly fewer negative emotions in vegetarians studies.[36] as compared to omnivores in the Depression Anxiety Stress Scale (8.32 vs 17.51 ± 1.88) and the Profile Limitations of the aforementioned meta-analyses of Mood States Scale (0.10 ± 1.99 vs 15.33 ± 3.10). The demonstrate great variation in the types of PPIs study also found vegetarians to have higher circuthat were used. Furthermore, none of the PPIs used lating concentrations of antioxidants, linoleic acid investigated the practice of ethical consumerism. and α-linoleic acid, amongst others, however the PPIs do however show great promise in shifting mechanisms explaining this association have not away from traditional mental health management 13


all improved life satisfaction and mental health.

Studies haves shown anxiety and depressive disorders to be common co-morbidities with chronic conditions such as cardiovascular disease, obesity, type 2 diabetes and certain malignancies.[39] These studies have shown that vegetarians typically enjoy a lower risk of these chronic conditions and hence, through successfully managing these conditions with plant-based diets, patients are expected to experience improved psychological well-being.[39]

The complex relationship between mental health and climate change presents as a unique public health concern, when considered independently and in conjunction. Ethical consumerism may show promise in future approaches to mental health and climate change issues. This is supported by the theoretical frameworks of positive psychology, which may warrant further investigation as a novel mental health intervention. Conclusion

In-vitro studies have explored health implications of organic foods, one of which suggested that organic foods have higher levels of vitamin C, iron, magnesium, phosphorous and a number of antioxidant phytochemicals, as well as lower levels of nitrates and pesticides than non-organic variations. However, this study did not discuss the direct implication of the results on mental health.[40] A separate study conducted by Mie et al. briefly discussed the significant negative impact of pesticide use in inorganic foods on neurodevelopment in children but consequent mental health implications for participants were not explored.[41]

Key gaps in knowledge that have emerged from this literature review recommend further investigations in the relationship between mental health and climate change, with specific investigation of psychoterratic syndromes and their contribution to poor mental health on a global scale. Further research suggestions include an analysis of the distribution of ethical consumerism and associated behaviours in an Australian population. Furthermore, it would be beneficial to further explore the relationship between ethical eating and mental health through long-term PPIs using ethical eating as an approach to improving mental health.

Interestingly, eco-psychologists have shown increased psychological well-being in individuals choosing organic foods in interview-based studies. [42] It was suggested that this increased well-being was due to the positive effects of their philosophical values and emotional attitudes towards food being practiced on a daily basis. Hence this positive attitude towards food can be seen to improve mental health in a manner that reflects aspects of the PERMA model.[42]

Preshita Pande is a fourth year medical student at the University of New South Wales, Sydney. Preshita is passionate about public health and preventative medicine and is excited to continue learning the process of research as a future practitioner. Within her interest in preventative medicine, she is also working under AMSA as the Healthy Communities national co-coordinator, aimed at empowering medical students’ knowledge surrounding NCD’s through advocacy campaigns, projects and grassroot initiatives.

Despite this growing body of research, it is important to consider negative mental health implications of ethical consumerism, such as those associated with increased financial costs, the psychological pressure of maintaining the lifestyle and relative inaccessibility. Furthermore, ethical consumerism has often been termed an ‘elitist alternative lifestyle’, hence, potentially negatively impacting social acceptance.[43] These factors are important to consider if ethical consumerism practice is to be considered in the context of other PPIs.

Acknowledgements

Other types of environmental ethical consumerism practices, such as reducing food waste, are currently understudied, especially in the context of mental health. However, the idea of a conscious life strategy as an action to improve mental health draws from the discussed theoretical frameworks and the efficacy of existing PPIs, demonstrating how ethical consumerism practices can contribute to over-

References

Dr Rebecca Reynolds, my Independent Learning Project supervisor, for her feedback and support through this process. Shrikant Pande, Tarana Purohit and Leanne Atkinson for their comments and valuable input whilst writing this article. Conflict of interest and funding None declared Correspondence preshita.pande@amsa.org.au

1. Manderscheid R, Ryff C, Freeman E, McKnight-Eily L, Dhingra S, Strine T. Evolving Definitions of Mental Illness and Wellness. Prev Chronic Dis. 2009;7(1):A19. 2. World Health Organisation. Mental health: a state of well-being [Internet]. Geneva: World Health Organisation; 2014. Available from: https://www.who.int/ 3. Steel Z, Marnane C, Iranpour C, Chey T, Jackson J, Patel V, et al.

14

AMSA Journal of Global Health

been explored.[38]


The global prevalence of common mental disorders: a systematic re-

(eds) Climate Change and Human Well-Being. International and Cul-

view and meta-analysis 1980–2013. Int J Epidemiol. 2014;43(2):476-93.

tural Psychology. New York: Springer; 2011.

4. Murray C, Vos T, Lozano R, Naghavi M, Flaxman A, Michaud C, et

24. Searle K, Gow K. Do concerns about climate change lead to dis-

al. Disability-adjusted life years (DALYs) for 291 diseases and injuries

tress? Int J Climate Change Strat Manage. 2010;2(4):362-79.

in 21 regions, 1990–2010: a systematic analysis for the Global Burden

25. Kearney J. Food consumption trends and drivers. Philos Trans R

of Disease Study 2010. Lancet. 2012;380(9859):2197-223.

Soc Lond B Biol Sci. 2010;365(1554):2793-807.

5. Vigo D, Thornicroft G, Atun R. Estimating the true global burden

26. Australian Institute of Health and Welfare. Australia’s Food &

of mental illness. Lancet Psychiatry. 2016;3(2):171-8.

Nutrition 2012. Canberra: Australian Institute of Health and Welfare;

6. Australian Institute of Health and Welfare. Mental health services

2012.

in Australia: in brief 2018. Canberra: AIHW; 2018.

27. Department of Agriculture, Fisheries and Forestry. Australian

7. Cocker F, Sanderson K, LaMontagne A. Estimating the Economic

Food Statistics 2010-2011. Canberra: DAFF; 2012.

Benefits of Eliminating Job Strain as a Risk Factor for Depression. J

28. Shavitt S, Cho H. Culture and consumer behavior: the role of hor-

Occup Environ Med. 2017;59(1):12-7.

izontal and vertical cultural factors. Curr Opin Psychol. 2016;8:149-54.

8. Watts N, Amann M, Ayeb-Karlsson S, Belesova K, Bouley T,

29. Ethical Consumer Research Association. Ethical Consumer Mar-

Boykoff M, et al. The Lancet Countdown on health and climate change:

kets Report 2018. Manchester: The Ethical Consumer; 2018.

from 25 years of inaction to a global transformation for public health.

30. Sustainable Shoppers Buy the Change They Wish to See in the

Lancet. 2018;391(10120):581-630.

World. New York: The Nielsen Company; 2018.

9. Lineman M, Do Y, Kim J, Joo G. Talking about Climate Change

31. Gordon L, Hudson E. Introducing Passport Ethical Labels [Inter-

and Global Warming. PLOS ONE. 2015;10(9):e0138996.

net]. Euromonitor International: Market Research Blog; 2016. Available

10. Bunz M, Mücke H. Klimawandel – physische und psychische Fol-

from: https://blog.euromonitor.com/

gen. Bundesgesundheitsblatt - Gesundheitsforschung - Gesundheitss-

32. Seligman M, Csikszentmihalyi M. Positive Psychology: An Intro-

chutz. 2017;60(6):632-9.

duction. Am Psychol. 2000;55:5-14.

11. Watts N, Adger W, Agnolucci P, Blackstock J, Byass P, Cai W, et al.

33. Henry J. Positive Psychology and the Development of Well-Be-

Health and climate change: policy responses to protect public health.

ing. In: Haworth J., Hart G. (eds) Well-Being. London: Palgrave Macmil-

Lancet. 2015;386(10006):1861-914.

lan; 2007.

12. World Health Organisation. Climate change and health. Geneva:

34. O’Connell B, O’Shea D, Gallagher S. Enhancing social relation-

World Health Organisation; 2018. Available from: https://www.who.

ships through positive psychology activities: a randomised controlled

int/

trial. J Pos Psychol. 2015;11(2):149-62.

13. Trombley J, Chalupka S, Anderko L. Climate Change and Mental

35. Sin N, Lyubomirsky S. Enhancing well-being and alleviating

Health. Am J Nurs. 2017;117(4):44-52.

depressive symptoms with positive psychology interventions: a prac-

14. Salcioglu E, Basoglu M, Livanou M. Post-traumatic stress disor-

tice-friendly meta-analysis. J Clin Psychol. 2009;65(5):467-87.

der and comorbid depression among survivors of the 1999 earthquake

36. Bolier L, Haverman M, Westerhof G, Riper H, Smit F, Bohlmeijer

in Turkey. Disasters. 2007;31(2):115-29.

E. Positive psychology interventions: a meta-analysis of randomized

15. DeSalvo K, Hyre A, Ompad D, Menke A, Tynes L, Muntner P.

controlled studies. BMC Public Health. 2013;13(1):119.

Symptoms of Posttraumatic Stress Disorder in a New Orleans Work-

37. Toumpanakis A, Alba-Barba I, Turnbull T. Effectiveness of

force Following Hurricane Katrina. J Urban Health. 2007;84(2):142-52.

plant-based diets in promoting well-being in the management of

16. Berry H, Bowen K, Kjellstrom T. Climate change and men-

type 2 diabetes: a systematic review. BMJ Open Diabetes Res Care.

tal health: a causal pathways framework. Int J Public Health.

2018;6(1):e000534.

2009;55(2):123-32.

38. Beezhold B, Johnston C, Daigle D. Vegetarian diets are associat-

17. Fritze J, Blashki G, Burke S, Wiseman J. Hope, despair and trans-

ed with healthy mood states: a cross-sectional study in Seventh Day

formation: climate change and the promotion of mental health and

Adventist adults. Nutr J. 2010;9(1):26.

wellbeing. Int J Ment Health Sys. 2008;2(1):13.

39. Position of the American Dietetic Association and Dietitians of

June 2019

18. Albrecht G. Chronic Environmental Change: Emerging ‘Psy-

Canada: Vegetarian diets. J Am Diet Assoc. 2003;103(6):748-65.

choterratic’ Syndromes. In: Weissbecker I. (eds) Climate Change and

40. Von Essen E, Englander M. Organic food as a healthy lifestyle:

Human Well-Being. International and Cultural Psychology. New York:

A phenomenological psychological analysis. Int J Qual Stud Health

Springer; 2011.

Well-being. 2013;8(1):20559.

19. Albrecht G, Sartore G, Connor L, Higginbotham N, Freeman

41. Mie A, Andersen H, Gunnarsson S, Kahl J, Kesse-Guyot E,

S, Kelly B, et al. Solastalgia: The Distress Caused by Environmental

Rembiałkowska E, et al. Human health implications of organic food

Change. Australas Psychiatry. 2007;15:S95-8.

and organic agriculture: a comprehensive review. Environ Health.

20. Pihkala P. Eco-anxiety, tragedy, and hope: psychological and

2017;16(1):111.

Issue 1

spiritual dimensions of climate change. Zygon. 2018;53(2):545-69.

42. Von Essen E, Englander M. Organic food as a healthy lifestyle:

21. Pfautsch S, Gray T. Low factual understanding and high anxiety

A phenomenological psychological analysis. Int J Qual Stud Health

about climate warming impedes university students to become sus-

Well-being. 2013;8(1):20559.

tainability stewards. Int J Sustain High Educ. 2017;18(7):1157-75.

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22. Joffe H. The Power of Visual Material: Persuasion, Emotion and Identification. Diogenes. 2008;55(1):84-93. 23. Reser J.P., Morrissey S.A., Ellul M. The Threat of Climate Change: Psychological Response, Adaptation, and Impacts. In: Weissbecker I.

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Abstract Aims: Australian immigration policy stipulates mandatory offshore processing of refugees, producing a number of ethical conflicts for medical professionals working within this framework. This article aims to discuss the role of medical professionals in Australiaâ&#x20AC;&#x2122;s practise of offshore immigration detention, as well as assess the applicability of normative tools of medical ethics in this context. Methods: A critical interpretive review was performed. This included searches of 4 academic databases (Pubmed, Medline, Web of Science and Scopus) and a targeted grey literature search. Articles were selected for review based upon their title and abstract.

THE ROLE OF ADVOCACY IN MEDICINE

Results: After removing duplicates, 233 resources were screened for eligibility; 32 peer-reviewed articles and 28 grey literature records were included. Offshore detention processing of refugees and asylum seekers has produced a wealth of experiential accounts examining and conceptualising ethical issues faced by Australian medical professionals. A number of ethical frameworks are available with which clinicians can approach the conflicting medical ethics of offshore processing. The recent legislative success of Phelpâ&#x20AC;&#x2122;s bill on medical transfers marks a turning point in Australian medical advocacy, with implications for the expansion of medical practise to include contentious political action, such as civil disobedience, petitions, and non-violent protest, amongst more conventional forms of political participation.

How medical professionals are upholding medical ethics in the face of Australian offshore immigration processing Rohanna Stoddart

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Conclusions: Medical professionals can draw on normative tools of medical ethics to approach ethical conflicts in offshore processing, a number of which deal with the refugee condition specifically. For medical students, in-depth analyses of these ethical arguments are essential in informing medical ethics teaching and moral enculturation.

17


D

etention of refugees and asylum-seekers has become institutionalised in migration management frameworks and policy worldwide, reflecting increasingly exclusionary and protectionist approaches to immigration.[1] Australia is notable in the extremity of its restrictive policies and anti-migrant rhetoric, despite receiving a relatively small number of asylum-seekers – only 0.99% of the global total in 2010-2015.[2]

Targeted grey literature searches were conducted using Google Scholar and selected websites from reputable research organisations, including the United Nations Organisation and the Kaldor Centre for International Refugee Law. The grey literature resources selected for review included policy documents, international conventions and declarations, letters of concern and position statements. Twelve resources for background information were utilised, including 7 peer-reviewed articles, 1 statistical report from the UN, 1 report from the Kaldor Centre and 3 news media articles. Experts in the field were contacted via email seeking additional material; as a result, some unpublished work (with permission) has been included.[19]

Since 1992, Australia is unique in holding the highly contentious policy of mandatory immigration detention. Under the Migration Act 1958, asylum-seekers can be detained indefinitely in prison-like facilities without judicial oversight,[1,3] and have been incarcerated for as long as 10 years.[4] The treatment of asylum-seekers under this policy has been described in the literature as “inhumane and degrading”,[5] and as analogous to torture.[6-8]

Results

The most widely-criticised aspect of Australian immigration detention is offshore processing, which has been condemned as violating both human rights and international law. Such protectionist immigration policies have been shown to compromise refugee health.[1,3,9-12] Thus, Australian immigration policy is as much a political issue as a public and global health challenge, and consequently requires critical review from such perspectives. The role of health services in maintaining offshore processing centres is particularly controversial, not least because clinician independence is compromised by contractual obligations to International Health and Medical Services (IHMS) and the Australian Department of Immigration and Border Protection (DIBP).[13-17] Herein, the literature discussing ethical frameworks for clinician advocacy in such settings is identified and examined.

In total, 233 resources were screened for eligibility; 32 peer-reviewed articles and 28 grey literature records were included. The body of literature examining medical practices in Australian offshore immigration processing reflects an intersection of public health and bioethics. Public health literature tends to focus on evidencing the effects of Australian immigration policy on refugee and asylum seeker health and wellbeing. Bioethics literature uses established evidence of immigration detention leading to poorer health outcomes as a premise for discussion, with an aim to: 1. Report documented conflicts of interests caused by current immigration practises; and, 2. Evaluate the physician’s role through bioethical and human rights frameworks.

Methods

Healthcare delivery in offshore immigration detention

In reviewing the literature, a critical interpretive review was utilised. Such reviews are not systemic in attempting to compile every relevant piece of

Within offshore processing centres (OPCs), health services are provided through independent con-

Table 1. Key search terms Academic database

Targeted grey literature

(detention OR offshore processing OR refugee OR asylum seeker) AND (medic OR doctor OR health professional OR physician) AND (Australia OR Christmas island) AND (whistleblow OR boycott OR response OR advoca* or activis* OR conduct) AND (“equivalence of care” OR ethic* OR “duty of care” OR conscience OR moral* OR physicians/ethics* OR Physician’s role). Australia refugees and asylum seekers and medical ethics, international convention on refugees and asylum seekers, code of medical ethics. Note: varied according to website or search engine, only some examples provided. 18

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research but are thorough and widely utilised in bioethics.[18] Literature searches were conducted of 4 academic databases (Pubmed, Medline, Web of Science and Scopus).

Introduction


tractors engaged by the Australian government. Since 2007, this role has been filled by International Health and Medical Services (IHMS), which is contractually obliged to “…provide a level of healthcare to people in immigration detention consistent with that available to the wider Australian community”. [10]

2. That mandatory detention is highly associated with psychological harm.[5,9] Silove [12] described symptom rates obtained through a review of Australian studies of detained asylum seekers as “extraordinarily high”, and reported severe attachment and developmental disorders in children in detention. Of note, 2 clinical studies comparing groups of asylum-seekers with similar levels of pre-migration trauma found that those who had experienced prolonged detention reported much higher levels of anxiety, PTSD and depression than their counterparts who were granted permanent visas upon arrival. Exposure to dehumanising conditions and post-migration stress were the major contributors to ongoing PTSD symptoms.[32,34] These findings support the view that immigration detention itself is implicated in the aetiopathogenesis of psychiatric disorders in such populations. While commended for their use of standardised assessment measures, both studies are limited in their transethnic generalisability and by cross-sectional study designs. A later longitudinal observation of systemic data of mental symptoms in these groups supports the original findings [33] and begins to address these shortcomings, as does a growing body of clinical evidence from varied refugee ethnic groups.[9] 3. That immigration detention fails as a therapeutic environment and compounds trauma. Unsurprisingly, time spent in detention was found to be correlated with severity of psychological distress.[3,5,9] Kotsioni [1] notes that, due to structured suffering: “aid workers had to accept that their work was geared towards damage control…”

Repeated failures to meet objective standards of patient care have been exposed in the literature. Both Durham et al. [20] and Newman et al. [11] have reviewed individual cases of sub-standard care and governmental interference as documented in clinical reports, the Christmas Island Medical Officer’s Letter of Concerns [21] and in multiple commissions-of-inquiry.[22-27] These inquiry reports reinforce clinician observations, thus strengthening descriptive evidence with credible, quantitative analysis. Systematic analyses by Durham et al. [20] and Newman et al. [11] provide strong arguments for clinicians to focus on professional obligations in the face of antithetical government action. The health and wellbeing of detained asylum seekers and refugees

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The causal relationship between detention and ill-health has been widely demonstrated in the literature.[3,6,20,28-31] In an article published in the international Refugee Survey Quarterly, Kotsioni conducted a small qualitative study of doctors working with the humanitarian agency Médecins Sans Frontières (MSF) in immigration detention centres (IDCs) worldwide. From their observations, and her personal experiences as a field worker, she found that the major cause of morbidity in detained refugees and asylum-seekers was substandard detention conditions (including overcrowding, inadequate sanitation and lack of basic relief items) and barriers to medical treatment. Patterns of deteriorating mental health were also attributed to the psychological stress of the detention environment.[1]

...health professionals not only hold a moral responsibility to document actions that are antithetical to their professional values, but to also disseminate this information.

These issues are compounded in the setting of Australian offshore processing, where indefinite detention in poor conditions has serious and long-standing impacts on mental and psychosocial health. [5,9,12,32-34] Conducting clinical research, case studies and systemic reviews in this area, Australian psychiatrists and academics Louise Newman and Derrick Silove reach a number of common conclusions:

Evidence for detention as a causal factor for mental ill-health is not conclusive. Indeed, no study has been performed to evaluate the prevalence of mental illness in a detained population. This remains a fundamental weakness in the literature, and will likely remain so due to the unethical nature of an interventional study design. In studies that have been undertaken, access restrictions determine what can be learned about detainees’ mental and

1. That refugee and asylum-seekers are a uniquely vulnerable population with shared experiences of trauma, oppression and displacement. As such, they are at high risk of mental ill-health.[3,5,9] 19


act in their patients’ best interests, but also because the presence of healthcare services in immigration facilities provides a veneer of respectability that facilitates ethical abuses.[14] Both Essex [13] and Zion et al. [16] employ a similar method of observational review to describe perceived incidences of dual loyalty. This body of literature has originated from a subset of clinicians engaged in advocacy and whistle-blowing who draw on their experience of immigration detention. Thus, the position and reflexivity of contributors should be assessed, and an opportunity exists here for a study evaluating trends behind perceptions of medical ethics in those clinicians engaged in advocacy.

How can the Australian medical community encourage clinical advocacy and ethical practises amongst its clinicians? Such a call to advocacy is essential under a government persistently violating the health rights of a vulnerable population.

In evaluating ethical issues, the literature relies on bioethical or human rights frameworks,[13,14] as examined in Table 2, or else presents a discussion of how clinicians have personally approached and mitigated ethical tensions.[15,16] Coffey asserts that departure from the principles of beneficence and non-maleficence are only justifiable when in the service of an overriding public good, and only when this conduct preserves human rights.[14] Along with Sanggaran et al. [15] Coffey calls for the development of guidelines that specifically address the dilemmas of detention centres.

Ethical and moral challenges of offshore detention The futility of treating patients within a system designed to promote suffering as deterrence has been evidenced in observational literature.[14,15,19,20] The involvement of medical professionals in Australian immigration thus raises complex clinical and ethical issues that are most commonly conceptualised in notions of dual loyalty and complicity.

Briskman et al. [17] look to current statements from peak medical bodies for advice on ethical practice. While the clear directional guidelines desired by Sanggaran and Coffey are notably absent, every recommendation asserts the primacy of the physician-patient relationship above all other obligations,[36,38,39] including position statements from the Australian Medical Association [40] and the Royal Australian and New Zealand College of Psychiatrists.[41] The problem with these recommendations is that they often overlook the institutional power realities, something that specific guidelines may help to address.

Dual loyalty Dual loyalty describes circumstances in which the best interests of patients compete with other obligations, such as those to a third party or employer. [36] Such conflicts are regularly faced by clinicians working in Australian IDCs, where the expectations of IHMS and the immigration department do not always align with patient interests or with reasonable standards of patient care.[13-17] As the psychiatrist and former medical director of IHMS Peter Young told The Guardian in 2014: “…you can’t mitigate the harm, because the system is designed to create a negative mental state. It’s designed to produce suffering”.[37]

Complicity Less ubiquitously, this dual loyalty associated compromise has been described as complicity[8,30,42]; in this context, complicity is taken to mean the facilitation of systemic abuse via the actions of medical practitioners, whether directly or indirectly, in facilitating operation of IDCs. The literature examines the role of clinicians in IDCs and assesses their moral burden in facilitating systemic abuse and “torture”. Jansen et al. [8] draw striking parallels between the moral situation of medical doctors providing treatment in Australian OPCs and in Guantanamo Bay.

In his seminal article of dual loyalty in the Australian immigration context, Coffey [14] presents numerous examples of medical professionals navigating role tensions in everyday clinical practise. He uses clinician testimony from national community-of-inquiries [22-24] as well as his own and others’ personal experiences, to inform in-depth ethical analyses. He concludes that it may not be justifiable for doctors to work within immigration detention. Firstly, because they are often unable to 20

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physical health, and researchers are often limited by government blockades.[11,14] These limitations extend to commissions-of-inquiry, which are often of a non-judicial nature.[35] Both Newman and Silove, among others, consider the current evidence persuasive enough to call for the abolition of mandatory detention,[3,5,9] as well as for health professionals to advocate for the removal of vulnerable children and patients.[1,11,12] These issues of clinical ethics and advocacy as discussed in the literature are formally reviewed below.


Demands are also made for the unity and mobilisation of the medical profession in protest,[7,57] and there is some discussion guiding broader social and political reform.[19,20,58]

Both Essex [30] and Jansen et al. [8] employ Lepora and Goodin’s [43] framework of moral complicity to conclude that doctors have a moral case to answer if they choose to work in Australian immigration detention. The extent of individual clinician responsibility is dependent on personal engagement with wrongdoings of the DIBP. Briskman & Zion [42] point out that complicity is higher for clinicians who submit to a “culture of acceptance” than for those who actively engage in advocacy and subversion.[21]

Clinical independence The physician’s duty to act in their patients’ best interests founds a number of recommendations for clinical autonomy. Patient-centered care must be given supremacy over third-party obligations.[9,17] Further, medical professionals are encouraged to make clinical recommendations independently and with appropriate regard to equivalency of care - irrespective of what is ‘normal’ within the immigration detention environment.[13]

Normative tools of medical ethics and intersections of international human rights Discussions of refugee and asylum-seeker health are inseparably linked with international law, as the ‘right to health’ is codified in the Universal Declaration of Human Rights [44] and other international treaties. These legal instruments are used to support and inform theories of clinical ethics in public health literature, whilst more traditional codes focus on the basis of the ‘physician’s role’. Table 2 below examines normative tools of medical ethics and how they can be applied to immigration detention. In doing so, the evidence available for clinicians attempting to navigate and reconcile ethical dilemmas of Australian immigration policy is critically analysed.

Witnessing, documenting and research The role of clinicians in documenting the human rights abuses they have witnessed is both well-evidenced and highly demonstrated in the literature. Kotsioni [1] describes how MSF approaches t ́emoignage (witnessing) as a core ethical principle, identifying it as a political responsibility based in humanitarian principles. This ‘speaking out’ in the face of abuse has formed the major basis of physician activism in Australian immigration. [16,31,59,60] Both Silove et al. [5] and Newman [9] emphasise the importance of such research, and describe how observational evidence gathered in Australian immigration detention has been used to counter systemic government denials of care equivalency. Consistently, the literature calls for all ethical clinicians to “relentlessly report wrongdoing”. [8] Faunce [61] takes this a step further by including healthcare whistleblowing as a foundational part of medical ethics, thus centralising it as part of the physician’s duty.

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Discussion Any discussion of medical ethics customarily begins with the principles outlined in The Hippocratic Oath of the 4th century, which remains a source of professional inspiration to this day (Table 2). Most importantly are the embedded values of beneficence and non-maleficence, famously represented in the tenant of, ‘first, do no harm.’ These values, along with justice and patient autonomy, are represented in other codified forms of medical ethics, namely principlism [54] and virtue ethics.[55] The Nuremburg trials were a further galvanising force of normativity in bioethics, providing the forum for a consequential analysis of ethical standards. The resultant Nuremburg Code builds on the idea of a Hippocratic duty to inform clinical research ethics and forms the basis for all modern ethical codes and international human rights frameworks.[56]

Advocacy Doctors within the immigration system are encouraged to engage in acts of advocacy and subversion to reduce their moral complicity and resist injustice.[42] Advocacy is further extended to the public sphere, with a number of authors expanding the clinical contract to centralise social and political action.[8,58,61] They claim that health professionals not only hold a moral responsibility to document actions that are antithetical to their professional values, but to also disseminate this information.

How should clinicians be responding to ethical issues in Australian immigration policy?

... political action is an inherent part of public health and an appropriate response to injustices and abuses of power.

Grounded in these (Table 2) frameworks of clinical ethics, the literature primarily focuses on informing clinician individualism, using ethical discourses to recommend application of physician values.[16,42] 21


The origins of physicians’ values are interrogated in the seminal article by Franks & Hafferty [65] on the ‘hidden curriculum’ of medicine. The idea of medical ethics as pedagogy comes from post-holocaust bioethics, with its aim in preventing the recurrence of ethical injustices. The teaching of virtues at the core of medicine’s professional identity in medical schools is likely an important part of understanding moral obligations in advocacy. In examining ethics education in medical training, Franks & Hafferty [65] describe a process of moral enculturation in which medical schools function as moral communities. Ethics as held by individual physicians are held to be a combination of this learned knowledge and of fundamental elements of personal identity.

In his case study of Australian immigration in public health bioethics, McNeill [62] argues that political action is an inherent part of public health and an appropriate response to injustices and abuses of power. He shares concerns with Durham [20] over the Australian government’s sustained indifference to human suffering, describing its treatment of asylum-seekers as “a paradigm case for taking political action”.[62] Reviewing commissions-of-inquiry, professional accounts, and observational literature prior to 2003, he concludes that the acceptable public health measures of advocacy and disseminating information may not be enough and encourages more radical forms of non-violent action. In this, he joins Berger [7] and Isaacs [60] in their impassioned calls for civil disobedience and collective protest.

Two qualitative studies have explored the values basis for clinicians taking up advocacy roles, drawing a number of comparative conclusions. Most importantly, both Oandasan & Barker [66] and Gallagher & Little [67] highlight personal ideals and experiences (including those of the ‘hidden curriculum’) as being more important than professional obligations in shaping engagement in advocacy. Qualitative studies of this nature are not meant to be generalised, instead providing detailed insights into the subjective experiences of small subgroups (8 and 20 respectively). Nonetheless, a parallel may be observed in asylum-seeker advocacy, as the contribution to medical activism and to the literature comes overwhelmingly from medical professionals who have worked inside immigration detention.

The question of the boycott Sanggaran initially introduced the concept of a boycott in 2014.[15] Since then both Sanggaran [59] John-Paul and Isaacs [60] have engaged deeply with the issue, using past personal experiences as clinicians working in IDCs to inform their agreed opinion that a boycott is ethically necessary. In opposition, Jansen et al.[8] argue that the physician’s duty of care must have primacy over all other obligations: even over their duty to not be complicit in torture. They conclude that a boycott would be morally unconscionable. Along with Miles [63] and Essex,[64] Jansen et al.[8] dispute the feasibility of a professional boycott and instead call upon the AMA to take responsibility for a collective and cooperative response to inform action.

Conclusion How can the Australian medical community encourage clinical advocacy and ethical practises amongst its clinicians? Such a call to advocacy is essential under a government persistently violating the health rights of a vulnerable population. There is a notable paucity in the literature dealing with reasons for engaging in supraclinical advocacy; however, studies do report a lack of awareness amongst the profession that ethical codes express advocacy as part of the physician’s duty.[67] Introducing students to these ethical understandings during formative years at medical school may be key in producing doctors with a strong sense of professional obligation, and more research is called for in this area.

It is interesting to note that Essex, a major contributor to the literature, changes his stance on this issue over 3 years of publication. Whilst he initially concluded that “engagement with Australian immigration detention cannot be justified on balance”,[30] the amendments to the Border Force Act{Essex, 2018 #164} (2015) and a review of the arguments affected him to reconsider his position. In particular he noted concern over the unknowability of a boycott’s impacts on detainee health and concludes that whilst ethically untenable at the current time, the proposal of the boycott should not be discarded but kept in the clinical repertoire.[64]

Abbreviations AHRC Australian Human Rights Commission AMA Australian Medical Association DIBP Department of Immigration and Border Pro tection HREOC Human Rights and Equal Opportunity Com

Morals in medicine: Educating students in duty and advocacy 22

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Medical professional outside the immigration system are similarly encouraged to lead political discussions and publicly forefront asylum seekers’ right to health. Further, they are urged to engage and educate the public in order to change community-opinion and secure policy change.[8,20,58,62]


mission IDC Immigration Detention Centre IHMS International Health and Medical Services OPC Offshore processing centre RANZCP Royal Australian and New Zealand College of Physicians UN United Nations UNHCR United Nations High Commissioner for Ref ugees

ers: The Challenge for Humanitarian Actors. Refug Surv Q. 2016;35(2):41-55. 2. United Nations High Commissioner for Refugees. Global Trends: Forced Displacement in 2016. United Nations; 2017. 3. Newman LK, Dudley M, Steel Z. Asylum, Detention, and Mental Health in Australia. Refug Surv Q. 2008;27(3):11027. 4. McPherson E. Asylum seeker diagnosed with cancer after spending almost 10 years detention. 9News; 2019. 5. Silove D, Austin P, Steel Z. No Refuge from Terror: The Impact of Detention on the Mental Health of Trauma-affected Refugees Seeking Asylum in Australia. Transcult Psychiatry. 2007;44(3):359-93. 6. Isaacs D. Are healthcare professionals working in Australia’s immigration detention centres condoning torture? J Med Ethics. 2016;42(7):413-5. 7. Berger D. Australia’s torture of asylum seekers. BMJ. 2016;354:i4606. 8. Jansen M, Tin AS, Isaacs D. Prolonged immigration detention, complicity and boycotts. J Med Ethics. 2018;44(2):138. 9. Newman L. Seeking Asylum—Trauma, Mental Health, and Human Rights: An Australian Perspective. J Trauma Dissociation. 2013;14(2):213-23. 10. Australian Parliamentary Joint Select Committee. Australia’s Immigration Detention Network: Final Report. Canberra: Australian Government; 2012. 11. Newman L, Proctor N, Dudley M. Seeking asylum in Australia: immigration detention, human rights and mental health care. Australas Psychiatry. 2013;21(4):315-20. 12. Silove D. The asylum debacle in Australia: a challenge for psychiatry. Aust N Z J Psychiatry. 2002;36(3):290-6. 13. Essex R. Human rights, dual loyalties, and clinical independence : challenges facing mental health professionals working in Australia’s immigration detention network. J Bioeth Inq. 2014;11(1):75-83. 14. Coffey G. ‘Locked Up Without Guilt or Sin’: The Ethics of Mental Health Service Delivery in Immigration Detention. Psychiatr Psychol Law. 2006;13(1):67-90. 15. Sanggaran JP, Ferguson GM, Haire BG. Ethical challenges for doctors working in immigration detention. Med J Aust. 2014;201(7):377-8. 16. Zion D, Briskman L, Loff B. Psychiatric ethics and a politics of compassion. J Bioeth Inq. 2012;9(1):67-75. 17. Briskman L, Zion D, Loff B. Care or Collusion in Asylum Seeker Detention. Ethics Soc Welfare. 2012;6(1):37-55. 18. McDougall R. Reviewing Literature in Bioethics Research: Increasing Rigour in Non-Systematic Reviews. Bioethics. 2015;29(7):523-8. 19. Essex R. Australian Immigration Detention: How Should Clinicians Respond? [PhD thesis]. In press: 2018. 20. Durham J, Brolan CE, Lui CW, Whittaker M. The need for a rights-based public health approach to Australian asylum seeker health. Public Health Rev. 2016;37:24. 21. Christmas Island Medical Officer’s Letter of Concerns. Letter of Concern: International Health and Medical Services. 2013.

Asylum-seekers and refugees: An asylum seeker is someone

who has fled their country and applied for protection as a refugee.[68] A refugee is an individual who has had their claim processed and been granted refugee status in accordance with the 1951 UN Refugee Convention.[69] Herein, ‘asylum seeker’ is used as a collective term to describe all individuals in Australian immigration detention, along with ‘detainees’ and ‘patients’.

Immigration detention: Defined as in the 2012 United Nations

Detention Guidelines as “the deprivation of liberty or confinement in a closed place which an asylum-seeker is not permitted to leave at will, including, though not limited to, prisons or purpose-built detention, closed reception or holding centres or facilities”.[70]

Offshore processing: The practise of detaining asylum-seekers

in a country other than the one in which they have sought asylum. Unique to Australia, ‘third country’ processing was first introduced in 2001 and later re-established in 2012.[71]

Operation Sovereign Borders: The 2013 government policy that all asylum seeker boats are turned back to their port-of-origin by the Australian Navy. Any individual who does reach Australia by sea without a valid visa is incarcerated in offshore detention centres on Nauru or Manus Island (Papua New Guinea).[71]

Border Force Act (2015): Passed with bipartisan support

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on July 1st, 2015, this act made the disclosure of information obtained whilst working in Australian immigration detention punishable by up to 2 years of imprisonment. Pressure from the medical community and legal organisations meant that by September 2016 the Act was amended to exempt clinicians from these secrecy provisions. Rohanna Stoddart is a fourth year medical student and the Crossing Borders Coordinator for UNSW, Sydney. She is also an administrator in the teleconference assessment team for the Medical Evacuation Response Group, transferring patients off Nauru and Manus island under the new Medevac legislation. Conflicts of Interest None declared Correspondence rohanna.stoddart@outlook.com References 1.

Kotsioni I. Detention of Migrants and Asylum-Seek23


41. Royal Australian and New Zealand College of Psychiatrists. Professional Practice Guideline 12: Guidance for psychiatrists working in Australian immigration detention centres. 2016. 42. Briskman L, Zion D. Dual Loyalties and Impossible Dilemmas: Health care in Immigration Detention. Public Health Ethics. 2014;7(3):277-86. 43. Lepora C, Goodin RE. On complicity and compromise: Oxford University Press; 2013. 44. United Nations General Assembly. Universal declaration of human rights. United Nations; 1948. 45. Edelstein L. The Hippocratic Oath: Text, Translation, and Interpretation. Baltimore: Johns Hopkins Press; 1943. 46. World Medical Association. Declaration of Geneva. World Medical Association; 1948. 47. World Medical Association. WMA Declaration of Helsinki - Ethical Principles for Medical Research involving Human Subjects. World Medical Association; 1964. 48. Australian Medical Association. AMA Code of Ethics 2004. Canberra: Australian Medical Association; 2004 49. United Nations General Assembly. International Covenant on Civil and Political Rights. United Nations; 1966. 50. United Nations General Assembly. Principles of medical ethics relevant to the role of health personnel, particularly physicians, in the protection of prisoners and detainees against torture and other cruel, inhuman or degrading treatment or punishment. United Nations; 1982. 51. United Nations General Assembly. Optional Protocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. United Nations; 2002. 52. Australian Health Practitioner Regulation Agency. Health Practitioner Regulation National Law Act 2009. Canberra: Australian Health Practitioner Regulation Agency; 2009. 53. United Nations Educational Scientific and Cultural Organisation. Universal Declaration on Bioethics and Human Rights. 3rd General Conference of UNESCO. Paris: UNESCO; 2005. 54. Beauchamp T, Childress J. Principles of Biomedical Ethics. Fifth Edition ed. New York: Oxford University Press; 2001. 55. MacIntyre A. After virtue: A study in moral theology: University of Notre Dame Press; 1981. 56. Annas GJ, Grodin MA. The Nazi Doctors and the Nuremberg Code : Human Rights in Human Experimentation: Human Rights in Human Experimentation. USA: Oxford University Press; 1992. 57. Isaacs D. Nauru and detention of children. J Paediatr Child Health. 2015;51(4):353-4. 58. Caldicott DG, Isbister J, Das R, Isbister GK. Medical activism, refugees, and Australia (The land of the ‘fair go’). Emerg Med Australas. 2003;15(2):176-82. 59. Sanggaran J-P, Haire B, Zion D. The Health Care Consequences Of Australian Immigration Policies. PLOS Med. 2016;13(2):e1001960. 60. Isaacs D. Doctors should boycott working in Australia’s immigration centres and must continue to speak out on mistreatment of detainees--despite the law. BMJ. 2015;350:h3269. 61. Faunce T. Developing and teaching the virtue-ethics 24

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22. Palmer N. Inquiry into the Circumstances of the Immigration Detention of Cornelia Rau: July, 2005. Canberra: Parliament of Australia; 2005. 23. Human Rights and Equal Opportunity Commission. Those who’ve come across the seas: detention of unauthorised arrivals. Sydney: Australian Human Rights Commission; 1998. 24. Human Rights and Equal Opportunity Commission. A Last Resort? National Inquiry into Children in Immigration Detention. Sydney: Australian Human Rights Commission; 2004. 25. Australian Human Rights Commission. The Forgotten Children: National Inquiry into Children in Immigration Detention. Sydney: Australian Human Rights Commission; 2014. 26. Australian Human Rights Commission. Immigration detention and human rights. Sydney: Australian Human Rights Commission; 2012. 27. Australian Human Rights Commission. Human rights standards for immigration detention. Sydney: Australian Human Rights Commission; 2013. 28. Essex R, Isaacs D. The Ethics of Discharging Asylum Seekers to Harm: A Case From Australia. J Bioeth Inq. 2018;15(1):39-44. 29. Essex R. Torture, healthcare and Australian immigration detention. J Med Ethics. 2016;42(7):418-9. 30. Essex R. Healthcare and complicity in Australian immigration detention. Monash Bioeth Rev. 2016;34(2):136-47. 31. Essex R. Healthcare and clinical ethics in Australian offshore immigration detention. Int J Human Rights. 2016;20(7):1039-53. 32. Momartin S, Steel Z, Coello M, Aroche J, Silove DM, Brooks R. A comparison of the mental health of refugees with temporary versus permanent protection visas. Med J Aust. 2006;185(7):357-61. 33. Steel Z, Momartin S, Silove D, Coello M, Aroche J, Tay KW. Two year psychosocial and mental health outcomes for refugees subjected to restrictive or supportive immigration policies. Soc Sci Med. 2011;72(7):1149-56. 34. Steel Z, Silove D, Brooks R, Momartin S, Alzuhairi B, Susljik I. Impact of immigration detention and temporary protection on the mental health of refugees. Brit J Psychiatr. 2006;188:58-64. 35. Once over lightly: the Palmer inquiry into Cornelia Rau’s detention. The Sydney Morning Herald National, 2005. 36. Physicians for Human Rights. Dual loyalty and human rights in health professional practice; Proposed guidelines & institutional mechanisms. 2002. 37. Marr D, Laughland O. Australia’s detention regime sets out to make asylum seekers suffer, says chief immigration psychiatrist. The Guardian, 2014. 38. Medical Board of Australia. Good Medical Practice: A Code of Conduct for Doctors in Australia. Melbourne: Medical Board of Australia; 2014. 39. World Medical Association. WMA International Code of Medical Ethics. World Medical Association; 2006. 40. Australian Medical Association. Position Statement on Health Care of Asylum Seekers and Refugees 2011. Revised 2015. Canberra: Australian Medical Association; 2015.


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foundations of healthcare whistle blowing. Monash Bioeth Rev. 2004;23(4):41-55. 62. McNeill PM. Public health ethics: Asylum seekers and the case for political action. Bioethics. 2003;17(5-6):487-502. 63. Berger D, Miles SH. Should doctors boycott working in Australiaâ&#x20AC;&#x2122;s immigration detention centres? BMJ. 2016;352:i1600. 64. Essex R. Should clinicians boycott Australian immigration detention? J Med Ethics. 2019;45:79-83. 65. Franks R, Hafferty FW. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69(11):861-71. 66. Oandasan I, Barker K. Educating for Advocacy: Exploring the Source and Substance of Community-Responsive Physicians. Acad Med. 2003;78:S16-9. 67. Gallagher S, Little M. Doctors on Values and Advocacy: A Qualitative and Evaluative Study. J Health Care Anal. 2017;25(4):370-85. 68. Australian Human Rights Commission. Asylum seekers and refugees guide. Sydney: Australian Human Rights Commission; 2015. 69. United Nations General Assembly. Convention relating to the Status of Refugees United Nations; 1951. 70. United Nations High Commissioner for Refugees. Guidelines on the Applicable Criteria and Standards relating to the Detention of Asylum-Seekers and Alternatives to Detention. United Nations; 2012. 71. Kaldor Centre. Australiaâ&#x20AC;&#x2122;s Refugee Policy: An Overview. Sydney: Kaldor Centre for International Refugee Law; 2018.

25


International

WMA: World Medical Association

International

WMA: World Medical Association

International Adopted by AMA

WMA: World Medical Association

Not applicable

Hippocrates of Kos

Jurisdiction

… provide competent medical service in full professional and moral independence, with compassion and respect for human dignity.[39]

A physician shall act in the patient’s best interest…and

4. to promote and safeguard the health, well-being and rights of patients.[47]

3. to act in the patients’ best interests, and

Ethical guidelines specific to medical research, that still holds general principles of the “duty of the physician”:

I will not use my medical knowledge to violate human rights and civil liberties.[46]

The health and well-being of my patient will be my first consideration.

I will come for the benefit of the sick, remaining free of all intentional injustice.[45]

Relevant recommendations

Not mentioned

Yes, over any other national or international law or requirement.

Yes2

Not applicable

Are doctors obligated to uphold human rights?*

No

Not in classical version

Does it address medical advocacy?*

No

High: international document

No

No

High: international Yes document Refer to Guideline 4.

No

High: international document

No

Voluntary traditional pledge

Is it enforceable?*

Strength of recommendation*

2

The right to health has been defined as “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” at the United Nations General Assembly [49]

*

1

When there are multiple revisions by an issuing body or assembly, the original date and the date of the most recent revision, this latter bracketed, are noted. The assessment columns are included to evaluate the strength, applicability and usefulness of these normative tools for clinicians attempting to navigate Australian immigration policy.

Ethics

Code of Medical

International

ration of Helsinki

Decla-

Declaration of Geneva

Hippocratic Oath

Normative tool

Issuing body

Table 2. Normative tools that can apply to medical ethics in Australian offshore detention

No

No

No

No

tion?*

tion deten-

Does it address immigra-


Australia

AMA: Australian Medical Association

Australia

MBA: Medical Board of Australia

International

4.2.5 Contemporary protections for whistleblowers should be supported by doctors.[48]

4.2.3 Recognise your right to refuse to carry out services which you consider to be professionally unethical, against your moral convictions… or which you consider are not in the best interests of the patient.

4.2.2 Refrain from entering into any contract… which you consider may conflict with your professional autonomy, clinical independence or your primary obligation to the patient.

4.2.1 Uphold professional autonomy and clinical independence and advocate… [for this] in the treatment of patients without undue influence by individuals, governments or third parties.

2.1.1 Consider first the well-being of the patient.

1.4 Doctors have a responsibility to protect and promote the health of individuals and the community.[46]

1.4 Doctors have a duty to make the care of patients their first concern.

4.6.3 Do not countenance, condone or participate in the practice of torture or other forms of cruel, inhuman or degrading procedures.

Yes 3

Doctors are encouraged to respect human rights, but legislative law takes precedence over the code.

Principle 2. Physicians cannot, “engage, actively or passively, in acts which constitute participation in, complicity Yes in, incitement to or attempts to commit torture or other cruel, inhuman or degrading treatment or punishment”.[50]

No, but misconduct can result in reprimand or deregistration by the Medical Board of Australia.

High: formal discourse that is, “strongly recommended to all doctors…”

Yes, misconduct can result in reprimand or deregistration by the Medical Board of Australia.4

High - formal code

Yes, under human rights treaties.3

International human rights law

Refer to: 4.2.1 re. advocating for clinical independence 4.2.3 re. boycotting, and both 4.2.5, as well as AMA position policy [40] Article 16 re. whistleblowing

Yes

Refer to 5.3 on health advocacy.

Yes

Not explicitly mentioned.

3

4

Doctors engaging in professional misconduct are subject to investigation by a national board under the Health Practitioner Regulation National Law Act.[52]

The Australian Government ratified the United Nations General Assembly [51]’s Optional Protocol to the Convention against Torture (OPCAT) on 15 December 2017.

Ethics

AMA Code of

duct for Doctors in Australia

A Code of Con-

Medical Practice:

Good

United Nations Principles of Medical Ethics

Office of the High Commissioner of Human Rights

Yes Refer to:

No

Yes Refer to Principle 1


Universal Declaration on Bioethics and Human Rights

Practice

Professional

Loyalty and Human Rights in Health

Dual

International

UNESCO: United Nations Educational, Scientific and Cultural Organisation

International

Physicians for Human Rights

18.3 Opportunities for informed pluralistic public debate, seeking the expression of all relevant opinions, should be promoted.[53]

18.2 Persons and professionals concerned and society as a whole should be engaged in dialogue on a regular basis.

3.1 Human dignity, human rights and fundamental freedoms are to be fully respected.

Cites all international human rights instruments of the United Nations.

Yes

3.9. …should take all possible steps to resist state demands to participation in a violation of the human rights of Refer to guidelines 1, 3, 5, 7, 9, patients. 10, 11, 12 and 13. 5.7.2. Advocacy to change laws and regulations that prevent or impede health professionals from meeting their human rights obligations to patients.[36]

3.3. …must place the protection of the patient’s human rights and well-being first whenever there exists a conflict Yes between the patient’s human rights and the state’s interests.

Health professionals:

No

High: non-binding international legal instrument

No

Medium: proposed guidelines from a semi-formal source.

Refer to articles 18 and 22.1

Yes

Yes. Refer to: 5.7 Collective action by the Professions

Implicit in articles 10, 11 and 28

Refer to: 4 (B) Guidelines on Health Care for Refugees and Immigrants

Yes.

AMSA Journal of Global Health

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Climate change, demographics, water, food, energy, global health, womenâ&#x20AC;&#x2122;s empowerment - these issues are all intertwined. We cannot look at one strand in isolation. Instead, we must examine how these strands are woven together.

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Ban Ki-moon

29


AMSA Journal of Global Health

Abstract Aims: Years of political mismanagement and economic decline in Venezuela has escalated to a complex humanitarian crisis, with disastrous consequences on health. This literature review provides a summary of the health impacts of this crisis and responses from international health organisations. Methods: A search was conducted on PubMed and Google Scholar using the terms “Venezuela” AND “health” AND “crisis”. A grey literature search was also performed. Articles were assessed on their relevance to the review question regarding health outcomes in Venezuela and/or neighbouring countries. Results:The collapse of the Venezuelan health system has had multiple severe consequences. Problems exist with water supply and food security, and rates of malnutrition and infant mortality have risen. Infant mortality, which was decreasing up until 2009, has risen back to levels comparable to the 1990s. Vaccine-preventable and vector-borne diseases have both increased. National shortages in medicines such as antiretrovirals have left many without treatment. Mass migration and poorer health status has caused strain on health systems of neighbouring countries. International responses have been obstructed by political disagreements and the blockade of humanitarian aid.

VENEZUELA’S PUBLIC HEALTH CRISIS

Conclusions: The collapse of the Venezuelan health system has caused a humanitarian crisis. The international community, including the United Nations, needs to continue to pressure Venezuela to allow aid organisations to enter the country. Multi-national coordination, with support from the World Health Organisation, is needed to address complex flow-on effects of the health crisis on neighbouring countries.

National and regional implications Caroline Lee

30


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E

scalating political tension, civil unrest, and widespread unmet humanitarian needs have brought the crisis in Venezuela to the forefront of global attention. As of November 2018, 3 million refugees and migrants had fled Venezuela due to the economic and political crisis.[1] Reasons for this mass exodus include ongoing threats of violence and inability to access medical care.[1] A confidential United Nations (UN) report circulated to media in March 2019 estimated 7 million people were in need of humanitarian assistance.[1] Indeed, the crisis has evolved into a complex humanitarian emergency,[1,2] defined by the Inter-Agency Standing Committee as “a humanitarian crisis in a country, region or society where there is total or considerable breakdown of authority resulting from internal or external conflict and which requires an international response that goes beyond the mandate or capacity of any single and/or ongoing UN country programme”.[3]

Basic living and hygiene standards, nutrition, infant and maternal mortality, infectious diseases and access to medications have all been severely compromised. Infant mortality has increased to levels approximating those in the 1990s.[5] Medication shortfalls have left people living with HIV without anti-retroviral therapy [10] and cancer patients without chemotherapy drugs.[11] Hospitals lack even basic supplies such as sutures and x-rays,[12] and interruptions in power and water supply have put patient lives at risk.[13] This literature review provides a general summary of the health impacts of the political and economic crisis in Venezuela and responses from international health organisations as documented by scientific articles and reports from international organisations.

Venezuela was once a regional leader in Latin America renowned for its socioeconomic development and progress in health outcomes. Infant mortality was successfully reduced from 108 per 1000 in 1950 to 18 in 2000.[4,5] However, severe economic decline precipitated by falling oil prices, government mismanagement and international sanctions, has crippled the health system and reversed such health gains. The annual percent change in gross domestic product (GDP) is -25% as of 2019, and the inflation rate has spiked from 254% in 2016 to 10 million per cent in 2019.[6] Public spending on the health system dropped from 5.8% of annual government expenditure in 2010 to 0.1% in 2014.[7] Severe

Methods A search was conducted on PubMed and Google Scholar using the terms “Venezuela” AND “health” AND “crisis”, limiting to articles published since 2008 and in English language. A grey literature search was performed, including reports from international bodies and non-government organisations. Due to the limited number of research studies on this topic, inclusion criteria were intentionally broad. Article types included were quantitative studies as well as literature reviews, commentaries and editorials, based on relevance to the review question regarding health outcomes in Venezuela and/or neighbouring countries, secondary to health, economic and political issues.

Venezuela was once a regional leader in Latin America renowned for its socioeconomic development and progress in health outcomes.

Findings Water, sanitation and nutrition

underfunding of the health system has resulted in the deterioration of public health programs, access to basic medical supplies and the health workforce. Students and health professionals are leaving the country for better opportunities, with a medical professor earning less than $10 USD per month.[8]

Water and sanitation issues in Venezuela have been aggravated by the crisis. Water and electricity, provided predominantly by the Guri hydroelectric dam, have been rationed since 2016 following a severe El Nino drought.[13] In 2018, around 28.5 million people (82% of the population) did not have continuous water supply.[14,15] By region, water distribution is inequitable, as the majority of the population live in the north of the country, only receiving 15% of the water supply.[13] Domestic water shortages have forced residents to store water in their homes, putting them at risk of unsafe consumption and creating an environment for waterborne and vec-

Deleterious effects on health from Venezuela’s economic and political crisis have been severe and numerous. No official health statistics have been published by the Ministry of Health since 2016,[7,9] compromising the ability to accurately capture the extent of these health implications. However, alter32

AMSA Journal of Global Health

nate sources – including reports from international organisations, academic institutes, and non-government organisations – highlight declines in health outcomes across the country.

Introduction


tor-borne diseases.[13] Health facilities have also been affected, with 75% having interrupted or no water supply.[14] Electricity failures caused 79 patient deaths in 40 main hospitals between November 2018 and February 2019.[16]

and migrants. This represents a significant deterioration in health capacity, as Venezuela was once praised for its strong prevention and control of tuberculosis,[19] and was the first country recognised by the World Health Organisation (WHO) as having eliminated malaria in the majority of the country.[8]

Food insecurity is a major concern in Venezuela, affecting 80% of households.[2,17] This has drastic consequences on child malnutrition, where children from vulnerable households are affected first. Increases in children hospitalised for acute malnutrition have been reported across the country, as well as alarming increases in mortality.[2] The food crisis is driven by the failing economy, which has resulted in food being scarce and unaffordable. For example, a dozen eggs was reported to cost the equivalent of 2 weeks wages in 2018.[2] Around 90% of households reported lacking sufficient funds to purchase food, and 60% went to bed hungry.[2,17] Protein consumption has reduced, reflecting poorer general nutrition.[2]

Spikes in vaccine-preventable diseases have occurred in Venezuela, in part due to lack of health infrastructure, vaccine shortages and cessation of public health programmes, ultimately stemming from political and economic instability. Not a single case of diphtheria had been reported in Venezuela for 24 years prior to 2016.[18] Outbreaks of diphtheria have been reported since 2016 and, to date, a total of 2,726 cases and 280 deaths have been reported.[20] The case-fatality rate has risen from 18% in 2016 to 26% in 2019.[20]

Basic living and hygiene standards, nutrition, infant and maternal mortality, infectious diseases, and access to medications have all been severely compromised... hospitals lack even basic supplies such as sutures and x-rays.

Infant mortality

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Although official data on infant mortality has been suppressed since 2013,[7] GarcĂ­a and colleagues undertook a study using direct and indirect methods to estimate infant mortality trends from 1985 to 2016. Their findings raised significant concern: declines in infant mortality from the late 20th century ceased in 2009, followed by a new rise to 21.1 deaths per 1000 live births (90% CI 17.8 â&#x20AC;&#x201C; 24.3), around 1.4 times higher than 2008.[5] Published data on leading causes of child mortality is limited; however, likely contributing causes include malnutrition and infectious diseases, including diarrheal illness and vaccine-preventable diseases, well-recognised common causes of child mortality in crisis zones. Acute child malnutrition rose from 3% in 2014 to over 15% in 2017, with more than 280,000 children at risk of death from malnutrition.[2] Incidence and mortality from childhood vaccine-preventable diseases including measles and diphtheria have also risen in recent years.[18]

Measles had previously been controlled since 2007 due to mass vaccination campaigns but re-emerged in 2017.[18] A total of 9,585 suspected cases of measles, including 6,534 confirmed cases and 76 deaths, according to a Pan American Health Organisation (PAHO) report published in April 2019.[21] Of particular concern is the disproportionate incidence of measles cases amongst Indigenous populations in Venezuela, including native communities in the remote Amazon, who are particularly vulnerable due to low vaccination coverage and difficulties in humanitarian aid access to these remote areas. [18] Beyond national borders, cases of measles and diphtheria in Brazil, Colombia and Ecuador have been connected to the large-scale migration of Venezuelan nationals.[19] Vaccines for polio, diphtheria, tetanus, pertussis, hepatitis B and Haemophilus influenza type b were not provided to children under 5 years by the Venezuelan Ministry of Health in 2007-2009, and approximately 20% of children were not vaccinated for these diseases in 2010.[22] Concern has been raised about the risk of possible re-emergence of polio due to incomplete vaccination coverage.[18]

Infectious diseases The collapse of the health system has led to increases in vaccine-preventable diseases, vector-borne diseases and poorer outcomes for people living with HIV. The incidence of tuberculosis rose from 6,000 in 2014 to over 13,000 in 2017, and an estimated 9 out of 10 people living with HIV did not have access to antiretroviral therapy (ART), resulting in large numbers of people forced to interrupt treatment.[10] Notably, this also has consequences for neighbouring countries such as Colombia and Peru, who receive a high intake of Venezuelan refugees

Vector-borne diseases have risen in incidence and geographic distribution. The incidence of malaria 33


led people to store water in their homes, with these stagnant bodies becoming breeding reservoirs for Aedes aegypti mosquitoes.[8] Insufficient public health communication, preparedness, surveillance, and health infrastructure have left Venezuela with little defence against outbreaks of vaccine-preventable and vector borne diseases. People living with HIV in Venezuela have been particularly affected by the health crisis. In 2016, it was estimated that 120,000 people with HIV infection were living in Venezuela; however, only 59% (71,210 people) were receiving ART.[24] Levels of virological suppression were poor, with only 7% having a suppressed viral load.[24] Since then, access to ART has plummeted even further due to lack of health funding and poor management. Complete interruptions in treatment access in 2017 and 2018 left over 79,000 people with HIV without ART, with a rise in deaths from 1800 in 2014 to over 5000 in 2018. [24] Increases in mother-to-child transmission are likely, with only 48% of women living with HIV able to access ART, an essential component of preventing mother-to-child transmission (PMTCT). [19] National shortages of several commonly-used ART medications, including those used for PMTCT, have been reported.[25] Other shortages affecting people with HIV include limitations in diagnostics, condoms to prevent sexual transmission and treatment for opportunistic infections.[26] Treatment interruptions, as well as being detrimental for patients’ health, contribute to ART resistance, the emergence of an illegal market for medications and people making risky journeys across the Colombian border in an attempt to access medication.[24,25]

As well as internal changes in malaria endemicity, there have been increasing cases reported in the bordering regions of Brazil and Colombia, threatening the malaria control efforts and successes in those countries to date.[8] Of 3395 cases of malaria

The collapse of the health system has led to increases in vaccine-preventable diseases, vector-borne diseases and poorer outcomes for people living with HIV. in Colombia originating from other countries from 2016 to 2018, 92% were from Venezuela.[23] ‘Spillover’ of Venezuela’s malaria epidemic into these bordering countries has become justifiably feared. [8,19,23]

Mass displacement of Venezuelan refugees and migrants to surrounding nations has increased the numbers of people in those countries with HIV infection, with consequences for already-strained health systems. In Colombia in 2018, there were 135 new cases of HIV imported from other countries, with approximately 90% from Venezuelan nationals.[24] Mass immigration of Venezuelans to Peru beginning in 2014 and rising steeply in 2018 has put increased financial strain on the National Ministry of Health in Peru, which provides ART free of cost to all patients.[26] As of 2018, 720 immigrant patients with HIV were receiving ART, most (76%) living in the metropolitan capital region around Lima.[26] As migrants, Venezuelan nationals living in other countries are vulnerable to poorer HIV outcomes due to factors such as previous treatment interruptions necessitating second or third-line therapies, co-morbidities such as malnutrition or other disease co-infections, late diagnosis and lack of social support.[26]

Other vector-borne diseases have also risen in prevalence. Transmission of Chagas disease, caused by parasite Trypanosoma cruzi has been increasing in Venezuela and seroprevalence is concerningly high at 12.5% amongst children under 10 years old.[8] In 1990 to 1998, seroprevalence was only 0.5% in this age group.[8] A study by Grillet et al. reported overall seroprevalence in 2016 to be 4.3%, and as high as 12.5% in one community (n = 64).[8] A 2019 outbreak of Chagas disease in Tachira State, Venezuela infected 40 people and caused 8 deaths.[8] Dengue, chikungunya and Zika viruses, all transmitted by Aedes aegypti mosquitoes, have also been increasing in incidence between 1990 and 2016.[8] At present, seroprevalence of Zika virus (IgG) – well recognised to cause birth defects such as microcephaly – is approximately 80%.[8] Increased crowding and interruptions in water supply and electricity have 34

AMSA Journal of Global Health

cases rose by 359% from 2000 to 2015, with 411,586 cases reported in 2017.[8] Across the region, malaria incidence and deaths had been decreasing until 2016. Venezuela accounted for 240,600 cases of malaria in 2016 but 411,600 in 2017.[8] Plasmodium vivax causes 71% of malaria reported in Venezuela, with Plasmodium falciparum and Plasmodium malariae also detected.[8] Part of the reason for this change has been migration to regional areas for illegal mining and forest exploitation, driven by economic insecurity in the country. People who have migrated for this work are exposed to mosquito bites; upon returning to their home regions, they then reintroduce malaria to areas in which it had been previously eliminated.[8] This has been exacerbated by shortages in malaria insecticides, bed nets and medications such as primaquine and chloroquine, stemming from the dysfunction of the health system.[8]


The international community has responded by providing humanitarian assistance, including $9.2 million USD...

Response to the Venezuelan health crisis

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June 2019

Political, humanitarian and health-specific responses have been taken by the international community in response to the crisis in Venezuela. In September 2018, the UN Human Rights Council adopted a resolution affirming the gravity of the humanitarian situation in Venezuela, particularly malnutrition and preventable infectious diseases.[24] However, efforts to pass resolutions in the UN Security Council have been hampered by diplomatic disagreements between the USA, Russia and China, particularly surrounding the recognition of Juan Guiado, the National Assembly leader who claimed interim presidency in January 2019. The government has blamed food shortages on United States-imposed sanctions despite the humanitarian crisis preceding such sanctions.[10] The Lima Group – consisting of 14 countries, mostly Latin American countries as well as Canada, have united in calling on the United Nations to act urgently to prevent further escalation of the humanitarian crisis.[27]

ease prevention and control, and improved disaster management and procurement of medicines, vaccines and other health supplies”. Further, PAHO has been instrumental in facilitating access to medical supplies through pooled procurement mechanisms such as the PAHO Strategic Fund for essential medicines and the PAHO Revolving Fund for vaccine procurement.[31] However, additional emergency funds may be necessary in addition to regular funding for medical supplies, due to the huge scale of the situation. PAHO has also supported health officials in countries neighbouring Venezuela, namely Brazil, Colombia, Ecuador, Guyana, Peru, and Trinadad and Tobago, to assist with the large-scale immigration resulting from the Venezuelan crisis.[31] Local urgent health priorities are numerous, but include addressing food and medicine shortages, strengthening infectious disease surveillance programs, and implementing mass- and routine immunisation campaigns.[18] PAHO/WHO have stressed the importance of vaccination and strong surveillance systems to prevent disease outbreaks.[20]

The international community has responded by providing humanitarian assistance, including $9.2 million USD raised through the United Nations Central Emergency Respond Fund (CERF) in 2018. [28] Additionally, $24.1 million USD in humanitarian aid was provided in 2018, and this has increased to $80.4 million USD as of May 2019.[29] The largest donors are the European Commission (68.1%), followed by Norway (9.1%), Switzerland (8.4%) and Denmark (6.3%).[29] The largest recipient of humanitarian assistance is PAHO ($7.1 million USD, 31.1% of total funding), as well as UNICEF (19.5%) and UNHCR (9.8%). Human Rights Watch (HRW) has called on the United Nations to lead a comprehensive humanitarian response in Venezuela to address immediate humanitarian needs.[10] Furthermore, it called on the UN Secretary General António Gutteres to declare that Venezuela is facing a “complex emergency”, a diplomatic term used to urgently mobilise resources. Additionally, the HRW has asked for the WHO to collaborate with the UN in supporting the health response, and the Venezuelan government to publish all available epidemiological data and allow humanitarian access into the country.[10] In May 2019, Amnesty International called for further response from the international justice system, including the UNHCR and the International Criminal Court, for crimes against humanity.[30]

Strengths and limitations The major strength of this study is the synthesis of multiple different studies, timeframes and approaches into a general assessment of the impact of the crisis. However, limitations include a broad search strategy, use of various secondary sources in the absence of primary sources and inclusion of various article types including correspondence and editorials. Conclusion The collapse of Venezuela’s health system is a humanitarian crisis precipitated by economic and political factors, with far-reaching impacts on the health of its nationals as well as neighbouring countries. This review identified and summarised a range of health implications using various published and grey literature sources - a useful strategy given the absence of published data from the Ministry of Health. Whilst the political crisis continues, the situation necessitates urgent international attention. This includes commitment of sufficient humanitarian aid to meet immediate health needs, access into the country to enable a comprehensive assessment that can guide the humanitarian response, and maintaining international politi-

PAHO, a regional division of the WHO, has had a significant role in coordinating with the Ministry of Health of Venezuela regarding its health crisis. This includes “management of health systems, improved communicable and non-communicable dis35


Provea; 2018. Available from: https://www.derechos.org.ve/ . 16. Venezuelans’ right to health crumbles amid political crisis. Lancet. 2019;393(10177):1177. 17. Espana LP, MG. Encuesta Nacional de Condiciones de Vida (ENCOVI). Caracas: Universidad Catolica Andres Bello; 2017. 18. Paniz-Mondolfi AE, Tami A, Grillet ME, Márquez M, Hernández-Villena J, Escalona-Rodríguez MA, et al. Resurgence of Vaccine-Preventable Diseases in Venezuela as a Regional Public Health Threat in the Americas. Emerg Infect Dis. 2019;25(4):625-32. 19. Huber C, Petrasek K, Yong JHE, Acosta H, Bhatia D, Thomas-Bachli A, et al. Infectious disease implications of large-scale migration of Venezuelan nationals. J Travel Med. 2018;25(1). 20. Pan American Health Organisation/World Health Organisation. Epidemiological Update: Diphtheria. Washington: PAHO/WHO; 2019. 21. Pan American Health Organisation/World Health Organisation. Epidemiological Update: Measles. Washington: PAHO/WHO; 2019. 22. Venezuelan Education-Action Program on Human Rights, Coalition of Organizations for the Right to Health and Life. The right to health in Venezuela. PROVEA/CODEVIDA; 2015. 23. Rodríguez-Morales AJ, Suárez JA, Risquez A, Villamil-Gómez WE, Paniz-Mondolfi A. Consequences of Venezuela’s massive migration crisis on imported malaria in Colombia, 2016–2018. Travel Med Infect Dis. 2019;28:98-9. 24. Rodríguez-Morales AJ, Bonilla-Aldana DK, Morales M, Suárez JA, Martínez-Buitrago E. Migration crisis in Venezuela and its impact on HIV in other countries: the case of Colombia. Ann Clin Microbiol Antimicrob. 2019;18(1):9. 25. Daniels JP. Drug supply crisis in Venezuela. Lancet HIV. 2018;5(10):e547-8. 26. Rebolledo-Ponietsky K, Munayco CV, Mezones-Holguín E. Migration crisis in Venezuela: Impact on HIV in Peru. J Travel Med. 2018;26(2). 27. Aljazeera. Venezuela in crisis: All the latest updates. Aljazeera; 2019. 28. United Nations Central Emergency Response Fund (CERF). Allocations by Country. New York: United Nations; 2019. 29. Financial Tracking Service. Venezuela, Bolivian Republic of 2019. Geneva: Financial Tracking Service; 2019. Available from: https://fts.unocha.org/ 30. Amnesty International. Venezuela: Crimes against humanity require a vigorous response from the international justice system [press release]. London: Amnesty International; 2019. 31. Pan America Health Organization (PAHO). Venezuela and neighboring countries institutional regional response to the health situation. Washington: PAHO; 2018. Available from: https://www.paho.org/

Caroline Lee is a final year medical student at the University of New South Wales with an interest in global health, particularly infectious diseases, refugee and migrant health, and indigenous health. She has experience in non-government organisations, the World Health Assembly and both academic and journalistic writing, including for the AMSA Journal of Global Health (previously Vector) where she was former Editor-in-chief in 2017. Conflicts of Interest None declared Correspondence caroline.carrie.lee@gmail.com References 1. Human Rights Watch. Venezuela: UN Should Lead Full-Scale Emergency Response. Washington: Human Rights Watch; 2019. Available from: https://www.hrw.org 2. Doocy S, Ververs M-T, Spiegel P, Beyrer C. The food security and nutrition crisis in Venezuela. Soc Sci Med. 2019;226:63-8. 3. ReliefWeb. Glossary of Humanitarian Terms. 2008. Available from: https://reliefweb.int 4. Economic Commission for Latin America and the Carribean. Population database 2016 revision [Internet]. ECLAC; 2016. Available from: http://interwp.cepal.org/ 5. García J, Correa G, Rousset B. Trends in infant mortality in Venezuela between 1985 and 2016: a systematic analysis of demographic data. Lancet Glob Health. 2019;7(3):e331-6. 6. International Monetary Fund. IMF DataMapper 2019. IMF; 2019. Available from: https://www.imf.org/ 7. The collapse of the Venezuelan health system. The Lancet. 2018;391(10128):1331. 8. Grillet ME, Hernández-Villena JV, Llewellyn MS, Paniz-Mondolfi AE, Tami A, Vincenti-Gonzalez MF, et al. Venezuela’s humanitarian crisis, resurgence of vector-borne diseases, and implications for spillover in the region. Lancet Infect Dis. 2019;19(5):e149-61 9. Muci-Mendoza R. Venezuela: violence, human rights, and health-care realities. Lancet. 2014;383(9933):1967-8. 10. Human Rights Watch. Venezuela’s Humanitarian Emergency: Large scale UN response needed to address health and food crises. Washington: Human Rights Watch; 2019. 11. Daryanani S. When populism takes over the delivery of health care: Venezuela. Ecancermedicalscience. 2017;11:ed73. 12. Fraser B, Willer H. Venezuela: aid needed to ease health crisis. Lancet. 2016;388(10048):947-9. 13. Assessment Capacities Project (ACAPS). Venezuela Situational Update and 2019 Outlook. Geneva: ACAPS; 2019. 14. Agua Clara. Complex Humanitarian Emergency in Venezuela: Right to Water National Report. Caracas: Agua Clara; 2018. 15. Silva L. José Norberto Bausson: 82% of the population does not have a continuous potable water service. Caracas: 36

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cal attention on this issue. Coordination between countries bilaterally as well as regionally, with involvement from PAHO, is also important to address complex flow-on effects from mass displacement of Venezuelans to neighbouring countries.


RESISTANCE: THE RISE AND SPREAD OF AMR

AMR is the ability of bacteria, viruses, parasites and fungi to grow in the presence of a drug that would normally kill them or inhibit their growth.[5] Antibiotic resistance refers to this ability in bacteria alone.

With resistant infections on the rise, the global community faces an unprecedented challenge.

Annually, resistant infections cause an estimated 700,000 deaths – a figure projected to rise to 10 million deaths by 2050 if policy changes are not adopted.[6] There are over 2 million resistant infections reported in the US every year, at an estimated cost of 20 billion USD.[7] Uncurbed, AMR could cost the global economy up to 100 trillion USD by 2050, wiping 3.8% off the annual global gross domestic product (GDP) – more than the 2008 global financial crisis.[6,8]

Jesse Schnall

I

t was September 3rd in London and the professor had just returned from a summer holiday. A physician in training but a biologist by trade, he set to work removing the left-over petri dishes in his laboratory at St. Mary’s Hospital.[1,2] Yet amidst the islands of bacteria that covered one particular dish, lay a blob of mould, clear on all sides. The fungus – later identified as Penicillium notatum – had stopped the bacterium dead in its tracks. It was 1928, and Scottish bacteriologist Sir Alexander Fleming had uncovered a breakthrough that would revolutionise medicine. The discovery was penicillin. Antibiotics were born.

June 2019

This phenomenon of microbial self-defence, and the threat it poses to global health security, has grown over the last 80 years. Today, antimicrobial resistance (AMR) represents one of the greatest challenges facing modern medicine.

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And yet, these medicines were no silver bullet. The first effective class of antimicrobials, the sulphonamides, were plagued by resistant bacteria since their introduction in 1937.[4] Penicillinase, an enzyme that breaks down penicillin antibiotics, was identified as early as 1940, several years before the drug was first put to market.[4]

Issue 1

Humble beginnings It would be over 10 years before penicillin was first administered to patients, an achievement for which Fleming would jointly receive the Nobel Prize in Physiology or Medicine in 1945.[1] The following decades heralded a ‘golden age’ of drug discovery, with half of the antibiotics commonly used today being discovered between 1950-1960 alone.[3] Infections such as pneumonia, syphilis and gonorrhoea, once life-threatening, could now be cured with a jab or a pill.

A growing problem 37

Low-income countries are likely to be the most affected, with an estimated 28 million additional people thrust into poverty globally, and reductions in livestock production of up to 11%.[8] Immunosuppressed patients would be vulnerable to everyday pathogens; routine surgeries could become too dangerous to perform; and previously treatable infections may once again be without cure. The origins of resistance Most antimicrobial drugs are naturally produced by micro-organisms, such as fungi and certain environmental bacteria, or are synthetic modifications of such compounds.[9] The emergence of antibiotic resistance – the most concerning subtype of AMR – is a natural evolutionary response of bacteria to these antimicrobials, offering protection through mechanisms such as changing drug binding sites, directly destroying drugs or active efflux from the cell. Resistant bacteria have been identified in every environment examined so far, including soil, the sea, drinking water, food and even Antarctica.[9] Invariably, many of these resistant strains become


tice, employed not only to treat active infections, but also to prevent infection in immunosuppressed patients and in the timeframe during and surrounding surgical procedures. Between 2000–2015, global antibiotic consumption increased by 65%.[14] This increase is primarily driven by low- and middle- income countries (LMICs) outside northern Europe and North America, where a significant percentage of antimicrobial use occurs without prescription. [15]

Selection pressures In the absence of external antibiotics, resistant and susceptible bacterial species tend to co- exist in a stable balance in both the environment and the human microbiome. [9] When antibiotics are administered for any reason, natural selection leads resistant strains to proliferate as susceptible bacteria are killed or inhibited. This process – known as ‘collateral selection’ – is the primary driver of resistance in many of the bacterial species posing the most significant problems today, including Escherichia coli and the ESKAPE species (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter spp., Pseudomonas spp., Enterobacter spp).[10]

Improper prescribing is also a contributor to AMR, often due to lack of patient awareness and pressure placed on practitioner. In some developed regions, up to 50% of antimicrobials may be inappropriately prescribed, often for respiratory infections (which are typically viral).[16] While antimicrobial stewardship (AMS) practices encourage coordinated actions designed to promote and increase appropriate use of antimicrobials in the interests of conserving their effectiveness, a lack of rapid point-of-care diagnostics often means antibiotics must be given empirically to hedge against risky infections.[17]

These resistant strains are typically transmitted through asymptomatic carriers rather than individuals with disease, and cause ‘opportunistic’ infections following a change in their host, such as immunosuppression, wounds or other illness.[10,11] Resistance-conferring genes – which are often stored in mobile segments of DNA known as plasmids – can also be directly passed to neighbouring bacteria through direct connections between cell membranes, indirect transmission from gene-capturing viruses called bacteriophages or absorption of DNA fragments from the surrounding environment.[9]

The overuse and misuse of antibiotics in the animal sector is a major contributor to AMR. The World Health Organization estimates that in some countries, up to 80% of the total consumption of medically important antibiotics is used in food-producing animals to promote growth and prevent infection. [18,19] Resistant organisms harboured by livestock can then be spread to humans via direct contact or meat consumption.[20] Rising antibiotic levels in the environment also lead to resistance development. Up to half of an administered dose of antibiotics – which are poorly broken down in the body – will ultimately be excreted in sewage.[21] Industrial effluent also contributes to these rising levels: an Indian wastewater treatment plant serving an estimated 90 drug manufacturers was recently found to expel an average daily ciprofloxacin load equivalent to the total average consumption of Sweden over a 5-day period.[22] Concentrations exceeded the level toxic to some bacteria by over 1000-fold.[22]

Resistance can also arise in non-commensal organisms through a process called ‘targeted selection’. This occurs during an infection, in which a population of pathogens enters the body and multiplies. As these bugs replicate, some will acquire genetic mutations that make them resistance to certain antibiotics, which may then be selected for during treatment.[10,12] In contrast to the ESKAPE species, this process is commonly associated with Neisseria gonorrhoea and Mycobacterium tuberculosis (TB), which are known to develop spontaneous mutations during treatment. [10] Preventing targeted selection is one of the main reasons why combination drug therapy is used in the management of TB.[13]

The markets are not alright While resistance has always been an issue, the pace of new drug development in the 20th century allowed medications to stay a step ahead. Yet there have been no successful discoveries of novel antibiotic classes in over 30 years, resulting in what some have termed ‘the discovery void’.[23]

The antibiotic boom In the context of unprecedented levels of antibiotic consumption seen in modern healthcare, veterinary medicine, agriculture and the environment, the burden of AMR has become significant.

In an age where big pharma and modern science reign supreme, the antibiotic pipeline is paradox-

Antibiotics are a mainstay of modern medical prac38

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part of the natural microbiome – the ecosystem of commensal bacteria that begin to colonise human beings and other animals after birth.


ically dry. A 2017 WHO report identified a total of only 51 antibiotics in the clinical pipeline, with 42 new therapeutic entities that target priority pathogens.[24] Yet most of these are simply modifications of existing antibiotic classes – short-acting solutions that will not provide answers for the most critically resistant bacteria.

Immunosuppressed patients would be vulnerable to everyday pathogens; routine surgeries could become too dangerous to perform; and previously treatable infections may once again be without cure.

The dwindling pool of antibiotic research and development (R&D) is largely due to market failure. Developing a new drug can take up to 15 years at a cost of an estimated 2.6 billion USD.[6,25] Failure rates are high, with only 1.5-3.5% of candidates making it to the market. [6] This daunting task typically falls to large pharmaceutical companies, which prioritise drug development based on projected profits, much of which is dependent on patent lifetimes. [26]

Following these developments, the UN called for the establishment of the Ad Hoc Interagency Coordination Group (IACG) to provide practical guidance on AMR.[33] Co-chaired by the UN Deputy Secretary-General and the WHO Director-General, the IACG will present its final report to the UN Secretary-General later this year.[34]

For many big pharma companies, the profit margins in antibiotic R&D appear to be too low to justify the significant costs. While the total market for antibiotics is significant at 40 billion USD per year, annual sales from patented antibiotics are only 4.7 billion USD – about the same as one top-selling cancer drug.[6] In contrast to lifetime drugs like ACE-inhibitors and statins, antibiotics are typically used for short courses. Their commercial return is made more uncertain by the fact new drugs will often be held in reserve until resistance to current regimens has emerged, after which time their patents may be near expiry. Further, the rise of AMS has mandated sparing use of antibiotics.

The WHO has also been making ground on the recommendations put forward in the GAP. The establishment of the Global Antimicrobial Resistance Surveillance System (GLASS) in 2015 aims to provide a central repository for AMR surveillance.[35] In 2017, a list of 10 priority pathogens was developed to guide R&D priorities for the international community.[36] The WHO’s 13 th General Programme of Work for 2019-2023 also includes a platform for tackling AMR – a step in the right direction.[37,38] Leadership has also been strong at the state level. A 2016 review commissioned by former UK Prime Minister David Cameron has elevated the public discussion around AMR, while the establishment of the Fleming Fund and Global AMR  Innovation Fund (GAMRIF) by the UK Government has seen 295 million GBP poured into AMR research.[39,40] Along with funding from the Wellcome Trust and the Bill & Melinda Gates Foundation, these resources will support ambitious efforts such as the mapping of global AMR burden through the Global Research on Antimicrobial Resistance (GRAM) project, a collaboration between the University of Oxford and the Institute for Health Metrics and Evaluation (IHME) in the US.[41]

Major multinational pharmaceutical companies such as Novartis AG, AstraZeneca Plc, and Sanofi have shut-down their antibacterial research departments, with big pharma giant GlaxoSmithKline PLC also putting some antibiotics under review.[27] In a time when R&D is desperately needed, the major players are closing up shop.

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June 2019

Have you been paying attention? In the face of this threat, the global discussion surrounding AMR has been gaining steam. In 2015, the WHO finalised the Global Action Plan (GAP) on Antimicrobial Resistance, with member states committing to develop their own national action plans within two years.[28,29] The GAP was followed by similar plans from the Food and Agriculture Organization of the United Nations (FAO) and World Organisation for Animal Health (OIE) in 2016.[30,31] Together, these 3 intergovernmental bodies comprise the Tripartite Collaboration on AMR, a coalition formed in 2010 to tackle AMR through a ‘One Health’ approach.[32] 39


pitals have also been on the decline.[47] Where to from here? AMR has caught our attention, yet a long road lies ahead. With the global price-tag on containing AMR pegged at between 4 and 9 billion USD per year, ongoing funding must be secured.[6,8] Coordinated, global leadership among intergovernmental organisations, state actors and non-governmental organisations will be equally critical in containing the AMR threat.

There are glimmers of hope from the private sector, too. Despite cutbacks to AMR research, the world’s leading pharmaceutical companies have formed the AMR Industry Alliance, outlining a roadmap of principles for global action through a declaration at Davos in 2016.[45] While serious progress remains to be seen, the Antimicrobial Resistance Benchmark – a report that monitors private sector efforts towards AMR R&D – will dutifully hold big pharma to task as they attempt to turn words into action. [46]

Our first step must be to gather the facts. The figures on AMR incidence remain patchy and inconsistent. The establishment of the GRAM initiative via the Global Burden of Disease (GBD) study is an important step toward a better understanding of the nature, scale and geographic diversity of this issue, and should be commended. The WHO’s GLASS mechanism will also provide sorely needed global surveillance estimates, yet is currently hampered by limited data and country participation. While over 100 of the organisation’s 194 member states operate national surveillance systems, only 71 have enrolled in GLASS.[48,49] Ongoing global collaboration, in addition to technical and financial support for lower income nations, will be crucial to building functioning surveillance networks in all nations.[50]

Here at home

When antibiotics are administered for any reason, natural selection leads resistant strains to proliferate as susceptible bacteria are killed or inhibited. Australia is responding proactively to the threat of AMR. The Federal Government’s first 5-year national strategy, released in 2015, has seen the establishment of a dedicated AMR website; participation in the WHO’s World Antibiotic Awareness Week (WAAW) campaign; and the development of key education and training programs for both human and animal health workers that will be key to raising awareness.[47] On the R&amp;D front, AMR has been designated a national research priority, with over $90 million in active National Health and Medical Research Council (NHMRC) grants as of early 2017.[47]

Continued funding and guidance will be equally critical in ensuring the widespread adoption and implementation of national action plans for AMR. As of 2018, nearly half of all member states have no national AMR strategy in place, while those that do often struggle to convert them into action.[49] At the same time, efforts to stimulate R&D must be intensified. The effectiveness of innovative financial incentives such as market entry rewards, extended patent licensing and the de-linkage of drug revenues from sale volumes, should be further investigated as avenues to bring the private sector back into the fold. [6] Vital international R&amp;D mechanisms like the Global Antibiotic Research and Development Partnership (GARDP), the JPIAMR, the Coalition for Epidemic Preparedness (CEPI) and CARB-X, the latter of which has received up to $550 million USD in multilateral funding, must receive ongoing support from key donors. [50,51]

The establishment of the Antimicrobial Use and Resistance in Australia (AURA) system and key surveillance mechanisms including the National Antimicrobial Prescribing Survey (NAPS) and National Alert System for Critical Antimicrobial Resistances (CARAlert) have been critical to monitoring of trends in resistance and antibiotic consumption. Our strong AMS and infection prevention and control (IPC) measures are vital to reducing the spread of resistant bugs, with hand hygiene rates exceeding the 80% benchmark set by the National Hand Hygiene Initiative in 2017.[47] Rates of overall and inappropriate antimicrobial use in Australian hos-

Implementation and operational research, often neglected, will be critical to optimizing antibiotic dosages and course durations, many of which are rooted in historical practices with uncertain evi40

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The European Union (EU) has also been active, banning growth-promoting agents in animal feed as early as 2006.[42] The recent establishment of the Joint Programming Initiative on Antimicrobial Resistance (JPIAMR) will see greater efforts toward global collaboration and research, while the German government has committed up to 500 million euros towards a Global AMR R&D hub, launched early last year.[43,44]


dence.[10] Despite limitations in application and efficacy, antibiotic alternatives such as vaccines, bacteriophages, lysins and peptides should be further investigated for their potential roles as adjunctive therapeutics.[52]

References 1. American Chemical Society. Discovery and development of penicillin. Washington: American Chemical Society; 2019. 2. BBC. Alexander Fleming. United Kingdom: BBC; 2014. 3. Davies J. Where have All the Antibiotics Gone? Can J Infect Dis Med Micro. 2006;17(5):287-90. 4. Davies J, Davies D. Origins and Evolution of Antibiotic Resistance. Microbiol Mol Biol Rev. 2010;74(3):417. 5. National Institute of Allergy and Infectious Diseases. Definition of Terms, Antimicrobial (Drug) Resistance. Maryland: National Institute of Allergy and Infectious Diseases; 2019. 6. UK Department of Health. The Review on Antimicrobial Resistance; Tackling drug resistant infections globally: final report and recommendations. London; UK Department of Health; 2016. 7. Centres for Disease Control and Prevention. Untreatable: Report by CDC details today’s drug-resistant health threats. United States: US Department of Health and Human Services; 2013. 8. World Bank Group. Drug Resistant Infections: A Threat to our Economic Future. Washington: World Bank Group; 2017. 9. Holmes AH, Moore LSP, Sundsfjord A, Steinbakk M, Regmi S, Karkey A, et al. Understanding the mechanisms and drivers of antimicrobial resistance. Lancet. 2016;387(10014):176-87. 10. Llewelyn MJ, Fitzpatrick JM, Darwin E, Tonkin-Crine S, Gorton C, Paul J, et al. The antibiotic course has had its day. BMJ. 2017;358:j3418. 11. Brown SP, Cornforth DM, Mideo N. Evolution of virulence in opportunistic pathogens: generalism, plasticity, and control. Trends Microbiol. 2012;20(7):336-42. 12. Pray L. Antibiotic Resistance, Mutation Rates and MRSA. Nature Education. 2008;1(1):30. 13. Kerantzas CA, Jacobs WR. Origins of Combination Therapy for Tuberculosis: Lessons for Future Antimicrobial Development and Application. mBio. 2017;8(2):e01586-16. 14. Klein EY, Van Boeckel TP, Martinez EM, Pant S, Gandra S, Levin SA, et al. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proc Natl Acad Sci. 2018;115(15):E3463-70. 15. Morgan DJ, Okeke IN, Laxminarayan R, Perencevich EN, Weisenberg S. Non- prescription antimicrobial use worldwide: a systematic review. Lancet Infect Dis. 2011;11(9):692-701. 16. Milani RV, Wilt JK, Entwisle J, Hand J, Cazabon P, Bohan JG. Reducing inappropriate outpatient antibiotic prescribing: normative comparison using unblinded provider reports. BMJ Open. 2019;8(1):e000351. 17. Australian Government. Australia’s First National Antimicrobial Resistance Strategy 2015-2019. Canberra: Department of Health; 2015. 18. World Health Organisation. Antimicrobial resistance. Geneva: World Health Organisation; 2018. 19. World Health Organisation. Stop using antibiotics in healthy animals to prevent the spread of antibiotic resistance. Geneva: World Health Organisation; 2017. 20. Andersson DI, Hughes D. Microbiological effects of sublethal levels of antibiotics. Nature Rev Microbiol. 2014;12:465. 21. Berkner S, Konradi S, Schönfeld J. Antibiotic resistance and the environment--there and back again: Science &amp; Society series on Science and Drugs. EMBO Rep. 2014;15(7):740- 4. 22. Larsson DGJ, de Pedro C, Paxeus N. Effluent from drug manufactures contains extremely high levels of pharmaceuticals. J Hazard Mater. 2007;148(3):751-5. 23. Silver LL. Challenges of antibacterial discovery. Clinical microbiology reviews. 2011;24(1):71-109. 24. World Health Organisation. Antibacterial agents in clinical development: An analysis of the antibacterial clinical development pipeline, including tuberculosis. Geneva: World Health Organisation; 2017. 25. DiMasi JA, Grabowski HG, Hansen RW. Innovation in the pharmaceutical industry: New estimates of R&amp;D costs. J

As one of few high-income countries in the WHO Western Pacific Region (WPR), Australia must take an active leadership role on AMR.[47,53] While constrained by limited resources in the past, the Federal Government’s launch of the Indo-Pacific Centre for Health Security in 2017 will see 300 million AUD devoted to containing and avoiding nearby infectious disease threats.[47,54] As a member of the Global Health Security Agenda (GHSA) and a contributing country to its AMR action package, Australia is well-positioned to aid our neighbours in bolstering their health infrastructure.[55] This could be partly achieved through supporting ongoing implementation of the Joint External Evaluation (JEE), a voluntary assessment of country capacity to handle public health threats under the International Health Regulations of 2005. As of today, only 9 WPR member states (including Australia) have participated in the JEE.[56]

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Members of healthcare professions have a key role to play. Educating ourselves and others on the causes and scale of AMR; promoting WAAW and the need for proper antimicrobial prescribing; and remaining vigilant around hand hygiene and other IPC measures are but a few actions we can take to shift the dynamic around this issue. While progress has been made, more than 60% of Australians with presumptively viral respiratory tract infections are still prescribed antibiotics.[47] We have a long way to go. Nearly a century has passed since Fleming and his petri dish, and the protection this discovery afforded us against illness and disease. Yet we now encounter the possibility of returning to the proverbial dark ages of medicine. In the face of this threat, a global commitment to curbing drug resistance would be a wise investment in our collective future. While the challenge is great, the cost of inaction will be far more severe. Jesse Schnall is a final year medical student at Monash University with an interest in communicable diseases and antimicrobial resistance. Conflicts of interest Jesse Schnall is employed by the University of Oxford Big Data Institute as a casual data analyst for the Global Research on Antimicrobial Resistance (GRAM) project. Ethics No formal ethics review process was undertaken for this article. Correspondence jasch13@student.monash.edu 41


second round of AMR country self-assessment survey 2018. Geneva: World Health Organisation; 2018. 50. Interagency Coordination Group on AMR. Draft recommendations of the ad hoc interagency coordination group on antimicrobial resistance. Geneva: Interagency Coordination Group; 2019. 51. CARB-X. Funding Partners. Boston: CARB-X; 2019. 52. Czaplewski L, Bax R, Clokie M, Dawson M, Fairhead H, Fischetti VA, et al. Alternatives to antibiotics; a pipeline portfolio review. Lancet Infect Dis. 2016;16(2):239-51. 53. World Health Organisation. WHO Western Pacific Region: JEE mission reports. Geneva: World Health Organisation; 2019. 54. Department of Foreign Affairs and Trade. Health Security Initiative for the Indo- Pacific region. Canberra: Department of Foreign Affairs and Trade; 2017. 55. Global Health Security Agenda. Antimicrobial Resistance Action Package. 2019. 56. Global Health Security Agenda. Assessments &amp; JEE. 2019

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Health Econ. 2016;47:20-33. 26. US Food and Drug Administration. Frequently Asked Questions on Patents and Exclusivity. Maryland: US Food and Drug Administration; 2018. 27. Paton J, Kresge N. Superbugs Win Another Round as Big Pharma Leaves Antibiotics. Bloomberg; 2018. 28. Sixty-Eighth World Health Assembly. Global action plan on antimicrobial resistance WHA 68.7. Geneva: World Health Organisation; 2015. 29. World Health Organisation. Global Action Plan on Antimicrobial Resistance. Geneva: World Health Organisation; 2015. 30. Food and Agriculture Organization of the United Nations. The FAO Action Plan on Antimicrobial Resistance 20162020. Rome: Food and Agriculture Organization of the United Nations; 2016. 31. World Organisation for Animal Health. The OIE Strategy on Antimicrobial Resistance and the Prudent Use of Antimicrobials. Paris: World Organisation for Animal Health; 2016. 32. Tripartite Collaboration on AMR. The FAO-OIE-WHO Collaboration: Sharing responsibilities and coordinating global activities to address health risks at the animal-human- ecosystems interfaces. Geneva: World Health Organisation; 2010. 33. United Nations 71st General Assembly. Political Declaration of the high-level meeting of the General Assembly on antimicrobial resistance. New York: United Nations; 2016. 34. World Health Organisation. UN Interagency Coordination Group on Antimicrobial Resistance (IACG). Geneva: World Health Organisation; 2019. 35. World Health Organisation. Global antimicrobial resistance surveillance system (GLASS) report: Early implementation 2016-2017. Geneva: World Health Organisation; 2018. 36. World Health Organisation. Global priority list of antibiotic-resistant bacteria to guide research, discovery, and development of new antibiotics Geneva: World Health Organisation; 2017. 37. World Health Organisation. WHO headquarters leadership team. Geneva: World Health Organisation; 2019. 38. Seventy-First World Health Assembly. Draft thirteenth general programme of work, 2019â&#x20AC;&#x201C;2023. Geneva: World Health Organisation; 2018. 39. UK Government. ÂŁ30 million of funding to tackle antimicrobial resistance. London: United Kingdom; 2018. 40. World Health Organisation. Sri Lanka receives funding boost to tackle AMR. Sri Lanka: World Health Organisation Sri Lanka; 2019. 41. University of Oxford Big Data Institute. New collaborative research project on tackling antimicrobial resistance announced in Berlin Oxford: University of Oxford Big Data Institute; 2017. 42. European Commission. Ban on antibiotics as growth promoters in animal feed enters into effect. Brussels: European Commission; 2005. 43. German Federal Ministry of Education and Research. Global AMR R&amp;D Hub. 44. Joint Programming Initiative on Antimicrobial Resistance. About JPIAMR. Stockholm: JPIAMR. 45. AMR Industry Alliance. Industry roadmap for progress on combating antimicrobial resistance. Geneva: AMR Industry Alliance; 2016. 46. Access to Medicine Foundation. Antimicrobial Resistance Benchmark 2018. Amsterdam: Access to Medicine Foundation; 2018. 47. Government of Australia. Antimicrobial Resistance Strategy 2015. 2019; Progress Report. Canberra: Department of Health; 2017. 48. World Health Organisation. Global Antimicrobial Resistance Surveillance System (GLASS) Report Early implementation 2017-18. Geneva: World Health Organisation; 2019. 49. World Health Organisation. Monitoring global progress on addressing antimicrobial resistance: analysis report of the


NUCLEAR’S SECOND WIND Tara Kannan

I

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magine a child with a life-threatening tumour in need of radiation therapy. Most people would consider this treatment appropriate. Though it has side effects, the radiation therapy will save the child’s life. Now, imagine a planet with a life-threatening disease, like climate change, that could similarly be addressed by utilising nuclear energy. This is considered controversial. In this context, nuclear energy has the potential to save lives, but this time, the side effects are more complicated. The nuclear brainstorm

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Today’s nuclear proposal springs from basic climate theory.[1] If industries are degrading the environment — in this case, by dumping greenhouse gases into the atmosphere — the answer is to replace the culprits, which here are fossil fuels, like coal, oil and gas. 43


er and creates little to no nuclear waste.[8] However, fission is the only nuclear power available on a large scale since fusion requires temperatures of 100 million degrees Celsius to even occur.[7] When it comes to energy generation and reliability, nuclear energy is unparalleled. For instance, the energy derived from 1g of uranium is equivalent to that generated by burning 3 metric tons of coal or 12 oil barrels.[7] In addition to its low fuel requirements, it’s capacity factor, or maximum power output, is 92%, which is 2 times as reliable as coal and 3 times as reliable as wind and solar energy.[9] For this reason, it is nuclear energy that is decarbonising traditionally difficult sectors such as transport and industry (for example, heating of buildings). [10] Transport alone is the fastest growing carbon emitter, contributing to nearly one-third of carbon emissions.[10]

In light of the complexities of the aforementioned renewable energy sources, it seems unwise to put all our eggs in the renewables basket, so to speak. A new United Nations report suggests that we may need to recalibrate our approach.[1] A global temperature rise of 1.5°C, revised from the original 2°C, is the threshold before climate catastrophe.[1] Given that temperatures have already risen 1°C, this threshold could be surpassed as early as 2030 unless we either cease carbon emissions completely or remove emissions from the atmosphere.[1] Needless to say, we have a tiny window of opportunity and a massive responsibility. This is where nuclear energy steps in. It is a power source that may be the closest thing we have to a silver bullet.

The environmental benefits of nuclear power are two-pronged. It redefines low-carbon energy, emitting a mere 9 g/kWh of carbon dioxide which far outshines the 500-1000 g/kWh emitted by fossil fuels and the 20-30 g/kWh emitted by various renewable energy sources.[11] Also, contrary to popular belief, living near a nuclear plant exposes you to <0.0001mSv/year of background radiation [12], which is 3 times less than the dose associated with living near a coal plant.[13] Playing with fire

When it comes to energy generation and reliability, nuclear energy is unparalleled. For instance, the energy derived from 1g of uranium is equivalent to that generated by burning 3 metric tons of coal or 12 oil barrels. Come rain or shine Nuclear energy accounts for 11% of all electricity generated globally, contributing to a third of low-carbon electricity production.[5] Today’s nuclear landscape comprises 450 powerplants in 30 countries and 60 upcoming reactors.[6] Nuclear energy can be derived from fission or fusion reactions - two very different animals.[7] Simply put, fission splits atoms, like uranium-235, into smaller atoms.[7] Fusion joins atoms, like hydrogen, to form a single, heavier atom.[7] Compared to fission, fusion produces three to four times more pow44

Despite its many attributes and potential to improve both carbon emissions and power reliability, public opinion on nuclear energy is often rooted in the drawbacks of the industry.[14] Firstly, uranium is a finite resource and based on current consumption rates, we may only be able to generate nuclear energy for another 200 years.[15] Furthermore, powerplants are undeniably expensive, which is mainly attributed to the high initial construction costs associated with large facilities, inefficient manufacturing, lengthy licensing periods, rigorous testing and expensive safety structures.[16] Safety concerns often predominate discussions of nuclear power, and however unlikely, accidents within nuclear facilities will pose significant health, safety and environmental risks in both the short and long-term. Most notably, in 1986, the Chernobyl powerplant in Ukraine faced the wrath of a flawed reactor design and, more recently, in 2011, the Fukushima powerplant in Japan succumbed to a magnitude 9 earthquake.[17] Both accidents have been linked to acute radiation syndrome and thyroid cancers in children.[17] Despite the direct effects of radiation, the Chernobyl Forum labelled mental health as “the largest public health problem created by the accident”.[17] For instance, The Lan-

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Here, renewable energy, like solar, wind and hydropower, tends to sap all the attention. Politicians, newspapers and utility executives alike can be quick to offer renewables as the antidote to our emissions problem.[2] While they offer this for good reason, the renewables mantra, in practice, has its drawbacks.[3] Solar power requires excess land and expensive storage technology.[3] Wind turbines kill hundreds of thousands of flying wildlife annually. [3] Hydropower disrupts river ecosystems, is vulnerable to drought and produces decaying matter that releases methane.[3] Most importantly, renewable energy is subject to seasonal and diurnal rhythms, rendering it inconstant.[3] Once baseload fossil fuel energy is phased out, intermittent renewable energy alone may struggle to maintain electricity grid security.[4]


With continued foresight and openness, several climate change experts are warming to nuclear energy.

cet noted that nearly 220,000 people were evacuated after Chernobyl which coincided with a doubling in the incidences of post-traumatic stress disorder and other mood and anxiety disorders.[17] Another issue beyond the associated costs and safety considerations is the production of nuclear waste, which contains plutonium and other fission biproducts and remains radioactive for several centuries. Nuclear waste can be precarious since it is susceptible to radioactive emission, leakage into soil and water, and release during natural disasters. [18]

Viable cost-reduction strategies, such as careful preparation, streamlined processing lines, and smaller scale designs have been modelled by France, a nation that generates 75% of its electricity from nuclear sources.[20] Nonetheless, nuclear investments have desirable payoffs due to their extensive facility lifespans and cheap fuel costs (Table 1).[21] Today, France has one of the lowest carbon emissions globally, and other countries, such as Sweden, are following suit as they expand their nuclear reactor fleet. In stark contrast, Germany, while a leader in renewable energy use, is still reliant on fossil fuels for baseload energy, making it home to six out of ten of Europe’s most polluting powerplants.[22]

There have been several moments in history where nuclear power has been utilised as more than a power source. North Korea’s provocative missile tests, the Cold War’s lingering memory, and the atomic bombings of Hiroshima and Nagasaki are haunting reminders of nuclear energy’s historical origins in warfare. Despite today’s strict regulations, several countries use their civil powerplants for militarisation purposes.[19]

Accidents, radioactive waste and nuclear proliferation continue to be major public concerns. New age waste storage facilities, like Finland’s US$3.9 billion Onkalo project, will allow underground storage in deep geological repositories, minimising the potential for environmental impact.[23] There is also new research into Generation IV reactor designs which consume all spent fuel and automatically shut down, preventing waste and accidents.[11] This is complemented with new hope for alternative fuels such as thorium which are more abundant than uranium and produce zero plutonium waste, reducing susceptibility to nuclear proliferation.[24]

The future of nuclear Undoubtedly, nuclear energy is splitting public opinion and there are many issues to address before nuclear energy is widely accepted as an alternative energy source. So, what has been happening to address these issues? To extend uranium supply, the potential exists to extract it from seawater which could unlock 4.5 billion metric tons of uranium, the equivalent of a 60,000-year supply.[15] Additionally, new technologies such as fuel-recycling fast-breeder reactors could efficiently consume current supplies so that they last for the next 30,000 years.[15]

With continued foresight and openness, several climate change experts are warming to nuclear energy. Major organisations showng support include the Intergovernmental Panel on Climate Change, the International Energy Agency, the UN Sustain-

June 2019

Table 1. An Evaluation of Different Energy Sources [21] Nuclear

Coal

Wind

Levelized cost of energy ($/MWh)a

112-189

60-143

29-56

Total capital cost ($/kW)b

6500-12,250

3000-8400

1,150-1,550

Fixed operation and main- 115-135 tenance cost ($/kW-yr)

40-80

28-36.50

Fuel price ($/MMBtu)

0.85

1.45

-

Capacity factor (%)

92

53

35

Construction time (months)

69

60-66

12

Facility life (years)

40

40

20

Issue 1

c

Levelized cost of energy ($/MWh): first-order economic assessment of cost competitiveness of an energy system that incorporates all costs over its lifetime: initial investment, operations and maintenance, fuel cost and capital cost b Total capital cost ($/kW): combines overnight construction cost and interest cost c Capacity factor (%): maximum power output indicating the reliability of an energy source

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www.nsc.org/resources/issues/rad/exposure.aspx 14. Ropeik D. The dangers of radiophobia. Bulletin of The Atomic Scientists. 2016; 72: 311–317. http://dx.doi.org/10.1080/00963402.201 6.1216670 15. Fetter S. How long will uranium deposits last? [Internet]. New York, NY: Scientific American; 2009 [cited 2019 May 5]; [about 2 screens]. Available from: https://www.scientificamerican.com/article/ how-long-will-global-uranium-deposits-last/ 16. Buongiorno J, Corradini M, Parsons J, Petti D. The Future of Nuclear Energy in a  Carbon-Constrained World. Massachusetts Institute of Technology Energy Initiative. 2017. Available from: http:// energy.mit.edu/wp-content/uploads/2018/09/The-Future-of-NuclearEnergy-in-a-Carbon-Constrained-World.pdf 17. Hasegawa A, Tanigawa K, Ohtsuru A, Yabe H, Maeda M, Shigemura J et al. Health effects of radiation and other health problems in the aftermath of nuclear accidents, with an emphasis on Fukushima. The Lancet. 2015; 386: 479-88. 18. Jennewein M. Looking for a Trash Can: Nuclear waste management in the United States [Internet]. Cambridge, MA: Harvard Medical School; 2018 [cited 2019 May 5]; [about 7 screens]. Available from: http://sitn.hms.harvard.edu/flash/2018/looking-trash-can-nuclearwaste-management-united-states/ 19. Green J. Civil Nuclear Programs & Weapons Proliferation. Energyscience.org; 2006. Available from: http://www.energyscience. org.au/FS09%20Proliferation.pdf 20. Brook B, Alonso A, Meneley D, Misak, J, Blees T, van Erp JB. Why nuclear energy is sustainable and has to be part of the energy mix. Sustainable Materials and Technologies. 2014; 1-2:8-16. https://doi. org/10.1016/j.susmat.2014.11.001 21. Lazard. Lazard’s Levelized Cost of Energy (LCOE) Analysis – Version 12.0 [Internet]. Hamilton, Bermuda: Lazard; 2018 [cited 2019 May 5]; [about 20 screens]. Available from: https://www.lazard.com/ media/450784/lazards-levelized-cost-of-energy-version-120-vfinal.pdf 22. Rhodes R. A Sensible Climate Change Solution, Borrowed From Sweden [Internet]. New York, NY: New York Times; 2019 [cited 2019 May 5]; [about 4 screens]. Available from : https://www.nytimes. com/2019/02/05/books/review/bright-future-joshua-s-goldsteinstaffan-a-qvist.html 23. Fountain H. On Nuclear Waste, Finland Shows U.S. How It Can Be Done. [Internet]. New York, NY: New York Times; 2017 [cited 2019 May 5]; [about 8 screens]. Available from: https://www.nytimes. com/2017/06/09/science/nuclear-reactor-waste-finland.html 24. Baker G. Thorium in Australia [Internet]. Canberra: Parliament of Australia; 2007 [cited 2019 May 18]; [about 17 screens]. Available from: https://www.aph.gov.au/About_Parliament/Parliamentary_ Departments/Parliamentary_Library/pubs/rp/RP0708/08rp11 25. Conca J. New Government Report On Climate Change -- Will It Matter? [Internet]. Jersey City, NJ: Forbes; 2018 [cited 2019 May 18]; [about 6 screens]. Available from: https://www.forbes.com/sites/jamesconca/2018/12/03/new-government-report-on-climate-change-will-itmatter/#5a22ad5562e0 26. Hansen J, Emanuel K, Caldeira K, Wigley T. Nuclear power paves the only viable path forward on climate change [Internet]. London: The Guardian: 2015 [cited 2019 May 18]; [about 4 screens]. Available from: https://www.theguardian.com/environment/2015/dec/03/ nuclear-power-paves-the-only-viable-path-forward-on-climatechange

Finding a climate change solution is a challenging task, and it is rarer still for a solution to balance the twin challenges of carbon-neutrality and energy security. With the support of many organisations and scientists, nuclear energy has risen to the challenge. But the industry is not quite there yet. The future of nuclear hinges on when, and if, it minimises its notorious side effects, which have plagued the industry for decades. Carrying this out will take skill, nerve, and innovation. Tara Kannan is a third year medical student at the University of Newcastle who is interested in medical journalism. Through her writing, she aims to raise awareness about pressing global health issues and spark tangible action. Conflicts of Interest None declared Correspondence tara.kannan@uon.edu.au References 1. Intergovernmental Panel on Climate Change (IPCC). Global Warming Of 1.5°C. IPCC. 2018 [cited 2019 May 4]. Available from: https://www.ipcc.ch/site/assets/uploads/sites/2/2018/07/SR15_SPM_ version_stand_alone_LR.pdf 2. Bulletin of the Atomic Scientists. Ozzie Zehner: Alternatives to alternative energy. Bulletin of the Atomic Scientists. 2012; 68:1-7. doi: 10.1177/0096340212459037 3. Nunez C. Renewable energy, explained [Internet]. Washington, D.C.: National Geographic; 2019 [cited 2019 May 4]; [about 2 screens]. Available from: https://www.nationalgeographic.com/environment/energy/reference/renewable-energy/ 4. Matek B, Gawell K. The Benefits of Baseload Renewables: A Misunderstood Energy Technology. The Electricity Journal. 2015; 28:101-12. https://doi.org/10.1016/j.tej.2015.02.001 5. Nunez C. What is nuclear energy and is it a viable resource? [Internet]. Washington, D.C.: National Geographic; 2019 [cited 2019 May 4]; [about 2 screens]. Available from: https://www.nationalgeographic. com/environment/energy/reference/nuclear-energy/ 6. International Atomic Energy Agency (IAEA). Power Reactor Information System [Internet]. Vienna, Austria: IAEA; 2019 [cited 2019 May 7]; [about 2 screens]. Available from: https://pris.iaea.org/PRIS/ home.aspx 7. Wiggins EG, Theilmann, JM. Nuclear energy. Salem Press Encyclopedia of Science; 2018 8. Grossman L. A Star Is Born. New York City: Time [Internet]; 2015 [cited 2019 May 18]; [about 10 screens]. 9. Office Of Nuclear Energy. Nuclear Power is the Most Reliable Energy Source and It’s Not Even Close; 2018 https://www.energy.gov/ ne/articles/nuclear-power-most-reliable-energy-source-and-its-noteven-close 10. World Health Organisation (WHO). Health and sustainable development [Internet]. Geneva, Switzerland: WHO; 2019 [cited 2019 May 5]; [about 2 screens]. Available from: https://www.who.int/sustainable-development/transport/health-risks/climate-impacts/en/ 11. Markandya A, Wilkinson P. Electricity generation and health. The Lancet. 2007; 370: 979-90. doi:10.1016/S01406736(07)61253-7 12. United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR). UNSCEAR 2008 Report to the General Assembly. UNSCEAR. 2008. 13. National Safety Council (NSC). Determining Your Exposure [Internet]. Itasca, IL: NSC; 2002 [cited 2019 May 7]; [about 2 screens]. Available from: https://web.archive.org/web/20090625161716/http://

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able Solutions Network, the Global Commission on the Economy and Climate and the Union of Concerned Scientists.[25] Dr. James Hansen, Dr. Tom Wigley, Dr. Ken Caldeira and Dr. Kerry Emanuel are amongst some of the world’s most renowned scientists arguing for a more comprehensive climate strategy which now includes the adoption of nuclear energy.[26]


CLIMATE CHANGE AND THE ROLE OF FUTURE HEALTH PROFESSIONALS

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Jeevan Jangam

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The environmental impacts of human interference with the climate system was first identified in 1988. It was understood then that the increase in atmospheric greenhouse gas levels and consequently, the increase in global atmospheric temperatures, were not attributable simply to the natural planetary cycle; but rather to emissions from the post-industrialisation era. In 1990, a team of researchers found that increases beyond 1°C (when compared to pre-industrial era temperatures) could provoke rapid, unpredictable and non-linear responses that could lead to extensive ecosystem damage.[1]

Direct health impacts pertain to the morbidity and mortality caused by more frequent and severe storms, floods, heatwaves and droughts. We can expect heat waves to place additional cardiovascular stress on already vulnerable populations such as the elderly, the young and the socioeconomically disadvantaged. Storms and floods will impair our health infrastructure and exacerbate the spread of infectious disease by contaminating water sources and preventing access.[4,5] Apart from significant economic damage, floods and droughts, and loss of people’s homes cause deep psychosocial traumas to those affected.[6] These scenarios are already taking place in developed and developing countries alike and have seen an inadequate response.[4] We can expect there to be significant strain on health systems as severe events become more frequent.

Nearly thirty years after the environmental impacts were first identified, average global temperatures have increased by 1°C and are expected to climb further.[2] It is important to note that this increased average includes areas in the world that have experienced severe increases in temperatures leading to prolonged heatwaves, droughts, floods, or storms. Current efforts aim to prevent the average global temperature from reaching a rise of 2°C by implementing policies that curb greenhouse gas emissions.[3] In recent times, global emissions have only risen, and it is becoming increasingly difficult to foresee a future where temperatures won’t rise higher than the target. Such elevated temperatures are unprecedented and have never been experienced by humans. Continuation of this trend would result in flooding of coastal cities, severe food shortages and a more hazardous environment for living triggering large-scale migration and socio-economic disruption across the world. It is becoming increasingly obvious that unabated climate change poses a devastating threat to humanity.[3] Urgent remediation, adapted to already deteriorating conditions is now required to slow its advance and minimise casualties.

Indirect health impacts result from the deterioration of environmental characteristics, such as air and water quality due to ecological and land use change.[4] Significant pollution and smoke from wild fires lead to pulmonary irritation and stress upon the cardiovascular system.[7] Warmer and more humid environments promote vector borne diseases and the proliferation of climate-sensitive disease such as tick-borne encephalitis, haemorrhagic fever with renal syndrome, Lyme disease and Japanese encephalitis.[4] In Australia, Dengue and Ross-river fever are being seen further south than ever before.[8] Similarly, reduced water quality can lead to consumption of unsafe water and consequent enteric diseases.[4] With increasing emissions, we can expect to see increased rates of allergies, respiratory diseases, infectious diseases and psychological trauma. Further, the deterioration of the environment will induce constraints on the equal distribution of necessary resources resulting in malnutrition and a reduced quality of life across large populations.[7]

As future doctors and health professionals, it is inevitable that we will need to

Climate change is an identifiable and ongoing issue for humanity. As future health professionals, understanding its mechanisms and its impact on health is necessary for us to elicit the urgent change in behavior required to slow its progress.

Socioeconomic disruptions are the result of the systemic effects of climate change and will cause the greatest impact in developing countries.[9] These can present as fundamental barriers to food supply, increased poverty and inequality leading to worsening malnourishment and stunted growth of children. These deteriorating conditions will lead 48

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adapt and deal with the fallout from climate change. Compared to the more visceral effects of previous health crises such as HIV/AIDS, tobacco and SARS, it is harder to grasp the extent of the damage that climate change will have on human health. It is imperative that we understand and prepare for the significant medical challenges caused by the impact of climate change. The health impacts of climate change can be attributed to three categories – direct, indirect and socioeconomic disruptions.[4]

limate change is an identifiable and ongoing issue for humanity. As future health professionals, understanding its mechanisms and its impact on health is necessary for us to elicit the urgent change in behaviour required to slow its progress.


nities that promote better health. For example, the design of our communities has been shown to play a significant role in determining the health of community members. A 2012 report by Natural England has estimated that if each household in England was provided with equitable access to quality green space then savings of £2.1bn could be achieved in the NHS every year in averted health costs due to the reduction of disease burden in the population. [13] Getting involved in these discussions provides us with the most impactful opportunities to combat climate change.

to mass migration and conflict as the local environment becomes too resource constrained or simply uninhabitable.[10] These effects are already being felt in areas that have experienced severe changes to their environment. This disruption provides opportunities for diseases to spread to areas which may not be ready to accept the burden of new disease.[9] Communication barriers and psychosocial trauma from such large disruptions further complicate the delivery of health care services to these populations.[11] A perspective on the magnitude of the issue can be garnered when we consider these health impacts in conjunction with growing antibiotic resistance worldwide and inadequate health, social and environmental policies in many countries.[4] The urgency of the action required is apparent. As health professionals, we speak from a position of privilege and with gravitas afforded to us by the profession. We can use this influence to empower our communities and advocate action against climate change. In addition, the interventions and changes required to combat climate change often have co-benefits towards patient health outcomes and provide powerful synergies between practices that promote environmental sustainability and those that promote health. Both as citizens of the world and as health professionals, we should heed the call to action and join the campaign to slow climate change.[12]

Operational changes are those that have a more concrete goal, seeking to reduce the emissions generated by the delivery of health care, and striving for sustainable healthcare delivery models and technology is one such example. Although greenhouse gas emissions stemming from delivery of healthcare are overshadowed by other industries, they are not

It is widely regarded that the likelihood of our patients’ behaviour changes toward a more healthy lifestyle is dependent on the practices of their treating doctor.19 Much like how patients are less likely to strive toward a health weight range if their doctor is obese, it is necessary for doctors to pursue a more sustainable practice and lifestyle.

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Reducing greenhouse gas emissions and moving towards a low-emission society will bring substantial health benefits globally, in both industrialised and developing countries. There are numerous approaches available that contribute towards curbing emissions and slowing climate change. Actions to slow this down can be categorized into 3 categories – strategic, operational and personal. The core objective is to reduce the emission levels and concurrently improve the health of the individual or community.[11]

insignificant.[14] Health professionals in hospitals and clinics can seek to implement sustainable care models to prevent growth in the burden of chronic disease and seek operational efficiencies in health care delivery. Currently, in New South Wales, health facilities consume more than 50% of the total energy consumed by government buildings.[15] Aside from the societal benefits of lower emissions, these efficiencies have a co-benefit of reducing operating costs. Pilot studies in the UK have shown that adopting a sustainable healthcare delivery model for patients on dialysis – a service that uses significant amounts of water, can save the NHS £1bn.[16] Another campaign to turn off machines and lights, and close doors saved approximately £400k per year on the operating costs of 5 sites.[17] Systemic implementation of these types of strategies would be a huge step towards sustainable healthcare provision. Furthermore, championing sustainable developments and innovations is a great way to support initiatives that seek to actively combat climate change. Developing partnerships between health-

Strategic changes involve taking actions that do not necessarily have a set objective that can be measured but ultimately have the greatest amount of impact due to the far-reaching effects. Divestment and Policy change are two such examples. Major banking and superannuation organisations invest in oil and gas companies which have strong interests in the consumption of greenhouse emitting fuels and consumables. By consciously choosing to invest our money into environmentally responsible institutions, we can encourage a reduction in the emission of greenhouse gases and empower innovators that seek to develop sustainable technologies and policies.[9] Furthermore, as health practitioners that are afforded a respected voice, we can support policies and initiatives in our commu49


Jeevan is a third year student at The University of Sydney. Jeevan has taken the opportunity to advocate and raise awareness about key global health issues with a particular with a focus on the impacts of climate change on health.

Finally on a personal level, utilising active transport and reducing meat consumption are two modifications to behaviour with a significant collective impact on health and environment. Reducing our dependence on modes of transport that use fossil fuels provides a direct opportunity to reduce our individual carbon footprint. In addition, active transport such as walking and cycling, is associated with improved cardiovascular and respiratory function. Encouraging active transport as a part of self-management for patients also has the co-benefit of reducing the growing burden of chronic disease associated with physical inactivity.[4] Reducing meat consumption in diets can further compound these benefits. The livestock sector accounts for up to 18% of greenhouse gas emissions and consumes a disproportionately large amount of water and feed compared to its caloric value. Reducing meat consumption is one of the most effective ways to reduce our carbon footprint.[18] Apart from the health co-benefits of a reduced meat diet, it facilitates better land use and reduced deforestation.

Conflict of Interest None declared Correspondence jjan7556@uni.sydney.edu.au References 1. Brangham W. Why 2 degrees Celsius is climate change’s magic number. PBS News Hour, PBS [Internet]. December 2015 [cited on 2018 October 20]. Available from: https:// www.pbs.org/newshour/show/why-2-degrees-celsius-is-climate-changes-magic-number 2. Evans S. Two Degrees: The history of climate change speed limit. Carbon Brief, Carbon Brief Ltd [Internet]. 2015 October 22 [cited on 2018 October 20]. Available from: https:// www.carbonbrief.org/two-degrees-the-history-of-climatechanges-speed-limit 3. Evans S. Two Degrees: Will We Avoid Dangerous Climate Change?. Carbon Brief, Carbon Brief Ltd [Internet]. 2015 October 22 [cited on 2018 October 20]. Available from: www. carbonbrief.org/two-degrees-will-we-avoid-dangerous-climate-change 4. Climate Change: Health Impacts and Opportunities [document on the Internet]. Global Climate and Health Alliance - Health Impacts and Opportunities, Climate and Health Alliance; 2014 September [cited on 2018 October 20]. Available from: www.climateandhealthalliance.org/asset/download/135/ Global Climate and Health Alliance - Health Impacts and Opportunities.pdf 5. Le Tertre A, et. al., Impact of the 2003 heatwave on all-cause mortality in 9 French cities. Journal of Epidemiology January 2006 - Volume 17 - Issue 1; 75-79. 6. Stanke C, Murray V, Amlôt R, Nurse J, Williams R. The Effects of Flooding on Mental Health: Outcomes and Recommendations from a Review of the Literature. PLOS Currents Disasters. 2012 May 30. Edition 1. DOI: 10.1371/4f9f1fa9c3cae. 7. World Health Organization. Climate Change, Extreme Weather Events and Public Health - Meeting Report. World Health Organization Europe. 2010. 8. Webb C. Is Climate Change to Blame for Outbreaks of Mosquito-Borne Disease?. The Conversation, The Conversation [Internet]. 2018 October 11 [cited on 2018 October 20]. Available from: www.theconversation.com/is-climate-changeto-blame-for-outbreaks-of-mosquito-borne-disease-39176 9. Woodward A, et al. Climate change and health: on the latest IPCC report. The Lancet 2014 383.9924; 1185-1189. 10. DROUGHT - Technical Hazard Sheet - Natural Disaster Profiles [document on the Internet]. World Health Organization, World Health Organization; 2018 February 13 [cited on 2018 October 20]. Available from: www.who.int/hac/techguidance/ems/drought/en/ 11. IPCC. Climate Change 2014 Impacts, Adaptation, and Vulnerability. 2014 June. doi:10.1017/cbo9781107415379 12. McMichael AJ, Woodruff RE, Hales S. Climate change and human health: present and future risks. The Lancet 2006 367.9513; 859-869. 13. Natural England. Links between Natural Environments and Physical Activity: Evidence Briefing (White Paper). Natural England. 2012. 14. Victorian Health and Human Services Building Authority, Sustainability Unit. State Government of Victoria, Department of Health & Human Services. Carbon Emissions in

It is widely regarded that the likelihood of our patients’ behaviour changes toward a more healthy lifestyle is dependent on the practices of their treating doctor.[19] Much like how patients are less likely to strive toward a health weight range if their doctor is obese, it is necessary for doctors to pursue a more sustainable practice and lifestyle. Collectively implementing sustainable strategies as a community will facilitate a significant reduction in the amounts of greenhouse gases emitted. It can easily be postulated that these approaches work in a synergistic manner. An effective implementation of key strategies provides the means to turn what is arguably the biggest global health threat of the 21st century into the greatest health opportunity to significantly improve the quality of life of billions of people around the world in an equitable manner.[20] A journey of a thousand miles begins with a single step. Addressing climate change will be such a journey for our generation. Implementing sustainable initiatives in our daily lives is the first step of many, and the benefits will only grow as we encourage our peers and colleagues to adopt a similar stance. Although humanity has started to consider the environmental impacts of business decisions, it is paramount that healthcare professionals and doctors join this movement to bring to light the disastrous effects of climate change on health. A multidisciplinary approach to this complex global challenge will show solidarity and foster innovation, giving us the best chance to minimise the health impact of 50

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care providers and innovators is the easiest way to develop safe and sustainable technologies that improve patient outcomes.[16]


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Victorian Healthcare Facilities [Internet].; 2015 October 5 [cited on 2018 October 20]. Available from: www2.health. vic.gov.au/hospitals-and-health-services/planning-infrastructure/sustainability/carbon-emissions 15. Audit office of New South Wales. Building energy use in NSW public hospitals â&#x20AC;&#x201C; hospital energy costs need more attention [Internet]. 2013 June 4 [cited on 2018 October 21]. Available from: https://www.audit.nsw.gov.au/media/building-energy-use-in-nsw-public-hospitals 16. Sustainable Specialties. Sustainable Specialties, Centre for Sustainable Healthcare [Internet]. 2017 September 27 [cited on 2018 October 20]. Available from: www. sustainablehealthcare.org.uk/what-we-do/sustainable-specialties 17. NHS Sustainable Development Unit. Operational TLC [Internet]. 2015 March [cited 2018 October 21]. Available from: www.sduhealth.org.uk/areas-of-focus/leadership-engagement-and-workforce-development/engagement/operational-tlc.aspx 18. Why Eating More Vegetables Is Good for the Environment. The Economist, The Economist Newspaper [Internet]. 2016 April 19 [cited on 2018 October 20]. Available from: www.economist.com/the-economist-explains/2016/04/19/why-eating-more-vegetables-is-goodfor-the-environment 19. While AE. Promoting healthy behaviours - do we need to practice what we preach?. London journal of primary care 2015 vol. 7,6; 112-114. 20. Patz JA. Solving the global climate crisis: the greatest health opportunity of our times?. Public Health Rev. 2016 37:30. pmid:29450071

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s a man in his mid-twenties, I can still remember the angst, humour and confusion that came with sexual education classes in the early years of my secondary school education. I sat in a classroom with a condom and one of a variety of phallic-shaped fruit or vegetables, be it a banana, eggplant or zucchini, while the intricacies of the male and female sexual organs were explained in painful detail. In hindsight, I can understand how the primary goal of these classes was to impart the knowledge and skills that would enable us to make responsible and safe sexual decisions in the future. However, safe and fulfilling sex lives do not rest solely on safe sexual practices, where most of the emphasis is often placed. What about factors such as consent, mutual respect and lack of coercion and pressure? All factors that contribute to healthy and safe sexual practices. Often left unaddressed are the acceptable and unacceptable behaviours that serve as a prelude to domestic violence and the gender inequality and stereotypes that subconsciously influence how young boys, in the process of becoming men, will perceive and ultimately come to treat their partners. It is these seemingly inconsequential events and toxic exposures that culminate in the kinds of attitudes that lead men to display abusive behaviours. Violence, in many of its forms, is strongly linked to exposure

at an early age. [1,2] The behaviours, attitudes, and views that boys and girls are exposed to at an early age will dictate which social behaviours both men and women deem acceptable and unacceptable. Domestic violence refers to violence, intimidation and abuse between 2 people who are in or have previously been in an intimate relationship.[3] The violence is used as a form of control by the perpetrator and can manifest itself not only in physical abuse, but also emotional, sexual, financial and verbal abuse.[4] Domestic violence may not be the first topic that comes to mind when you think of sexual education classes or global health, but it has been recognised by both the World Health Organisation (WHO) and the Australian Institute of Health and Welfare (AIHW) as a public health issue of epidemic proportions, associated with devastating individual and community consequences.[5,6] The pervasive and insidious nature of this problem is often, and misguidedly, seen as a private family matter.[3] Recent damning reports from the AIHW highlight just how prevalent domestic violence is in Australia. Domestic violence affects 1-in-4 Australian women, mostly in the form of physical or sexual violence, 52

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DOMESTIC VIOLENCE: THE MOURNED, THE OUTRAGED AND THE FORGOTTEN


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usually at the hands of a current or former partner. [6] It also leads to the death of 1 Australian woman per week.[6-8] Globally, the WHO found that 30% of women worldwide are affected by intimate partner violence, which is the most common subtype of violence against women.[5] Although domestic violence can affect any woman at any point throughout their lives, the AIHW has identified particular groups of women who are at greater risk, including indigenous women, women experiencing financial hardship, young women, pregnant women, differently-abled women and women who had witnessed abuse as children, all of whom are more likely to become victims, survivors and statistics of domestic violence.[6]

Gillette, a well-known men’s razor and grooming brand, released an advertising campaign, “We Believe: The Best Men Can Be”, a spin on the company’s long-term slogan “The Best A Man Can Get”. The campaign explores how the aforementioned toxic behaviours observed in childhood are nurtured into adulthood, and additionally highlighted the need for positive role models to shape impressionable boys into respectable young men.[11,12] As stated by Gillette in championing the campaign: “It encourages men to stamp out the culture of toxic masculinity and call out their mate’s behaviour”. [11,12] The advertisement received an outpouring of support, with more than 25 million views on YouTube.[10] As you might expect, it was simultaneously met with a torrent of anger and backlash, with calls from a particular subgroup of disgruntled men to boycott the company.[10] The reaction from this subgroup of men stemmed from the perceived generalisation that all men are perpetrators of domestic violence. However, what the outraged subgroup failed to comprehend and understand is that in order to target the minority of men who are perpetrators of domestic violence, all men need to be put in the spotlight and encouraged to call out their mates, colleagues and acquaintances on the toxic behaviours they exude and support. Take drink driving as another example where addressing the majority helped stamp out a particular behaviour in a minority: in 2011, the Transport Accident Commission (TAC) released drink-driving advertisements that addressed all drivers. How could we forget “If You Drink, Then Drive, You’re a Bloody Idiot”. While the campaign drew attention to the minority who drove under the influence of alcohol,[13] its message – which highlighted the consequences of

The health impacts of domestic violence on victims extend well beyond the obvious physical bruises and scars victims sustain. Given the spectrum of different ways domestic violence may occur, naturally the health impacts are manifest in a plethora of ways. Depression and the development of substance abuse issues are a major concern, with women who have fallen victim to domestic violence being twice as likely to experience depression or have a substance abuse issue.[3] Unwanted pregnancies, abortion and the increased incidence of sexually-transmitted diseases are just a few more of the health impacts that are observed in victims of domestic violence. Furthermore, transgenerational effects are seen with higher rates of low-birth weight babies being born to women whose unwanted pregnancies resulted from an act of domestic violence. [5] Beyond the undeniable negative impacts of domestic violence on the victims themselves, from a purely economic stance, domestic violence is estimated to cost Australia $21.7 billion each year, with federal and state governments carrying over onethird of the cost burden.[9] Given both the magnitude of the personal and community consequences, it begs the question as to why more is not being done to prevent domestic violence and the associated sequelae from occurring? Is it possible we are targeting the issue too far downstream where the abuse has already occurred, rather than upstream where the problem originates?

These tragedies occur at the hands of men who believe that a woman’s life, their independence and their right to feel safe walking home or after a relationship has ended, is somehow less important. drink driving on both a personal and public level – was designed to reach the broader community, with a reminder that this was an issue that affected all those who used the roads. In a similar fashion, the Gillette campaign asked men to question how their ideals, thoughts, behaviours and actions would affect not only themselves, but the boys, men, girls and women around them.[11,13]

Domestic violence is an issue that is entrenched in decades of gender inequality, disrespect and stereotyped gender constructs.[6] The term ‘toxic masculinity’ has recently come into vogue and is heavily associated with men ultimately becoming perpetrators of domestic violence. However, while it has been comprehensively used and referenced in this context, it is a concept that has been around for centuries. ‘Red- blooded’ and ‘macho’ are all terms used interchangeably to describe the type of masculinity to which men should aspire.[10] Recently

Many other preventative programs and interventions have focused on the growing issue of domestic violence. Campaigns such as the Do Something 53


The Federal Labor government has recently pledged $60 million to help women who are fleeing from domestic violence. Such a move is likely a bid to increase poll popularity, especially as, thus far, government interventions have made little difference to the morbidity and mortality associated with domestic violence, with numbers of women falling victim increasing rather than decreasing. [19] Why is this the case? The majority of current anti-violence interventions aim to target the issue downstream, after women have become the victims of domestic violence, rather than implementing primary interventions that aim to eliminate the central drivers of violence. School-based sex education classes should highlight the notion that safe sex and respectful sex are not mutually exclusive. If young boys and girls, on the precipice of sexual exploration, were taught the values of respect and the boundaries of acceptable behaviours at a young age, perhaps we could instil values that work to create equality rather than gender stereotypes of dominance and submissiveness that often lead to violence. Given that men are the most likely perpetrators of violence against women, targeting boys at school and working to disband rigid gender roles would be far more effective than waiting for the violence to occur.

So far, 2019 has seen the deaths of 19 women and 5 children from domestic violence in Australia.[16] Recent media coverage of the rape and murder of Aiia Maasarwe, a Palestinian-Israeli student who was studying in Melbourne, received an outpour of community support in the weeks that followed. Less than 2 months later, another tragedy occurred: the murder of Sydney-based dentist Preethi Reddy, who was murdered by her former partner and her body stuffed into a suitcase.[17,18] These scenarios are not a new phenomenon; they are scenarios that we have heard countless times in the past, each time labelled an ‘unacceptable tragedy’. Nonetheless, each time we mourn, accept and ultimately forget until the next tragedy occurs. These tragedies occur at the hands of men who believe that a woman’s life, their independence and their right to feel safe walking home or after a relationship has ended, is somehow less important. Men should not be worried that their masculinity is being threat-

Note that throughout this article, ‘domestic violence’ has not been abbreviated to ‘DV’, despite a broader publication trend towards such colloquialism; indeed, as though the weight of the 2 words themselves are too much for our minds to handle repetitively. I have chosen to repeat the term as many times as I possibly can, in order to give the issue and its tragic consequences the respect it deserves. This will, with any luck, leave a heavy impression on the minds of readers who have contemplated what has been said. It is an issue that should weigh on our minds. An issue that affects millions and millions of women worldwide should not be allowed to simply disappear into a meaningless abbreviation, as so many serious issues in this day and age do. The victims of domestic violence deserve more than abbreviation; more than being mourned for a week or a month and forgotten over time. Furthermore, the perpetrators need to understand the impact of their beliefs and more so, their actions. While society is quick to diagnose and call out toxic masculinity and label the kind of behaviours it constitutes, much less time has been spent attempting to prevent its conception. Society is far more fixated on exploring

If young boys and girls, on the precipice of sexual exploration, were taught the values of respect and the boundaries of acceptable behaviours at a young age, perhaps we could instil values that work to create equality rather than gender stereotypes of dominance and submissiveness that often lead to violence. ened, as they have done in response to the Gillette campaign. Instead they should look introspectively and recognise which behaviours and traits “make a 54

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man”, compared to those which are responsible for domestic violence. Men need to recognise the impacts of their actions, become allies of anti-violence campaigns and begin to stand in solidarity with the actual victims.

campaign funded by the Queensland government focuses on bystander intervention and urges community members to take an active role in reducing domestic violence.[14] Other government campaigns such as Let’s Change the Story and Stop It at the Start, have focused on the primary prevention of domestic violence. At the core of these campaigns is the notion that domestic violence is rooted in gender inequality and learned toxic behaviours. These campaigns focus on changing our society’s perception of gender norms and to prevent young boys from becoming future perpetrators.[7,15] Only a handful of these public health campaigns have succeeded in highlighting and emphasising the upstream factors that ultimately cause men to become violent towards women. Many have highlighted downstream consequences through simply providing statistics, stating that victims require protection and reiterating the fact that domestic violence is a growing concern.


the way that toxic masculinity festers and spreads rather than finding a way to stop the problem from manifesting in the first place. This should be our primary focus. In an age where gender constraints have loosened and the notion of toxic masculinity is being both defined and questioned, it is up to us to find the cure for a social disease which has become so rife, so commonplace and so accepted. Domestic violence is not an unavoidable or inflexible social problem. It is the product of multifaceted yet amendable environmental and social factors, many of which boys and girls are exposed to in the early years of their life.

partment of Parliamentary Services, Parliamentary Library; 2014. 5. Violence Against Women: a ‘global health problem of epidemic proportions’[Internet]. Geneva: World Health Organisation; 2013 [cited 2019 Apr 10]. Available from: https://www. who.int/mediacentre/news/releases/2013/violence_against_ women_20130620/en/ 6. Australian Institute of Health and Welfare. Family, domestic and sexual violence in Australia [Internet]. Cat no. FDV 2. Canberra: AIHW; 2018 [cited 2018 Jul 15]. Available from: https://www.aihw.gov.au/getmedia/d1a8d479-a39a-48c1bbe2-4b27c7a321e0/aihw-fdv-02.pdf.aspx?inline=true 7. OurWatch. End Violence Against Women And Their Children [Internet]. Melbourne: OurWatch; 2018 [cited 2018 Jul 18]. Available from: https://www.ourwatch.org.au/ 8. White Ribbon Australia Foundation. Domestic Violence Statistics [Internet]. Canberra: White Ribbon Australia; 2019 [cited 2019 Mar 4]. Available from: https://www.whiteribbon. org.au/understand-domestic-violence/facts-violence-women/ domestic-violence-statistics/ 9. Family and Domestic Violence. Canberra: Australian Medical Association; 2016 [cited 2019 Apr 10]. Available from: https://ama.com.au/position-statement/family-and-domestic-violence-2016 10. Salam M. What is Toxic Masculinity? [Internet]. New York: The New York Times; 2019 [cited 2019 Apr 10]. Available from: https://www.nytimes.com/2019/01/22/us/toxic-masculinity.html 11. Ritson M. Gillette: how vexed a man can get [Internet]. The Australian. 2019 [cited 2019 Jan 18]. Available from: https://www.theaustralian.com.au/news/inquirer/gillettehow-vexed-a-man-can-get/news-story/0c3c1e01a162599bdfb2e3798d245022 12. Ford C. Who could hate Gillette’s campaign for positive masculinity? Men could [Internet]. The Sydney Morning Herald. 2019 [cited 2019 Jan 16]. Available from: https://www. smh.com.au/lifestyle/life-and-relationships/who-could-hategillette-s-campaign-for-positive-masculinity-men-could20190116-p50ro1.html 13. Drinking. Driving. They’re better apart. Towards Zero Campaign [Internet]. Canberra: Transport Accident Commission; 2010 [cited 2019 Mar 9]. Available from: https://www.tac. vic.gov.au/road-safety/tac-campaigns/drink-driving 14. Do Something About Domestic Violence, Bystander Campaign [Internet]. Brisbane: Queensland Government; 2019 [cited 2019 Mar 4]. Available from: https://campaigns.premiers. qld.gov.au/dosomething/ 15. We Can Help Stop It At The Start, Respect Campaign [Internet]. Canberra: Australian Government; 2019 [cited 2019 Mar 4]. Available from: https://www.respect.gov.au/the-campaign/ 16. Australia’s Death Toll [Internet]. Melbourne: IMPACT For Women; 2019 [cited 2019 Apr 10]. Available from: http://www. impactforwomen.org.au/australias-death-toll-2019.html 17. Cuthbertson D. ‘Everyone has the right to get home safely’. Aiia Maasarawe and the adopted city she loved [Internet]. The Age. 2019 [cited 2019 Mar 4]. Available from: https://www. theage.com.au/national/victoria/everyone-has-the-right-toget-home-safely-aiia-maasarwe-and-the-adopted-city-sheloved-20190117-p50rwe.html 18. Chung L, Rawsthorne S, Olding R. ‘It’s pretty awful’: Body of missing dentist found in suitcase [Internet]. The Age. 2019 [cited 2019 Mar 9]. Available from: https://www.theage.com. au/national/nsw/very-concerned-about-her-sydney-dentistpreethi-reddy-missing-20190305-p51200.html 19. Leah N. Labor Pledges $60 Million To Help Women Fleeing Domestic Violence [Internet]. Canberra: SBS News; 2019 [cited 2019 Apr 10]. Available from: https://www.sbs.com. au/yourlanguage/korean/en/article/2019/03/04/labor-pledges-60-million-help-women-fleeing-domestic-violence

The boys that we bring up today will become the men of tomorrow. We need to assess and target the factors that ultimately lead to disrespect, hostility and violence. We need to stop endorsing an upbringing where women are seen to be weak and are less valued, while men are raised to be dominant and controlling. We need to take the opportunity to tackle the issue at the beginning, before the notions of inequality and violence rear their ugly heads. We need to ensure that a generation of boys and girls are able to learn from male and female role models. Most importantly, we need to do everything in our power to ensure that the giggles that echo in classrooms around the country during sexual education classes are not blunted by dated, misconstrued beliefs that may someday lead to devastating consequences. Kyrollos is a final year medical student at Deakin University. His passion for global health and social justice started well before journeying into medicine. However, the last four years and involvement in AMSA Global Health has provided him with the platform to learn, educate and advocate for issues we will all face in future practice. Kyrollos hopes that his work will shed some light on an issue that lingers beneath the surface but is often overlooked. Conflicts of Interest None declared Correspondence kyrollos@deakin.edu.au

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References 1. Moffitt TE. Childhood exposure to violence and lifelong health: Clinical intervention science and stress-biology research join forces. Dev Psychopath. 2013;25(4):1619-34. 2. Aliprantis D, Chen A. The Consequences of Exposure to Violence during Early Childhood [Internet]. Cleveland: Economic Commentary. 2016 [cited 2019 May 16]. Available from: https://www.clevelandfed.org/newsroom-and-events/publications/economic-commentary/2016-economic-commentaries/ ec-201603-consequences-of-exposure-to-violence-during-early-childhood.aspx 3. Domestic Violence: A Public Health Problem and a Public Health Concern [Internet]. Massachusetts: National Network to End Domestic Violence; 2016 [cited 2019 Apr 10]. Available from: https://nnedv.org/latest_update/domestic-violence-public-health-concern/ 4. Phillips J, Vandenbroek P. Domestic, family and sexual violence in Australia: an overview of the issues. Canberra: De-

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PANDORAâ&#x20AC;&#x2122;S BOX The benefits and burdens of compulsory mental health treatment in the community Natalie S

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t’s humiliating,” she responded, when I asked Lizzy*, a patient on a community treatment order (CTO), how she felt about her compulsory medication. Lizzy and a series of encounters with other people during my mental health rotation led me to wonder about the problems which are inherent to compulsory treatment.

the perspective that they may violate patient rights. Similarly, psychiatrists in Israel have commented that CTOs may not be effective, are difficult to enforce and may violate individual liberties.[6]

The use of compulsory treatment in psychiatry is an ethical dilemma which provokes differing opinions and powerful emotional responses. Psychiatry is unique among medical specialties in its capacity to mandate treatment on otherwise unwilling patients. This can be particularly difficult when someone with a mental health condition has the capacity to refuse treatment, but is forced to engage regardless.[1] In Australia, patients are otherwise allowed to make their own decisions if they can understand and retain information related to the different options, weigh them up and conceive the outcomes. It has been argued that forcing treatment onto mental health patients who have capacity is discriminatory and a human rights violation.[2]

With a checkered past of paternalism, psychiatry has turned to self-reflection in order to find ways to move forward.

CTOs are designed to improve clinical outcomes and mental health. In Victoria, CTOs are implemented for people with a mental illness who require treatment to prevent harm or deterioration in their health, where treatment is available and there are no less restrictive means to offer treatment.[3] Legislation which authorizes compulsory community treatment varies across the world but shares basic similarities.[6] Such compulsory orders are used to promote contact with mental health services for people in need, thereby encouraging treatment adherence with the goal of improving symptoms and functioning. However, many patients have described the experience of compulsory treatment as akin to “imprisonment, punishment, helplessness and marginalization”.[4] Such reflections are concerning, as the use of compulsory treatment is high in Australia compared to global standards.[5] The rates of people under a CTO in Queensland and Victoria are 20-30 times higher than those in Canada and some areas of the United States, and substantially higher than rates in Israel.[6] Furthermore, these rates have been rising across New Zealand, Australia, Israel and regions of the United States.[6] The comparatively lower rates in parts of the United States have been attributed to concerns around liability, lack of resources, strict criteria for orders and poor understanding of these criteria.[6] In Canada, lower rates have been linked to a lack of familiarity with orders, doubts around their efficacy and

With a checkered past of paternalism, psychiatry has turned to self-reflection in order to find ways to move forward. It is therefore important to explore whether we can progress further with compulsory treatment and improve outcomes for patients and clinicians alike. The discussion is especially vital in a country with high CTO rates, such as Austra-

lia. This article will explore the benefits and harms of compulsory treatment in psychiatry, ultimately showing that the harm can often outweigh benefits. Potential benefits of CTOs An obvious question arising from compulsory treatment is the impact it may have between a patient and clinician. A recent review showed that compulsory treatment may not be perceived in a negative light if the therapeutic relationship is positive and the individual feels staff members are supportive and acting in their best interests.[7] In Sweden, a small number of patients in acute psychiatric care were interviewed by Andreasson and Skärsäter,[8] who found that patients perceived compulsory treatment as positive if they were provided with good care by staff, informed about the situation and asked for their input on treatment. Some patients have reported that CTOs gave structure to their life. In Canada, interviews with family members showed that they found CTOs helpful when patients had limited insight.[9] A New Zealand study determined that many patients liked the sense of security and immediate access to healthcare services from CTOs and felt that their health and stability had improved as a result.[10] Many psychiatrists interviewed also reported that it promoted greater patient contact, helped with medication compliance and allowed earlier identification of potential relapses.[10] Some psychiatrists also believed that the benefits outweighed the harms and that therapeutic relations improved with the insight that came with successful treatment. CTOs can also help families and carers, subsequently improving these relationships.[10] Some patients report that CTOs increase the control they have over their lives and provide a sense of security through 57

*The above article includes names that have been changed for patient confidentiality.

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in the community within the United States made no difference in terms of quality of life, social function or use of mental health services.[17] Another systematic review found that CTOs do not have a significant impact on hospitalization or utilization of other services.[18] An Australian study reported that patients on CTOs were actually more likely to experience readmission, even after controlling for demographic traits, mental health history and treatment settings.[19] CTOs were introduced in England and Wales during 2008, but a randomized controlled trial in England determined that CTOs did not reduce hospital readmissions for patients with psychosis.[20] A review on the international experiences of CTOs across countries in North America, Australasia, Europe and Asia found similarly mixed results, with conflicting evidence regarding whether CTOs affected clinical outcomes or service use. Clinicians from different countries all had varying perceptions on the benefit and harms of CTOs and many studies contained poor quality evidence due to practical and methodological limitations.[21] The data available on the clinical benefits of CTOs is clearly restricted in terms of both quantity and quality. There are mixed and inconsistent results, with evidence existing both for and against CTOs. Studies with improved designs and fewer limitations are needed to elucidate the disparities and contradictions in the literature.

Compulsory treatment may have other clinical benefits. One Canadian study showed that compulsory community treatment decreased the amount of time spent as an inpatient for people with psychosis.[12] Another study in Canada found that CTOs delayed time to re-hospitalisation, as they allowed patients to reside and be managed in the community for longer.[13] Delaying the need for inpatient treatment is arguably a less restrictive act as it allows for greater freedom in the long term. A study in Western Australia found that CTOs may reduce overall mortality, due to greater contact with community health services.[14] Similarly, a study which examined CTOs after they were introduced in Scotland during 2005 determined that CTOs may reduce the duration of hospital stay for patients with mental health conditions.[15] This suggests that perhaps increased surveillance in the community leads to earlier intervention. Potential harms of CTOs The discussion regarding whether compulsory treatment is ethical is redundant if compulsory treatment does not actually have therapeutic benefits. Therapeutic benefits can be measured by a number of outcomes, such as reduced hospitalisation. Whilst the aforementioned studies reflect these advantages alongside reduced overall mortality, multiple studies have shown no clinical benefits. An epidemiological study in Western Australia assessed whether CTOs reduced use of health services by measuring inpatient admissions, bed days and contact with outpatient services, compared to psychiatric patients who were not under CTOs. The study controlled for clinical features, mental health history and sociodemographic variables, and found that CTOs were associated with greater outpatient contact, but no further advantages.[16] This is consistent with results from across the world. A systematic review determined that compulsory treatment

During the Maudsley debate in London, it was proposed that compulsory community treatment is a form of social control which is discriminatory, unethical and damages therapeutic relationships. [1] It was argued that compulsory treatment may deter patients from the mental health system, resulting in delay to treatment and poorer outcomes. [1] Furthermore, an inherent danger of long-term CTOs is that patients may recover capacity during treatment, but still wish to refuse treatment. A focus group involving patients of the public mental healthcare system in Victoria appeared to agree, stating they were overall dissatisfied with CTOs and found them â&#x20AC;&#x2DC;stigmatising and disempoweringâ&#x20AC;&#x2122;. [22] Patients have reported depot antipsychotics as particularly coercive and stigmatizing compared to oral medication, although this is balanced by their role in assisting medication compliance for disabling mental illness.[12] When I spoke to George*, an engaging client who was more than willing to help medical students, he would nod off during our conversations. He later clarified that he often received only 5 hours of broken sleep a night - his compulsory risperidone depot gave him intolerable akathisia, which was barely relieved by pacing up and down his bedroom until 3 AM. Antipsychotics in general can have severe or significant adverse effects, like extrapyramidal symptoms, which signifi-

He later clarified that he often received only 5 hours of broken sleep a night - his compulsory risperidone depot gave him intolerable akathisia, which was barely relieved by pacing up and down his bedroom until 3 AM 58

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the available professional support.[11] After an acute episode has resolved, some patients retrospectively agree with the justifications behind forced medication in their care.[10] This demonstrates how CTOs may be beneficial under certain circumstances.


cantly impact quality of life. They may also shorten lifespan through metabolic side effects.[23] Certainly, there are many legitimate reasons why someone may refuse treatment which can be addressed through means other than enforcement, such as a collaborative approach.

and parents. Int J Law Psychiatry. 2003; 26(6):627-45. 5. Light E, Kerridge I, Ryan C, Robertson M. Community treatment orders in Australia: rates and patterns of use. Australas Psychiatry. 2012;20(6):478-82. 6. Lawton-Smith S. A question of numbers: The potential impact of community based treatment orders in England and Wales, London: King’s Fund; 2015 [cited 27/4/2019]. Available from: https://www.kingsfund.org.uk/ 7. Sheehan KA. Compulsory treatment in psychiatry. Curr Opin Psychiatry. 2009;22(6):582-6. 8. Andreasson E, Skärsäter I. Patients treated for psychosis and their perceptions of care in compulsory treatment: Basis for an action plan. J Psychiatr Ment Health Nurs. 2012;19(1):1522. 9. O&#39;Reilly RL, Keegan DL, Corring D, Shrikhande S, Natarajan D. A qualitative analysis of the use of community treatment orders in Saskatchewan. Int J Law Psychiatry. 2006;29(6):516-24. 10. Gibbs A, Dawson J, Ansley C, Mullen R. How patients in New Zealand view community treatment orders. J Ment Health. 2005;14(4):357-68. 11. Burns T, Dawson J. Community treatment orders: how ethical without experimental evidence?. Psychol Med. 2009;39(10):1583-6. 12. Frank D, Perry JC, Kean D, Sigman M, Geagea K. Effects of compulsory treatment orders on time to hospital readmission. Psychiatr Serv. 2005;56(7):867-9. 13. Nakhost A, Perry JC, Frank D. Assessing the outcome of compulsory treatment orders on management of psychiatric patients at 2 McGill University-associated hospitals. Can J Psychiatry. 2012;57(6):359-65. 14. Kisely S, Preston N, Xiao J, Lawrence D, Louise S, Crowe E. Reducing all-cause mortality among patients with psychiatric disorders: a population-based study. CMAJ. 2013;185(1):E50-6. 15. Taylor M, Macpherson M, Macleod C, Lyons D. Community treatment orders and reduced time in hospital: a nationwide study, 2007–2012. BJPsych Bull. 2016;40(3):124- 6. 16. Preston NJ, Kisely S, Xiao J. Assessing the outcome of compulsory psychiatric treatment in the community: epidemiological study in Western Australia. BMJ. 2002;324(7348):1244. 17. Kisely SR, Campbell LA, O&#39;Reilly R. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev. 2017;3:CD004408. 18. Maughan D, Molodynski A, Rugkåsa J, Burns T. A systematic review of the effect of community treatment orders on service use. Soc Psychiatry Psychiatr Epidemiol. 2014;49(4):65163. 19. Kisely SR, Xiao J, Preston NJ. Impact of compulsory community treatment on admission rates: survival analysis using linked mental health and offender databases. Br J Psychiatry. 2004;184(5):432-8. 20. Burns T, Rugkåsa J, Molodynski A, Dawson J, Yeeles K, Vazquez-Montes M, et al. Community treatment orders for patients with psychosis (OCTET): a randomised controlled trial. Lancet. 2013;381(9878):1627-33 21. Churchill R, Owen G, Singh S, Hotopf M. International experiences of using community treatment orders. London: Institute of Psychiatry; 2007. 22. Brophy L, Ring D. The efficacy of involuntary treatment in the community: Consumer and service provider perspectives. Soc Work Ment Health. 2004;2(2-3):157-74. 23. O’Reilly R. Why are community treatment orders controversial?. Can J Psychiatry. 2004;49(9):579-84.

Mental health professionals, as the individuals charged with the task of enforcing compulsory treatment, are also personally affected. Compulsory treatment stigmatizes both patients and staff members. And the coercive aspect of compulsory treatment can prove to be an obstacle to establishing a positive therapeutic relationship.[1] Andrew*, a man who spent much of his time on the ward buried in books, had firmly refused hospitalisation. During his initial admission, his doctor had recommended he agree to become a voluntary patient, which would allow him to have less restrictions and ward leave on the condition that he would not self-discharge. Andrew subsequently questioned the true meaning of ‘voluntary’. It is clear here that the voice of the patient is also crucial in deciding whether compulsory treatment will benefit management.

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All human beings have the right to self-determination. Enforcing treatment without patient consent can open a Pandora’s box of problems. Even unintentionally, involuntary treatment could be used too broadly, for too long or incorrectly. There are clearly defined benefits and harms associated with CTOs. Whilst CTOs may improve access to healthcare, patient contact and decrease relapses, some studies show that CTOs may not improve clinical outcomes and can lead to stigma and damaged rapport. Whether the benefits outweigh the harms requires further research and investigation. Regardless of the evidence, one thing is clear – irrespective of the type of treatment an individual is receiving, all patients have a right to respect, compassion and for their voice to be heard. Natalie S is a final year medical student at The University of Melbourne and in her second year of a Master of Youth Mental Health. She is currently undertaking a research project relating to psychotic symptoms among young people. Conflicts of interest None declared References 1. Pinfold V, Bindman J. Is compulsory community treatment ever justified?. Psychiatry Bull. 2001;25(7):268-70. 2. Callaghan S, Ryan CJ. Rising to the human rights challenge in compulsory treatment–new approaches to mental health law in Australia. Aust N Z J Psychiatry. 2012;46(7):611-20. 3. Department of Health &amp; Human Services. Treatment orders [Internet]. State Government of Victoria. Department of Health &amp; Human Services; 2015 [cited 27/4/2019]. Available from: https://www2.health.vic.gov.au/ 4. Tan JO, Hope T, Stewart A, Fitzpatrick R. Control and compulsory treatment in anorexia nervosa: the views of patients

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A ‘fresh’ perspective on closing the gap Anna-Louise Bayfield Setting the scene: Questions evoked by travelling to remote Australia

H

ow do we ‘Close the Gap’? If you are a member of the Australian health care system you have undoubtedly asked this question at least once. Perhaps a question less frequently considered is: how do fresh fruit and vegetables travel to remote, Central Australia, and what are they like when they arrive? The significance of this question may not seem apparent at first, but given that an estimated one-fifth of the burden of disease of Indigenous Australians is attributable to a poor diet low in fresh fruit and vegetables,[1] and given that 19% (148, 700) of these Australians live either remotely or very remotely,[2] perhaps the answer is worth exploring.

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To aid this exploration, let us envisage the journey of an avocado from its production point to remote Central Australia. Avocados are not grown in the remote communities of Central Australia; the land is arid and economically unviable from a large-scale commercial perspective, and gardens though desirable, are scarce.[3] The avocado is hence imported from elsewhere, most often from larger centres, like Alice Springs or Darwin. This is not often an easy task. In the vast, 1.3 million square kilometres of the Northern Territory,[4] swaths of remote land are serviced by unsealed roads that may be closed during the wet season. If road travel is eliminated, the avocado must come by charter plane or barge service. The company running this service may have a monopoly, which combined with inelastic demand results in high transport prices. On the way, freight difficulties or frequent stops may disrupt the cold chain and reduce the shelf-life and quality of the avocado. If and when the avocado ar-

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FOOD AND REMOTE AUSTRALIA


rives, it arrives to a single, local community store. This store must operate as a viable business and is often the only store servicing a small community. There is no competition, and there are very high operating prices. The avocado arrives over-ripe, perhaps bruised in some areas, and the price sticker attached to it is much heftier than where it started.

(Table 1) 2. Evidence of poorer quality food (Figure 1), and 3. Reduced supply of nutritious foods (Figure 2). Expanding the scope: From personal experience to endemic failure in Indigenous Australian Healthcare This trifecta of food insecurity is not an isolated phenomenon in Australia.[3,5,6] Research consistently finds that healthy food baskets cost 20-43% more in remote areas compared to major cities.[5] Fresh food is more likely to be of poorer quality,[6] and communities can go days or weeks without fresh produce due to transport delays.[5]

Though the journey of this avocado was a theoretical one, each of the difficulties faced have been well described in the literature documenting food supply to remote Australia,[3,5,6] and the outcome is far from theoretical. I learnt this personally after accompanying a visiting cardiologist to 3 remote Aboriginal Australian communities in Central Australia during April 2019. There were no shortage of patients, with high rates of poorly controlled diabetes, obesity and ischaemic heart disease. All 3 of the communities were “dry” meaning that alcohol was not permitted. Through taking dietary histories, I found that while patients were aware of what constituted a nutritious diet, there were nonetheless high rates of consumption of “takeaways” – readyto-eat hot meals sold at the community store, items such as meat pies and pizzas – and products high in refined sugars, such as sugar-sweetened beverages (SSB), compared to fruits and vegetables.

The stagnant, seemingly unmovable gap in life expectancy between Indigenous and non-Indigenous Australians of approximately 10 years is well known.[7] Eighty percent of this health gap is estimated to be due to chronic diseases including diabetes and ischaemic heart disease.[5] The following data are worth emphasising, despite being less publicised: 1. More than half (59%) of Indigenous Australians living in very remote Australia are estimated to be on the lowest quintile of equivalised household income.[8] 2. In 2010, families receiving welfare in remote communities in Western Australia would need to spend 50% of their disposable income to afford a healthy diet. For a non-Indigenous, non-remote Australian family with an average income, this number was 16%.[6] 3. Only 6% of remote Aboriginal Australian households have “health hardware”; that is, infrastructure necessary for the preparation and storage of perishable food, such as refrigeration, a functioning stove and a sink.[6]

Was this an issue of poor choices or was something else at play? In each community, there was a single store supplying the vast majority of food to the population. By attending and reviewing each of the 3 stores, I discovered an unambiguous answer to this question. Each store demonstrated a trifecta of food insecurity consisting of: 1. Consistently higher prices of nutritious food

A time-matched comparison of the prices of fresh produce in 3, unidentified local stores in remote Central Australia and large supermarkets in larger Australian cities in April 2019

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Product

Store 1

Store 2

Store 3:

$8.37

Strawberry punnet 250g

Alice Springs Woolworths

South Yarra Woolworths

$3.50

$3.50

$1.78

$2.67

Red capsicum each

$6.90

Green capsicum each

$4.40

$3.70

$1.73

$1.98

1kg carrots

$3.00

$3.65

$1.00

$2.00

Cauliflower each

$6.10 (half)

$4.40 (half)

$2.50 (whole)

$4.90 (whole)

Shepard avocado each

$3.90

$4.50

$2.50

$2.50

Broccoli 300g

$4.70

$2.01 (340g)

$1.47

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The 2008 House of Representatives Standing Committee on Aboriginal and Torres Strait Islander Affairs report “Everybody’s Business” gave 33 recommendations for improving community stores, including government subsidies for freight charges, increased store licensing and government partnership with individual communities in the decision-making process. This report received no formal response.[3,5,6,11]

Figure 1: Fresh produce available at an unidentified community store in Central Australia in April 2019

What do these pieces of information mean when laid out side-by-side on the red dirt of remote Australia? Current efforts to improve Aboriginal Australian health focus on nutritional education, such as the Aboriginal and Torres Strait Islander component of Go for 2 &amp; 5 fruit and vegetable promotion.[9] These efforts attempt to educate a group of people with high rates of poverty to buy food that is expensive, a day away from going rotten, and may not even be available on the shelf at all. If these people do decide to purchase the expensive, poor quality food, only 6% have the means to cook the food or store it for more than a few days.[5] Indeed, is it any surprise the diet of this group remains obstinately poor?

The 2009 Council of Australian Government’s National Strategy for Food Security in Remote Indigenous Communities outlined a nationally-coordinated approach between the states to improve health outcomes, including a national quality improvement scheme for stores, increasing the Indigenous Australian nutrition workforce and a national healthy-eating action plan. The 2014 audit of the strategy found that of the 5 intended goals with a mid-2010 expected completion date, only 1 had been completed. The audit concluded that “overall, the administration of the food security initiatives over time has been mixed”.[11]

A review of the solutions: Nationwide and local responses

Licensing of stores is an approach introduced by the Commonwealth Government in the Northern Territory in 2007. Once licensed, stores are assessed periodically against health-based licensing requirements and, if required, receive funding for initiatives to help meet these requirements. This policy has demonstrated positive results, including improved availability and quality of nutritious food, and of note, was reformed and renewed by the government in 2012 for 10 years.[12]

National responses Whilst there have been several attempts to address food security in remote Australia in the recent past systematically, most have been marred by inadequate resourcing and premature abandonment. The Commonwealth Government-funded National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan (NATSINSAP) ran between 2000-2010 and outlined a scaffolding for states and territories to collaborate with an aim to improve food security in remote Australia. A notable achievement was the Remote Indigenous Stores

Local responses In the absence of a coordinated national response since 2010, a number of strategies aimed at improving food security through targeting local communities have emerged, with outcomes worth examining.

The avocado arrives over-ripe, perhaps bruised in some areas, and the price sticker attached to it is much heftier than where it started.

Outback Stores is a Commonwealth-owned company established in 2006. The company is premised on enabling local communities to voluntarily sign 62

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and Takeaway Project (RIST) which included guidelines for stocking healthy foods and marketing strategies to promote its consumption. Pointof-sale data was also collected in order to monitor community consumption of healthy foods.[6] This data can provide food spending patterns and nutrient profiles and has been recommended as an effective and cheap way to analyse community response to food policy.[10] Since its completion in 010 there has been no ongoing funding or review of the NATSINSAP.[5]


Allowing remote communities to access affordable, good quality, nutritious food in no way ensures that the diets of these communities will improve, but not having access is a nonstarter.

on to a long-term management agreement, which then converts their community store to an “Outback Store”. This store is still community-owned and operated, but external management and standardised store policies are implemented to ensure the stock and quality of healthy foods. The company board is composed of Woolworths and Coles executives who are able to utilise established supplier networks to negotiate with freight companies.[3,6] While the government-subsidised company aims to be self-sufficient and profitable, it has received $77 million of government funding so far.[6] This funding has been injected into initiatives including employing on-site nutritionists, implementing a pointof-sale system to monitor store performance, as was used as a part of the RIST project, and overcoming losses in stores deemed economically unviable due to market failure.[3,6] The variety and quality of healthy food has improved under Outback Stores. [3,13] The stores have seen a consistent decrease in SSB sales and an increase in fruit and vegetable sales. Further, 85% of Outback Stores staff identify as Aboriginal Australian or Torres Strait Islander. [13] However, several problems have been highlighted, the most poignant of these being the relative disempowerment of the community. While Outback Stores aim to work with individual communities, ultimate management control is signed over to a government body.[3,6]

MW stores have been found to achieve better relative affordability of healthy foods when compared to Outback Stores and have substantially improved nutritious food accessibility. Road trains have delivered supplies weekly instead of fortnightly since 2005 and more than 98% of all recommended healthy food items are consistently available on MW shelves. In saying this, in April 2014 the price of a standard Market Basket of “healthy foods” in MW stores was still 35% more than the large supermarket in Alice Springs. Furthermore, there have been no significant dietary improvements within the APY lands. Energy dense ready-to-eat takeaway options and items high in refined sugar remain in high demand. These items have incredibly high profit margins driven by multinational food companies. Without government subsidisation MW stores are more vulnerable to market pressures.[14] Looking to the future I am under no impression that there is a simple solution to the problems outlined by this article. However, what is simple is this: people cannot eat food they cannot access. Remote Central Australia is a giant red amphitheatre, where the blaring sun shines a brutal spotlight on chronic disease. In 2008-09, the hospitalisation rate for regular dialysis treatment among Indigenous Australians was 11 times the rate of other Australians.[17] In many remote communities, the lifestyle factors contributing to this crisis may include alcohol but are also intrinsically linked to food. Nutritional education alone will not improve food security or change diet practices. Remote Australia has unique and specific challenges to food supply that can be targeted by market intervention. This intervention cannot be intermittent or short term and must rely on continuous and accurate auditing of data. It is essential these actions are taken in consultation with the local communities, not simply because this strategy is empowering but because it works better.

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The Mai Wiru Regional Stores Aboriginal Corporation is a not-for-profit organisation with similar goals to Outback Stores, established by the local Aboriginal health council and communities spread over the Anangu Pitjantjatjara Yankunytjatjara (APY) lands in South Australia.[14,15] Mai Wiru (MW) currently operates 9 stores, and its board members are made up entirely of Aboriginal Australian members of the APY lands. MW stores are government-independent and must remain financially viable without assistance.[16] Despite this,

Figure 2: Fresh vegetable selection available at an unidentified community store in a Central Australian community of approximately 500 people at 11:30am in April 2019

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Our previous efforts offer a promising framework, yet my own experience with the Australian outback tells me we need to do better. Simple, coordinated measures including providing funding to Mai Wiru and similar projects, allocating subsidies for fresh produce where appropriate, strategic partnerships with the food industry to improve the efficiency and quality of transportation, and consistently au-


10. Ferguson M, O&#39;Dea K, Chatfield M, Moodie M, Altman J, Brimblecombe J. The comparative cost of food and beverages at remote Indigenous communities, Northern Territory, Australia. Aust N Z J Public Health. 2015;40(1):S21-6. 11. Pratt S, DeMamiel M, Reye K, Huey A, Pope A. Food security in remote Indigenous communities. Report no. 1 [Internet]. Canberra: Australian National Audit Office; 2014 [cited 2019 Apr 23]. Available from: https://www.anao.gov.au/ 12. Department of the Prime Minister and the Cabinet. Stronger futures in the Northern Territory. Part 2: Six monthly progress report [Internet]. Canberra: AIHW; 2014 [cited 2019 Apr 23]. Available from: https://www.pmc.gov.au/ 13. Outback Stores. Outback Stores Annual Report 20172018. Berrimah: DPMC; 2018 [cited 2019 Apr 23]. Available from: https://outbackstores.com.au/ 14. Lee A, Rainow S, Tregenza J, Tregenza L, Balmer L, Bryce S, et Al. Nutrition in remote Aboriginal communities: lessons from Mai Wiru and the Anangu Pitjantjatjara Yankunytjatjara Lands. Aust N Z J Public Health. 2015;40(1):81–8. 15. Bierbaum N. Mai Wiru: process and policy Regional Stores Policy and associated regulations for the Anangu Pitjantjatjara lands [Internet]. Alice Springs: Nganampa Health Council; 2002 [cited 2019 Apr 23]. Available from: https://healthinfonet. ecu.edu.au/ 16. Whiting N. Food security plan for South Australia’s remote indigenous communities cut short by Government [Internet]. ABC News; 2014 [cited 2019 Apr 23]. Available from: https://www.abc.net.au/ 17. Australian Institute of Health and Welfare. Chronic Kidney Disease Compendium [Internet]. Canberra: AIHW; 2017 [cited 2019 Apr 23]. Available from: https://www.aihw.gov.au/

Allowing remote communities to access affordable, good quality, nutritious food in no way ensures that the diets of these communities will improve, but not having access is a nonstarter. Food security enables the possibility of change, which is an excellent place to start. Anna is a final-year Monash student enthusiastic about the unlikely, yet riveting combination of critical care and public health. She is an insatiable reader with a love of writing and a passion for medical education, particularly mentorship amongst junior and senior doctors. Acknowledgements Dr. Michele McGrady, consultant cardiologist, FRACP MBBS PhD FCSANZ Conflicts of interest None declared Correspondence albay5@student.monash.edu References 1. Department of Health and Ageing. Eat For Health: Australian Dietary Guidelines [Internet]. Canberra: NHMRC; 2013 [cited 2019 Mar 8]. Available from: https://www.eatforhealth. gov.au/ 2. Australian Bureau of Statistics. Estimates of Aboriginal and Torres Strait Islander Australians, June 2016 [Internet]. 2018 [cited 2019 May 8]; ABS cat. no. 3238.0.55.001. Available from: https://www.abs.gov.au/ 3. Hudson S. Healthy stores, healthy communities: the impact of outback stores on remote Indigenous Australians / Sara Hudson [Internet]. Sydney: Centre for Independent Studies; 2010 [cited 23 Apr 2019]. Available from: http://www.cis.org.au/ 4. Geoscience Australia. Land areas of States and Territories [Internet]. Canberra: Commonwealth Government of Australia; 2004 [cited 2019 May 8]. Available from: https://www.ga.gov. au/ 5. Pope A. Australian Red Cross, Dietitians Association of Australia and Public Health Association of Australia: Submission on Performance Audit of Food Security in Remote Indigenous Communities [Internet]. Canberra: Public Health Association of Australia; 2014 [cited 2019 Apr 23]. Available from: https://www.phaa.net.au/ 6. Davy D. Australia&#39;s Efforts to Improve Food Security for Aboriginal and Torres Strait Islander Peoples. Health Hum Rights. 2016;18(2),209–218. 7. Australian Institute of Health and Welfare. Deaths in Australia [Internet]. Canberra: AIHW; 2018 [cited 2019 Apr 23]. Available from: https://www.aihw.gov.au/ 8. Australian Health Ministers’ Advisory Council. Aboriginal and Torres Strait Islander Health Performance Framework 2014 Report Tier 2 Determinants of Health. [Internet]. Canberra: AHMAC; 2015 [cited 2019 Apr 23]. Available from: https:// www.pmc.gov.au/ 9. Lee A, Ride K. Review of programs and services to improve Aboriginal and Torres Strait Islander nutrition and food security. Australian Indigenous Health Bulletin. 2018;18(4):1-24. 64

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diting data from licensed stores are ways we can ensure that if you live in remote Australia you can afford and have access to an avocado worth eating. These are achievable, inexpensive efforts. In the 2017-18 financial year Outback Stores spent AU$1.76 million on economically unviable stores while the rest ran to profit, an average of $392 per community member.[13]


Of all the forms of inequality, injustice in health care is the most shocking and inhumane.

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Martin Luther King Jr

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AMSA Journal of Global Health

CASE STUDY FATAL NEONATAL TETANUS FROM RURAL BANGLADESH Madeline Fitzpatrick

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Abstract

overwhelming medical care needs. Despite these challenges, they endeavour to provide high-quality medical care.

Introduction

Patient B

Tetanus is a life-threatening disease caused by Clostridium tetani. It is a particularly dangerous and potentially fatal disease when contracted by neonates. Bangladesh has been declared free of neonatal tetanus. However, despite this status, isolated cases do still occur. This case describes the challenges faced by the Bangladeshi health system in combating this illness.

During one such hospital ward round, we examined an 8-day-old infant with profound hypertonia and hyperreflexia of all 4 limbs. He also exhibited opisthotonos (i.e., spasm of the muscles leading to arching of the upper body) and scissoring of the legs. He had significant respiratory distress, showing intercostal recession and tracheal tug. This was being managed with oxygen, delivered via nasal prongs. The hospital did not have the necessary facilities to attempt an intubation. He received intravenous cannulation through a superficial vein on his head, which enabled the administration of fluids. A brief translated history from his mother suggested that a clean blade had been used to sever the umbilical cord at birth, which had occurred at home without skilled medical help. Several days after birth, his initial symptoms of irritability and rigidity appeared. He was no longer able to feed normally and had markedly decreased oral intake. He was admitted to hospital on his third day of life with a clinical diagnosis of tetanus. His management was primarily supportive. The day after he was seen on the ward, the patient arrested and died at 9 days old.

Case Report Patient B was seen during a hospital ward round in rural Bangladesh with his mother, who had noted irritability and rigidity in his limbs from day 3 of life. He was no longer able to feed normally and had markedly decreased oral intake. On examination, he exhibited profound hypertonia and hyperreflexia of all 4 limbs, opisthotonos, and scissoring of the legs. His management in hospital was primarily supportive and he died at 9 days of age. Conclusion Vaccination with tetanus toxoid in women of reproductive age has vastly improved the incidence of neonatal tetanus across Bangladesh. Despite this improvement, cases do still occur and may result in poor outcomes. This case study identifies 2 contributing problems: firstly, access to public health services in rural areas and, secondly, a paucity of appropriate resources in hospitals servicing these areas.

The problem can be partly attributed to (1) gaps in the vaccination program and other public health measures, and (2) the resource-poor nature of the health system attempting to manage tetanus in young children.

Introduction

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An Australian research team, comprised of 2 neonatal nurses, 1 paediatrician, 1 general practitioner, a public health professional and, 11 fourth-year medical students from Western Sydney University visited hospitals in rural Bangladesh in the context of a paediatrics research expedition.

Discussion Pathophysiology Tetanus was once considered a terrifying illness throughout the world. The gram positive, anaerobic bacterium Clostridium tetani produces a toxin (i.e., tetanospasmin) which causes profound muscle spasms and autonomic dysfunction via inhibition of GABA and glycine release at the spinal cord. [1,2] The resulting loss of inhibitory signals for motor neurons results in the characteristic rigid paralysis of tetanus. In neonatal cases, such as the one described, the bacterium is typically introduced via the umbilical cord, where it then multiplies and releases the toxin.[3] The disease course of fatal neonatal tetanus usually culminates in respiratory arrest, when severe muscle rigidity prevents normal

The trip was designed as a 12-day field survey in the regional towns of northern Bangladesh. Three thousand children under the age of 12 and their mothers were examined and interviewed. Throughout this research expedition, the group was given the opportunity to attend ward rounds in various hospitals around Bangladesh. Cases of diphtheria, tetanus, measles, untreated thalassemia with profound clinical signs, and many cases of bronchopneumonia were diagnosed in these paediatric patients. Doctors and nurses in Bangladesh are faced with a resource-poor health system and a population with 67


maternal immunisation against tetanus increased from 4% to over 90%.[9] Correspondingly, neonatal fatalities due to tetanus decreased from 40 cases per 1,000 births to approximately 3 cases per 1,000 live births over the same time period.[9] A 2017 study of national-level data examining the impact of antenatal TT administration further shows that mortality is significantly reduced when the mother has had at least 2 TT vaccinations.[10] Patient B’s mother had not received her TT vaccination prior to pregnancy, which was attributed to her rurality and a lack of access to nearby health services.

Management Treatment protocols include antibiotic therapy to eradicate any remaining Clostridium tetani bacteria and the administration of tetanus antitoxin.[2] The late detection of the illness often means that large amounts of the toxin have already reached nerve terminals, reducing the efficacy of its antitoxin.[2] Benzodiazepines may be used to acutely relieve muscle spasms and rigidity. Magnesium may also be used to combat autonomic dysfunction.[2] As the disease progresses, intubation is essential for respiratory support.[4] These treatments, amongst other options, all rely on ICU-level nursing, medical care and facilities.[4]

Bangladesh has prioritised tetanus in public health campaigns and vaccination programs in recent years, yet cases such as these persist.[11] The problem can be partly attributed to (1) gaps in the vaccination program and other public health measures, and (2) the resource-poor nature of the health system attempting to manage tetanus in young children.

Tetanus in Bangladesh Thanks to immunisation and improved public health awareness, disease rates of tetanus remain low in high-income countries.[5] In low- and middle-income countries, tetanus is still a common disease. Despite this, many countries have successfully eliminated tetanus, including several countries across Africa and Asia.[1] Bangladesh is one such country declared by UNICEF to have eliminated neonatal tetanus; this has been attributed to an aggressive and successful public vaccination program.[6] “Eliminated” is defined as less than one case for every 1000 live births in the country.[3] Yet, tetanus is a pervasive disease due to its presence in the soil of every country in the world, meaning that herd immunity is unreliable and cases such as the one described still occur.[3]

Public health measures In Bangladesh, the most common venue for a woman to give birth is at home, with rates estimated at 81.7%, according to national data.[10] Patient B’s mother delivered at home and was not attended by skilled medical help, meaning that the umbilical cord was likely cut without sterile instruments. Improving maternal education and birth hygiene is a key element in further reducing tetanus rates in countries such as Bangladesh.[3] Further, uptake of community health services during the antenatal, perinatal, and postnatal periods is essential to ensure early detection of any problems with a new baby. These services exist across Bangladesh, but a major access barrier is a lack of community awareness regarding these services.[12] A 2017 cross-sectional study determined that only one-third of women of reproductive age in Bangladesh were aware of the clinics available to them.[12] The authors identified a need for public health education measures to increase attendance at these health services.[12] Increased understanding amongst rural communities will hopefully improve vaccination, disease prevention, birth education and health literacy amongst families.

Public health and vaccination In a vast majority of countries, vaccination with tetanus toxoid (TT) is routinely suggested for women during pregnancy. Antibodies generated against the toxin are able to pass through the placenta to the foetus and confer valuable protection after birth.[7] In Bangladesh, women of reproductive age are immunised against tetanus with a five-dose TT program. This program was established in response to a previously higher rate of neonatal mortality from the disease, and it has been supported by the WHO and UNICEF.[8] Between 1986 and 2001, the rates of

Management of tetanus in regional Bangladesh

Increased understanding amongst rural communities will hopefully improve vaccination, disease prevention, birth education and health literacy amongst families.

Tetanus is still seen in high-income countries, albeit rarely.[1] As previously discussed, the effective management of neonatal tetanus requires ventilatory support and ICU facilities. In Bangladesh, the first part of the tetanus puzzle (i.e., vaccination and education) has been partially solved. The second 68

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respiration.


part of the equation â&#x20AC;&#x201C; adequate facilities to treat cases of tetanus â&#x20AC;&#x201C; requires further development. The management of Patient B may have been very different if his treating team were able to utilise ICU-level facilities, including ventilatory support. Until healthcare professionals in this setting are properly resourced, cases such as these will inevitably occur.

ONE. 2017;12(10):e0187303.

Madeleine is a final year medical student at Western Sydney University. She is not great with geography and often finds herself getting lost, so she likes to travel to distant places where getting lost is a tad more socially acceptable. Acknowledgements The author would like to thank Prof. John Whitehall, the Chair of Paediatrics at Western Sydney University; Dr. Lara Wieland; Mr. MacKenzie Pickering; and the medical student research team. Our research project was a team effort, and this is one case out of many from a very large survey. Most importantly, I cannot adequately express my gratitude to the many young patients and their families who allowed us to see them in Bangladesh. Conflict of interest None declared

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Correspondence 18428399@student.westernsydney.edu.au References 1. McElaney P, Iyanaga M, Monks S, Michelson E. The Quick and Dirty: A Tetanus Case Report. Clin Pract Cases Emerg Med. 2019;3(1):55-8. 2. Yen LM, Thwaites CL. Tetanus. Lancet. 2019;393(10181):1657-68. 3. Hassel B. Tetanus: pathophysiology, treatment, and the possibility of using botulinum toxin against tetanus-induced rigidity and spasms. Toxins. 2013;5(1):73-83. 4. Thwaites CL, Loan HT. Eradication of tetanus. Br Med Bull. 2015;116:69-77. 5. Australian Institute of Health and Welfare. Tetanus in Australia. Canberra: AIHW; 2018 [cited 2019 May 24]. Available from: https://www.aihw.gov.au/ 6. Owusu-Darko S, Diouf K, Nour NM. Elimination of maternal and neonatal tetanus: a 21st-century challenge. Rev Obstet Gynecol. 2012;5(3-4):e151-7. 7. UNICEF. Elimination of Maternal and Neonatal Tetanus. New York: UNICEF; 2019 [cited 2019 April 19]. Available from: https://www.unicef.org/ 8. Munoz FM, Jamieson DJ. Maternal Immunization. Obstet Gynecol. 2019;133(4):739-53. 9. World Health Organisation. Maternal and Neonatal Tetanus. Geneva: World Health Organisation; 2019 [cited 2019 April 19] Available from: http://www.who.int/ 10. UNICEF. Eliminating maternal and neonatal tetanus. New York: UNICEF; 2019. 11. Abir T, Ogbo FA, Stevens GJ, Page AN, Milton AH, Agho KE. The impact of antenatal care, iron-folic acid supplementation and tetanus toxoid vaccination during pregnancy on child mortality in Bangladesh. PloS ONE. 2017;12(11):e0187090. 12. Hasnain MG, Maruf S, Nath P, Anuwarul A, Ahmed MNU, Chowdhury IH, et al. Managing Severe Tetanus without Ventilation Support in a Resource-limited Setting in Bangladesh. Am J Trop Med Hygiene. 2018;99(5):1234-8. 13. Yaya S, Bishwajit G, Ekholuenetale M, Shah V. Awareness and utilization of community clinic services among women in rural areas in Bangladesh: A cross-sectional study. PloS

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WHAT AUSTRALIA CAN LEARN FROM NEW ZEALAND & THE COOK ISLANDS Alexander Johnson

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I

n November and December 2018, I undertook a four-week elective placement at Rarotonga Hospital in the Cook Islands, a nation comprised of 15 islands and around 17,000 people. The Cook Islands is a New Zealand protectorate, meaning it is its own self-governing nation but receives significant input and funding from New Zealand.

In one month in the Cooks, I learnt more about the struggles Māoris face than I have about Indigenous Australians over the course of twenty-three years. majority of what I can remember learning in high school regarded the purpose of the First Fleet, rather than how Indigenous cultures were displaced.

As a result of this close relationship between the Cook Islands and New Zealand, many medical students from New Zealand undertake their electives in the Cooks. Through both the hospital placement and staying at the same hostel I became close friends with five Kiwi students from the University of Otago, three of whom are Māori. New Zealand Māoris and Cook Island Māoris are very closely linked to each other and to the other natives of Polynesian islands, all with similar language and culture, having emigrated from Taiwan in 1000-3000. Hence, it was no surprise that my three Māori friends found it easy to understand what it means to be a Cook Islander, and the issues that they face in day-to-day life.

In medical school, I again found the situation frustrating. Thankfully, our first exposure to cultural sensitivity was early, but it didn’t have much of a lasting impact. After a long bus journey from Hobart on our first-year rural week, we spent roughly an hour learning about middens – collections of shells that display evidence of past Aboriginal hunting and gathering. Although middens are historically significant, this experience felt like relative minutia for medical students who had hardly been taught the first thing about the barriers in Aboriginal health. From first year onwards, it was mostly downhill. I vaguely recall didactic lectures in second and third year on Indigenous health which were inevitably not assessed. The only thing in fourth year was a tedious online module that was required to be completed prior to starting placement.

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What did surprise me, however, was how educated the two non-Māori New Zealand medical students were about the culture of the Indigenous Cook Island and New Zealand people. They understood basic Māori language and customs, knew all about what the haka represents, and much of the history of the Māori people’s journeys across New Zealand’s islands some 700 years ago. This understanding of Māori culture was impressive to me, and was further compounded as I began reflecting on how shallow my own multicultural understandings were by comparison.

The best opportunity for us as University of Tasmania medical students to engage with members of the Aboriginal community actually arose this year. During our wilderness weekend, we had the opportunity to speak to two Indigenous Australians from the Riawunna Centre for Aboriginal Education, a UTAS organisation focussed on providing a culturally safe space for Indigenous Australians to access tertiary studies. The setting could not have been more pristine or inviting, in their ancestors’ traditional home, takayna (the Tarkine). They encouraged us to ask hard hitting, potentially offensive questions that we were clueless about so that we wouldn’t end up asking insensitive questions to

My thoughts and feelings regarding Indigenous Australians have always been somewhat subconscious. I’ve always had a basic understanding of the atrocities that occurred both with James Cook’s voyage to Australia and the Stolen Generation, and my medical degree has taught me the basics of their unique health issues. However, I know none of the language, hardly anything about their traditional values and have had discussions with very few Indigenous Australians. In one month in the Cooks, I learnt more about the struggles Māoris face than I have about Indigenous Australians over the course of twenty-three years. I understand that my lack of cultural understanding is something I ultimately need to take responsibility for. However, after developing bonds with my fellow medical students in New Zealand, I can’t help but think there are certain things Australia can change for the better. I’ve always found it disheartening how our education system addresses Indigenous culture. The 71


Indigenous Australians have noticeably worse health outcomes compared to New Zealand’s Māoris, with poverty often being a driving factor in early mortality and overall poorer health. I find this concerning, given that Australia and New Zealand are quite similar socioeconomically. Finding and interpreting both nations’ health data has reaffirmed my belief that we have much to learn from our neighbours across the Tasman. Although both communities are certainly marginalised and disadvantaged, it’s telling that Australia performs worse than New Zealand across the board.

It was a shock to hear that New Zealand, a country I thought to be so similar to Australia does things so differently. The reason why my Kiwi colleagues appeared so much more knowledgeable about Indigenous issues quickly became evident. Firstly, it appeared that they simply got the fundamentals right – they were all taught Māori language and culture extensively when they were in primary school.

The gap in life expectancy between Indigenous and non-Indigenous Australians is over 10 years for males and 9 years for females. In New Zealand, both Māori males and females are expected to live around 7 years less than non-Māoris. Although the raw numbers for youth suicides show that there are less in Australian Aboriginals than Māoris (34 per 100,000 vs 40.7 per 100,000), the comparison between their respective non-Indigenous counterparts shows a far darker picture in Australia. Indigenous Australians aged between 15 and 19 are almost five times more likely to end their lives with suicide than non-Indigenous Australians, while the New Zealand equivalent shows Māoris are 2 and a half times more likely to choose suicide than non-Māoris.[1] Indigenous Australians also had higher comparative rates of diabetes and low birth weight.

They then revealed what I believe is the most significant example of how the University of Otago ensures that students have a good understanding of Māori health before becoming doctors. In each of the final three years of the course, they are guaran-

Indigenous Australians aged between 15 and 19 are almost five times more likely to end their lives with suicide than non-Indigenous Australians, while the New Zealand equivalent shows Māoris are 2 and a half times more likely to choose suicide than non-Māoris. [1]

An important factor to address when comparing New Zealand and Australia is that on the surface, it appears New Zealand has historically had a number of factors favouring the achievement of better social outcomes for their Indigenous populations. Perhaps most importantly, Māoris make up a larger portion of New Zealand’s population than Aboriginals do in Australia (15% [2] and 3%,[3] respectively), meaning that Māori issues make up a greater proportion of New Zealand’s total issues.

teed that one of their eight OSCE stations will focus on Māori health. From what I understood from my friends’ words, these stations generally have less to do with the medical and instead focus on how well the student engages with the patient through customs and language issue. For example, a hug and a kiss on the cheek as a greeting instead of a handshake, and asking if they’ve had trouble with ‘mimi’ rather than if they’ve had problems urinating. Using an assessment as critical as an OSCE station to determine a student’s understanding of Māori culture and custom is a fantastic way to ensure that New Zealand medical students are well equipped to treat Māori patients. My non-Māori friends spoke always passionately and intelligently about New Zealand Indigenous health, displaying the strategies in Otago and wider New Zealand certainly served their intended purpose. 72

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our future patients and souring relationships. In the 25 minutes my group of four spent with them we were able to discuss several issues that Indigenous Australians face, most notably the Close the Gap initiative and ideas surrounding how colonial Australians and Indigenous Australians can work together to form more cohesive communities. It was a comfortable and informative session that I have taken a lot away from. However, it is disappointing that this session was so short and was only offered to a small percentage of the cohort, that being the 24 of us at the Rural Clinical School.


and it’s crucial that my colleagues and I ensure that we are as well informed about Indigenous Australians’ unique health challenges as we can be. I’m thankful my elective in the Cook Islands gave me the opportunity to see how treating Indigenous populations can be done well. It was a great example of how we can learn lessons from all over the world, particularly from smaller countries. Our ancestors’ wrongs aren’t our fault, but it’s our obligation to amend this relationship and help Indigenous Australians enjoy the same health and prosperity as the rest of our nation.

Even if it’s only 3%, Aboriginals still make up a significant part of our population and deserve greater recognition of their poorer health outcomes. One of the issues we discussed in takayna was how Australia’s health system is changing to improve health outcomes for Indigenous Australians. This was a great opportunity to learn more about the Close the Gap initiative and the perspective that Indigenous Australians have on it.

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The Close the Gap campaign is an initiative aimed at decreasing the discrepancy between Indigenous and non-Indigenous life expectancy and overall health in Australia. In 2018, Close the Gap had its 10-year review, which looked at the likelihood of attaining its targets by 2030. Unfortunately, the campaign has thus far been markedly unsuccessful. The life expectancy gap between Indigenous and non-Indigenous Australians has sadly increased and its goals are unlikely to be met by 2030. The Riawunna staff that I met in takayna believed that the reason for Close the Gap’s underperformance was due to a blanket approach whereby the same goals were expected nationwide and the same tools were used to achieve them. Additionally, the political climate of the last decade hasn’t fostered an environment in which governments can effectively work together to make Closing the Gap a priority.[4] The 10-year review did however birth some promising changes with a state-by-state approach to be adopted so as to address the unique health concerns of smaller areas. The initiative is expected to receive improved backing at all levels of government.

Alex Johnson is a fifth year student at UTAS. He hopes to take his career overseas and is passionate about social justice, health promotion and climate change. Conflict of Interest None declared Correspondence gerardj@utas.edu.au

References 1. Maguire G, Robson B. Aboriginal – Māori: how Indigenous health suffers on both sides of the ditch [Internet]. The Conversation. 2016 [cited 31 March 2019]. Available from: https://theconversation.com/aboriginal-maori-how-indigenoushealth-suffers-on-both-sides-of-the-ditch-48238 2. Major ethnic groups in New Zealand | Stats NZ [Internet]. Stats NZ. 2015 [cited 31 March 2019]. Available from: https://www.stats.govt.nz/infographics/major-ethnic-groups-in-new-zealand 3. Australian Bureau of Statistics. 2016 Census shows growing Aboriginal and Torres Strait Islander population [Internet]. 2017. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/ MediaRealesesByCatalogue/02D50FAA9987D6B7CA25814800087E03 4. Close the Gap - 10 Year Review (2018) [Internet]. Australian Human Rights Commission. 2018 [cited 31 March 2019]. Available from: https://www. humanrights.gov.au/our-work/aboriginal-and-torres-strait-islander-social-justice/publications/ close-gap-10-year-review 5. Supporting Language Reclamation [Internet]. Victorian Aboriginal Education Association Inc. 2019 [cited 31 March 2019]. Available from: http://www.vaeai.org.au/support/dsp-default.cfm?loadref=144

The conversation in takayna further revealed to me that Australia’s education system must change to ensure that all Australians, Indigenous or not, have a sound understanding of the history and culture of our land’s original custodians. The Victorian Koorie Languages in Schools Program is currently being delivered in eleven schools across the state, with seven Victorian languages and one Northern Territory language being taught. The classes are offered in both primary school and high school with the language taught depending on the land the school is situated on.[5] Similar projects are also underway in New South Wales and the Australian Capital Territory. It appears that these programs are going well, and their reported success so far has many Aboriginal people confident that it may only be a matter of time before this is the norm in schools across the country. Perhaps the improvement in primary and secondary education is an indication that some positive changes are just around the corner for Australian medical schools. Indigenous health has become a passion of mine, 73


Reflections from the 63rd United Nations Commission of the Status of Women (CSW63) Helena Qian

of Discrimination Against Women) is a binding treaty which Australia signed in 1983. By doing so, the Australian government has committed to take ‘all appropriate measures, including legislation, to ensure the full development and advancement of women, for the purpose of guaranteeing them the exercise and enjoyment of human rights and fundamental freedoms on a basis of equality with men’.[3]    The CEDAW Committee regularly reviews each member state’s adherence and commitment to the treaty with Australia being praised for delivering our first Paid Parental Leave Scheme  and positive developments  but also criticized about the gender pay gap, violence against women and the disproportionate impact on the indigenous population.

Background “Women’s rights are human rights and human rights are women’s rights.” – Hillary Clinton, UN Fourth World Conference for Women (Beijing, 1995) On June 21st, 1946, ECOSOC (Economic and Social Council) established CSW (Commission on the Status of Women), the ‘principal global intergovernmental body exclusively dedicated to the promotion of gender equality and the empowerment of women’.[1]  This involved documenting the reality of being a woman around the world and shaping global standards.  The role was further expanded in 1996 to monitor and review progress pertaining to the 1995 Beijing Declaration and Platform for Action.[2]

Consequently, each year for 2 weeks in March, member states, UN entities, multi-nationals, NGOs, civil society and multi-stakeholder groups  convene at the UN Headquarters in New York to discuss priority themes, share experiences and deliberate strategies to further advance progress and address setbacks.  The priority theme for CSW63 this year was social protection systems, access to public services and sustainable infrastructure for gender equality and the empowerment of women and girls. 

The Beijing Declaration and Platform for Action was a landmark agreement adopted by all 189 countries at the time (including Australia) as the defining framework with which to ‘advance the goals of equality, development and peace for all women everywhere in the interest of all humanity.’ (Declaration 3).[2] Of note, 2020 marks 25 years since the Beijing Declaration and will be  the  core theme of CSW next year.    Whilst the Beijing Declaration is non-binding, CEDAW (Convention on the Elimination of All Forms 74

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TWENTY FIRST CENTURY WOMAN


The F Word

Invest in women, invest in peace, invest in economic stability

“Feminism isn’t about making women stronger, women are already strong, it’s about changing the way the world perceives that strength.” – G.D. Anderson

As part of the Young Feminist Caucus’ photo campaign this year, I was asked to self-reflect on why feminism matters to me. 

Before delving into my CSW63 experience, there is one word that simultaneously unites,  divides and embodies a concept I felt necessary to reconcile with before attending CSW63. 

Equality. Dignity. Respect. Universal Emancipation. Generalising humanity down to gender differentiation and expectations is a restrictive paradigm that prevents us from maximising our full potential. In this age of self-awareness  and collective movement towards achieving the  Sustainable Development Goals (SDGs), we should be recognising our individual strengths, not the pre-defined box people may want to place us in. 

Feminism. From the French word, feminisme, it was first used by French socialist Charles Fourier to describe the emancipation of women in 1837.  Some definitions of the word feminism found online include: “the advocacy of women’s rights on the ground of the equality of the sexes”[4

The Experience

“the belief in social, economic, and political equality of the sexes”[5]

“Justice for women is first and foremost a human right and critical for progress across all the SDGs. It’s not just the right thing to do, it’s the best thing to do.” – Jeni Klugman, Georgetown Institute for Women, Harvard Kennedy School 

“world-wide revolt against all artificial barriers which laws and customs interpose between women and human freedom. It is born of the instinct within every natural woman’s soul that God designed her as the equal, the co-worker, the comrade of the men of her family, and not as their slave, or servant, or dependent, or plaything.”[6]

I was privileged to attend CSW63 as part of the IFMSA (International Federation of Medical Students’ Association) delegation. We were a group of 8 medical students  from different countries around the world  but all passionate about gender equality and the empowerment of women.

“movement that seeks superior rights and privileges for women while hiding under the guise of equality”[7]

The commission itself is structured in a way whereby numerous sessions run concurrently on-site at UN HQ and offsite. At one time, there could be as

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“a bastardized corruption of the world favouritism”[7] The stark contrast between  these definitions encapsulates  the  polarising nature of feminism and its varying interpretations.  However, if we navigate through history  from a Western perspective, the first wave of feminism centred around the suffragette movement which sought voting rights for women, the second wave centred on sexual and reproductive rights including economic parity and the third wave - the current wave - has challenged the gender binary and existing social paradigms surrounding gender roles and intersectionality.  However, at the core, one value resonates within all these waves. Feminism, as I define it, is simply about all genders having equal rights and opportunities.  How this manifests is dependent on personal values and  kept fluid by the emergence of  new ideologies and critical analysis of old doctrines. One key distinction that I only came to appreciate this year, is that  being equal does not mean being the same. We are not all the same, but equal in value.    Thus, I am a feminist. 

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It was a surreal experience having direct access to world leaders and fascinating hearing the successes and failures of gender equality around the world. Above all, I was grateful to have the opportunity to converse with a multitude of interesting characters I would  have  otherwise  not  met.  For example, when conversing with women in the military at CSW63, it was intriguing to hear of their revelation that they initially made unconscious choices to emulate conventionally male characteristics such as wearing suits, having short hair and no  makeup.  Through mentorship and self-reflection, they’ve continued to be leaders in their field whilst maintaining their expression of femineity and reinforcing the sentiment that you do not need to behave more like a man to lead in a male-dominated industry—being equal and being the same are not congruent, a key revelation I alluded to earlier. 

many as a dozen events going on, hence, it was imperative for us to thoroughly analyse the side events beforehand  and create our ideal timetable for the fortnight.  Events start as early as 7 am and as late as 7 pm.  For us, we made the effort of attending as many events as possible that were relevant to youth  and sexual and reproductive health and rights (SRHR). Conversely,  many veteran attendees selectively chose to attend around 1-3 events per day.  Some events required invitations or early RSVP due to venue capacity so teamwork and continual communication was vital.    Regardless, the rooms filled to capacity quickly after day 3 and we realised we’d been much too optimistic thinking we could attend side events in differing locations consecutively without factoring in at least 30 minutes in between.

The Highlights: “I want you to remember 2 numbers today, the first is a threat: 18 million shortage of health workers and the second is a hope: 1.8 billion young people around the world…women make up 70% of the health workforce, but hold the majority of unpaid and undervalued positions.  Why is women’s leadership seen as such a threat?” – Batool Wahdani

Nearly all the sessions onsite at UN HQ involved a panel with distinguished guests from various sectors that were brought together to discuss a particular theme with the opportunity for questions at the end.  In all honesty, many of the member state speakers merely read statements highlighting the positive work their government had done for gender equality without contributing meaningful insight and dialogue.  Hence, it became important to note who was hosting the event and stalking the

During the Opening Ceremony, UN Secretary-General Antonio Guterres exclaimed:  “I am a proud feminist”.  In addition, the point he emphasised most heavily was to “push back against the pushbacks  – because people do not like to see power being taken” which became the buzz phrase of the Commission.

Generalising humanity down to gender differentiation and expectations is a restrictive paradigm that prevents us from maximising our full potential.

Whilst waiting for UN Secretary-General Antonio Guterres at the Townhall Meeting of Civil Society, UN CSW63 member states, in an impromptu fash76

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profiles of the speakers. It was particularly compelling, albeit confronting, attending side events hosted by organisations with fundamentally different views to mine (i.e. on the topic of abortion).    Offsite, there was a lot of variability, ranging from interactive workshops to social gatherings involving canapes, live music and a bar tab! 


ion, started performing traditional songs and dance before breaking out in unison and singing together.

care. How do we teach moral values?  As children, we often learn about the outside world through stories before we even step foot in the classroom.  From stories,  we teach the future generation about love, distinguishing kindness from malice, recognizing justice from injustice and encouraging moral integrity.  This inspired UN Women Georgia to compile 21 fairy tales inspired by real female figures from Georgian history into a book,  “Once There Was a Girl”.  A wonderful initiative for a wonderful cause.

Meeting Hon Dr Sharman Stone, the Australian Ambassador for Women and Girls who has been an inspirational advocate for gender equality and championed the elimination of FGM, child marriages, human trafficking, poverty and disease in the Asia Pacific region.  She is also responsible for spearheading the national strategy to eliminate Foetal Alcohol Spectrum Disorders  and has expressed interest in working closer with AMSA Global Health to facilitate increased engagement with the Asia Pacific

The Permanent Mission of Germany hosted a viewing of “Digital Warriors” and panel discussion with the film subjects themselves and Karlie Kloss afterwards, highly recommend watching the documentary!

At the International Olympic Committee (IOC) Women and Sport Awards, my  own unconscious bias was challenged as I reflected on the disparity in recognition, media coverage and pay between men and women in sports.  If asked, I could rattle off at least half a dozen male  soccer players  but would struggle with naming even one female soccer player.  We had the pleasure of meeting Marta Vieira da Silva, 6 time FIFA World Player of the Year - Olympian -Inspiration.  She moved me to tears as she delivered a personal account on the power of sport to change lives for the better.  

Learning about the complex interplay between economics and the disproportionate impact of taxes on women.  An OECD analyst estimated that gender inequality cost the worldwide economy 14 billion dollars each year, meaning that only an inclusive society can reach economic stability.  The most enlightening quote  from these sessions:  “Livelihood projects and micro-entrepreneurship are reducing  gender based  violence because they elevate the status of women.  But micro will remain micro unless we interweave macro which is about the economic rights of women to own land, be employed and so forth”.  In addition, UNFPA hosted a fascinating session on the status of women in post conflict areas, where they noted an interesting increase in political leadership, the effects of which did not translate to women-centred care despite research indicating that women tend to spend more economic reserve on family and social needs and hence, disproportionately contribute to post-conflict social recovery.  Thus, women should be a key beneficiary group in post-conflict employment programs.  In saying so, we often talk about the right to work but we mustn’t forget about the disproportional unpaid care work many women undertake. 

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“Prejudice and lack of opportunities hurt me many times along the way. It hurt me when the boys did not let me play, it hurt when adult coaches from opposing teams took me out of championships, because I was a girl, it hurt to leave my family at the age of 14 to face a 3-day bus trip with little money in the pocket and go live alone in Rio de Janeiro to play professional football.  But my certainty of where I wanted to go never let me give up”  Attending the Australian Commission’s side event on Sexual Harassment in the Workforce with the keynote by Hon Kelly O Dwyer, the  Minister for Women. This was also an  opportunity  to meet  the  Sex Discrimination Commissioner Kate Jenkins whom spearheaded the National Report on Sexual Assault and Sexual Harassment at Australian Universities report and is now leading the first National Inquiry into Sexual Harassment in Australian workplaces.  These leading ladies epitomize the mantra that change does not take time, it takes action.

All the interesting conversations and fascinating people who congregate for CSW63.  A truly won-

Supporting IFMSA’s (International Federation of Medical Students’ Association)  event with Ipas  where one of our own, Egle, was on the panel.  The core message surrounded the simple statement that abortion is health77


b. The Adequate extent of healthcare coverage to ensure access to essential services. c. Affordability and financial protection for users of healthcare services.  It was sobering to learn that 1 in 7 people worldwide went into debt due to catastrophic health spending meaning they likely had no other choice but die.  Invest in women, invest in peace, invest in economic stability.   Do not instrumentalise faith leaders during periods of devastation and unrest, include them throughout.   derful experience, compounded by the incredible delegation I had the privilege of attending with .

Let girls be girls and not brides. “Girls don’t just choose to drop out of school, they drop out due to patriarchy, due to poverty, due to inequality” – UNGEI 

The Takeaways

Embrace both female and male champions of gender equality as it is naïve for us to think we can do it on our own. “Why do we only accept what’s given? If there’s one spot for a woman in leadership, then women will fight one another for it.  But why don’t we work together to demand 4 spots for women instead?” –Katja Iversen, CEO Women Deliver 

“Privilege is when you think something is not a problem because it’s not a problem to you personally.”  CSW63 is a rich opportunity for information exchange and cross-collaboration, although the productive dialogue and innovation typically happen  in between sessions.  Networking is the key advantage of attending in person. This provided the opportunity to engage with the people around you.  Conversations which left the deepest impression on me were often had whilst waiting for coffee or resting between sessions in East Lounge.

At times, I often feel frustrated and overwhelmed when I read of the atrocities faced by women my age at this very moment in time. Many harrowing experiences were shared over the fortnight, but as the familiar feeling of my heart breaking for the victims engulfed me, this was extinguished with tales for survival, courage and determination.  The high attendance and coverage of CSW63 is a testament to the importance of gender equality, the legacy of past champions and the collective efforts of everyday people to leave no one behind. 

Adequate pre-departure training and research is essential for making the most out of CSW63 and being able to meaningfully engage with speakers and delegates.   No matter how well informed you think you are about your passion, there is always much to learn and unconscious bias you hold. Do not view these as self-inadequacies, but rather, a continual opportunity to do better. 

“Alone we are strong, together we are stronger. Justice for women is justice for everyone.”  Helena Qian is a University of Newcastle student and current Chair of AMSA Global Health with a penchant for travel, passion for effective altruism and love for youth empowerment.

Universal healthcare is a fundamental right encompassing 3 key aspects:

Conflict of Interest None declared

a. Full healthcare coverage to the entire community, including social protection systems for vulnerable and disadvantaged populations. “Half the world’s population still lack access to essential health services…in countries that have dropped their MMR, the rate in their indigenous population is actually increasing so we should not be talking about UHC with a broad stroke” – Amy

Correspondence helena.qian@amsa.org.au References

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1. UN WOMEN. Commission on the Status of Women.  [Internet].  New York: UN Women. [cited  2019 April 20th]. Available at <http://www.unwomen.org/en/csw>  2. UN. Fourth World Conference on Women Beijing Declaration.  [Internet]. New York: UN.  [updated 1995; cited 2019

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Boldosser-Boesch.


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April 25th].   Available at  <https://www.un.org/womenwatch/ daw/beijing/platform/>  3. Australian Human Rights Commission.  The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW): Sex Discrimination – International Activities.  [Internet]  Sydney: Australian Human Rights Commission. [updated 2012 December 14th; cited 2019  May 10th]. Available at <https://www.humanrights.gov.au/our-work/ sex-discrimination/convention-elimination-all-forms-discrimination-against-women-cedaw-sex>  4. Oxford Dictionaries. Feminism. [Internet]. Oxford: Oxford Dictionaries.  [cited 2019 April 20th]. Available at <https:// en.oxforddictionaries.com/definition/feminism>  5. E. Burkett, L. Brunell.  Feminism.  [Internet].  Chicago: Britannica.  [updated 2019 February 8th; cited 2019 May 1st].  Available at <https://www.britannica.com/topic/feminism>  6. S. Weiss. What does Feminism Mean?  A Brief History of the Word, From Its Beginnings All the Way Up to the Present.    [Internet].    New  York: Bustle.  [updated 2015 December 16th; cited 2019  April 10th].  Available at <https://www.bustle. com/articles/129886-what-does-feminism-mean-a-brief-history-of-the-word-from-its-beginnings-all-the-way>  7. Guru of Reason. Feminism. [Internet].  Urban Dictionary. [updated 2012 November 20th; cited 2019 April 10th]. Available at <https://www.urbandictionary.com/define.php?term=Feminism> 

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CLINICAL CHALLENGE Presented by AMSA MedEd Chair Samuel Smith

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S

There was no peripheral or central cyanosis and no signs of clubbing. Peripheral pulses were palpable and slightly reduced, but her capillary refill time was normal. There was reduced lung expansion on the left-hand side, as well as dullness to percussion and coarse inspiratory and expiratory crepitations in the upper left lung zone. Heart sounds were dual with no murmurs and her jugular venous pressure was not elevated. Abdominal and neurological examinations are unremarkable. There were signs of non-crusted scabies in the intertriginous areas of her hands and feet.

.M. was a 52-year-old Aboriginal woman who presented to a North Queensland general practitioner in February 2019 complaining of a three week history of dyspnoea and a persistent cough. The cough was productive of sputum, but she denied any haemoptysis or chest pain. In the last seven days, S.M. started to notice increasing shortness of breath and a worsening of the cough which was now waking her up at night. Upon further questioning at this time, she said that she started to feel feverish. She denied any chest pain, lower limb swelling or palpitations and a systems review was unremarkable.

The GP ordered a number of investigations, with relevant results below:

She had a past medical history of frequent presentations with non-crusted scabies, chronic obstructive pulmonary disease and type two diabetes mellitus. She had a history of heavy alcohol abuse, consuming roughly 10 standard drinks per day for the last thirty years, and had a 40 pack-year smoking history. There was no history of intravenous or other recreational drug use. There is no relevant surgical history. Her medications include metformin 500mg once daily and salbutamol 100Âľg PRN. She has no known drug allergies. Socially, she is the matriarch for a large family. Prior to her presentation, the family had been stressed cleaning up after the recent floods, and S.M. had spent much time outdoors cleaning the yard.

FBC: Marked neutrophilia with toxic changes EUC: eGFR 50, urea 7mmol/L, normal electrolyte levels LFT: Mild raise in AST and GGT, albumin 30g/L CRP: 100 mg/L VBG: pH 7.30, HCO3 25 mEq/L, CO2 55mmHg, Pa02 65mmHg Blood and sputum cultures: Results pending Chest X-ray: Lobar consolidation in the left upper lobe with air bronchograms Of the following options, what was the most appropriate management for S.M.? a. Outpatient therapy with amoxicillin b. Outpatient therapy with amoxicillin + doxycycline c. Inpatient therapy with IV ceftriaxone + azithromycin d. Inpatient therapy with IV meropenem + azithromycin e. Inpatient therapy with IV azithromycin + piperacillin/ tazobactam

Heart rate: 120 bpm and regular Respiratory rate: 32 breaths/ min Blood pressure: 90/70 mmHg Oxygen saturation: 90% RA Temperature: 38.9oC

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Upon examination, she was clearly dyspnoeic at rest, but alert and oriented. Her vital signs were:

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This is a case of community acquired pneumonia (CAP) – with a twist. Her presenting complaint and examination are typical of lobar pneumonia. The remaining question is how to treat it. First, we must determine the severity of the pneumonia. This can be done using the CURB-65 or SMART-COP scoring systems.[1,2] Using either of these in this patient will return a result of “severe pneumonia”. The studies supporting the use of CURB-65 and SMART-COP report a 30-day mortality of 14.0% to 30.0% in these patients, thus options A and B (outpatient therapy) are inappropriate – this patient is critically ill and requires hospitilisation. According to the Therapeutic Guidelines, for most patients with severe pneumonia, intravenous (IV) ceftriaxone plus azithromycin (Option C) is a reasonable empirical therapy.[3] However, this patient is seen in tropical North Queensland, and during the wet season (October to April). Even more importantly, she reports being outdoors in the recent floods. This, alongside her risk factors (alcohol use, diabetes and skin sores secondary to scabies), puts her at risk for Burkholderia pseudomallei infection – melioidosis. Melioidosis is an uncommon, but often life-threatening illness that most commonly presents as a severe pneumonia. It occurs predominantly in Southeast Asia and Northern Australia, but with increasing monsoonal seasons, global temperatures and prevalence of diabetes, the global incidence of melioidosis is on the rise.[4] The gram-negative pathogen causing this infection is a soil living saprophyte that can either enter the skin directly through breaks in the skin, or be aerosolised and inhaled during rain. Melioidosis is a terrifying infection – it is generally resistant to penicillins, first and second generation cephalosporins, gentamicin, macrolide and polymyxin antibiotics. Thus, the recommended regimen for severe pneumonia in a tropical region during the wet seasons (when the risk of melioidosis is highest) is IV meropenem and azithromycin (Option D) rather than relying on a penicillin such as piperacillin (Option E). The main learning points from this case are to keep in mind the geographic setting of your practice, and to be aware of local environmental changes that can impact the epidemiology of disease. If you were to treat this patient unaware of the local epidemiology of pneumonia in the wet season (especially after a flood event), you may very well fail to correctly treat the true cause until it is too late. In conclusion, knowing how to assess disease severity, understanding the rationale behind the guidelines’ empirical therapy and being aware of local patterns of disease will all serve you well in your future medical career, especially for those of you planning to work abroad. Conflict of Interest None declared Correspondence samuel.smith@amsa.org.au References 1. Lim WS, van der Eerden MM, Laing R, et al. Defining community acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax. 2003;58(5):377–382. 2. Charles GPP, Wolfe R, Whitby M, Fine MJ, Fuller AJ, Stirling, R, et al. SMART-COP: A Tool for Predicting the Need for Intensive Respiratory or Vasopressor Support in Community-Acquired Pneumonia. Clinical Infectious Diseases. 2008;47(31):375-384. 3. Therapeutic Guidelines. Community Acquired Pneumonia in Adults. eTherapeutic Guidelines. https://tgldcdp.tg.org.au/viewTopic?topicfile=community-acquired-pneumonia-adults. Updated 2019. Accessed 1st May, 2019. 4. Currie BJ. Meliodosis: evolving concepts in epidemiology, pathogenesis and treatment. Semin Respir Crit Care Med. 2015;36(01):111-125 82

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FOOD FOR THOUGHT Fighting malnutrition in rural India one meal at a time

Abstract Aims: Children in India face one of the worst crises of malnutrition in the developing world. Despite the government initiative, the ‘Midday Meals Scheme’, children continue to suffer from micronutrient deficiencies, perpetuating lifelong health and socioeconomic disadvantage and a cycle of undernutrition. To address this deficit, the Medical Students’ Aid Project, an Australian medical student global health group, launched the ‘Food for Thought’ (FFT) childhood health and nutrition project in Seem Shala Jibhaipura, a school in rural Gujarat.

Sharanya Mohan & Heeral Thakkar

Methods: The FFT project began in 2016, providing 3 nutritionally fortified meal supplements per week and 6-monthly health education videos. Student demographics and growth metrics including height, weight and mid-upper-arm-circumference (MUAC) were recorded. Height for age (HAZ) and weight for age (WAZ) scores, and MUAC percentiles were calculated using the American Centre for Disease Control and Prevention growth charts and tables. Results were compared at baseline, 12-months and 24-months. Results: One-hundred-and-fifty-one students were enrolled at Seem Shala Jibhaipura at baseline, with more than 1-in-3 students severely undernourished (35%) or stunted (34%). Two-year improvements show enrolment increased by 32%, while the number of students who were stunted decreased by 16%. HAZ scores improved by 0.40 (p<0.001) and WAZ scores improved by 0.40 (p<0.001).

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Conclusions: Marked improvements were noted in HAZ and WAZ scores following 24-months of nutritional supplementation. Community engagement is central to FFT’s success and this fundamental principle should be extended to similar international grassroots projects. Micronutrient supplementation and health education should be incorporated into government initiatives.

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Introduction Globally, undernutrition is the cause of nearly 45% of all deaths in children under the age of 5.[1] Children in India face one of the worst crises of malnutrition in the developing world.[2, 3] The Government of India launched the ‘Midday Meal Scheme’ in 1984 to incentivise education and address poor nutrition rates nationwide. The scheme aims to provide1 square meal per day to children attending school. [4] However, bureaucratic corruption is rampant throughout the meal provision system. As a result, the food provided is often inadequate in quantity, prepared unhygienically and lacking in nutritional value.[5, 6] Consequently, the children have deficiencies in micronutrients including iron, iodine and vitamin A, leading to health consequences such as anaemia and stunted growth.[7]

Image 2: Supplement consists of banana and chickpeas

Methods Food provision

Despite the ‘Midday Meal Scheme’ originating in Gujarat, 45.5% of the children under 5are stunted and only 1-in-3 women have 10 years of schooling.[8] The impact of this is grave, with early undernutrition being linked to irreversible life-long effects on educational attainment, income, and low birth weight of offspring, perpetuating a cycle of undernutrition.[9, 10]

Literature was reviewed to identify common nutritional deficiencies in school-aged Indian children. These were protein, iodine, iron, calcium, B complex vitamins, and vitamin C.[11] To target these deficits, a menu was created in consultation with childhood nutritionists. The menu consisted of a glass of milk mixed with Bournvita (a nutritional supplement akin to Sustagen), a seasonal fruit, dates, boiled and lightly seasoned chickpeas and chikki (groundnuts and Jaggery). The menu and the nutrient content is summarised in Table 1. These foods are culturally acceptable and have been suggested as nutritional supplements by numerous critiques of the ‘Midday Meal Scheme’ (images 1 & 2).[7]

The ‘Food for Thought’ (FFT) project was initiated in 2016 following the Medical Students’ Aid Project (MSAP) visit to 4 schools in rural Gujarat, where alarming rates of childhood undernutrition and poor health literacy were observed. The FFT project was designed in consultation with local school officials, MSAP executive and nutritionists to holistically address these issues. The project provides micronutrient-rich meal supplements to support nutrition and encourage school attendance, while also providing health education videos in the local dialect to improve health awareness and sanitation. This article examines the effectiveness of the FFT project by analysing improvements in growth metrics and observing qualitative improvements in health and education.

Monitoring The purchase, delivery and provision of food is overseen by local businessman Mr. Kishore Bhinde and the school principal Mr. Vasant Prajapati. All food is obtained from local grocers to support the local economy. Mr. Bhinde and Mr. Prajapati provide MSAP with a monthly account of expenses along with daily photos and videos of the children receiving the meal supplements. In conjunction with meal supplementation, MSAP sends 6-monthly health education videos in the local dialect to improve health literacy on topics including hand-washing, drugs and alcohol and nutrition. Quantitative measures of outcomes

Image 1: Student receiving nutritional meal supplement

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Baseline data was collected shortly after project initiation in 2016. Baseline demographics included date of birth and school year. Measurements of the children’s height, weight and mid-upper arm


circumference (MUAC) were recorded yearly (images 3 & 4). MUAC is an indicator of muscle and subcutaneous fat and is hence a predictor of protein malnutrition.[12] Age at each measurement was calculated by subtracting the date of birth from the date that measurements were recorded. Height for age (HAZ) and weight for age (WAZ) scores, and MUAC percentiles were calculated using the Centre of Disease Control and Prevention growth charts and tables.[13] Analysis was performed using IBM SPSS Statistics 2.4. Only students who remained at school for the duration of the project and had measurements at both baseline and 24 months of data collection were analysed. Normality of data was tested using the Shapiro-Wilk test. HAZ and WAZ scores at baseline and 1year were compared using paired sample t-tests. A p-value <0.05 was considered significant. Z scores between -2 and 2 were considered in the normal range. Students with height z scores below -2 were defined as stunted.[14] Students with weight z scores below -3 were defined as having severe under-nutrition and below -2 were defined as being underweight.[15]

Image 4: Student measured for MUAC

Results Qualitative Baseline demographics of the students are shown in Table 2. The total number of students enrolled at Seem Shala Jibhaipura was 149 in 2016. This increased to 167 in 2018. Enrolment in 2017 increased to 31 newly enrolled year 1 students, a 50% increase, and 24 year 8 students. The final cohort for analysis of HAZ and WAZ included 100 students, and for MUAC included 91 students that were present for baseline and 24month measurements. Seventeen students in 2016, 9 students in 2017, and 5 students in 2018 were absent on the days that measurements were recorded and were excluded from the study. At the end of 2017, 18 students graduated from the school and were excluded from the study.

Qualitative measures of outcomes Heeral Thakkar, one of the founders of the FFT project, visits at least once a year to further foster community engagement and monitor progress. In these visits, discussions with the principal, teachers, parents and students are held to obtain their point of view on the progress of the project in reaching its aims, academic performance and general wellbeing of the students, topics for health education videos and potential avenues for project expansion (images 5 & 6). Knowledge retention from health education videos was informally assessed by observing if students performed adequate hand washing prior to eating. Students were also interviewed on their understanding of nutritionally diverse foods.

At baseline, more than 1-in-3 students were severely undernourished (39%) or stunted (39%). At 12 months, the number of students who were stunted decreased by 10%, while those who were underweight decreased by 5%, and the percentage of students with a MUAC below the 10th percentile decreased by 9% (Table 3, Figure 1).

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From baseline to 24months after the initiation of the project, the HAZ scores improved by 0.41 while the WAZ scores improved by 0.40 (p<0.001) as illustrated in Figure 2 below.

Despite the â&#x20AC;&#x2DC;Midday Meal Schemeâ&#x20AC;&#x2122; originating in Gujarat, 45.5% of the children under 5 are stunted and only 1-in-3 women have 10 years of schooling. Image 3: Student measured for height

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Discussion Analysis of results The demographics at Seem Shala Jibhaipura have drastically changed since the initiation of the FFT program. A rise in student numbers in the youngest (29 to 38 students) and eldest age groups (28 to 48 students) were seen 12 months following initiation of the project. This can be attributed to the widespread publicity about the project in the local community which likely encouraged parents to enrol their children at the school. At 24 months, the year 1 enrolment returned to baseline levels, likely due to the declining novelty surrounding the project. The new classroom built in 2016 (images 7 & 8) now allows students to continue their education into year 8, thus targeting high dropout rates in the transition to upper primary school.[16]

Image 6: Stakeholders at community meeting with MSAP

respectively (p<0.001). These results are strong evidence that micronutrient supplementation is the key to breaking disadvantaged children out of the cycle of undernutrition. Similar findings have been reported in other micronutrition interventions in school aged children in India and in other countries.[17, 18] A study by Sarma et al. measured height and weight data in Indian students after 14months of nutritional supplementation. They found a significant increase in HAZ and WAZ scores of 0.04 and 0.02 in the supplemented group compared to -0.14 and -0.09 respectively in the placebo group.[19] Our results may show a greater improvement in WAZ scores due to inclusion of foods with higher total fat and protein content in comparison to Sarma et al. who supplemented with only a fortified beverage similar to BournVita.[19] Parikh et al. measured chronic undernutrition and stunting in 148 children aged 18 years or younger over 12 months. Children were supplemented with oatmeal, milk powder, rice and sardines. From baseline to 12months post intervention, there was a decrease in the percentage of children in the mild (21% versus 15%, p=0.006), moderate (9% versus 2%, p=0.006), and severe (3% versus 1%, p=0.006) categories for stunting.[19]

Menon et al. calculated the average prevalence of stunting from district-level data to be 39% in Gujarat, and 36% nationwide in India.[16] This value is comparable to the baseline prevalence of stunting (39%) in the students at Seem Shala Jibhaipura. After 24 months of supplementation, the proportion of students in our population who were stunted decreased by 16%. There has been a significant improvement in the growth metrics of children at Seem Shala Jibhaipura after the initiation of the FFT project, as evidenced objectively by the statistically significant upward trend in HAZ and WAZ scores. From baseline to 24 months after the initiation of the project, the HAZ and WAZ scores improved by 0.41 and 0.40

When developing similar grassroots projects, we strongly recommend fostering enduring community relationships and respecting the local culture for project success.

Image 5: Parents at community meeting with MSAP

Although FFT does not measure academic results, qualitative data from teachers suggests improvements in concentration and learning. This is supported by the double-blind randomised feeding trial by Shahnaz et al. who provided a micronutrientfortified beverage for 14months, recording metrics of student intelligence, attention and concentration, memory, and school achievement at baseline and completion.[20] They found that post-supplementation, the micronutrient group showed statistically significant improvements in attention and concentration, compared to the placebo group. Similarly, a randomised controlled trial by Djazayery et al. found that daily milk supplementation in female primary school aged 88


children in Tehran resulted in improved mental growth and school performance.[21]

Image 8: Newly built classroom (interior)

the local culture for project success. Discussions with teachers at the school revealed that there had been an observable increase in student attention and participation in classes. Interviews conducted with parents revealed that they were more inclined to send their children to school knowing that meal supplementation was being provided. After the first health education video on the topic of handwashing, observations of students before and after meal times revealed improved adherence to adequate hand hygiene practices.

Community engagement with the project has been the key to its success. Annual visits to the school have developed a relationship of trust and openness between the MSAP and the principal, students and parents at Seem Shala Jibhaipura. All discussions with project stakeholders are conducted in the local dialect to demonstrate respect for the local community and create a mutual vision for the future of FFT. Local businesses in Nadiad have been inspired to show their support for the project with donations of liquid soap on a monthly basis to encourage hand washing. The mayor was also motivated by the FFT initiative to build a bore well, to provide clean running water, and 2 new classrooms which enabled the students to continue their education into year 8. This local government and business interest in the project offers increased opportunities for project development and further strengthens acceptance amongst the local community. When developing similar grassroots projects, we strongly recommend fostering enduring community relationships and respecting

In 2016, FFT conducted eye checks for all students with the help of Santram Eye Hospital, 7 students were identified as requiring glasses and these were donated by the hospital (images 9 & 10) In 2017, screening dental checks were conducted on students, identifying that more than half had dental caries. Common dental disease and the importance of good dental care will be targeted in the next health education video. In 2018, MSAP raised enough funds through its annual Diwali Mela food stall to build a new toilet block for the school (images 11 & 12). The toilet block was completed in March 2019 and consists of 9 cubicles. Future growth for the project includes expansion to a second school and continued health education on dental hygiene and reproductive health. The project was developed and run by medical students involved in MSAP since 2016. The project has become sustainable with profits from the annual Diwali Mela stall funding food supplementation and construction of the new toilets. Ultimately the FFT project is a simple and feasible supplementation program that may be easily integrated into the current ‘Midday Meals Scheme’.

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Paul et al. discussed how effective implementation of a project is intimately connected with underlying ‘social, economic and environmental determinants including poor literacy, women’s status, sociocultural beliefs, caste, taboos and income level’.[9] Use of nutritional supplements familiar to students including chickpeas and BournVita (a popular brand in India), ensures that students consume the supplements. Indeed, there have been no issues with children declining to consume the meal supplements at any stage of the project. The health education videos that have been developed have focused on issues including handwashing, good nutrition and the risks of drugs and alcohol. These videos are created in the local dialect and targeted towards a young audience to maximise student engagement. Roy et al. have demonstrated that health promotion education and activities in a Bangladesh community improve the nutritional status of children independent of food supplementation.[22]

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Limitations of project design Frequent interruptions to food provision due to Image 7: Newly built classroom (exterior)

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summer vacations for 2 months in the middle of the year and long-distance monitoring are limitations of this project. The FFT project supplements the nutrition of school-aged children, however, it has been well recognised that the first 2 years of life are crucial to addressing undernutrition.[9] To address this, FFT encourages students to bring their younger siblings along to school on meal supplementation days. Additionally, the project does not measure academic performance, and hence assessment of this is limited to qualitative observations from teachers, which may be affected by bias. However, the continuation of the project is not contingent on academic improvement, reducing the likelihood of bias in qualitative reports from teachers. The American CDC growth charts use global population standards for height, weight and MUAC, and hence may not be accurately extrapolated for an Indian population.

Image 10: Student with new glasses donated by the Santram Eye Hospital Heeral Thakkar and Sharanya Mohan are two final year medical students at UNSW who were Projects Officers for Medical Student’s Aid Project for two years. They started the ‘Food for Thought’ health and nutrition project in rural India three years ago and plan to continue running and expanding this project after they graduate.

Conclusion Despite the efforts of the Indian Government’s ‘Midday Meals Scheme’, undernutrition continues to contribute to millions of childhood deaths in India. The FFT project aims to directly target this issue in school-aged children in rural Gujarat by providing nutritional supplements, incentivising school attendance, and improving sanitation and health literacy. Qualitative and quantitative data obtained from the project 24 months since initiation show improvements in multiple student growth metrics. Community engagement has been central to the success of the FFT project. We strongly suggest that any plans for similar grassroots projects should include culturally appropriate discussions with the local community to be successful. The FFT project has been shown to be an affordable and feasible micronutrient supplementation program that can be integrated with the ‘Midday Meals1 Scheme’ to improve growth and health in school aged children, thus assisting to breaking the cycle of undernutrition in India.

Acknowledgements We would like to extend our gratitude to the principal of Seem Shala Jibhaipura, Mr. Vasant Prajapati, the project supervisor and Mr. Kishore Bhinde, without whom this project would not be possible. We would like to also acknowledge the hard work of the entire MSAP executive and subcommittee over the years in making this project a success. Ethics: All research was conducted in line with the Helsinki Declaration of 2013. The principal of Seem Shala Jibhaipura provided permission for the deidentified audit data to be retrospectively analysed and the results published, however formal ethics approval was not sought for this study. Conflicts of interest None Declared Correspondence coordinating.officers.fft@gmail.com References 1. World Health Organisation. Children: reducing mortality 2018 [Available from: https://www.who.int/en/newsroom/fact-sheets/detail/children-reducing-mortality. 2. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al. Maternal and Child Undernutrition Study Group Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371(9608):241-60. 3. Cavatorta E, Shankar B, Flores-Martinez A. Explaining Cross-State Disparities in Child Nutrition in Rural India. World Development. 2015;76:216-37. 4. Ministry of Human Resource Development. Mid Day

Image 9: Optometrist and opthalmologists checking eyes

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Meal Scheme. In: Department of School Education & Literacy, editor. Online: National Informatics Centre; 2018. 5. Tiwari J. Relevance of Midday Meal Programme with special reference to local body schools of Durg and Bhilai town. International Journal of Research - Granthaalayah. 2017;5(4):263-7. 6. Vibhute K. Mid day meal: Government aided schools flouting norms. DsDNA. 2014. 7. Deodhar SY, Mahandiratta S, Ramani KV, Mavalankar D, Ghosh S, Braganza V. An Evaluation of Mid Day Meal Scheme. Journal of Indian School of Political Economy. 2010;22:33-48. 8. Menon P, Nguyen PH, Kohli N, Mani S, Avula R. Improving nutrition in Gujarat: Insights from examining trends in outcomes, determinants and interventions between 2006 and 2016. POSHAN Policy Note 3 New Delhi: International Food Policy Research Institute. 2017. 9. Paul VK, Sachdev HS, Mavalankar D, Ramachandran P, Sankar MJ, Bhandari N, et al. Reproductive health, and child health and nutrition in India: meeting the challenge. Lancet. 2011;377(9762):332-49. 10. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, et al. Maternal and child undernutrition: consequences for adult health and human capital. Lancet. 2008;371(9609):340-57. 11. National Nutrition Monitoring Bureau. Diet and Nutritional Status of Rural Population, Prevalence of Hypertension & Diabetes among Adults and Infant & Young Child Feeding Practices. National Institute of Nutrition, Hyderabad ICoMR; 2012. 12. Mogendi JB, De Steur H, Gellynck X, Saeed HA, Makokha A. Efficacy of mid-upper arm circumference in identification, follow-up and discharge of malnourished children during nutrition rehabilitation. Nutr Res Pract. 2015;9(3):268-77. 13. McDowell MA, Fryar CD, Ogden CL, Flegal KM. Anthropometric reference data for children and adults: United States, 2003–2006 CDC. . National health statistics reports. 2008;10. 14. Menon P. Childhood Undernutrition in South Asia: Perspectives from the Field of Nutrition. eCESifo Economic Studies. 2012;58(2):274-95. 15. WHO Multicentre Growth Reference Study Group.

Image 12: New toilet block (exterior) constructed by MSAP in 2019

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WHO Child Growth Standards: Length/height-for-age, weightfor-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and development. Geneva: World Health Organization. 2006. 16. Menon P, Headey D, Avula R, Nguyen PH. Understanding the geographical burden of stunting in India: A regression‐decomposition analysis of district‐level data from 2015–16. Maternal & Child Nutrition. 2018;14(4):12620. 17. Avula R, Frongillo EA, Arabi M, Sharma S, Schultink W. Enhancements to nutrition program in Indian integrated child development services increased growth and energy intake of children. J Nutr. 2011;141(4):680-4. 18. Parikh K, Marein-Efron G, Huang S, O’Hare G, Finalle R, Shah SS. Nutritional status of children after a foodsupplementation program integrated with routine health care through mobile clinics in migrant communities in the Dominican Republic. Am J Trop Med Hyg. 2010;83(3):559-64. 19. Sarma KVR, Udaykumar P, Balakrishna N, Vijayaraghavan K, Sivakumar B. Effect of micronutrient supplementation on health and nutritional status of schoolchildren: growth and morbidity. Nutrition. 2006;22(1):814. 20. Shahnaz V, Balakrishna N, Vijayapushpam T, Vijayaraghavan K, Sivakumar B. Effects of micronutrient supplementation on health and nutrition status of schoolchildren: mental function. Nutrition. 2006;22:26-32. 21. Djazayery A, Rahmani KH, Pourshariari M, Habibi MA, Heydari H. The effects of a daily milk supplement on the mental growth and school performance of female primary school children. Proceedings of the Nutrition Society. 2011;70(4):230. 22. Roy SK, Fuchs GJ, Mahmud Z, Ara G, Islam S, Shafique S, et al. Intensive Nutrition Education with or without Supplementary Feeding Improves the Nutritional Status of Moderately-malnourished Children in Bangladesh. J Health Popul Nutr. 2005;23(4):320-30.

Image 11: New toilet block (interior) constructed by MSAP in 2019

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Table 1: Food for Thought menu showing nutritional components [12] Day

Food provided

Calories (kcal)

Total fat, g (%RDI)

Protein, g Vitamin A (%RDI) (%RDI)

Vitamin B group (%RDI)

Vitamin C (%RDI)

Calcium (%RDI)

Iron (%RDI)

1

Masala channa (100g)

164

2.6 (4)

8.9 (18)

1

B6: 7

2

5

16

2

Banana (100g)

89

0.3 (0)

1.1 (2)

1

B6: 18

14

0

1

3

Milk (1 cup)

102

2.4 (4)

8.2 (16)

2

B12: 19 B6: 4

0

30

0

BournVita (2tbsp)

80

0

1 (6)

20

-

25

-

-

Medjool dates (per date)

66

0

0.4 (1)

1

B6: 3

0

2

1

Milk (1 cup)

102

2.4 (4)

8.2 (16)

2

B12: 19 B6: 4

0

30

0

BournVita (2 tbsp)

80

0

1 (6)

20

-

25

-

-

Chikki (1 bar)

209

13 (20)

6.2 (12)

0

B6: 3

0

3

2

4

5

RDI= recommended daily intake; tbsp, tablespoon. Percentages as based on a diet of 2000 kcal/day. Table 2: Basic demographics of students Baseline

12months

24months

Number (%)

Number (%)

Number (%)

149

183

167

Male

84 (56)

94 (56)

96 (57)

Female

65 (44)

74 (44)

71 (43)

Year 1

21 (14)

31 (17)

19 (11)

Year 2

24 (16)

22 (12)

30 (18)

Year 3

19 (13)

23 (13)

22 (13)

Year 4

28 (19)

20 (11)

22 (13)

Year 5

17 (11)

28 (15)

17 (10)

Year 6

17 (11)

18 (10)

24 (14)

Year 7

23 (15)

17 (9)

17 (10)

Year 8

0*

24 (13)

16 (10)

Total number of students Sex

Year groups

*The Year 8 class was started in 2017 after the construction of an additional classroom.

Figure 1: Improvement in percentage of underweight and stunted students


Table 3: Height and weight z scores, and MUAC percentiles at baseline and after 24months Baseline

24months

Number (%)

Number (%)

Stunted (Z score <-2)

39 (39)

23 (23)

Z score -2<z<2

61 (61)

77 (77)

Severe undernutrition (Z 39 (39) score <-3)

31 (31)

Z score -3<z<-2

61 (61)

69 (69)

<10%

80 (88)

72 (79)

10-25%

9 (9)

18 (20)

25-75%

2(2)

1 (1)

Height (n=100)

Weight (n=100)

MUAC (n=91)

IQR= interquartile range; WAZ= weight for age z score; HAZ= height for age z score; MUAC=, mid-upper arm circumference.

Figure 2: Improvement in height and weight


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Profile for The Australian Medical Students' Association

AJGH Volume 13 Issue 1  

The aim of the AJGH is to provide an accessible platform for medical students to engage with global health through academic writing and to g...

AJGH Volume 13 Issue 1  

The aim of the AJGH is to provide an accessible platform for medical students to engage with global health through academic writing and to g...

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