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VOL 13


OCT 2019

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SUGAR SWEETENED BEVERAGE TAX Health economy effects 19

THE CHICKEN OR THE EGG Conflict versus inequality


AJGH 2019 Volume 13 Issue 2

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

Beyond Borders

Hospital for Children

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

Reading is a form of travel.

Space Medicine at the Baylor College of Medicine.

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

Articles can push us beyond our comfort zone,

University of New South Wales.

Manuscripts provide direction in uncharted territory;

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

Words on a page can move us,

the Pan American Health Organization / World Health

They broaden our horizons, help us tread new ground.

Organization Regional Office for the Americas.

We seek knowledge when we are lost,


Dr Mariana Galrao-Labourie Dr Helena Obermair Stephen Duckett Dr Tom Van Der Touw Prof John Freebairn Joanne Anugerah


Koshy Mathew


Nicholas Mattock Simran Dahiya


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



Ishka De Silva Design and layout © 2019, AJGH Australian Medical Students’ Association Ltd, 42 Macquarie Street, Barton ACT 2600,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.

And save quotes to look back on, or frame on our walls; Such ideas help us understand a landscape that was previously foreign. So let the authors of issue two bring you on a journey, A journey that explores what lies beyond our borders.
















Recognizing Hikikomori as a clinical term in psychia try: Moving beyond a cultural idiom of distress Thomas Nguyen

Prevalence and risk factors for unintended pregnancy in Tigray, Ethiopia Tesfay Gebregzabher

The sugar sweetened tax: Health economic implications Jackie Maher

Waterpipe (“Shisha”) versus cigarette smoking: Implications for oral health Yasmine Toufaili

The chicken or the egg: A complex relationship between conflict and inequality Natalie S

HIV/AIDS in Sub-Saharan Africa: To what extent is poverty responsible for the high prevalance? Juliana Wu

Termination of pregnancy: How far do we really have to go? Jordan Kirby

Stem cell therapy: A cure or curse

Thanh Ha Thy (Rose) Phan

Project beyond borders

Kay Yuan Tey, Teresa Liew & Ellis Yee


Clinical challenge

Samuel Smith



ikikomori refers to a state of prolonged social withdrawal for 6 months or longer in adolescents and young adults. Marked by social isolation in one’s home, it may result in functional impairment, psychological distress as well as a lack of social participation and attendance at school and or work.[1,2] Made prominent in the late 1990s by Japanese psychiatrist, Tamaki Saito, the term Hikikomori is a portmanteau of the words ‘hiku’ (to pull back) and ‘komoru’ (to seclude oneself).[1] In 2010, Koyama et al. estimated that 1.2% of Japanese people were of Hikikomori status using a community-based survey.[3] Though once thought to be a phenomenon only affecting those living in Japan, reports have identified cases in other countries such as Oman and Spain and a telephone survey in Hong Kong identified a prevalence rate of 1.9%.[4-6]

symptoms, illness, or distress.”[9] Whilst DSM-IV included 25 cultural-bound syndromes, the DSM5 reclassification into cultural concepts of distress narrowed its predecessor’s list down to 9 cultural syndromes. Interestingly, taijin kyofusho, being the fear of offending others through either perceived physical defect or awkward social interaction, is a cultural syndrome that prevails mainly in Japanese society.[9] Whilst taijin kyofusho affects a similar age group to Hikikomori and also has a significant psychiatric comorbidity, the understanding of its epidemiology is poor, despite its firmer establishment in psychiatric nosology.[10,11] Responses to arguments against recognizing Hikikomori as a clinical term in psychiatry Due to its non-inclusion as a cultural syndrome in DSM-5, Hikikomori is widely regarded as a cultural idiom of distress. Sociologists view Hikikomori as an anomic response to post-industrialist societal changes such as the casualization and instability within the labour force as well as the rise of indirect communication via the internet.[12] This view suggests that the idiomatic response to experiencing these stressful life events is communicated by what Tajan calls a “passive resistance” which is manifested by remaining at home and withdrawing from society.[13] However, these patterns of experience

Whilst it has been established that individuals with Hikikomori have high incidence levels of psychiatric comorbidity, which may be brought on or exacerbated by their state of prolonged social withdrawal, its place within current psychiatric nosology remains ambiguous.[7] This editorial will first describe the status of cultural syndromes (formerly culture-bound syndromes) in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Using this framework, it will discuss why Hikikomori has been labelled as a cultural idiom of distress and warrant its case for inclusion in future classifications of psychiatric illnesses through highlighting the relevance of recent research developments.

Whilst it is now known that cases of Hikikomori exist outside Japan, cases of other cultural syndromes such as Dhat syndrome and taijin kyofusho have also been identified outside their respective cultural origins.

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The classification of cultural concepts of distress in DSM-5 Formerly referred to as “culture-bound syndromes” in DSM-IV, the phrase was revised in DSM-5 to “cultural concepts of distress” to remove the exaggeration of the local confinement and exoticism inferred through its naming.[8] The phrase “cultural concepts of distress” is defined in DSM-5 as the “ways that cultural groups experience, understand and communicate suffering, behavioral problems, or troubling thoughts and emotions.”[9] These cultural concepts of distress are further subclassified into “cultural syndromes”, “cultural idioms of distress” and “cultural explanations”.[9] “Cultural syndromes” are locally recognized patterns of experience, symptoms and attributions that co-occur amongst those in specific cultural groups, communities or contexts.[9] Whilst “cultural idioms of distress” do not include symptoms or syndromes, they refer specifically to collective ways of communicating and experiencing personal or social concerns.[9] Lastly, “cultural explanations” refers to an explanatory model that integrates a “culturally recognized meaning or etiology for

which can lead to functional impairment and a clinical course of symptomatic psychological distress such as passive aggression and a loss of motivation are all factors that are also synonymous with a cultural syndrome.[1] Whilst it is now known that cases of Hikikomori exist outside Japan, cases of other cultural syndromes such as Dhat syndrome and taijin kyofusho have also been identified outside their respective cultural origins.[8,14] In this way, the identification of Hikikomori as a cultural syndrome would recognize the influence of not only the shifting values in Japanese culture but of modern-day society. This is not to say that Hikikomori may still not be thought of as a cultural idiom of distress, as the act of withdrawing from society does mark an expression of mental suffering itself. This can be likened to major depression in a Western cultural context, where as an idiom of distress, 5

mental health service structures.[2] The discussion recommended adopting the Hikikomori Questionnaire (HQ-25) as a screening tool that offers promising psychometric properties.[2,18] Recently, Kato et al. have offered a revised definition of Hikikomori and a list of criteria that reflects the growing influence of the internet and a more realistic picture of the time course in psychological distress following social withdrawal.[1] With these advancements in the area of Hikikomori research, we are closer to ascertaining a universal definition for Hikikomori, backed up by a clearer cultural and biopsychosocial understanding of its psychopathology and thus its place in psychiatric nosology.

As the high psychiatric comorbidity of individuals with Hikikomori is well known, a key argument against its recognition as a clinical term comes from the view that the prolonged social withdrawal is a secondary effect of having a prior mental illness.[2] Studies have reported psychiatric comorbidity with social anxiety disorder, major depression and avoidant personality disorder and suggest overlapping symptomatology with autism spectrum disorder as well as the prodromal state of schizophrenia.[15,16] However, in a 2010 community-based survey, Koyama et al. found that 16% of respondents developed a psychiatric disorder (namely generalized anxiety disorder, hypomanic episode, alcohol abuse or dependence) following the onset of Hikikomori.[3] Furthermore, the majority of individuals identified as Hikikomori in the 2015 Hong Kong telephone survey conducted by Wong et al. were also found to be primary Hikikomori (without previous psychiatric comorbidity) as opposed to secondary Hikikomori (psychiatric illness leading to social withdrawal.)[6] Whilst these studies alone aren’t enough to refute this argument entirely, it paves the way for further research to delineate between primary and secondary Hikikomori in order to better understand the bidirectionality of these psychiatric comorbidities.

Conclusion Precipitated by a range of socio-cultural, psychological and behavioural factors, Hikikomori refers to social withdrawal for a period of over 6 months. Emerging research in the area has revealed how these influences underlie its psychopathology and round-table discussions have elucidated a better definitional basis for Hikikomori. Whilst more research must be undertaken to better understand its subtypes, cross-cultural epidemiology, bidirectionality of psychiatric comorbidities and effective, evidence-based treatments, Hikikomori should begin to be seen as more than just a cultural idiom of distress. Its clear syndromic features warrant further discussion regarding its recognition as a clinical term in psychiatry, particularly in context of its alarming prevalence levels in a growingly individualist and technology-reliant society. Thomas is currently a second year medical student at Western Sydney University. His research interests lie at the intersection of psychiatry and minority group healthcare. He is currently collaborating on research within the areas of transgender medicine and mental health literacy.

Tajan, in his 2015 review, asserts that the lack of definitional consensus for Hikikomori and the methodological inaccuracies in studies looking at the existence of Hikikomori outside Japan were reasons for its non-inclusion in DSM-5.[14] He refers specifically to two studies with one asking psychiatrists outside of Japan whether a clinical vignette of Hikikomori existed in their own country of practice.[14,17] He argues that the clinical vignettes used only represented a minority of Hikikomori cases, rendering the suggestion that Hikikomori is perceived to occur worldwide by Kato et al. as inconclusive.[14,17] Since the publication of his review, the Hikikomori Round Table and Regional Symposium was organized in late 2017, bringing together Hikikomori experts across East Asia.[2] The round table made constructive progress in forming a consensus definition for Hikikomori and addressing how heterogenous, cross-cultural presentations of Hikikomori may be treated in the context of differing

Acknowledgements None Conflicts of interest None declared Correspondence Image Offri G. Hikikomori [Internet]. 2011 [cited 26 October 2019]. Available from: File:Hikikomori_by_Galia_Offri.jpg References 1. Kato TA, Kanba S, Teo AR. Hikikomori: Multidimensional understanding, assessment, and future international perspectives. Psychiatry Clin Neurosci. 2019;73(8):427-40. 2. Wong JCM, Wan MJS, Kroneman L, Kato TA, Lo TW, Wong PW-C, et al. Hikikomori Phenomenon in East Asia: Regional 6

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a person may verbalize their feelings of depression to communicate the experience of personal sadness.[9] Recently, Kato et al. suggested that Hikikomori should be subtyped or given its own specifier code in a future revision of psychiatric nosology.[1] In contrast to classifying Hikikomori as a cultural syndrome, subtyping or providing a specifier code would recognize its transcultural epidemiology and its underlying psychopathology as a reaction to the changing values of modern day society.

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Perspectives, Challenges, and Opportunities for Social Health Agencies. Front Psychiatry. 2019;10(512). 3. Koyama A, Miyake Y, Kawakami N, Tsuchiya M, Tachimori H, Takeshima T. Lifetime prevalence, psychiatric comorbidity and demographic correlates of “hikikomori” in a community population in Japan. Psychiatry Res. 2010;176(1):69-74. 4. Sakamoto N, Martin RG, Kumano H, Kuboki T, Al-Adawi S. Hikikomori, is it a Culture-Reactive or Culture-Bound Syndrome? Nidotherapy and a Clinical Vignette from Oman. The Int J Psychiatry Med. 2005;35(2):191-8. 5. Garcia-Campayo J, Alda M, Sobradiel N, Sanz Abos B. A case report of hikikomori in Spain. Med Clin. 2007;129(8):318-9. 6. Wong PW, Li TM, Chan M, Law Y, Chau M, Cheng C, et al. The prevalence and correlates of severe social withdrawal (hikikomori) in Hong Kong: A cross-sectional telephone-based survey study. Int J Soc Psychiatr. 2015;61(4):330-42. 7. Stip E, Thibault A, Beauchamp-Chatel A, Kisely S. Internet Addiction, Hikikomori Syndrome, and the Prodromal Phase of Psychosis. Front Psychiatry. 2016;7(6). 8. Ventriglio A, Ayonrinde O, Bhugra D. Relevance of culture-bound syndromes in the 21st century. Psychiatry Clin Neurosci. 2016;70(1):3-6. 9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington DC, 2013. 10. Teo AR, Gaw AC. Hikikomori, a Japanese culture-bound syndrome of social withdrawal?: A proposal for DSM-5. J Nerv Ment Dis. 2010;198(6):444-9. 11. Essau CA, Sasagawa S, Chen J, Sakano Y. Taijin Kyofusho and Social Phobia Symptoms in Young Adults in England and in Japan. J Cross Cult Psychol. 2012;43(2):219-32. 12. Furlong A. The Japanese Hikikomori Phenomenon: Acute Social Withdrawal among Young People. Sociol Rev. 2008;56(2):309-25. 13. Tajan N. Japanese post-modern social renouncers: An exploratory study of the narratives of Hikikomori subjects. Subjectivity. 2015;8(3):283-304. 14. Tajan N. Social withdrawal and psychiatry: A comprehensive review of Hikikomori. Neuropsychiatr Enfance Adolesc. 2015;63(5):324-31. 15. Kato TA, Kanba S, Teo AR. Hikikomori: experience in Japan and international relevance. World Psychiatry. 2018;17(1):105-6. 16. Teo AR, Stufflebam K, Saha S, Fetters MD, Tateno M, Kanba S, et al. Psychopathology associated with social withdrawal: Idiopathic and comorbid presentations. Psychiatry Res. 2015;228(1):182-3. 17. Kato TA, Tateno M, Shinfuku N, Fujisawa D, Teo AR, Sartorius N, et al. Does the ‘hikikomori’ syndrome of social withdrawal exist outside Japan? A preliminary international investigation. Soc Psychiatry Psychiatr Epidemiol. 2012;47(7):1061-75. 18. Teo AR, Chen JI, Kubo H, Katsuki R, Sato-Kasai M, Shimokawa N, et al. Development and validation of the 25-item Hikikomori Questionnaire (HQ-25). Psychiatry Clin Neurosci. 2018;72(10):780-8.


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Tesfay Gebregzabher Gebrehiwot Isabel Goicolea2 Miguel San Sebastian2 Yirgu Gebrehiwot3 Misganaw Fantahun Afework4


Aims: In developing countries, unintended pregnancies result in approximately 25 million births annually. A further 46 million unintended pregnancies are aborted, often in an unsafe manner. This study aimed to determine the prevalence and determinants of unintended pregnancy among women of reproductive age in Tigray, Ethiopia. Methods: This study used a community-based, cross-sectional design. The total sample comprised 473 women of reproductive age. The data was collected using a structured, preexisting questionnaire. A multi-stage sampling technique was employed. Women who were pregnant at least once in the 3 years prior to the distribution of the survey were included. Bivariate and multivariate regression analyses were performed to determine the impact of each factor on the occurrence of unintended pregnancy. Results: The survey had a response rate of 94.6% (n = 473). The mean age of the study participants was 28.3 ¹ 6.2 years. Sixty-two women (13.1%) had experienced at least 1 unintended pregnancy. Factors associated with unintended pregnancy included being divorced (adjusted odds ratio [AOR] 3.74 [1.63,8.61]) or separated (AOR 2.32 [1.0,5.39]), having 2 to 3 (AOR 19.76 [4.34,89.9]) or ≼4 pregnancies (AOR 61 [10.3,360.52]) and sexual abuse (AOR 1.99 [1.00,4.02]).

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Conclusions: Though most women attest to receiving information on family planning, the rate of unintended pregnancy remains high. Significant effort is needed to counsel and empower women in order to effectively prevent sexual abuse. Special attention should be given to raising awareness about emergency contraceptives.


Study area


The Tigray regional state is in the northern part of Ethiopia. The region is divided into 7 zones and 52 weredas (districts), of which 34 are rural and 18 are urban. According to the Ethiopian Population and Housing Census of 2007, the region has an estimated total population of 5.24 million, with 50.8% of these residents being female. Eighty percent of the population is estimated to be rural, and about 85% of the population are farmers.[20] The majority of the population is Christian. There is 1 specialized referral hospital, 15 general and 20 primary hospitals, 214 health centers and more than 600 health posts providing different levels of health services to the public sector.[21]

orldwide, an estimated 46 million pregnancies are terminated annually, almost half of which are done in unsafe conditions. Unsafe abortions are responsible for 1 in every 8 pregnancy-related maternal deaths annually.[1-3] An unintended pregnancy is defined as any pregnancy that occurs when the woman did not intend to conceive.[4-6] Unintended pregnancies may end in termination; in regions where access to safe abortion care is not available, women may be required to undergo unsafe and risky procedures.[7-9] Unintended pregnancy has been proven to be associated with marital status, living in a rural housing location, parity, female poverty, level of education and inadequate knowledge on the risks of pregnancy following unprotected sexual intercourse. Further, women may be restricted in their capacity to make decisions regarding contraceptives due to physical or sexual violence (e.g., marital rape), forced sexual intercourse and, in some cultures, their husband’s disapproval. Contraceptive failure has also been reported as a factor contributing to unintended pregnancy.[10-15]

As part of the collaboration between the Tigray Regional Health Bureau (TRHB) and Ipas (a nonprofit organization that focuses on the provision of safe abortion care), efforts have been underway since 2007 to improve access to contraceptive services in 12 hospitals and 38 health centers.[22] This community-based cross-sectional study was carried out from January to June 2009. Participants were women of reproductive age residing in 2 selected districts in the eastern zone of the Tigray region: the Wukro and Kilte Awlaelo districts. These regions have populations of 30,208 and 112,788, respectively. Wukro is a district undergoing rapid urbanization and is located 45 km north of Mekelle. Kilte Awlaelo is a rural district with over 25,000 women in the reproductive age group. There is a total of 1 hospital, 6 health centers and 15 health posts in both districts.[21] In addition, each rural kebele (a local administrative unit with a population of 5000–7000) has a health post with 2 health extension workers (HEWs).[23]

To reduce the health toll of abortion complications and decrease the incidence of unsafe abortion, it is vital to help women avoid unintended pregnancies. [16,17] Moreover, a woman’s control over the decision to become pregnant is a human right. The exercise of this right depends not only on the equitable access to information, contraceptives and safe abortion services, but also the individual freedom to make decisions regarding sexuality and reproduction. Both access and freedom are highly influenced by social factors, such as socioeconomic status and gender relations.[8,9,12,18]

Sample size and sampling technique

In Ethiopia, the Demographic and Health Survey (DHS) reported that 29% of pregnancies were unintended. Of these pregnancies, 20% were labeled as mistimed and 9% were considered unintended. [19] Although exploring the determinants of unintended pregnancy is essential for improving reproductive health, few community-based studies of this type have been conducted nationally, particularly in the Tigray region. Additionally, there is still an information gap regarding the prevalence of unintended pregnancy and its associated factors in Ethiopia. Therefore, the aim of this study was to determine the prevalence and determinants of unintended pregnancy in women aged 15 to 49 years who are living in the Tigray region of Northern Ethiopia.

The sample size was estimated using a single population proportion formula. The prevalence of unintended pregnancy was assumed to be 15%, with a marginal error of 5%, a non-response rate of 10% and a design effect of 2. This gave a calculated sample size of 500. The 2 districts were purposely selected with the aim of representing both an urban and rural population. A multistage sampling technique was employed. First, 6 kebeles were randomly selected based on the calculated sample size and estimated population of a typical kebele. Then, every village in the 6 kebeles was listed, leading to a total of 24 villages. Four of the rural villages were excluded due to their remote location and difficulty in

Methods 10

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accessing the population. Of the remaining 20 villages, 14 villages were randomly selected using a lottery method and included in the study. On average, 45 to 50 women from each village who had been pregnant at least once in the last 3 years were included. To find study participants, data collectors started randomly from a central place in the village and spun a pen to determine what direction to walk towards the edge of the village, numbering all the households they passed along the way. Then, a random number was chosen to identify one of the numbered households as the starting household for the cluster, and the data collectors continued rightward from the starting house until the required number of individuals had been recruited for the study. If no household members or women fitting the selection criteria were present at the time of the visit, the next closest household was visited.

Data was entered using Epi-Info (Atlanta, GE: CDC) software and analyzed using SPSS version 19 (Armonk, NY: IBM Corp.). Cross-tabulation was performed on selected categorical variables against the outcome variable. Bivariate logistic regression analysis was carried out between the selected predictor variables and the outcome variable (i.e., unintended pregnancy). Subsequently, all variables that showed significant associations (p < 0.05) in the bivariate analysis were included in a multivariate logistic regression analysis. Results Socio-demographic characteristics of participants The response rate was 94.6% (n = 473). The mean age of the study participants was 28.3 years. The mean reported ages at first marriage and first pregnancy were 16.5 years and 18.5 years, respectively.

Data collection

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Data was collected using a structured preexisting questionnaire administered in Tigrigna, the local language. The questionnaire included information on socio-demographic characteristics of the study subjects, as well as their reproductive history (i.e., number of pregnancies, parity, age at first pregnancy and age of first marriage). Participants were asked about issues relating to forced or unwilling first sexual intercourse, awareness of contraception and its benefits, attitudes of women toward contraceptives and knowledge of emergency contraception. To collect data on the outcome variable, women were asked if they had ever had an unintended pregnancy and whether their last pregnancy was unintended. If their last pregnancy was unintended, they were then also questioned on the reasons why the pregnancy was unintended. All results and analyses were performed regarding their last pregnancy. The questionnaire was adopted from a previous study conducted in the eastern region of Ethiopia.[13] Pre-testing was conducted in villages not included in the survey.

The proportion of respondents who had an unintended pregnancy as their last conception was 13.1% (n = 62). A little over half (51.6%, n = 32) of the women who experienced an unintended pregnancy lived in an urban location and 48.4% (n = 30) lived in a rural location. The proportion of unintended pregnancies was higher among divorced women (21.1%) and separated women (20%) than women with current partners (9.3%). Among the survey respondents, women with a college level of education or higher experienced a greater proportion of unintended pregnancy compared to non-educated women. (Table 1) Reproductive health characteristics of participants Of all survey respondents, 26% reported that their first experience of sexual intercourse occurred against their will. The proportion of unintended pregnancies among women who experienced forced intercourse during their first instance of sexual intercourse was 18.7%.

Three female nurses and 6 HEWs were recruited to collect data from urban and rural settings, respectively. The data collectors and supervisors were trained for 1 day on the interview methodology. Interviews were conducted during the morning hours because men (for various tasks) and children (for school) are usually outside of the house during that time, which ensured privacy and provided an environment for women to respond freely. Data was checked for completeness by supervisors on the spot. The data was rechecked by the primary investigator when it was compiled from supervisors.

Almost all the participating women (98.3%, n = 465) had heard information about at least 1 type of family planning method. However, only 10.2% of the women had information on emergency contraceptive use. The prevalence of unintended pregnancy among participants who did not have knowledge regarding emergency contraceptives was 12.7%. Among the women who reported an unintended pregnancy, the most frequently mentioned reasons were inadequate knowledge (24.2%, n = 15), forced sexual intercourse (20.9%, n = 13), poor access to family planning methods (3.2%, n = 2) and improper use of family planning methods, such as forgetting to take the pill or not going to the

Data analysis 11

by separated and single women. Previous studies in Ethiopia have pointed out that divorce and premarital sexual intercourse are highly associated with unintended pregnancy.[28] Extramarital sexual intercourse is perceived negatively in the community. Thus, divorced and separated women might tend to consider their pregnancies as unintended. The number of pregnancies was another factor significantly associated with unintended pregnancy, which is consistent with other local studies.[13,25,27] Modern Ethiopian families are having fewer children, likely due to increasing costs of living and enhanced awareness and access to modern family planning methods.

Factors associated with unintended pregnancy When the independent variables were analysed using multivariate logistic regression, a marital status of divorced or separated, higher gravidity and forced sexual intercourse were the main predictors associated with unintended pregnancy (Table 2). Separated (adjusted odds ratio [AOR] 2.32 [1.0,5.39]) and divorced women (AOR 3.74 [1.63,8.61]) were 2.3 and 3.7 times more likely to experience an unintended pregnancy, respectively, compared to married or widowed women. Women with 2 to 3 pregnancies were almost 20 times (AOR 19.76 [4.34,89.9]) more likely to experience an unintended pregnancy, and those with 4 or more pregnancies were 61 times (AOR 61 [10.3,360.52]) more likely to experience unintended pregnancy, when compared with primigravid women. Women who experienced domestic violence through forced sexual intercourse (marital rape) were 2 times (AOR 1.99 [1.00,4.02]) more likely to experience an unintended pregnancy.

In this study, a significant proportion of women labeled their pregnancies as unintended, even though 98% of women reported being aware of modern contraceptive methods. Increased awareness alone is insufficient to address this issue, and continuous education and access initiatives will be required. School-based reproductive health education with customized content has shown an impact in avoiding unintended pregnancy.[30] The provision of family planning counseling has also been found to improve womenâ&#x20AC;&#x2122;s decisionmaking capacity in the prevention of unintended pregnancy.[31,32] Moreover, the World Health Organization (WHO) recommends interventions, such as childhood education, school-based sex education and youth and life skill development, for reducing risky sexual behavior and unintended pregnancy.[33]

Discussion This study discusses the prevalence and determinants of unintended pregnancy in Tigray, Northern Ethiopia. In the present study, the prevalence of unintended pregnancy was 13.1%. This is similar to a study conducted in rural southern Ethiopia where the prevalence was 12.9%. [24] Some studies in Ethiopia have shown a lower [4-7] or higher [13,28] prevalence of unintended pregnancy compared to this study, ranging from 6.7 to 19.6%. In this study, over 50% of the participants were rural inhabitants, whereas other studies have a higher proportion of participants from urban areas with different socio-demographic characteristics. The study may also be highly influenced by the prevalence of Orthodox religious beliefs, where many community members feel that a pregnancy is always a â&#x20AC;&#x2DC;gift from Godâ&#x20AC;&#x2122;. Consequently, reporting an unintended pregnancy might not be perceived as appropriate.[29]

In this study, forced sexual intercourse (marital rape) was reported as one of the factors that increase the risk of unintended pregnancy. The findings of this study were similar to previous studies conducted in Ethiopia, where marital rape was significantly associated with unintended pregnancy.[15,34] Several articles from other sub-Saharan African countries also showed an association between forced first sexual intercourse and unintended pregnancy.[35,36] One of these studies revealed that young African girls experience forced first sexual intercourse at similar or higher rates than what was found in our study (18.7%), ranging from 15% in Burkina Faso to 38% in Malawi.[37] Lack of awareness and access to emergency contraceptives might further contribute to the increased risk of unintended pregnancies among women who have experienced reproductive coercion. Our study revealed that almost 90% of women had no information on emergency contraception.

In the current study, divorced women were more likely to report an unintended pregnancy, followed

Unlike other studies in Africa,[35] this study did not 12

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health facility for scheduled health appointments (51.6%, n = 32) (Figure 1). In the bivariate analysis, socio-demographic characteristics, such as a marital status of divorced or separated, a higher-level education, higher parity, having an unemployed husband and experiencing forced sexual intercourse, were found to be predictors of unintended pregnancy (Table 2).

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find lower levels of education to be a risk factor for unintended pregnancy. For example, a study from southwest Ethiopia revealed an increased risk of unintended pregnancy in women with no formal education compared to educated women.[31] Evidence showed that educated women are motivated to use contraceptives and to delay pregnancy.[30,33] In contrast, our study found that higher education levels were a predictor of unintended pregnancy in the univariate analysis. It is not entirely clear whether this observation reflects a lack of statistical power or instead a discrete social trend. For example, whilst absolute rates of pregnancy may be lower in educated women, it is likely that such women will have negative cognitions related Figure 1. Reasons given for unintended pregnancy in women aged 15–49 years to the impact of a pregnancy on their personal and professional lives; for this reason, a higher proportion of To enhance the social acceptability of contraceptive pregnancies would be perceived negatively, despite use, considerable effort is needed to educate and lower overall rates. Nonetheless, this predictor lost empower women, in addition to behavioral change its significance in the multivariate model. communication targeting both sexes. Special attention should be given to raising awareness This study has a few limitations. The crossabout emergency contraceptives, as it seems that sectional study design limited the ability to draw this information has not reached the community causal inferences. Furthermore, the evaluation of effectively. To prevent reproductive coercion in reproductive coercion, a form of domestic abuse all its forms, the regional government needs to in which a woman’s reproductive choices are readdress the implementation and enforcement of controlled, was limited only to forced first sexual women’s reproductive health rights policies in order intercourse, leading to a probable underestimation to create greater equity in gender power relations. of reproductive coercion and its effects. Using the questionnaire to assess unintended pregnancy Dr. Gebregzabher Gebrehiwot has been working as a nurse and among women over a period of 3 years preceding non physician clinician. Additionally working in the zonal health data collection might have introduced recall bias. department, district health office and regional health bureau in Participants were also only asked about their last the health system organization, Dr Gebregzabher Gebrehiwot is pregnancy, and the prevalence of women who currently working as Head of Public Health at Mekelle University. experienced unintended pregnancy may be greater if women were asked to answer with reference to all previous pregnancies. As previously mentioned, Authors 1 Department of Public Health, College of Health Sciences, Mewomen might also have been reluctant to report a kelle University, Mekelle, Ethiopia pregnancy as unintended due to cultural or religious 2 Department of Public Health and Clinical Medicine, Epidemibeliefs. ology and Global Health, Umeå University, Umeå, Sweden Department of Gynaecology and obstetrics, Addis Ababa University Addis Ababa, Ethiopia 4 School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia 3

Conclusion This study identified that a marital status of divorced or separated, higher gravidity and forced sexual intercourse were significant predictors of unintended pregnancy. Despite committed efforts to increasing women’s access to contraceptives, much remains to be done in order to ensure women’s reproductive health rights. 13

Ethics approval and consent to participate This study received ethical approval from the ethics committee of Mekelle University, Ethiopia. Permission was obtained from the district health authorities, and informed consent was obtained from every participant. Confidentiality and privacy were guaranteed, and names and other identifying information were removed. Participants were also informed that they

3. Sedgh G, Henshaw S, Singh S, Åhman E, Shah IH. Induced abortion: estimated rates and trends worldwide. Lancet. 2007;370(9595):1338-45. 4. Faghihzadeh S, Rochee GB, Lmyian M, Mansourian F, Rezasoltani P. Factors associated with unwanted pregnancy. J Sex Marital Ther. 2003;29(2):157-64. 5. World Health Organization. Safe motherhood fact sheet. Geneva (Switzerland): World Health Organization; 1998. 6. Adetunji J. Unintended childbearing in developing countries; levels, trends and determinants: demographic and analytic health report surveys. Calverton (Maryland): Macro International Inc.; 1998. 7. Ipas. Facts of unintended pregnancy and abortion in Ethiopia. New York City (New York): Guttmacher Institute; 2008. 8. Glasier A, Gülmezoglu AM, Schmid GP, Moreno CG, Look PFV. Sexual and reproductive health: a matter of life and death. Lancet. 2006;368(9547):1595-607. 9. Gruskin S. Reproductive and sexual rights: do words matter? Am J Public Health. 2008;98(10:1737). 10. World Health Organization. The world health report 2002: reducing risks, promoting healthy life. Geneva (Switzerland): World Health Organization; 2012. 11. Izugbara C, Ochako R, Izugbara C. Gender scripts and unwanted pregnancy among urban Kenyan women. Cult Health Sex. 2011;13(9):1031-45. 12. Goicolea I. Adolescent pregnancies in the Amazon Basin of Ecuador: a rights and gender approach to adolescents’ sexual and reproductive health. Glob Health Action. 2010;24(3). 13. Worku S, Fantahun M. Unintended pregnancy and induced abortion in a town with accessible family planning services: the case of Harar in eastern Ethiopia. Ethiop J Health Dev. 2007;20(2):79-83. 14. Rosenfield A, Maine D. Maternal mortality–a neglected tragedy: where is the M in MCH? Lancet. 1985;326(8446):83-5. 15. Gessessew A, Mesfin M. Rape and related health problems in Adigrat Zonal Hospital, Tigray Region, Ethiopia. Ethiop J Health Dev. 2005;18(3):140-4. 16. Sedgh G, Bankole A, Singh S, Eilers M. Legal abortion levels and trends by woman’s age at termination. Perspect Sex Reprod Health. 2013;45(1):13-22. 17. Singh S, Fetters T, Gebreselassie H, Abdella A, Gebrehiwot Y, Kumbi S, Audam S. The estimated incidence of induced abortion in Ethiopia, 2008. Int Perspect Sex Reprod Health. 2010;36(1):16-25. 18. Orza L. Community innovation: achieving sexual and reproductive health and rights for women and girls through the HIV response [Internet]. Joint United Nations Programme on HIV/AIDS (UNAIDS) and the ATHENA Network; 2011 [cited 2019 Aug 15]. Available from: sites/default/files/media_asset/20110719_Community%20 innovation_0.pdf 19. Central Statistical Agency [Ethiopia]. Ethiopia Mini Demographic and Health Survey 2014. Addis Ababa (Ethiopia): Central Statistical Agency; 2014. 20. Federal Democratic Republic of Ethiopia Population Consensus Commission. Summary and statistical report of the 2007 population and housing census: population size by age

Availability of data and materials The datasets generated and/or analysed for the current study are available and can be shared by the corresponding author upon request. Funding This research was covered by the Netherlands Project for Training and Research fund (NPT). Authors’ contributions TG, MF and YG were involved in the conception and design of the study. TG was further involved in data collection, supervision, processing, cleaning and analysis, as well as the interpretation of results. TG, MF, YG, IG and MSS were involved in reviewing the interpretation of the results and developing the manuscript. IG and MSS contributed to the interpretation of the results, reviewing the manuscript and providing scientific advice on the design and further analysis of the study. All authors approved the final manuscript. Acknowledgements We sincerely express our appreciation to Dr. Azarias Assefa for his enormous contribution in developing the preliminary draft before he left for his PhD study. We are very grateful to the respondents and data collectors of this study. We are greatly indebted to the Mekelle University, College of Health Sciences NPT project for covering the expenses of data collection and other related costs. We acknowledge Hannah Yang for her commitment to conducting the language revision of this manuscript. We also thank the Tigray Regional Health Bureau and the District Health Office for allowing us to carry out this study. Conflicts of interest None declared Correspondence Image UK Department for International Development. The risks of child marriage [Internet]. 2014 [cited 26 October 2019]. Available from: References 1. Shah I, Åhman E. Unsafe abortion: global and regional incidence, trends, consequences, and challenges. J Obstet Gynaecol Can. 2009;31(12):1149-58. 2. Grimes DA, Benson J, Singh S, Romero M, Ganatra B, Okonofua FE. Unsafe abortion: the preventable pandemic. Lancet. 2006;368(9550):1908-19. 14

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could cease participating at any time, for any reason, without negative consequences.

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and sex. Addis Ababa (Ethiopia): United Nations Population Fund; 2008. 21. Tigray Regional Health Bureau. The Tigray Regional Health Bureau annual profile of 2004 EFY, 2012. Mekelle (Ethiopia): Tigray Health Bureau, 2012. 22. Alemayehu T, Otsea K, GebreMikael A, Dagnew S, Healy J, Benson J. Abortion care improvements in Tigray, Ethiopia: using the Safe Abortion Care (SAC) approach to monitor the availability, utilization and quality of services. Chapel Hill (North Carolina): Ipas; 2009. 23. Federal Ministry of Health. Health extension program in Ethiopia: health extension and education center. Addis Ababa (Ethiopia): Ministry of Health, 2007. 24. Dibaba Y, Fantahun M, Hindin MJ. The association of unwanted pregnancy and social support with depressive symptoms in pregnancy: evidence from rural Southwestern Ethiopia. BMC Pregnancy Childbirth . 2013;13(135). 25. Kassa N, Berhane Y, Worku A. Predictors of unintended pregnancy in Kersa, Eastern Ethiopia, 2010. Reprod Health. 2012;9(1):2-7. 26. Habte D, Teklu S, Melese T, Magafu MG. Correlates of unintended pregnancy in Ethiopia: results from a national survey. PloS One. 2013;8(12):e82987. 27. Hamdela B, Tilahun T. Unwanted pregnancy and associated factors among pregnant married women in Hosanna Town, Southern Ethiopia. PLoS One. 2012;7(6):e39074. 28. Hurissa BF, Tebeje B, Megersa H. Prevalence of premarital sexual practices and associated factors among Jimma Teacher Training College students in Jimma Town, South West Shoa Zone, Oromiya Region, Ethiopia, 2013. J Womens Health Care. 2014;4(221). 29. Michal G, Ada S, Karen JA, Carol R, Batya T, Revka N. Pregnancy and delivery practices and beliefs of Ethiopian immigrant women in Israel. West J Nurs Res. 1996;18(3):299313. 30. Kirby D, Obasi A, Laris B. The effectiveness of sex education and HIV education interventions in schools in developing countries. World Health Organ Tech Rep Ser. 2006;9380:103. 31. Dibaba Y. Child spacing and fertility planning behavior among women in Mana District, Jimma Zone, South West Ethiopia. Ethiop J Health Sci. 2010;20(2). 32. Calvert C, Baisley K, Doyle AM, Maganja K, Changalucha J, Watson-Jones D, Hayes RJ, Ross DA. Risk factors for unplanned pregnancy among young women in Tanzania. J Fam Plann Reprod Health Care. 2013;39(4):e2. 33. Chandra-Mouli V, Camacho AV, Michaud PA. WHO guidelines on preventing early pregnancy and poor reproductive outcomes among adolescents in developing countries. J Adolesc Health. 2013;52(5):517-22. 34. Gessessew A. Abortion and unwanted pregnancy in Adigrat Zonal Hospital, Tigray, North Ethiopia. Afr J Reprod Health. 2010;14(3):183-8. 35. Marston M, Beguy D, Kabiru C, Cleland J. Predictors of sexual debut among young adolescents in Nairobiâ&#x20AC;&#x2122;s informal settlements. Int Perspect Sex Reprod Health. 2013;39(1):22-31. 36. Mchunu G, Peltzer K, Tutshana B, Seutlwadi L. Adolescent pregnancy and associated factors in South African

youth. Afr Health Sci. 2013;12(4):426-34. 37. Moore AM, Awusabo-Asare K, Madise N, John-Langba J, Kumi-Kyereme A. Coerced first sex among adolescent girls in sub-Saharan Africa: prevalence and context. Afr J Reprod Health. 2007;11(3):62.



% of respondents

% of unintended pregnancy


































No school












College and above




No school












College and above












Age groups <20

Marital status Not married Married


Husband’s education

Husband’s occupation

Parity 1

















































Ever heard of family planning

Information on emergency contraception

Forced sex (marital rape)

Table 1. Unintended pregnancy rates in relation to various socio-demographic characteristics in the Wukro and Kilte Awlaelo districts of Northern Ethiopia (n = 473)


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Unadjusted OR*

Adjusted OR**

0.86 (0.19,3.93)

2.53 (0.31,20.51)


0.73 (0.23,2.29)

1.07 (0.23,4.82)


0.65 (0.20,2.07)

0.72 (0.19, 2.71)





2.79 (0.56, 14.1)

6.63 (0.98, 44.9)


2.45* (1.24, 4.85)

2.32** (1.0, 5.39)


2.61* (1.34, 5.12)

3.74** (1.63, 8.61)




1.06 (0.56, 1.99)

1.04 (0.48, 2.30)


1.54 (0.74, 3.21)

1.69 (0.64, 4.46)

College and above

4.35 (1.35, 14.1)*

2.77 (0.58, 13.27)



0.69 (0.35, 1.39)

0.88 (0.38, 2.02)

Age groups <20

40 and above Marital status Married + widowed Not Married

Education No school

Husband’s education No school Primary Secondary

1.4 (0.63, 3.09)

College and above

2.4 (0.98, 6.05)

1.28 (0.41, 3.97) 2.61(0.65, 10.46)

Age at first marriage ≤ 18

1.95 (0.81, 4.69)

2.11 (0.58, 13.27)

≥ 19





1.96 (1.12, 3.46)*

1.85 (0.82, 4.17)




3.42 (1.27, 9.2)

19.76** (4.34, 89.9)


3.89 (1.47, 10.4)

61.0** (10.3,360.52)





1.83 (1.05, 3.22)*

1.99** (1.00, 4.02)

Husband’s occupation Employed Unemployed Gravidity 1

Table 2. Socio-demographic characteristics and their association with unintended pregnancy in the Wukro and Kilte Awlaelo districts in Northern Ethiopia (n = 473) * Variables associated with the outcome variable either by bivariate or multivariate logistic regression analysis.

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Forced sexual intercourse


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ustralia is in an obesity epidemic. Over twothirds of all adults and over one in four children are now overweight or obese and this trend is predicted to continue.[1,2] The health consequences of obesity are severe and numerous, with a known correlation to premature death and new research frequently linking obesity to further health conditions.[1,3] The most common conditions linked to obesity include diabetes mellitus, osteoarthritis and cardiovascular disease alongside its risk factors, such as hypertension and hypercholesterolaemia.[3] Both obesity and its comorbidities demand comprehensive care from the public health system.[1] Government policy has previously focused on individual responsibility and voluntary practices, not fiscal practices such as a taxation on sugar.[1] Examples of this individual responsibility approach include the Commonwealth Government’s “Healthy Food Partnership” and “Weighing Up: Obesity in Australia” initiatives which aimed to raise awareness about healthy food choices. [4,5] These programs have been largely unsuccessful, with public health experts critical of this personal responsibility approach.[6]

THE SUGAR SWEETENED BEVERAGE TAX Health economic implications Jackie Maher

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Beyond the medical consequences of obesity are the costs borne on a personal, community and governmental level. The personal costs of obesity include reduced wellbeing and quality of life, reduced income due to lower employment rates and increased out-of-pocket expenses due to higher use of healthcare services.[1,7] Third-party or community costs of obesity are mostly worn by the government and were estimated to be $5.3 billion in 2014-2015.[7] Governmental costs include; health care costs generated by obesity, the foregone tax revenue (due to lower employment rates, absenteeism and lower productivity) and higher social services payments.[8] These costs have indirect effects on the community at large, as explained by the principle of finite resources. The costs of obesity related healthcare are exhaustive; one demonstrative example is research revealing the annual direct cost of one case of diabetes to be approximately $3000.[9]


ugar sweetened beverages (SSBs), defined as “non-alcoholic, water-based beverages with added sugar, including soft drinks, flavoured mineral waters, fruit juices/drinks, energy drinks, flavoured waters and iced teas” by Duckett and Swerissen, are estimated to account for 10% of Australia’s obesity epidemic, containing a disproportionately high energy content and minimal to no nutritional value. [1] Evidence from international studies shows that reduced consumption of SSBs will directly reduce weight with further modelling in Australia also showing a small reduction in obesity rates, particularly for those who are heavy consumers.[10] The health benefits of weight loss are proportional to the amount of weight lost, however cardiovascular disease risk reduction occurs even for losses of <10% of body weight.[11] An excise tax (of a good at purchase) on the sugar content of SSBs is suggested, as a key part of a multifactorial response to address the health and economic consequences of obesity and to restore market efficiency.

the health and welfare systems was factored into SSB production costs (internalised into the market), less consumers would choose to face this cost, implying that these items are not appropriately priced, representing an allocative inefficiency in the market which requires correction. This transfer of responsibility can also be described as a moral hazard if consumers continue to take the risk of drinking SSBs, knowing that the public system will take care of their health. The alternate situation in which consumers lack appropriate information to make rational decisions creates information asymmetry. Health information has the properties of a public good but is often not supplied sufficiently or in a regulated way.[8] This lack of information leaves consumers confused, from the individual food component or calorie amount, to the associated health outcomes. Hence consumers are vulnerable to the market and poor food choices such as SSBs, leading to a risk they would not otherwise take.[12] Notably, SSBs are consumed heavily by children and teenagers who may not grasp the risk they are taking for their health or other people’s wallets.[1]

This essay will discuss: 1) the economic basis for the increasing obesity rates in Australia, 2) the economic justification of an SSB tax and 3) how this tax could be implemented, and revenue utilised. Three key assumptions are made in this analysis. Firstly, evidence from SSB markets in other Western countries has been generalised to the Australian circumstance, for example the elasticity of demand. Secondly, health has been discussed with the features of a merit good in the Australian health system, supported by taxation and government assistance. Finally, health literacy and information are considered to have features of a public good.

As described by Karnani et al,[12] demand-side problems further exacerbate the failure of information asymmetry. Demand is distorted by the irrationality and vulnerability of consumers in the SSB market. Like cigarette smoking and alcoholic beverages, in the case of a substance such as high-energy SSBs, consumers may not always be ‘rational’. Multiple behavioural and personality factors that limit self-control in relation to energy intake are known, leading to excess consumption and subsequent obesity in these populations.[13] As for other “substances” like tobacco or alcohol, SSBs are addictive, overriding consumer rationality entirely.[12]

The Economic Causes of the Australian Obesity Epidemic The cause of the Australian obesity epidemic is multifactorial and complex. However, the primary cause of obesity is the overconsumption of unhealthy food, which can be understood in the context of several market failures.[1] These market failures include; externality of the costs of obesity on the public system, information asymmetry for consumers regarding the risks for their health and demand-side problems such as irrationality and supplier-induced demand.

Supplier induced demand - is created via million-dollar research and marketing strategies designed by junk-food companies.[13] The situation of asymmetrical information is used by suppliers to encourage consumers to demand a higher quantity of SSBs. Firms such as “Coca-Cola” have used their financial position in the past to create the false effect of “superior knowledge” about the safety of their product.[14] In the 1960s and 1970s the sugar industry sponsored a research program that successfully cast doubt about the hazards of sucrose while promoting fat as the dietary culprit in Coronary Heart Disease.[14] Children are particularly vulnerable to the effects of these campaigns.[12] Advertising effects compound innate biological tendencies to prefer sweet, fatty and salty foods leading to the behaviour underpinning the Australian obesity epidemic.[13]

Externality is created by consumers not taking full responsibility for the cost of obesity when purchasing an item such as an SSB that leads to obesity. The externalised cost of obesity is two-pronged, including the increase in healthcare costs and the increase in welfare costs. Both costs are covered by the government via taxpayers. Thus, through this negative externality, there is a cost transfer from obese people to non-obese taxpayers. If the cost of obesity on 20

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mation asymmetry.

The Economic Justification of an SSB Tax

As both current and future patients of Australia’s health system, and taxpayers of Australia’s economy, over 70% of Australian children exceed WHO’s 2015 recommendation for free sugar intake.[22] These children could benefit directly from the reduced consumption associated with the tax and from the revenue generated being directed to obesity prevention public health efforts. This tax is the next logical step in repairing a market that is currently failing, with obesity rising and the associated impacts on mortality and third-party costs becoming increasingly burdensome.

Taxation of SSBs would successfully address many of the market failures that contribute to obesity in Australia. Taxation would correct for the negative externality created by SSB associated obesity by internalising the inefficiency into the market. This tax would have two important effects: reduction in consumption due to a shift in the supply curve upwards and generation of revenue to compensate for the social cost of obesity created by SSBs. Reduction in consumption, simply due to consumers averting the raised retail price, would directly reduce obesity and its associated effects on healthcare, dental and welfare costs. Evidence for this reduction in obesity includes cohort studies which have demonstrated a long term causal relationship between SSBs and obesity [15-17] and trials which have found reduction in weight by replacing SSBs alone.[16,18] The estimated revenue for an SSB tax is between $400-$550 million annually.[1] This revenue generation could offer some compensation for the remaining high costs of obesity imposed on non-obese Australians. There is also important evidence that the contribution of SSBs to costs of obesity are beyond the high-energy content owing to their hunger inducing and addictive properties, creating extra support for the positive benefits of an SSB tax.[19]

Design of the SSB Tax Taxing a whole product is the most feasible option to correct for the third-party costs due to excessive calorie intake. SSBs are the most appropriate item as: 1) they are high in energy and contain no to minimal nutritional benefits otherwise; 2) SSBs are known to contribute directly to obesity and 3) substitutes are easily available, such as water and artificial sweeteners, with minimal to no loss of consumer utility.[1] Targeting specific ingredients is more difficult and could easily lead to avoidance strategies by firms or be generalised to foods that would otherwise be encouraged.[1] Based on the work of Duckett and Swerissen,[1] the SSB tax suggested is an excise tax by the government on the quantity of sugar within SSBs. The taxation will be imposed on manufacturers or importers. The tax should target only water-based drinks that have added sugar and have no alcohol content. At this stage, there is insufficient evidence to warrant taxation on artificially sweetened beverages, and these beverages also provide a close substitute to SSBs.[22] While other options exist, taxing sugar is the best option; sugar is the known link to obesity and a direct tax will encourage both producers to reduce sugar content and consumers to drink less sugary beverages.[1] The specific rate suggested is 40 cents per 100 grams of sugar.[1]

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An excise tax on SSBs would also directly improve allocative efficiency of the market by defining the government as, in part, responsible for purchasing and firms as responsible for production. Through taxation, the government can also delegate responsibility for the negative consequences of consumption onto the consumer. SSBs can be priced at the true societal “production” cost, with consumers needing to consider their health within their preference for SSB intake and instead paying the maximum “willing to pay” price. This concept is demonstrated in Figure 1 of the Appendix. Justification for a tax also lies in previous failed attempts by the government to address SSB consumption. It has been shown that addressing information asymmetry alone is not enough to change behaviour.[2] Taxation has not been attempted before and SSBs continue to be consumed at very high rates, with more than 80% of the population consuming SSBs and a per capita consumption of approximately 87 litres.[20,21] While SSB taxation needs to be one part of a complex strategy to overcome obesity, it would successfully send an important signal about the health impacts of the product, also speaking to correct the market failure of infor-

Modelling of SSB taxes suggests that a substantial revenue will raised by this tax, between $400-550 million dollars.[1] A tax on sugar is estimated to raise $520 million in its first year.[1] This revenue is proportional to the extreme total sales of SSBs, with the Australian SSB industry estimated to be worth $4.4 billion in 2018-2019.[23] Further detail on the economic justification of an SSB tax and modelling of its design can be found in the Appendix. 21

The revenue generated from an SSB tax could be used in targeted ways to ensure maximal impact and subsequent societal benefit. Three potential options include: 1) additional spending on health or health research, 2) obesity prevention programs or interventions and 3) reducing Australia’s budget deficit. Additional spending on health or health research could begin to compensate those that are most burdened by obesity. The revenue could be added to the health budget to assist hospitals or general practitioners in better managing other factors underpinning the obesity epidemic. Beyond managing the epidemic, revenue could be invested in health research to better understand the mechanisms behind obesity, such as consumer irrationality and the outcomes of new treatment options, in part recovering the community costs of obesity.

In response to the current obesity epidemic in Australia, economic analysis justifies the implementation of an excise tax on the sugar in SSBs as a key part of the solution. Obesity is a significant cause of burden on the health of Australians and their wallets. Costs are borne on the personal, community and governmental level. This epidemic can be explained in the context of market failures including negative externality and information asymmetry. Demand side problems, including the irrationality and vulnerability of consumers, are also highly relevant. An SSB tax will successfully recover the community costs of obesity and address these market failures, with the result of reduced obesity, improved health outcomes and generation of significant revenue. This revenue could be used to target the broader issues relevant to the obesity epidemic including research, management and prevention on a biological and social level.

Arguably the most effective use of the tax revenue would be in preventing future obesity. Current recommendations for obesity prevention include improving access to healthy and unprocessed foods; the World Health Organisation (WHO) argues that fruit and vegetables currently exceed the socially optimal price at point of purchase.[26] Mechanisms to achieve this access include a direct subsidy, breakfast/lunch programs in schools and targeting remote or disadvantaged areas, which are particularly vulnerable to raised prices of fresh food.[27] These objectives could be realised through the revenue generated by an SSB tax. Reducing the price of healthy foods is best done in combination with a tax on goods such as SSBs to prevent overall energy intake increasing.[28]

Appendix - Economic Detail of The SSB Tax Design The elasticity of demand — the percentage of change in demand following a percentage price change — for SSBs is slightly inelastic, at -0.9,[1] meaning consumer demand reduces close to proportionately with increase in price, with slight resistance. Demand is even more inelastic for heavy users of SSBs, mirroring the addictive nature of the substance.[1] Elasticity of the SSB market is demonstrated in Figure 2. While there will be some reduction in quantity purchased, some consumers will continue to buy SSBs even at a higher price. Presently, the discrepancy between current market price and the “willing to pay” price represents a consumer surplus and a subsequent deadweight loss to society, as demonstrated below in Figure 1. Here the short term marginal benefit — the benefit from consuming one more unit of an SSB — to the consumer is larger than the real marginal cost — the cost of the additional unit — to society, which should be capitalised on. Operating at the higher ‘willing to pay’ price and the associated lower consumption represents a more efficient SSB market for society due to the reduction in welfare loss.

Finally, the government could use the tax revenue to reduce the budget deficit, which currently sits at $4.1 billion; Achieving a budget surplus for the 20192020 financial year is a current target of the newly elected government.[29] This budget deficit is related to important factors such as unemployment and welfare-funding which are related to obesity on a larger scale. Conclusions Obesity is a highly complex and multifactorial phenomenon which requires multiple policy changes and a “whole systems approach” to overcome.[1] An SSB tax, justified in theory by this economic analysis, presents a pivotal opportunity for the Australian government to step up in managing the obesity epidemic, which currently costs Australian taxpayers approximately $5 billion annually and up to 8% of 22

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Disability Adjusted Life Years (DALYs) annually.[30] The time is now, with the Lancet Eat Commission stating that “Food in the Anthropocene represents one of the greatest health and environmental challenges of the 21st century”.[31] These thoughts are echoed by the President of the Australian Medical Association, Dr Tony Bartone.[32] Many countries in Europe and South America as well as parts of the US have already successfully implemented such a system, with evaluation demonstrating reductions in SSB sales and increase in sales of untaxed beverages, including water.[1,33]

Use of the Tax Revenue

A taxation on SSBs will disproportionately impact people who have lower rates of unemployment and form low-income households, as they spend a higher proportion of their disposable income on SSBs. [1] Hence the major of the burden of tax will fall to low-income households and it will likely be regressive as these groups will pay a higher proportion of their income in tax. However, the health benefits from the SSB tax are also most likely to be felt by these low-income households, as: 1) these households have higher rates of obesity and 2) they will be more responsive to price changes due to their lower disposable income. Furthermore, they are more likely to make use of alternatives such as water or artificially sweetened beverages.[1,24] Thus, for low income households, demand of SSBs is more elastic, as demonstrated in Figure 2. That is, low SES households are more likely to reduce their consumption of SSBs upon price increases â&#x20AC;&#x201D; a net societal benefit due to the decrease in obesity and subsequent healthcare costs. A taxation imposed on sellers will cause a shift upwards in the supply curve to a new equilibrium in the SSB market. This equilibrium will involve a higher price paid per unit by buyers and lower quantity of SSBs purchased. This is demonstrated in Figure 3 below. Thus, the tax will successfully reduce consumption and generate revenue. An excise tax would be simple to administer as a similar model has already been used for alcoholic beverages.[4] It would only need to be added to a pre-existing schedule: Excise Tariff Act 1921. Set up costs are estimated to be $7 million, with ongoing administration also at $7 million annually, these are relatively small compared to the revenue gained. [25]

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Jackie Maher is a Doctor of Medicine student at The University of Melbourne currently completing the integrated Masters of Public Health program and AMSA Global Healthâ&#x20AC;&#x2122;s 2020 Vice Chair External. She is passionate about many areas of global health, particularly paediatric and refugee and asylum seeker health. Acknowledgements None Conflicts of interest None declared Correspondence Image Chow E. [Internet]. 2019 [cited 26 October 2019]. Available from: 23

Figure 2: Three demand curves are represented for different groups of consumers in the SSB market with varying elasticities of demand for SSBs. Elasticity low SES > elasticity average > elasticity heavy users. Average elasticity is approximately constant (1).

Figure 3: A tax imposed on sellers shifts the supply of SSBs upwards from S1 to S2(tax) by the amount of the tax. The price buyers pay rises from P*1. The equilibrium quantity falls from Q1 to Q2(tax). The price firms received also falls from P*1.


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Figure 1: Two supply curves are demonstrated: Scurrent for the current market equilibrium and SWTP for supply at the higher cost that some consumer would be willing to pay, which would result in a lower quantity supplied. The area above market price to the left of the demand curve represents the consumer surplus and the area below represents the producer surplus. The low price of SSBs raises this surplus or â&#x20AC;&#x153;deadweight lossâ&#x20AC;? in this inefficient market.

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17. Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. Bmj. 2013;346:e7492. 18. de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar-sweetened beverages and body weight in children. New England Journal of Medicine. 2012;367(15):1397406. 19. Schulte EM, Joyner MA, Potenza MN, Grilo CM, Gearhardt AN. Current considerations regarding food addiction. Current psychiatry reports. 2015;17(4):19. 20. Levy GS, Shrapnel WS. Quenching A ustralia’s thirst: A trend analysis of water‐based beverage sales from 1997 to 2011. Nutrition & dietetics. 2014;71(3):193-200. 21. Popkin BM, Hawkes C. Sweetening of the global diet, particularly beverages: patterns, trends, and policy responses. The lancet Diabetes & endocrinology. 2016;4(2):174-86. 22. Lei L, Rangan A, Flood VM, Louie JCY. Dietary intake and food sources of added sugar in the Australian population. British Journal of Nutrition. 2016;115(5):868-77. 23. IBIS World. Soft Drink Manufacturing - Australia Market Research Report 2019 [Available from: https://www.ibisworld. html. 24. Colchero MA, Popkin BM, Rivera JA, Ng SW. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. BMJ. 2016;352:h6704. 25. Parliamentary Budget Office. Policy costing for the Australian Greens: Tackling Obesity: Sugar sweetened beverages. 2016. 26. World Health Organization. Using price policies to promote healthier diets: WHO Regional Office for Europe; 2015. 27. Thurber K, Boxall A-M, Partel K. Overweight and obesity among Indigenous children: Individual and social determinants. Canberra: Deeble Institute. 2014. 28. Morley B, Martin J, Niven P, Wakefield M. Health Public Policy Public opinion on food-related obesity prevention policy initiatives. Health Promotion Journal of Australia. 2012;23(2):86-91. 29. The Treasury C. 2019/20 Budget, Budget Paper No. 1. 2019. 30. Crosland P, Ananthapavan J, Davison J, Lambert M, Carter R. The health burden of preventable disease in Australia: a systematic review. Australian and New Zealand Journal of Public Health. 2019;43(2):163-70. 31. Willett W, Rockström J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. The Lancet. 2019;393(10170):447-92. 32. Johnson C. Lack of sugar tax leaves a sour taste. Australian Medicine. 2018;30(11):3. 33. Silver LD, Ng SW, Ryan-Ibarra S, Taillie LS, Induni M, Miles DR, et al. Changes in prices, sales, consumer spending, and beverage consumption one year after a tax on sugar-sweetened beverages in Berkeley, California, US: A before-and-after study. PLOS Medicine. 2017;14(4):e1002283.

1. Duckett S, Swerissen H, Wiltshire T. A sugary drinks tax: recovering the community costs of obesity: Grattan Institute; 2016. 2. Hayes AJ, Lung TWC, Bauman A, Howard K. Modelling obesity trends in Australia: unravelling the past and predicting the future. International Journal of Obesity. 2017;41(1):178-85. 3. Ghouri N, Clifton P, Craigie AM, Anderson AS, Christensen P, Waters L, et al. Consequences and comorbidities associated with obesity. Advanced Nutrition and Dietetics in Obesity. 2018:39-84. 4. Australia. Parliament. House of Representatives. Standing Committee on H, Ageing. Weighing it up : obesity in Australia / House of Representatives Standing Committee on Health and Ageing. Georganas S, editor. Canberra: Printing and Publishing Office House of Representatives; 2009. 5. Jones A, Magnusson R, Swinburn B, Webster J, Wood A, Sacks G, et al. Designing a Healthy Food Partnership: lessons from the Australian Food and Health Dialogue. BMC Public Health. 2016;16(1):651. 6. Swinburn B, Wood A. Progress on obesity prevention over 20 years in Australia and New Zealand. Obesity Reviews. 2013;14(Suppl. S2):60-8. 7. Australia PC. Weighing the cost of obesity: A case for action. Sydney, NSW. 2015. 8. Freebairn J. Taxation and obesity? Australian Economic Review. 2010;43(1):54-62. 9. Lee CMY, Goode B, Nørtoft E, Shaw JE, Magliano DJ, Colagiuri S. The cost of diabetes and obesity in Australia. Journal of medical economics. 2018;21(10):1001-5. 10. Briggs AD, Mytton OT, Kehlbacher A, Tiffin R, Rayner M, Scarborough P. Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study. Bmj. 2013;347:f6189. 11. Wing RR, Lang W, Wadden TA, Safford M, Knowler WC, Bertoni AG, et al. Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes care. 2011;34(7):1481-6. 12. Karnani A, McFerran B, Mukhopadhyay A. The Obesity Crisis as Market Failure: An Analysis of Systemic Causes and Corrective Mechanisms. Journal of the Association for Consumer Research. 2016;1(3):445-70. 13. Ruhm CJ. Understanding overeating and obesity. 2012. p. 781-96. 14. Kearns CE, Schmidt LA, Glantz SA. Sugar Industry and Coronary Heart Disease Research: A Historical Analysis of Internal Industry DocumentsSugar Industry and Coronary Heart Disease ResearchSugar Industry and Coronary Heart Disease Research. JAMA Internal Medicine. 2016;176(11):1680-5. 15. Hu FB. Resolved: there is sufficient scientific evidence that decreasing sugar‐sweetened beverage consumption will reduce the prevalence of obesity and obesity‐related diseases. Obesity reviews. 2013;14(8):606-19. 16. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review–. The American journal of clinical nutrition. 2006;84(2):274-88. 25

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Abstract Aims: Waterpipe smoking poses a range of adverse health impacts given the toxicant exposure involved with its use. This review aims to compare these consequences with cigarette smoking specifically in terms of oral pathology. Methods: A review was performed using 3 academic databases (MEDLINE, PubMed, and Web of Science). This was accompanied by a targeted grey literature search for supplementary information. Articles were selected based on the inclusion and exclusion criteria applied, and subsequent screening of titles and abstracts. Inclusion criteria included articles dating from the year 2000 onwards, written in English and longitudinal or cross-sectional observational studies.


Results: Information gathered from the 11 articles selected were summarised under 3 pathological categories: (1) premalignant and malignant lesions; (2) periodontal disease and (3) impact on the oral microbiome. It was found that waterpipe smoking induces comparable effects on oral health to cigarette smoking. However, further research into their differences in toxicant exposure would better define these impacts.

Implications for Oral Health

Conclusions: Waterpipe smoking induces the development of oral pathologies in a manner comparable to cigarette smoking. For further understanding of their relative impacts over time, longitudinal studies need to be conducted.

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Yasmine Toufaili



common method of smoking tobacco is through the use of cigarettes, and the relationships between cigarette smoking and oral disease have been extensively researched. An alternative method of smoking tobacco, increasing in popularity on a global scale, is waterpipe smoking (WPS), also known as “shisha”, “argileh” or “hookah”. WPS is a cultural custom in Middle Eastern countries such as Lebanon and Saudi Arabia, but has become commonplace in countries such as Greece, Canada, Malaysia, and the United Kingdom.[1] Currently, nearly 100 million people engage in WPS daily causing approximately five million deaths per annum.[1] The waterpipe instrument consists of a water bowl connected to a head and a hose; the smoker inhales through the hose, heating air through the charcoal on the aluminium wrapped head and through the flavoured tobacco. Surveys have shown that the increasing appeal of WPS is attributable to the different flavours of tobacco available such as double apple and mint.[2] The World Health Organisation (WHO) states “A typical 1-hour long waterpipe smoking session involves inhaling 100-200 times the volume of smoke inhaled with a single cigarette”, and that WPS exposes smokers to a greater amount of carbon monoxide and carcinogenic polyaromatic hydrocarbons (PAHs) than cigarette smoking.[3, 4] This comparable toxicity profile between cigarette smoking and WPS suggests that their health implications can be adjacently investigated. It is par-

ticularly relevant to discuss their associations with oral diseases given the known relationship between cigarette smoking and oral malignancy, periodontal disease, and oral infections.[1] This review aims to examine the body of evidence that currently exists investigating the impact of WPS on oral health and how it compares to cigarette smoking. Methods Articles were chosen using three databases: MEDLINE, PubMed, and Web of Science. A targeted grey literature search for supplementary information was also performed, which included not-for-profit websites and fact sheets from the WHO. Basic and advanced searches were used in this process, involving the MESH headings “smokers”, “smoking devices”, “oral health” and “oral manifestations”, Boolean Operators, and truncation symbols. Key terms and synonyms used in these searches were “tobacco smokers”, “shisha OR sheesha OR waterpipe OR water-pipe OR argileh OR hookah OR waterpipe smoke* OR water-pipe smoke”, “cigarette*”, “oral disease OR periodontal disease OR dental caries OR oral lesion* OR “gingivitis” OR “premalignant lesion*” OR “malignant lesion* OR microbial infections OR oral microbiome OR oral Candida”. Exclusion and inclusion criteria were then applied to the articles found. Limits were used to filter results to articles that date from the year 2000 onwards, were written in English, and allow access to the full-text. Articles included in this review were systematic reviews, observational cross-sectional studies, and longitudinal study designs such as cohort studies. Systematic reviews that collated information from various articles were also included as their conclusions are based on a pooled effect encompassing large sample sizes. The inclusion of longitudinal study designs such as cohort studies may have been beneficial, though such data is currently limited. Case reports were excluded as they involve a limited sample size without a comparison group, limiting generalisability of results. Further information on study identification, inclusion and exclusion criteria is detailed in Figure 1. Results

Figure 1: Flowchart of study identification, inclusion and exclusion criteria. 28

Overall, 11 studies were selected for this review comparing the impact of WPS and cigarette smoking on oral

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health. All articles suggested that WPS and cigarette smoking predispose individuals to a greater risk of oral pathologies compared to non-smokers. 9 of the articles suggested that WPS has at least the same detrimental effect as cigarette smoking, 1 suggested that WPS has a greater effect, and 1 suggested that cigarettes have a greater impact. The consistent conclusion was that further longitudinal studies are needed in order to elucidate the exact nature of the risks associated with waterpipe smoking over time. The results are summarised in Table 1.

cost-efficient method. For instance, 761 individuals in Northern India underwent visual and tactile oral examinations to identify potential malignant lesions.[6] Waterpipe smokers were statistically proven to have the highest risk associated with such lesions, although follow-up histological data is needed to ascertain a causal relationship.[6] Periodontal disease Periodontal diseases involve infections of structures surrounding the teeth, predisposing to bacterial trapping and cavity formation.[13] One study involving 262 participants defined periodontal disease as â&#x20AC;&#x153;a minimum of 10 sites with a proving depth 5mm.â&#x20AC;? [7] In accordance with this definition, measurements reflected an increase in relative risk of periodontal disease, compared to non-smokers, of 5.1 for waterpipe smokers and 3.8 in cigarette smokers.[7] Periodontal status has also been assessed using measurements of inflammatory biomarkers, such as cotinine, IL-1 and IL-6 in saliva.[8] Whole salivary levels of all three parameters were found to be similar in waterpipe and cigarette smokers, but significantly higher when compared to individuals who have never smoked.[8]

Discussion Premalignant and malignant lesions Clinical findings have suggested cigarette smoking can lead to the development of premalignant and malignant oral lesions such as leukoplakia and squamous cell carcinomas. [1] Given that WPS involves a comparable toxicant exposure, it has been hypothesised to trigger similar inflammatory mechanisms that result in these lesions. The WHO has stated that WPS exposes users to carcinogens such as polycyclic aromatic hydrocarbons, volatile aldehydes, benzene and toxicants such as nitric oxide and heavy metals.[4] The exposure to PAHs has been estimated to be 20-50 times greater in a single session of waterpipe smoking, compared to a single cigarette.[4]

A comparative study assessing the effect of exclusive WPS (EWPS) and exclusive cigarette smoking (ECS) on periodontal health suggests they both have a detrimental effect, but cigarette smoking to a greater extent.[5] This was based on data gathered regarding probing pocket depth, teeth mobility, number of remaining teeth, plaque index, and number of decay/missing/filled teeth.[5] Statistical disparities between the two groups were attributed to the difference in the chemical profile of each method of smoking, particularly the difference in nicotine exposure.[5] A similar study design comparing EWPS with ECS has produced divergent conclusions, suggesting that a similar percentages of bone loss occurs in the two groups.[11] Ultimately, inconsistencies in these studies highlight methodological and structural limitations in current research, and the need for further investigations to be conducted.

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Studies have investigated the relationship between WPS and oral lesions by examining changes in the oral mucosa of waterpipe smokers. Diagnostic markers of tumour development that have been used include the p53 tumour suppressor protein. [9] Changes in the quantity of the p53 protein have been significant in smokers, with research findings showing the greatest number of positive p53 nuclei in smokers of both cigarettes and waterpipe, followed by waterpipe smokers, then cigarette smokers, and finally non-smokers.[9] Genotoxic changes in the oral mucosa of waterpipe smokers have also been investigated using non-invasive buccal smears, and subsequent evaluation of the number of micronuclei (MN) in these exfoliated cells.[10] MN are small nuclei containing chromosomal material produced by defective cell division in carcinogenic processes.[10] Over a 2-fold increase in MN frequency in the buccal smears of waterpipe smokers compared to non-smokers has been documented, indicative of malignant transformation. [10] A similar 2-fold increase has been associated with cigarette smoking.[10]

Impact on the oral microbiome The normal oral microbiome includes approximately 600 bacterial species and an undetermined number of fungal species.[14] An imbalance in these microorganisms can be induced by WPS and cigarette smoking leading to infectious disease. Candida species are present in the oral cavity normally in a range between 17-75%, but excess growth of this fungi can result in oral candida infections.

Larger studies have utilised screening tests to detect suspicious lesions as a quicker and more 29

Correspondence Image Dedhia S. Portrait man smoking hookah [Internet]. 2017 [cited 26 October 2019]. Available from: portrait-man-man-smoking-hookah-2915452/ References 1. Javed F, ALHarthi S, BinShabaib M, Gajendra S, Romanos G, Rahman I. Toxicological impact of waterpipe smoking and flavorings in the oral cavity and respiratory system. Inhalation Toxicology. 2017;29(9):389-396. 2. Ramôa C, Eissenberg T, Sahingur S. Increasing popularity of waterpipe tobacco smoking and electronic cigarette use: Implications for oral healthcare. Journal of Periodontal Research. 2017;52(5):813-823.  3. Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators [Internet]. 2005 [cited 9 August 2019]. Available from:https:// 4. Fact Sheet: Waterpipe Tobacco Smoking & Health [Internet]. 2015 [cited 9 August 2019]. Available from: WHO_NMH_PND_15.4_eng.pdf;jsessionid=69E3FA669E7F012CDCA7CCA058F3AD79?sequence=1 5. Khemiss M, Ben Fekih D, Ben Khelifa M, Ben Saad H. Comparison of Periodontal Status Between Male Exclusive Narghile Smokers and Male Exclusive Cigarette Smokers. American Journal of Men’s Health. 2019;13(2):155798831983987.  6. Dangi J, Kinnunen T, Zavras T. Challenges in Global Improvement of Oral Cancer Outcomes: Findings from Rural Northern India. Tobacco Induced Diseases. 2012;10(1):5.  7. Natto S, Baljoon M, Bergström J. Tobacco Smoking and Periodontal Health in a Saudi Arabian Population. Journal of Periodontology. 2005;76(11):1919-1926.  8. Mokeem S, Alasqah M, Michelogiannakis D, Al-Kheraif A, Romanos G, Javed F. Clinical and radiographic periodontal status and whole salivary cotinine, IL-1β and IL-6 levels in cigarette- and waterpipe-smokers and E-cig users. Environmental Toxicology and Pharmacology. 2018;61:38-43.  9. Amer H, Waguih H, El-Rouby D. Development of field cancerization in the clinically normal oral mucosa of shisha smokers. International Journal of Dental Hygiene. 2018;17(1):39-45. 10. El-Setouhy M, Loffredo C, Radwan G, Rahman R, Mahfouz E, Israel E et al. Genotoxic effects of waterpipe smoking on the buccal mucosa cells. Mutation Research/Genetic Toxicology and Environmental Mutagenesis. 2008;655(1-2):36-40.  11. Khemiss M, Khelifa M, Rejeb M, Saad H. Periodontal bone height of exclusive narghile smokers compared with exclusive cigarette smokers. Libyan Journal of Medicine. 2016;11(1):31689.  12. Akram, Z., Al-Kheraif, A., Kellesarian, S., Vohra, F. and Javed, F. (2018). Comparison of oral Candida carriage in waterpipe smokers, cigarette smokers, and non-smokers. Journal of Oral Science, 60(1):115-120. 13. Periodontitis (gum disease) - Dental Health Services Victoria [Internet]. [cited 9 August 2019]. Available from: 14. Dewhirst F, Chen T, Izard J, Paster B, Tanner A, Yu W et al. The Human Oral Microbiome. Journal of Bacteriology. 2010;192(19):5002-5017. 

Study Limitations The selection process was limited to manuscripts written in English, whilst WPS is widespread in non-English speaking countries. Therefore potentially valuable research articles in different languages could not be included. Limitations to the systematic reviews selected include potential bias in the studies they incorporated, and valuable individual data being overlooked for the use of summary data. A disadvantage of cross-sectional studies is that they do not provide temporal information about the relationship between the risk factors and pathological progression. Consistent weaknesses in the studies selected included potential recall bias due to self-reporting of tobacco exposure via questionnaires, questionnaires not providing an option for using various forms of tobacco simultaneously, and inaccurate estimations of lifetime smoking exposure. Conclusions Waterpipe smoking is a behaviour that has increased in popularity globally, and thus the health risks of this practise need to be understood. An abundance of research has been conducted with regards to cigarette smoking and the various health issues it is associated with. This review aimed to compare the new trend of WPS with what is already known about cigarette smoking, specifically in terms of oral health to ascertain its relative toxicity. Most studies identify WPS as having at least the same oral health risks as smoking including premalignant and malignant lesions, periodontal disease and microbial disturbances. The results of this review suggest there is a pressing need to more fully investigate the adverse health outcomes from waterpipe smoking, and to develop and implement effective anti-WPS strategies. Acknowledgements None Conflicts of interest None declared 30

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[14] Tobacco smoking has been studied as a risk factor for this overgrowth as chemicals in tobacco may serve as sources of nutrition for Candida species. [12] A study comparing Candida carriage amongst WPS, cigarette smokers and non-smokers explores this hypothesis, with swabs of the dorsal tongue and buccal mucosa taken, cultured, and analysed. [12] Results reveal that there is indeed an increase in the prevalence of oral Candida species in waterpipe smokers and cigarette smokers, but no significant difference between the two smoker groups.[12]

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Sample Size

Khemiss M, Ben Fekih D, Ben Khelifa M, Ben Saad H., 2019.[5]

Exposure Variable(s)

Outcome Variable(s)

Summary of findings

Males between 20-40 WPS or cigarette smoking. years old who were either exclusive narghile smokers (N = 74) or exclusive cigarette smokers (N = 74).

Oral health conditions e.g. plaque index, gingival status, tooth mobility, the number of remaining teeth, and periodontal disease.

Cigarettes affect oral health to a greater extent than WPS.

Javed F, ALHarthi S, BinShabaib M, Gajendra S, Romanos G, Rahman I., 2017.[1]

A total of N = 5, 463 across the 8 studies included in the review.


Oral and pulmonary diseases e.g. periodontal disease and COPD.

WPS compromises respiratory function, further investigation is needed to confirm its impact on oral health.

Dangi J, Kinnunen T, Zavras T., 2012.[6]

N = 761 individuals, aged 45-95 years old.

Tobacco use in 3 formsWPS, bidi, or tobacco smoking.

Suspicious oral lesions i.e. a red, painless and firm lesion that has been there for over 14 days.

WPS has the strongest association with suspicious lesions.

Natto S, Baljoon M, BergstrĂśm J., 2005.[7]

N = 262 individuals, aged WPS, cigarette smok17-60 years old. ing, mixed smoking, no smoking.

Gingival status and periodontal disease.

WPS impacts periodontal health to at least a similar extent as cigarette smoking.

Mokeem S, Alasqah M, Michelogiannakis D, Al-Kheraif A, Romanos G, Javed F., 2018.[8]

N = 154 male individuals WPS, cigarette smoking, (39 cigarette smokers, 40 E-cigarette smoking, no waterpipe smokers, 37 smoking. E-cigarette smokers, and 38 non-smokers.

Clinical and radiographic periodontal parameters e.g. PPD and marginal bone loss. Biomarkers of oral inflammation: whole-salivary cotinine, IL-6 and IL-1B levels.

Clinical and radiographic periodontal parameters were the poorest in the waterpipe and cigarette smoking groups.

Amer H, Waguih H, El-Rouby D., 2018.[9]

N = 64 (16 in 4 groups: waterpipe smokers, cigarette smokers, smokers of both, and non-smokers).

WPS, cigarette smoking, mixed smoking, no smoking.

Oral mucosa changes: Salivary detection of CYFRA21-1 and immunohistochemical expression of p53 on mucosal biopsies.

CYFRA 21-1 levels failed to show any carcinogenic changes. A significant difference in p53 levels between the non-smokers and the 3 smoker groups was apparent, however no significant changes between among the 3 smoker groups was apparent.

RamĂ´a C, Eissenberg T, Sahingur S., 2017.[2]

A total of N = 81, 215 across the 7 studies included in the review.

Waterpipe and E-cigarette smoking.

Oral conditions e.g. periodontal diseases and dry socket, and systemic conditions e.g. lung function.

Waterpipe smoke has some of the same toxicants as cigarette smoke, as well as additional ones. Further research is required to confirm that this induces similar oral and systemic pathologies as cigarette smoking.

El-Setouhy M, Loffredo C, Radwan G, Rahman R, Mahfouz E, Israel E et al., 2008.[10]

N = 206 (128 waterpipe smokers, 78 never smokers).

WPS and no smoking.

Number of micronuclei per 1000 cells.

Waterpipe smokers have a 2-fold increase in micronuclei compared to never smokers.

Khemiss M, Khelifa M, Rejeb M, Saad H., 2016.[11]

Males aged 20-35 years old. N = 120 (60 waterpipe smokers, 60 cigarette smokers).

WPS and cigarette smoking.

Periodontal bone height signifying bone loss.

Both waterpipe and cigarette smokers showed similar periodontal bone loss.

Akram, Z., Al-Kheraif, A., Kellesarian, S., Vohra, F. and Javed, F., 2018. [12]

N = 141 (46 waterpipe smokers, 45 cigarette smokers, and 50 non-smokers).

WPS, cigarette smoking, no smoking.

Oral Candida carriage.

Candida growth is increased in waterpipe and cigarette smokers compared to non-smokers, thus smokers have an increased risk of oral candida infections.

Table 1: Summary of literature reviewed 31

A complex relationship between conflict and inequality Natalie S


AMSA Journal of Global Health


after conflict is uneven positive development across different population groups. This positive development can result in more economic opportunities for beneficiaries and greater exclusion and deprivation for disadvantaged groups.[2] Furthermore, war has an adverse effect on economic output, decreasing productivity.[4] Relative product scarcity causes price inflation while increasing unemployment and decreasing the wages of the unskilled workforce who are most disproportionately affected by war.[4] This drives the redistribution of wealth and assets in war ravaged countries, which may affect rural populations such as farmers the most, as they can no longer access markets and subsequently benefit from market exchange. Annihilated regions with food insecurities are linked with looting, theft and seizing of private property. People in illegal trades and markets such as militia taxation or drug cultivation may prosper while others do not.[4] Income inequality rises during war, particularly in the immediate post-war period. This income inequality is transient, peaking approximately five years after conflict resolves and then declining to pre-war baselines.[4] This peak is due to redistribution of wealth and assets during the transitional period after conflict.[4]



he relationship between conflict and inequality is a vital discussion in todayâ&#x20AC;&#x2122;s world. The countries burdened by conflict make up one third of all people who live in extreme poverty.[1] This has a massive impact on global health through the rise of communicable diseases, malnutrition and shortened life expectancy.[2] Conflict and violence can be used to seize power and ravage cities or right wrongs and improve inequalities.[2] War and conflict can also create inequality by dividing communities, annihilating assets and land as well as destabilizing infrastructure and markets, leading to morbidity, mortality and income loss. This impact may endure long after the war is over.[2] Despite this, conflict can also permit new ideologies and groups to form power. Society can improve or deteriorate under new governance. A more inclusive society may be built in the aftermath, despite the violent means to achieve this. A progression to a shared society after conflict may improve equality and a sense of community.[2] These outcomes are difficult to disentangle from pre-existing inequality which can potentially precipitate conflict itself. This chicken-or-the-egg dilemma is a complex area which warrants discussion. This article will firstly explore whether conflict exacerbates different inequality types within society. Secondly, it will discuss whether pre-existing inequality triggers conflict and the merits of reducing inequality to bring about peace. These two sides of the same coin are important to explore.

Many specific historical examples demonstrate these points. World War I in Germany brought about socioeconomic inequality and starvation.[3] Military conscription created a labour shortage, causing declines in agriculture production and subsequently food, livestock and milk supply.[3] After the outbreak of war, there was a mass slaughter of cattle by farmers due to the cost of maintaining them and meat prices dramatically increased as a result. [3] The enforcement of price ceilings was furthermore mismanaged by government forces. Despite food rationing, the famine disproportionately affected economically underdeveloped countries and regions. Black markets were formed to avoid price ceilings and government regulation as these markets favoured citizens with greater spending power due to inflated prices.[3] Generations from lower or middle classes such as the unskilled or semi-skilled workers showed a drop in height throughout the war which may have been linked with poorer nutrition.[3] In contrast, the higher someoneâ&#x20AC;&#x2122;s social class was, the less their height was impacted.[3] Further examples include the civil war in Rwanda during 1990-1994, which ended in violence and mass genocide. After the conflict, the mean income significantly dropped, but this drop was disproportionately greater for the poorest citizens.[5] The wealthy were largely unaffected, with the richest minority increasing their average income [5].

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Does Conflict Exacerbate Inequality? Conflict may exacerbate the levels of inequality in income, between different demographic groups as well as access to health, education and shelter. These measures can be difficult to determine due to limited data on pre-conflict conditions.[3] However, there is ample evidence to suggest that conflict exacerbates inequality throughout time and space. A review examining 128 countries from 1960 to 2004 showed that immediately after war there were stable inequality levels.[4] Inequality then rises after conflict has broken out and peaks five years after the war has ended, as there is often a delay between the multifaceted impacts of war and the resulting redistributive adjustments.[4] Conflict and Income Inequality The large income gap amongst the poorest countries can be partly attributed to conflict. Uneven positive development, a decrease in economic productivity and wealth redistribution are among the range of reasons responsible for a rise in poverty with violence.[2,3,4] A key predictor of inequality increasing

Conflict and Demographic Inequality 33

periencing a traumatic stressor, even though males report more frequent exposure to stressors.[3] War can increase military spending at the expense of priorities such as public education, affecting the educational opportunities of disadvantaged populations.[4] Wealthier families have the resources to invest in schooling for their children, while children from lower socioeconomic classes can be deprived of adequate education.[6] Child stunting due to poor health and reduced schooling opportunities from conflict causes downstream illiteracy and a future loss of earnings as adults. Finally, displacement can contribute to poverty, the loss of social networks and the destruction of individual capital. People may be displaced for years, stuck in the limbo of refugee camps.[3]

Conflicts can also affect population demographics, with a higher percentage of female heads of households arising.[4] A decreased household income from the death of males prompts women into the labour force.[3] Moreover, the post-conflict period shows an increased age dependency ratio, with a greater number of children and elderly compared to working-age individuals. This largely returns to baseline levels five years after the conflict has ended.[4]

Does Inequality Provoke Conflict? The ‘killing capacity of inequality’ refers to the poor working conditions, selective abortions, environmental discrimination, barriers to healthcare, unemployment and education barriers that can lead to obesity and poor nutrition.[7] Dysfunctional inequalities occur from social exclusion, discrimination and subsequently restricted opportunities. Countries with greater dysfunctional inequality more often use violence to end social conflict and these conflicts are less likely to facilitate a shared society.[2] Dysfunctional inequality and social exclusion may cause social discontent, which has been linked to crime and violence.[2] Sometimes a precipitant is required, such as a switch in ideologies or the end of a dictatorship. Inequality based on demographic characteristics and income will be discussed respectively as potential causes of downstream conflict.[6]

Conflict and Healthcare, Education and Shelter Inequality A key post-conflict determinant of inequality is whether the economy can sustain social spending. A scarce budget devotes more money to areas such as reconstruction over public healthcare or education.[4] Decreased public healthcare access can impact women’s health through unwanted pregnancies, prenatal complications, premature birth and maternal mortality. A decline in healthcare services is particularly inopportune as HIV rates increase during conflict, in part due to sexual violence.[3] Civilians can otherwise become vulnerable to disease through displacement and loss of parents, assets, land and income. Violent conflict can also result in increased infectious diseases, worsening sanitation and decreased vaccinations. When refugees fled from Burundi and Rwanda to Tanzania during mass genocide in 1994, Tanzania had an increase in child mortality and infectious diseases.[3] Mental health is significantly affected with both adults and children suffering from conditions such as post-traumatic stress disorder (PTSD), anxiety and depression. Females are more likely to develop PTSD or depression after ex-

Demographic Inequality as a Cause of Conflict Horizontal inequality between groups of different religions or ethnicities can trigger the outbreak of violent conflicts.[3] Ethnic groups deprived of power, authority or resources are at greater risk of engaging in conflict.[8] For example, racial discrimination was one of the triggers for the Nepalese Civil War involving Maoist insurgency from 1996 to 34

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These outcomes are difficult to disentangle from pre-existing inequality which can potentially precipitate conflict itself. This chicken-or-the-egg dilemma is a complex area which warrants discussion.

Violent conflict has unequal consequences for males and females. Mortality rates disproportionately affect males, while women and children are more likely to be displaced from their homes and become refugees or become internally displaced persons.[3] For violent conflict, the first-round impacts include excessive young male mortality and morbidity from war trauma, widowhood, income loss, loss of assets, displacement and migration of refugees and sexual violence.[3] Fatalities increase among women when the conflict occurs in their homeland.[3] Furthermore, women are also more likely to experience sexual violence and domestic violence whilst children may be subject to violent corporal punishment.[3,4] It is difficult to estimate the prevalence of sexual violence from conflict due to underreporting, which can occur when civilians are afraid to report these crimes.[3] However, it is well known that subject to these traumas is linked with poorer mental health outcomes.[3]

2006. It involved a high death toll with widespread violation of human rights, including the rape and torture of civilians and use of them as human shields.[9] Ethnic diversity has been proposed as a potential driving force behind ethnic conflict, due to a fragmented and non-cohesive society.[10] However, this is difficult to disentangle from the impact of class inequality and poverty as possible causes. Countries with greater gender inequality as measured by higher fertility rates from reduced contraception access, increased sexual violence and other factors and a lower female percentage in the labour force, are more likely to undergo intrastate conflict. [11] The reasons for this are unclear and may involve different confounders. Tackling discrimination based on ethnicity, religion, gender and other qualities may be among one of the many steps toward reaching peace.[12]

cycle of lagging development and political violence. [16] International policies to prevent financial crises are also important. The United Nations and other international organizations could support global interventions to prevent financial crises and reduce their impact.[12] Addressing income inequality in addition to inequality based on discrimination may be paramount to reaching the ultimate goal, which is peace and harmony. Conclusion There may be a bidirectional relationship between conflict and inequality. This inequality can take many forms, such as racial discrimination, gender inequality, or poverty. Sometimes, political upheaval and change can be beneficial through collective action and community involvement after war and conflict.[17] Directly experiencing violence could result in more altruism among those who lived through it.[18] Furthermore, measures to decrease inequality such as promoting social inclusion, improving land equality and increasing opportunities for disadvantaged groups, may decrease future conflict.[19] Preventing and reducing inequality is imperative toward the advancement of peace and resolution. Ultimately, people from different groups and nations often have a common goal that all can relate to — peace, harmony and prosperity for all citizens.

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Income Inequality as a Cause of Conflict The theory of relative deprivation posits that unfavourable comparisons between one’s personal situation compared to others fosters rebellion, rather than poverty itself.[13] Inequality leads to relative deprivation, and an individual who observes themselves deprived of an asset that another receives may become angered. This is known as the ‘frustration-aggression hypothesis’ and can lead to violence and conflict.[14] Income inequality can lead to political instability and conflict through disintegrating social cohesion and promoting revolution.[15] While inequality and poverty are highly associated with downstream conflict, a causal link has been difficult to establish. Structural inequalities such as among religions, castes and ethnicities who have separate identities along with income disparities can breed conflict and resentment. Economic growth of one group and not the other can also prompt conflict. This includes Mexico’s growth which excluded the impoverished South leading to the Chiapas rebellion in 1994, the Maoist insurgency in Nepal between 1996-2006 and the Tamil population uprising against the Sinhala community in Sri Lanka in the 1980s which gradually sparked civil war. Financial crises which adversely affect the economy can also precipitate conflict.[12] Exploitation of migrant workers and poor immigrant farmers, in addition to farmers forced from their land, ignited protests and anticolonial rebellion in Angola, during the 1970s-1980s.[6] A primary cause of inter-group violence in Sub-Saharan Africa was asymmetrical access to socio-economic welfare, unfair ethnic favouritism and political corruption across different groups.[16]

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. Image B J. Children of war hungry [Internet]. 2016 [cited 26 October 2019]. Available from: Acknowledgements None Conflicts of Interest None declared Correspondence Image B J. Children of war hungry [Internet]. 2016 [cited 26 October 2019]. Available from: References 1. Baranyi S, Beaudet P, Locher U. World development report 2011: Conflict, security and development. The World Bank; 2011. 2. Justino P. Shared societies and armed conflict: Costs, inequality and the benefits of peace. IDS Working Papers. 2012 Nov;2012(410):1-23. 3. Buvinic M, Gupta MD, Casabonne U, Verwimp P. Violent

Improving access to education and basic necessities is vital to stabilizing poorer nations trapped in a 35

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conflict and gender inequality: An overview. The World Bank; 2013 Feb 1. 4. Bircan C, Brück T, Vothknecht M. Violent conflict and inequality. Bonn: Institute for the Study of Labor; June 2010. 5. Ansoms A. Resurrection after civil war and genocide: growth, poverty and inequality in post-conflict Rwanda. Eur J Dev Res. 2005 Sep 1;17(3):495-508. 6. Cramer C. Does inequality cause conflict?. J Int Dev. 2003 May;15(4):397-412. 7. Therborn G, Aboim S. The killing fields of inequality. Análise Social. 2014 Sep(212):729-35. 8. Kuhn PM, Weidmann NB. Unequal we fight: Between-and within-group inequality and ethnic civil war. Poli Sci Res Meth. 2015 Sep;3(3):543-68. 9. Murshed SM, Gates S. Spatial–horizontal inequality and the Maoist insurgency in Nepal. Review of development economics. 2005 Feb;9(1):121-34. 10. Esteban J, Ray D. Linking conflict to inequality and polarization. Am Econ Rev. 2011 Jun;101(4):1345-74.. 11. Caprioli M. Primed for violence: The role of gender inequality in predicting internal conflict. Int Stud Quart. 2005 Apr 25;49(2):161-78. 12. Kanbur R. Poverty and Conflict: The Inequality Link. New York: International Peace Academy; June 2007. 13. Gurr TR. Why Men Rebel. Abingdon: Routledge; 2015 Nov 17. 14. Bartusevičius H. The inequality–conflict nexus re-examined: Income, education and popular rebellions. J Peace Res. 2014 Jan;51(1):35-50. 15. Thorbecke E, Charumilind C. Economic inequality and its socioeconomic impact. World Dev. 2002 Sep 1;30(9):1477-95. 16. Fjelde H, Østby G. Economic Inequality and Inter‐group Conflicts in Africa. In presentation at the Democracy as Idea and Practice conference, Oslo, January 2012 Jan 12 (pp. 12-13). 17. Bellows J, Miguel E. War and local collective action in Sierra Leone. J Public Econ. 2009 Dec 1;93(11-12):1144-57. 18. Voors M, Nillesen EE, Verwimp P, Bulte EH, Lensink R, Van Soest D. Does conflict affect preferences? Results from Field Experiments in Burundi. HiCN Working Papers. 2010 Jan 3. 19. Macours K. Increasing inequality and civil conflict in Nepal. Oxf Econ Pap. 2010 Aug 4;63(1):1-26.


HIV/AIDS IN SUB-SAHARAN AFRICA To what extent is poverty responsible for the high prevalence?

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Juliana Wu



IV infection has long been concentrated in the poorest, most marginalised region of the world- Sub-Saharan Africa. The relationship between HIV/AIDS and economic destitution has therefore become a pivotal topic for discussion particularly in the context of defining the most effective way to advance treatment and care against the HIV/AIDS pandemic. This paper argues that there is value in moving beyond viewing poverty merely as an economic disadvantage that can be quantified in monetary terms, and rather that poverty should be viewed as an abstract web with various projections that cast influence on all aspects of one’s life. Each of these projections represents a separate determinant for the contraction of HIV/AIDS- such as perpetuating gender inequality, a lack of employment and social unrest- all of which converge at the central core that represents poverty. Introduction Sixty-two percent of the world’s population of people living with Human Immunodeficiency Virus (HIV) are found in the region of Sub-Saharan Africa.[1] It is an area where 14,000 people are being infected daily and an additional 11,000 are dying each day from illnesses related to the epidemic, such as opportunistic bacterial and viral infections, pneumonia and lymphomas.[2] In a region of the world where more than 60% of people live below the United Nations (UN) poverty line of US$1 per day, it is not difficult to highlight the strong links between the prevalence of HIV/AIDS and capital poor settings.[2] This paper however, seeks to critically analyse the extent to which the growing incidence of HIV/AIDS in Sub-Saharan African is solely attributed to monetary poverty. A subsequent evaluation of the prevailing causes and circumstances perpetuating HIV/AIDS in Sub-Saharan Africa show that the factors driving HIV infection extend well beyond money. Rather, this paper will highlight that instead, the prevalence of HIV in the aforementioned region is the cumulative result of complex cultural, social and political determinants that create and sustain poverty and consequently, HIV transmission. These determinants include economic deprivation, gender inequality, political and social unrest, as well as a distinct lack of educational and employment opportunities.

While there is compelling evidence to suggest that poverty is proportional to incidences of HIV/AIDS, analysis of some of the most capital-rich countries in Sub-Saharan Africa have suggested that HIV/ AIDS is not directly correlated with a country’s capital wealth. Botswana, for instance, represents one of Sub-Saharan Africa’s richest countries with a GDP per capita of US$13,000.[2] Unexpectedly, the prevalence of HIV in terms of the proportion of the population affected is amongst the highest in the Sub-Saharan region—with 24.1% of 15-49 year olds affected as of 2005.[2] By contrast only 3.5% of the total population of Ethiopia, one of the poorest countries not only within Sub-Saharan Africa but the world, are affected by HIV/AIDS. In comparison to Botswana, Ethiopia’s GDP per capita is a meagre $1,000.[2] This suggests that poverty and HIV/AIDS do not occur in a vacuum isolated from other factors. Rather, these statistics suggest that the prevalence of HIV/AIDS cannot be explained solely by a country’s monetary wealth, and as such, there must be other external forces perpetuating the HIV/AIDS epidemic in Sub-Saharan Africa.

Given the region of Sub-Saharan Africa represents an area where 70% of the world’s poorest people live, one could argue that the link between poverty and HIV is conspicuous.[3] Indeed, the distinct relationship between the two variables is well trans-

Reasons for the association between HIV/AIDS and poverty are diverse and rely more on the factors 38

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lated through research and statistics. Sub-Saharan Africa appears to be the only region in the world where the proportion of people living in extreme poverty is increasing.[4] Numbers of those living below the UN poverty line has almost doubled from 164 million in 1981 to 314 million in 2005.[1] In a similar manner, the HIV/AIDS epidemic has been affecting the sub-continent far more severely than any other region in the world.[1] These statistics suggest that the extreme state of destitution, that characterises many regions of Sub-Saharan Africa, is responsible for facilitating the rapid spread of the HIV/AIDS epidemic. Those constrained in terms of financial capital are constrained in terms of choices and capabilities. These constraints ultimately impede on the quality of life of those living in poverty. As a result, poor households and in turn, individuals do not have the financial resources that allow for accessibility to the most basic of healthcare facilities, nor the food security that provides them adequate nutrition and sustenance.[2] Ultimately, this severely increases an individual’s vulnerability to infectious diseases such as HIV, with strong biomedical evidence to suggest that those who are malnourished are particularly susceptible to opportunistic and parasitic infections due to weakened immunity.[1] Therefore, the predisposed health risks that are associated with poverty seem to provide a compelling argument attributing for the high prevalence of HIV/AIDS in the most poverty-stricken regions of Sub-Saharan Africa.


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that may initially perpetuate the cycle of poverty, rather than poverty itself. Some of these reasons are grounded in theories of sexual behaviour related to economic deprivation.[5] In an effort to overcome the financial restrictions associated with poverty, those living in a state of poverty are far more likely to engage in behaviours and activities precarious to their health, including commercial sex. And indeed, with weak endowments of financial capital and human resources, women often turn to commercial sexual transactions as a pivotal survival strategy. [2] Those engaged in poverty-driven sex work and sexual transactions are particularly vulnerable to contracting HIV/AIDS through unprotected sex. [2] Young girls, who are often concerned only with the imminent day-to-day threat of survival, often overlook the high risk of infection that comes with engaging in unprotected sex.[2] Moreover, the dangers associated with the sex trade are compounded by the temptation offered by men who are willing to pay inflated prices for unprotected sex.[2] Given that in some regions of Sub-Saharan Africa, an estimated 12% of the female population aged 15-49 regularly engage in commercial sex work and many more estimated to engage in sex work part-time, it is not difficult to gauge the effect that poverty-driven sex work has on the rapid dissemination of HIV infection and subsequent AIDS illness.[2]

gender inequality, which in this case, manifests in a lack of control over their reproductive and sexual healthcare decisions. Established cultural influences that promote female submission and perpetuate gender inequality only represents only one of the various ways in which poverty shapes risk and intensifies one’s vulnerability for HIV transmission. Despite the impact that gender discrimination has on the prevalence of HIV/AIDS, monetary poverty still remains a pivotal force in mounting one’s vulnerability to HIV infection. While it may not be the direct and only cause, it must be considered in the context of the aforementioned determinants. Take for example the crucial issue of condom negotiation, which represents one of the greatest forms of HIV mitigation.[7] Given relatively recent ideological liberation in many countries of Sub-Saharan Africa, practices of traditional polygyny and social norms relating to a male’s power to dictate the sexual decision-making process has weakened substantially.[8] Yet within severely poverty-stricken circumstances, the vulnerability of women to contract HIV/AIDs is grossly compounded by the wide availability of substitute female partners such that the men are able to carefully select those that are so desperate for money that it overrides and clouds their judgement of the potential consequences of such dangerous and risky sexual behaviours.[8] Their docility subsequently increases their vulnerability to infectious diseases such as HIV/AIDS as the economic value of sex and sexuality becomes their income and lifeline. Therefore, poverty not only plays a crucial role in perpetuating the prevalence of HIV, it also reverses processes of societal and cultural progression that serves to intensify the manifestation of female discrimination.

An argument correlating the prevalence of HIV/ AIDS to poverty motivated sex-work in Sub-Saharan Africa sheds light to a far more fundamental social and cultural issue. Women’s engagement in transactional sex and their ability to negotiate condom use reflects the cultural expectation that women should exhibit submissiveness and obedience to men.[6] Indeed historically, within the context of many Sub-Saharan African countries, established social norms dictate that it is men, solely, who are able to determine the process of sexual decision-making.[6] Therefore, one could argue that it is the socially established pre-conditions that render a woman less powerful than a man—a consequence that results in a woman’s unnecessarily heightened vulnerability to HIV contraction. This, in turn, highlights the broader issue of gender inequality running parallel to long-standing historical social issues including inequities in income and assets. As such, the mechanisms of HIV transmission are not reducible to poverty-driven sex work and transactions. Instead, they are embedded in centuries of

Additionally, as pivotal as the concept of poverty is in contributing to life disruption and exposure to hazardous or dangerous environment, it is as imperative to acknowledge the causal factors that supplement and sustain the cycle of poverty. Education represents a crucial tool that can be utilized for greater financial capital, which in turn increases accessibility to health facilities and reduces cases of malnutrition.[10] However, extensive research has shown that children raised in poor households face a higher probability of obtaining only a low-level education.[10] Moreover, there is a high level of intergenerational transfer of low-level education attainment, attributed in part to the vicious cycle of destitution and poverty that is often bestowed at birth.[11] Low levels of education, much like many variables of poverty, exhibits characteristics that make it almost impossible to break the transgenerational cycle that perpetuates the evident vulnerability. Further compounding the issue surrounding

Analysis of some of the most capital-rich countries in Sub-Saharan Africa have suggested that HIV/ AIDS is not directly correlated with a country’s capital wealth. 39

tive of an array of fundamental underlying forces that drive HIV transmission. Therefore, it is essential to acknowledge the vast array of social, political and cultural dynamics that create, maintain and exacerbate poverty and perpetuate a fervent breeding ground for HIV infection. Acknowledging that poverty is one of the key pillars driving HIV infection rates represents the crucial first step in transforming societal stigma against HIV/AIDS and may assist in ascertaining methods of primary prevention rather than secondary prevention where the focus can be shifted towards cultivating an environment where individuals feel empowered to make proper decisions for their health not engage in the risky and destructive sexual behaviours that perpetuate HIV infection.

In addition to education, the lack of social and political cohesion in Zimbabwe is also a major conditioning factor of poverty and consequently, HIV/ AIDS.[12] Historically, Zimbabwe has suffered under numerous political campaigns that have severely undermined the productivity of their economy. [12] The 1999 land redistribution campaign, which represented the governmentâ&#x20AC;&#x2122;s bid to evict white farmers from their land following political independence from British rule in 1980, disrupted the economy in many ways. As the economy deteriorated, levels of poverty increased and violence ensued.[12] A climate of unlawfulness was established where rape became increasingly prevalent, severely heightening individual vulnerability to contracting HIV infection.[12] Levels of HIV infection have risen simultaneously with the climate of hyperinflation, economic ruin and political disruption, peaking from 10% in the end of the 1980s to 36% between 1995 and 1997.[12] Therefore, it is clear that collapse or disruption of political and social order and cohesion prove to be an important determinant of the HIV epidemic. Societies living in the midst of social and political discourse appear to cope with such frustrations through destructive mechanisms that heighten societal susceptibility to HIV infection.

Acknowledgements None Conflicts of Interest None declared Correspondence Image World Bank Photo Collection. A patient receives an HIV test [Internet]. 2003 [cited 26 October 2019]. Available from: https:// References 1. Ganyaza-Twalo T, Seager J. Literature Review on Poverty and HIV. AIDS: Measuring the Social and Economic Impacts on Households accessed at www. sahara. org. za/index. php. 2005. 2. Mbirimtengerenji ND. Is HIV/AIDS epidemic outcome of poverty in sub-saharan Africa?. Croatian medical journal. 2007 Oct;48(5):605. 3. Mishra V, Assche S, Greener R, Vaessen M, Hong R, Ghys P et al. HIV infection does not disproportionately affect the poorer in sub-Saharan Africa. AIDS. 2007;21(Suppl 7):S17-S28. 4. Poku NK. Poverty, debt and Africaâ&#x20AC;&#x2122;s HIV/AIDS crisis. International Affairs. 2002 Jul 1;78(3):531-46. 5. Gisselquist D, Rothenberg R, Potterat J, Drucker E. HIV infections in sub-Saharan Africa not explained by sexual or vertical transmission. 6. Mbizvo MT, Bassett MT. Reproductive health and AIDS prevention in sub-Saharan Africa: the case for increased male participation. Health policy and planning. 1996 Mar 1;11(1):8492. 7. Ainsworth M, Teokul W. Breaking the silence: setting realistic priorities for AIDS control in less-developed countries.

There is no doubt that Sub-Saharan Africa exhibits an alarming rate of HIV infection, with poverty often implicated as the main contributing factor. The argument of poverty as the cause of the epidemic has been challenged by the idea that some of the richest countries in the region exhibit the most serious and widespread prevalence of the disease. Poverty, although pivotal in exacerbating the AIDS epidemic through numerous channels including gender disempowerment, poor health outcomes and overall decreased quality of life, is representa40

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Reasons for the association between HIV/AIDS and poverty are diverse and rely more on the factors that may initially perpetuate the cycle of poverty, rather than poverty itself.

educational attainment is the distinct lack of job opportunities available in many areas of Sub-Saharan Africa, educated or not.[10] This is primarily a consequence of an increasing working age demographic which is increasing faster than new jobs can be established in the stagnant-type economies characteristic of the region.[10] Women in these regions are likely to be subjected to low levels of employment, underemployment and gender bias, resulting in early marriage or engagement in the sex industry. [10] This further highlights the intricate nature of factors contributing to HIV/AIDS epidemic which extend beyond monetary poverty. In their totality, the plethora of external factors including demographic, social and cultural influences, are responsible for establishing an environment that prolongs and entraps those in a cycle of poverty, ultimately serving to perpetuate HIV infection in Sub-Saharan Africa.

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The Lancet. 2000 Jul 1;356(9223):55-60. 8. Luke N, Kurz K. Cross-generational and transactional sexual relations in sub-Saharan Africa. Washington, DC: International Center for Research on Women (ICRW). 2002 Sep. 9. Duffy L. Suffering, shame, and silence: The stigma of HIV/ AIDS. Journal of the Association of Nurses in AIDS Care. 2005 Jan 1;16(1):13-20. 10. Okojie CE. Employment creation for youth in Africa: the gender dimension. Jobs for Youth: National Strategies for Employment Promotion. 2003 Jan:15-6. 11. Foster G, Williamson J. A review of current literature on the impact of HIV/AIDS on children in sub-Saharan Africa. AIDS-LONDON-CURRENT SCIENCE THEN RAPID SCIENCE PUBLISHERS THEN LIPPINCOTT RAVEN-. 2000 Jan 1;14:S275-84. 12. Premkumar R, Tebandeke A. Political and socio-economic instability: does it have a role in the HIV/AIDS epidemic in sub-Saharan Africa?. SAHARA-J: Journal of Social Aspects of HIV/AIDS. 2011 Jun 1;8(2):65-73.


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TERMINATION OF PREGNANCY How far do we really have to go? Jordan Kirby 42


ly become a reality. From the late 1800s, abortion was deemed illegal nationwide. This was until 1969, when a Supreme Court case, R v Davidson, deemed abortion legal on the grounds that it must be an absolute necessity for the preservation of maternal physical or mental health, and that the risks of the procedure did not outweigh the perils it sought to prevent.[7] Gradually, a number of Australian states have progressively reformed their legislation to decriminalise abortion over the last 20 years. However, the laws and ramifications for illegal abortion differ from state to state, leading to confusion in the general public.[6]

merican flags fly high as anti-abortion protestors swarm the well-manicured lawns of abortion clinics, plastering large protesting signs across the gates safeguarding women’s reproductive health services. It’s the 21st century, yet women’s reproductive rights are under attack with the most aggressive anti-abortion law to be enacted by November 2019 in Alabama, with no exceptions for rape victims.[1] Conversely, across the Atlantic, cheers of celebration are heard throughout Ireland, following major changes to longstanding anti-abortion laws in 2018. The Irish referendum ended with a 66% vote towards decriminalising abortion; a notable triumph for women’s reproductive rights.[2]

South Australia first legalised abortion in 1969, yet women are still required to have two medical practitioners approve of the procedure within the first 28 weeks of gestation on the grounds of maternal health or foetal disability.[8] Western Australia and Victoria deem abortion legal before 20 weeks’ and 24 weeks’ gestation respectively, whereas, the Australian Capital Territory has no legislated restrictions based on gestational age.[8] Furthermore, Queensland recently removed termination of pregnancy from the state’s crimes act in 2018, leaving NSW as the last state to definitively decriminalise abortion this September.

Despite the deep-rooted social stigma and controversy, access to an abortion along with the necessary medical and psychological support is a common and normal part of a woman’s reproductive life. However, 20th century medical literature framed the medicolegal conflict of abortion as the “doctor’s dilemma”, failing to recognise the woman as the most important decision-maker during her pregnancy.[3] The medicolegal conflict that traverses decades of abortion history starkly reminds us that reproductive medicine continues to be a practice where paternalism in the legal system impedes on the delivery of necessary and safe healthcare worldwide.[3]

After these outlined gestational ages, women may access abortions depending on the doctor they see and their circumstances. However, the chances of obtaining an abortion following these legislated dates are dismal.[9] Ultimately, these convoluted legislative disparities exist due to the fact that abortion falls under the jurisdiction of the state government, making it challenging to achieve a nationwide consensus.

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Abortion in Australia One in three Australian women have an abortion at least once during their lives with maternal mental health being the reported reason for over 95% of terminations.[4,5] A termination of pregnancy may either involve medications or surgical treatment. Medical termination of pregnancy involves the use of oral medications, prescribed by a qualified medical practitioner, to cease the pregnancy.[6] In contrast, a surgical termination, used in abortions after 9 weeks of gestation, requires the use of surgical instruments to remove the fetus safely.[6] Both medical and surgical abortions are available in Australia, with variations in laws between states and territories.[6]

Recent legal challenges in New South Wales After three days of tiring debate, the new Abortion Law Reform Act 2019 passed the NSW lower house. [10] Politicians cheered as the bill passed through parliament with a vote of 59 to 31.[10] The bill recently passed the Senate after an exhausting 40 hours of discussion, fully decriminalising abortion in NSW for the first time in 119 years.[11] Despite divisive opinions on the matter, this movement symbolises, perhaps, the growing acceptance and ongoing support for abortion and the recognition of the necessity for women’s reproductive rights.

The long and arduous path to the decriminalisation of abortion in Australia has not been an easy one, and for New South Wales (NSW), has only recent-

Approximately 13% of all worldwide maternal deaths are due to unsafe terminations of pregnancy

The legal controversy around abortion in NSW recently came under the limelight, fuelling political conflict and discourse. The new Abortion Law Reform Act 2019 was introduced to the NSW parliament in late July, aiming to remove abortion from the Crimes Act 1900.[12] The new bill proposes ter43

Previously, the NSW government theoretically allowed for termination of pregnancy, however, only under strict circumstances. A termination was only deemed lawful if a physician believed the mother was in serious danger physically or mentally by continuing the pregnancy.[13] Consequently, a violation of this criminal law would cost the woman, doctor and any assistant up to 10 years imprisonment, letting archaic paternalism shadow over women’s reproductive rights and their autonomy. [14] This truly embodied a tangible and sombre example of how legal technicalities and quarrelling politicians can deleteriously impact on human rights and health outcomes of everyday individuals.

The anti-abortion movement, re-ignited in America by a rise in conservative state governments, has started a wave of legislative challenges. A number of American states, including Missouri, Mississippi, Louisiana and Georgia, have begun pursuing “heartbeat” bills, aiming to criminalise termination of pregnancy as soon as a heartbeat is detected during the pregnancy.[18] However, a foetal heart beat can be detected as early as 6 weeks in pregnancy with many women unaware of being pregnant at all. This significantly restricts a woman’s autonomy early on during pregnancy. Additionally, what is interpreted as a foetal heartbeat, a small flickering shadow of greys on the ultrasound screen, is not anatomically, nor clinically, a completely formed heart.[19]

The Australia Medical Association (AMA) have welcomed the call to decriminalise abortion in NSW. [15] However, the AMA have warned that the emotionally fuelled fearmongering from those opposing the decriminalisation may have led to further imposed restrictions and barriers against women. [16] The AMA outlined their concern on the previously proposed amendment to mandate abortions after 22 weeks’ gestation be subject to review by a four person panel, further delaying treatment and worsening a women’s anxiety and suffering.[16] The thought of having to ask permission from a panel of strangers during the utmost private, daunting and emotionally traumatic time of one’s life is the epitome of entrenched paternalism in healthcare.

Unsafe abortion The World Health Organization (WHO) has stressed that legal restrictions do not lead to a reduction in the number of abortions or births. However, the number of unsafe terminations and the significant mortality and morbidity associated with unsafe terminations of pregnancy spikes.[20] The WHO defines unsafe termination of pregnancy as one that is performed by unqualified individuals or self-induced abortion, all of which are prone to unhygienic and dangerous consequences.[20] These practises leave women at risk of substantial harm and in critical danger if complications, such as severe bleeding, occur.

However, the current form of the legislation allows access to termination of pregnancy after 22 weeks’ gestation with the approval of two medical specialists, removing the amendment to require an extensive panel to review the abortion.[12] Across international waters… The Australian narrative of the abortion decriminalisation movement starkly differs to other international jurisdictions. In Ireland, a polarising referendum in 2018 led to the removal of the criminal sanctions against termination of pregnancy for the first time since 1861.[2] Prior to 2018, women in Ireland would have to leave the country to access the treatment needed for a termination.

Despite a decline in the rate of unsafe abortions since 1990, approximately 13% of all worldwide maternal deaths are due to unsafe terminations of pregnancy. [20] An estimated 25 million unsafe terminations occur worldwide annually, with over 99.9% occurring in developing countries.[21] However, these numbers are likely to be considerably higher due to the ongoing underreporting from both mothers and doctors due to their concerns for safety, imprisonment and avoiding hospital presentation.

On the other hand, the state government of Alabama recently approved of a new draconian law banning abortion from November 2019 onwards .[17] The legislation will only allow a termination if a lethal foetal abnormality is detected or if there are serious health risks to the mother regardless of ges-

Access to safe and early abortion can potentially prevent 500,000 maternal deaths and the related morbidity of an additional 8.5 million women globally each year.[20] With higher rates of maternal death and injury from unsafe abortions, greater 44

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tational age. Appallingly, there are no exceptions for rape victims. Ultimately, this legislation responds punitively to the needs of rape victims, subjecting women to significant mental, emotional and physical harm and furthering restrictions on women’s reproductive rights. Violation of this law is classified as a Class A felony, with the maximum sentence comprising life imprisonment.[18]

mination of pregnancy be allowed up to 22 weeks’ gestation, with abortions hereafter available if approved by two doctors.[12].

in Victoria were for residents of Victoria, indicating the extent of travel women are needing to go to receive an abortion.[29] With variations in the restrictions in legal abortion criteria, women may need to travel longer distances to access the same level of care for a delayed termination. However, South Australia places further constraints on women, making those who have not lived in the state for at least 2 months ineligible for a termination of pregnancy [8].

volumes of healthcare resources are required in the long-term compared to safe terminations of pregnancy. The WHO estimates an annual global cost of US $533 million due to major complications associated with unsafe abortions, such as massive haemorrhage and post-natal infection.[22] In developing regions, this places immense strain on an already economically burdened healthcare system. The ‘Unsafe Abortion’ WHO report outlines that only 28% of all nations allow for legal terminations on request from the woman herself, illustrating the need for major international reform on abortion law.[20] Yet, this proves difficult when legal systems can be largely influenced by religion and cultural beliefs across the world, even if these philosophies are viewed as outdated by many.

Conclusion The decriminalisation movement has led to polarising changes across the world, with some states legislating to permit abortion whilst other states aggressively criminalise such reproductive services, archaically shackling women’s human rights once again. However, decriminalisation will never entirely equate to pragmatism nor complete removal of the deep-rooted and damaging stigma that has stood for decades. As Rosa Luxemburg once said, “Those who do not move, do not notice their chains” and, therefore, remain in a state of enduring deprivation of their rights.

Only 49% of all countries allow for a legal termination for rape victims, adding to the ongoing life-long pain suffered by rape victims.[20] Additionally, only 85% of developed countries allow rape victims to access abortion treatment, undoubtedly refuting the idea that this is a third world problem.[20] Ultimately, the decriminalisation of termination of pregnancy largely impacts on the rates of unsafe abortion and begins the path to improving access to women across the world. However, providing equal access does not end with the signature of a politician’s pen.

In fostering and protecting women’s reproductive rights, unequivocally a form of human rights, we must collectively challenge the paternalistic status quo. We must fight for more developed services in rural areas, encouraging our state governments to fund these services and thereby combating the financial barriers that prevent so many from accessing a fundamental human right.

Decriminalisation ≠ Access

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Australian women are often hit with great difficulty in raising the appropriate funds needed for the high-priced procedure, travel, time off work and childcare expenses when arranging care for their family while being away.[23] The median Medicare-rebated upfront cost was $560 for a medical termination and $470 for a surgical termination in 2017. An abortion after 19 weeks can cost up to a steep $7,700.[23]

Acknowledgements None Conflicts of interest None declared Correspondence

Similar to the US, Australia is a vast country and has approximately 29% of its population living in rural and remote regions,[24] where increasing rurality has had a long-standing association with a lack of access to abortion.[25] With closure of a Tasmanian women’s reproductive health clinic in 2018, there has been a fivefold increase in the number of women needing to travel interstate for access to abortion clinics.[26] This comes down to a lack of gynaecologists offering the service in Tasmania.[27] The shortage of willing doctors across rural Australia is prominent in the literature.[28]

Image Shaull L. Erin May Quade speaking at a Stop Abortion Bans Rally in St Paul, Minnesota [Internet]. 2019 [cited 26 October 2019]. Available from: photolist-2fYV1W2-2fYV1v2-2fYWm3X-2ezY3Hx-25nj3GD-2fYV82t2fYVs6F-2ezY2vn-2ezY2zk-2ezZmDR-25nkcMk-2eMagqY-2fYWmFR2fYWkVH-25njqCH-2enQk9W-25nrYar-2fZ1ghB-2fUpEy1-2fUoUwo25noEr6-25nR1F2-2eMf2ky-2eMf2mf-2eA3zYR-2fURTsq-2eMf2hh2fURTy7-2eMGHSy-2fURTN5-2fZsAr6-2fURU9L-2fZsAvz-2eMGJaN25nR25Z-25nR234-25nR1QF-25nR2c2-2fZsAyv-2fURU2w-2fZsAtk References

Moreover, a review conducted by de Moel-Mandel and Shelley found only 37% of delayed terminations

1. Near-total abortion ban signed into law in Alabama [Internet].


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2. Conneely A. Eight Amendment repealed after bill signed into law

16. Unfounded fearmongering on abortion puts women and doctors

[Internet]. Ireland; Raidió Teilifís Éireann [cited 2019 Aug 7]. Available

at risk [Internet]. NSW: AMA; 2019 Aug 7 [cited 2019 Aug 8]. Available



3. Swanson KW. The doctor&#39;s dilemma: paternalisms in the


medicolegal history of assisted reproduction and abortion. The Jour-

17. Alabama passes bill banning abortion [Internet]. UK: BBC News;

nal of Law, Medicine &amp; Ethics. 2015 Jun;43(2):312-25.

2019 May 15 [cited 2019 Aug 8]. Available from:

4. Pregnancy Outcome in South Australia 2016 [Internet]. Ade-


laide: Pregnancy Outcome Unit, SA Health, Government of South

18. Law T. Here are the details of the abortion legislation in Alabama,

Australia; 2018 [cited 2019 Aug 7]. Available from: https://www.

Georgia, Louisiana and elsewhere [Internet]. New York: Time; 2019

May 18 [updated 2019 Jul 2; cited 2019 Aug 8]. Available from: https://


4e8cd54e9ea1/Pregnancy+Outcome+in+South+Australia+2016+V2. pdf?MOD=AJPE


19. What’s going on in the fight over US abortion rights? [Internet].


UK: BBC News; 2019 Jun 14 [cited 2019 Aug 9]. Available from: https://

5. Drabsch T. Abortion and the law in New South Wales. NSW Parlia-

mentary Library Research Service; 2005 Aug.

20. Ahman E, Shah I. Unsafe abortion: global and regional estimates

6. de Costa, de Costa. Medical abortion and the law [Internet]. Aus-

of the incidence of unsafe abortion and associated mortality in 2003.

tralia: University of New South Wales Law Journal; 2006 [cited 2019

21. Preventing unsafe abortion [Internet]. Geneva: WHO; 2019 Jun

Oct 10]. Available from:

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7. R v Davidson [1969] VicRp 85; [1969] VR 667 (3 June 1969) [Inter-

22. Vlassoff M, Shearer J, Walker D, Lucas H. Economic impact of un-

net]. Victoria: Victorian Reports; 1969 Jun 3 [cited 2019 Aug 4]. Avail-

safe abortion- related morbidity and mortality: evidence and estima-

able from:

tion challenges. Brighton, UK: Institute of Development Studies; 2008



8. Australian abortion law and practice [Internet]. Australia; Chil-

23. Shankar M, Black KI, Goldstone P, Hussainy S, Mazza D, Petersen

dren By Choice Association Incorporated; 2019 Feb 26 [cited 2019 Aug

K, Lucke J, Taft A. Access, equity and costs of induced abortion services

7]. Available from:

in Australia: a cross‐sectional study. Australian and New Zealand


journal of public health. 2017 Jun;41(3):309-14.

9. Keogh LA, Newton D, Bayly C, McNamee K, Hardiman A, Webster

24. Australia’s Health 2018: 5.2 Rural and remote populations [Inter-

A, Bismark M. Intended and unintended consequences of abortion law

net]. Canberra: AIHW; 2018 [cited 2019 Aug 09]. Available from:https://

reform: perspectives of abortion experts in Victoria, Australia. J Fam

Plann Reprod Health Care. 2017 Jan 1;43(1):18-24.


10. Lam C. MPs cheer, applaud as bill to decriminalise abortion

25. Davis J. Access to abortion in regional Australia still depends

passes NSW lower house [Internet]. Australia: SBS News; 2019 Aug 9

on ‘your postcode and your income’ [Internet]. Australia: ABC News;

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11. Abortion decriminalised in NSW after marathon debate [In-

26. Wahlquist C. Number of Tasmanians traveling interstate for

ternet]. Australia; Australian Associated Press; 2019 Sep 26 [cited

abortions rises fivefold [Internet]. Australia: The Guardian; 2018 Apr

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12. Reproductive Health Care Reform Bill 2019 [Internet]. New

27. Dawson A. FactCheck: do women in Tasmania have access to safe

South Wales: Parliament of New South Wales; 2019 Jul 30 [cited 2019

abortions? [Internet]. Australia: The Conversation; 2018 Feb 28 [cited

Aug 7]. Available from:

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13. Law on Abortion in NSW [Internet]. NSW: Family Planning NSW;

28. Dawson A, Bateson D, Estoesta J, Sullivan E. Towards compre-

2019 Jun [cited 2019 Aug 7]. Available from:

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sights for improving universal access to abortion in Australia. BMC


health services research. 2016 Dec;16(1):612.

14. Aubusson K. NSW set to overturn ‘archaic’ abortion in historic

29. de Moel-Mandel C, Shelley JM. The legal and non-legal barriers

vote [Internet]. Australia: The Sydney Morning Herald; 2019 Jul 28

to abortion access in Australia: a review of the evidence. The European

[cited 2019 Aug 7]. Available from:

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20190726-p52b5w.html 15. AMA (NSW) president welcomes bill to decriminalise abortion


AMSA Journal of Global Health

New York City;Associated Press News; 2019 May 16 [cited 2019 Aug


Volume 13

Issue 2

October 2019

Thanh Ha Thy (Rose) Phan


The unregulated stem cell industry has compromised the ability of patients to make informed decisions by exploiting vulnerable individuals with little medical knowledge and portraying these therapies as evidence-based cures without appropriate substantiation.


tem cells are broadly defined as cells with the ability to differentiate into a number of specialised tissues. There are at least 2 kinds of stem cells: haematopoietic stem cells, which form all types of blood cells in the body; and mesenchymal stem cells (MSC), which can generate bone, cartilage and fat cells that support the formation of blood and fibrous connective tissue.[1] Stem cell transplantation (SCT) includes the transplantation of both of these cell types. Haematopoietic stem cell transplantation (HSCT) refers to the infusion of hematopoietic stem cells into a patient, typically obtained from peripheral blood or bone marrow.[1] HSCTs are classified as either allogeneic when sourced from a matching donor, or autologous when stem cells from the patient are used. MSC therapy uses cells from bone marrow, adipose, muscle, peripheral blood or the umbilical cord; however, the application of MSCs has been associated with variable clinical outcomes.[2]

High costs and long waits in the medical system could compel patients from developed countries to travel to developing countries to seek out treatments from SCT facilities that offer unproven therapies.[7] This article aims to discuss the feasibility of establishing SCT centres in developing countries in terms of cost, and to explore the rising SCT medical tourism industry. Cost, SCT and developing countries

In developing countries, rates of non-communicable diseases such as diabetes, cardiovascular disease and cancer continue to rise rapidly, and are increasingly consuming health resources at the expense of the provision of basic health necessities.[3,4] While SCT remains expensive and unproven in many diseases, it has the potential to address the epidemic of non-communicable disease in developing and developed countries. Several developing countries are already participating in stem cell research, with the aim to address non-communicable disease.[4] However, a majority of stem cell research remains at the experimental stage, with clinical trials still uncommon.[5] Despite this, there are over 700 clinics estimated to be operating, mostly in developing countries. Clinics in Argentina, China, India and Thailand, amongst others, offer SCT without evidence of efficacy from clinical trials.[5] Conversely, HSCT is rigorously established as a treatment modality for a number of primary and secondary disorders of the haematopoietic system. According to the World Health Organisation (WHO), more than 50,000 HSCT are carried out annually worldwide, with further increases expected.[6] Consequentially, a growing of number of people in Europe, North America and Australia are seeking medical care in developing countries, creating an industry known as medical tourism which has become a US$60 billion-a-year business.[7] Moreover, there is a remarkable discrepancy between the costs for HSCT between developed and developing countries (Table 1). This could be due to the differences in fees charged for inpatient stays, medical teams and drug treatments.[7]

Cost is a significant barrier to SCT availability and access, especially in developing countries. SCT is associated with a relatively high financial burden given the requirement for nursing staff, laboratory exams, mobilisation of stem cells, blood products, donor selection, cell collection and quality control. [5] Therefore, SCT requires sophisticated hospital infrastructure, a haematology team with specific training and transplant experience and modern technology. Such resource requirements mean that only specialised referral centres can provide such services. In many circumstances, this may also produce a financial burden for the patient, both in direct expenditure and the need to relocate from smaller provinces. Relocation may present an opportunity cost associated with interruption to income and career progression.[5] Furthermore, financial burden may arise with complications of SCT. This may involve expensive antibiotics, antifungals, blood transfusions and immunosuppressive treatments further increasing costs associated with SCT, potentially at the cost of the individual.[8]


In developing countries financial circumstances can prevent access to therapeutic treatments. A study in India found that high dose chemotherapy for multiple myeloma combined with autologous HSCT had a median survival of 5-7 years, which is greater than the 3-4 years after conventional treatment.[12] Another study showed that combined therapy with autologous HSCT may lead to improvements in progression-free survival and complete response rates of up to 40-50% for patients with multiple myeloma.[8] However, better health outcomes with autol-

AMSA Journal of Global Health


it was possible to conduct autologous HSCT on an outpatient basis using non-frozen haematopoietic stem cells. In addition, the intensity of nonmyeloablative conditioning regimens was reduced. A conditioning regimen may include chemotherapy, monoclonal antibody therapy and radiation therapy, which aims to prevent transplant rejection and allow newly injected stem cells to grow.[15] However this can lead to high regimen-related toxicities in elderly patients, especially those with comorbidities. [15] Thus, lowering the intensity of conditioning regimens can decrease high regimen-related toxicities and lessen the number, duration and severity of infections secondary to neutropenia caused by immunosuppression. Coincidentally, this also reduces the associated costs of chemotherapy and radiotherapy and does not appear to result in more complications or further hospital admissions.[8] The hospital also attempted to reduce costs for allogeneic HSCT by using peripheral haematopoietic stem cells instead of bone marrow-derived stem cells. This resulted in faster haematological and immunological reconstitution, easier stem cell harvest and shorter antibiotic treatment courses.[16] By using these strategies, the number of allogeneic transplants in Mexico has increased remarkably in recent years making HSCT a valuable therapeutic tool for patients with malignant and non-malignant haematologic diseases.[16] Given variations in financial burden, discussions on which therapies to make available for certain diseases in middle-income countries may be different to those in high-income countries. In certain circumstances, for diseases such as multiple myeloma, conducting a simplified autologous HSCT may be more affordable than the prolonged use of novel antimyeloma drugs.[11]

ogous HSCT are associated with a greater financial burden. In comparison to conventional chemotherapy, autologous HSCT incurs an incremental cost of 5245 USD per quality-adjusted-life-year (QALY). [8,13] This cost must be borne either by individuals in the form of out-of-pocket expenditure (OOP) or by the government. The WHO Commission for Macroeconomics and Health (CMH) suggests that interventions with an incremental cost less than triple the per capita GDP are considered â&#x20AC;&#x153;cost-effectiveâ&#x20AC;?.[14] India has a per capita GDP of 1805 USD [12]; therefore, using the CMH assessment of cost-effectiveness, this would make HSCT marginally cost-effective (5245 USD per QALY from HSCT vs. 5415 USD as triple per capita GDP). Given uncertainties in epidemiology, clinical effectiveness and costs to the unit health system in India, a sensitivity analysis was conducted to account for ambiguity in parameters and assumptions. This analysis found that the probability for HSCT to be cost-effective at 3-times the GDP per capita threshold was only 59%.[14]. Therefore, improvements in survival with HSCT are likely to be associated with significant expense, which may not be the most cost-effective option in developing countries. Despite coming at a reasonably high cost, it may be possible to considerably reduce OOP expenditures

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A majority of stem cell research remains at the experimental stage, with clinical trials still uncommon.[5] Despite this, there are over 700 clinics estimated to be operating, mostly in developing countries.

Cost of treatment and lack of facilities capable of offering SCT are challenges to the provision of stem cell interventions in developing countries. Financial barriers are frequently listed as reasons why patients would not seek treatment, with inpatient hospital fees and therapeutic drugs as the most expensive components.[8] Consequently, hospitals have derived approaches to reduce costs for patients by increasing government funding, shifting the treatment focus from an inpatient to an outpatient setting and reducing the intensity of nonmyeloablative conditioning regimens. These approaches have reduced a significant proportion of the previously overwhelming costs of HSCT,[8] and have increased accessibility to HSCT treatments. However, other trials have found that by reducing the intensity of conditioning regimens, the associated initial cost savings are offset by the higher costs of later complications and readmission due to transplant rejection.[17] Therefore, international adoption of cost-saving practices requires further investigation.

for HSCT. In Mexico, the GDP per capita is 8902 USD and the median cost for an allogeneic HSCT is 12,504 USD.[8] Based on the approach suggested by the CMH, HSCT is already cost-effective in Mexico (12,504 USD per HSCT vs. 26,706 USD as triple per capita GDP).[8,14] To significantly reduce the burden of costs placed upon individuals and increase accessibility for uninsured patients, a hospital in Northeast Mexico utilised allocated funding from the government to absorb hospitalisation fees and medical team payments.[8] Therefore, patients only had to pay a significantly reduced standard fee of 1200 USD for HSCT.[8] Such OOP expenditures demonstrate the possibility of reducing financial burdens associated with SCT. Furthermore, the primary focus of care was switched from inpatient to outpatient, which resulted in notable cost savings for low-risk patients, without compromising the quality of care and survival rates.[8] For example, 49

Median cost in US dollars


12,504 [8]


124,627 [9]


265,355 [10]


271,375 [11]

Table 1. Cost comparison of all allogeneic HSCT for adults between medical centres in Mexico and developed countries

An alternative solution to maximise the cost-efficiency of HSCT therapy is to restrict the eligible age of patients. In Thailand, it was found that provision of HSCT to severely thalassaemic patients with related or sibling donors was likely to only be cost-effective in patients under 10 years. This was primarily due to an increase in transplant-related complications, mortality and rejection for unmatched donors and older patients.[18] However, this raises ethical and practical issues regarding the implications of restricting certain therapies to individuals under a given age and denying a potentially curative therapy to other populations. A more suitable approach would be for the government to increase funding for HSCT research and establishment of HSCT referral centres. This would diminish the need for patients to relocate to major hospitals, prevent overcrowding and limit the opportunity costs associated with leaving work. Additionally, if adequate preparation for SCTs and rigorous screening procedures for patient risk factors are implemented, this will limit post-HSCT complication rates and thus reduce transplant rejection and readmission fees.[19] Most importantly, HSCT has the potential to completely cure select diseases meaning patients would no longer rely on expensive and life-long drug therapies if HSCT is successful.[18]

these practices.[22] However, unproven interventions are also available in high-income countries including those with historically well-regarded medical systems. For example, in 2011, a German stem cell clinic was shut down over the death of an infant injected with stem cells.[23] Despite very limited evidence for their efficacy, demand for SCT therapies among international patients remains high.[21] The unregulated stem cell industry has compromised the ability of patients to make informed decisions by exploiting vulnerable individuals with little medical knowledge and portraying these therapies as evidence-based cures without appropriate substantiation. It is essential that scientists, academics and clinicians continue to monitor and challenge the availability of unproven interventions, and increase availability of critical information on stem cell interventions to patients.

Medical tourism The direct-to-consumer marketing of unproven stem cell-based interventions has developed into an international industry. Stem cell clinics often make extraordinary and implausible claims regarding the efficacy of SCT.[16] These are typically made without supporting evidence from randomised, controlled and independent clinical trials. Consequentially there are substantial medical risks associated with the use of unproven stem cell interventions including infection, rejection, uncontrolled cell differentiation and death.[20] Unfortunately, there is typically little follow-up with patients once they have left treatment facilities, and as these interventions are unregulated there is no reporting of adverse events. As a result, the extent of complications resulting from these stem cell interventions remains unknown.[21] Furthermore these clinics are typically located in developing countries that lack the regulatory infrastructure to adequately control


Medical tourism associated with unproven stem cell interventions raises ethical, social and public safety concerns. National governments should regulate the SCT industry by monitoring clinics and reviewing the efficacy and safety of therapies offered by such clinics. However, this should be coupled with a coherent international response to promote the regulation of clinical stem cell applications. Such requirements have prompted the International Society of Stem Cell Research, an international non-profit organisation of stem cell scientists, to issue the Guidelines for stem cell research and clinical translation.[24] Important criteria raised in these guidelines include conducting informed consent discussions with individuals who are seeking treatment and explaining to prospective patients that major therapeutic benefits in early phase studies are exceedingly rare, as well as providing additional education materials. While such voluntary guidelines are useful, they lack the political, legal and moral authority that guidelines from major organisations such as the WHO may offer. Hence, adoption of these guidelines by the WHO is highly recommended. If this were to occur, all member states would be required to take the corresponding legislative steps and strengthen national regulatory frameworks for the establishment and monitoring of stem cell clinics.[25] Multiple developing countries have already implemented such regulatory structures. For example, the Thai Medical Council has recommend-

AMSA Journal of Global Health


ed stricter oversight for procedures involving stem cells for conditions other than blood disorders for which HSCT is already a recognised treatment.[24] The WHO can also provide much-needed technical guidance to resource-poor countries and convene expert advisory panels and committees on issues regarding licensing, regulation and proper use of stem cells. Developed countries should also promote collaborative exercises, such as training courses, joint grant-writing initiatives and research partnerships, with the intent to share knowledge and experience. [25] Such strategies should improve public safety and future research to increase evidence-based interventions in the stem cell industry.

World. PLoS Med. 2006;3(9):e381. 4. Lander B, Thorsteinsdottir H, Singer P, Daar A. Harnessing Stem Cells for Health Needs in India. Cell Stem Cell. 2008;3:11-5. 5. Einsiedel E, Adamson H. Stem Cell Tourism and Future Stem Cell Tourists: Policy and Ethical Implications. Dev World Bioeth. 2012;12:35-44. 6. World Health Organisation. Haematopoietic Stem Cell Transplantation [Internet]. International Bulletin [cited 2019 Sep 28]. Available from hsctx/en/ 7. MacReady N. Developing countries court medical tourists. Lancet. 2007;369(9576):1849-50. 8. Jamie-Perez J, Heredia-Salazar A, Cantu-Rodriguez O, Gutierrez-Aguirre H, Villarreal-Villarreal C, Mancias-Guerra C, et al. Cost Structure and Clinical Outcome of a Stem Cell Transplantation Program in a Developing Country: The Experience in Northeast Mexico. The Oncologist. 2015;20:386-92. 9. Blommestein H, Verelst SG, Huijgens PC, Blijlevens N, Cornelissen JJ, Uyl-de Groot CA. Real-world costs of autologous and allogeneic stem cell transplantations for haematological diseases: A multicentre study. Ann Hematol. 2012;91(12):194552. 10. Mayerhoff L, Lehne M, Hickstein T, Salimullah S, Prieur SK, Thomas J, et al. Cost Associated With Hematopoetic Stem Cell Transplantation (HSCT): A Retrospective Claims Data Analysis in Germany. J Comp Eff Res. 2018;21(s3):s36. 11. Broder MS, Quock TP, Chang E, Reddy SR, Agarwal-Hashmi R, Arai S, et al. The Cost of Hematopoietic Stem-Cell Transplantation in the United States. Am Health Drug Benefits. 2017;10(7):366-74. 12. Prinja S, Kaur G, Malhotra P, Jyani G, Ramachandram R, Bahuguma P, et al. Cost-Effectiveness of Autologous Stem Cell Treatment as Compared to Conventional Chemotherapy for Treatment of Multiple Myeloma in India. Indian J Hematol Blood Transfus. 2017;33(1):31-40. 13. Koreth J, Cutler C, Djulbegovic B, Behl R, Schlossman R, Munshi N, et al. High-dose therapy with single autologous transplantation versus chemotherapy for newly diagnosed multiple myeloma: a systematic review and meta-analysis of randomized controlled trials. Biol Blood Marrow Transplant. 2007;13:183–96. 14. Robinson LA, Hammitt JK, Chang AY, Resch S. Understanding and improving the one and three times GDP per capita cost-effectiveness thresholds. Health Policy Plan. 2017;32(1):141-5. 15. Atilla E, Ataca Atilla P, Demirer T. A Review of Myeloablative vs Reduced Intensity/Non-Myeloablative Regimens in Allogeneic Hematopoietic Stem Cell Transplantations. Balkan Med J. 2017;34(1):1–9. 16. Ruiz-Argüelles GJ. Stem cell transplantation procedures are becoming affordable for individuals living in developing (middle income) countries. Acta Haematol. 2016;135:79–80. 17. Abboud MR, Ghanem K, Muwakitt S. Acute lymphoblastic leukemia in low and middle-income countries: Disease characteristics and treatment results. Curr Opin Oncol. 2014:26:650–5. 18. Kasemsup V, Hongeng S, Chaikledkaew U, Leelahavarong P, Lubell Y, Teerawattananon Y. A cost-utility and budget impact analysis of allogeneic hematopoietic stem cell transplan-

Conclusion Due to the economic constraints faced in developing countries, several changes can be made to HSCT to substantially decrease associated costs and increase accessibility. Given that SCT is, in certain circumstances, the only curative treatment for a range of diseases, additional funding for both research and implementation of evidence-based interventions is strongly recommended. To address the issue of stem cell clinics offering unproven therapies to patients, an international regulatory framework should be established. Rose is a third year medical student at the University of New South Wales. Rose is interested in stem cell research in both developed and developing countries Acknowledgements Special thanks to Sophia Moshegov who provided editorial assistance in the writing of this manuscript. Conflicts of interest None declared

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Correspondence Image Maennchen. DNA molecules biology [Internet]. 2015 [cited 26 October 2019]. Available from: References 1. Garcia-Elorriaga G, Rey-Pineda G. Tuberculosis and hematopoietic stem cell transplant: Review of a difficult and often underestimated problem. World J Clin Infect Dis. 2013;4:70-8. 2. Brown C, McKee C, Bakshi S, Walker K, Hakman E, Halassy S, et al.  Mesenchymal stem cells: Cell therapy and regeneration potential. J Tissue Eng Regen Med. 2019;13:1738-55. 3. Greenwood H, Singer P, Downey G, Martin D, Thorsteinsdottir H, Daar A. Regenerative Medicine and the Developing 51

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tation for severe thalassemic patients in Thailand. BMC Health Serv Res. 2010;10:209. 19. Moreno F, Marti J, Palladino M, Lobos P, Gualtieri A, Cacciavillano W. Childhood Neuroblastoma: Incidence and Survival in Argentina. Report from the National Paediatric Cancer Registry, ROHA network 2000-2012. Pediatr Blood Cancer. 2016;8:1-6. 20. Berger I, Bansal A, Kapoor T, Sipp D, Rasko J. Global Distribution of Businesses Marketing Stem Cell-Based Interventions. Cell Stem Cell. 2016;19(2):158-62. 21. McMahon, D. The global industry for unproven stem cell interventions and stem cell tourism. Tissue Eng Regen Med. 2014;11:1–9. 22. Lau D, Ogbogu U, Taylor B, Stafinski T, Menon D, Caulfield T. Stem Cell Clinics Online: The Direct-to-Consumer Portrayal of Stem Cell Medicine. Cell Stem Cell. 2008;3:591–4. 23. Ghavamzadeh A, Alimoghaddam K, Ghaffari F, Derakhshandeh R, Jalali A, Jahani M. Twenty Years of Experience on Stem Cell Transplantation in Iran. Iran Red Crescent Med J. 2013;15(2):93-100 24. International Society for Stem Cell Research. Guidelines for stem cell research and clinical translation [Internet]. [cited 2019 Jun 26]. Available from: 25. Lee T, Lysaght T, Lipworth W, Hendl T, Kerridge I, Munsie M, et al. Regulating the stem cell industry: needs and responsibilities. Bull World Health Organ. 2017;95(9):663-4.



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October 2019

Kai Yuan Tey Teresa Liew Ellis Yee



lobal health has been defined as â&#x20AC;&#x153;health issues that transcend national boundaries and governments and call for actions on the global forces that determine the health of peopleâ&#x20AC;&#x2122;. [1] The call for global health has become the focus of attention over the last decade with an increasing number of medical students undertaking humanitarian aid projects and electives in rural and remote communities in a to gain effort to gain a better understanding of healthcare in low-resource settings. Armed with a greater understanding of the barriers to health access and the challenges associated with health provision in developing countries, future doctors may champion the cry for global health equity and apply their knowledge to improve global health outcomes. Exposure to healthcare in different settings allows medical students to broaden their experiences in various cultures and traditions. These experiences may allow them to provide appropriate care to patients from different backgrounds in a culturally sensitive manner and enable them to be better advocates for health.

To meet these goals, the team went the extra mile to ensure that healthcare provided to the locals was safe and culturally appropriate. The team attended a two-day training course where they learned about the language, culture and common traditions of the villagers. The team also attended a crash course on the common presentations and appropriate pharmacological management, including their indications, side effects and dosages. 3, 2, 1 Action! The team left for Chiang Mai, Thailand on 15th December 2018 and arrived in the S Orphanage, where their accommodation was located, after a 3-hour flight and a 3-hour bus journey. Upon arrival, the team was warmly welcomed by the residents as well as Pastor A, Auntie R, and Auntie M. With their assistance, the team was able to assimilate into the environment very quickly and after a delicious meal prepared by Auntie R, the team immediately went into action â&#x20AC;&#x201C; packing medicines, setting up the clinic and simulating clinic operations to ensure a smooth and efficient clinic the following day.

Project Beyond Borders Project Beyond Borders is a humanitarian aid trip initiated by the Singapore Medical Society of Australia and New Zealand (SMSANZ), which aims to provide sustainable medical relief to people living in rural and remote communities.

Each clinic was attended by approximately 50 patients and prior to the start of each clinic, the team would deliver a public health education session to the locals. This included the prevention and management of common transmissible diseases such as malaria, dengue fever and HIV. The segment was well-received by the locals as they found it engaging and informative.

In December 2018, a team of 16 Singaporean medical students across Australia came together to provide healthcare to the villages around Chiang Mai, Thailand, under the guidance of Dr. M and Dr. E. Background The target population for Project Beyond Borders 2018 were the Lahus villagers from Mae Gong, Pa Sak and Nong Khio villages. These villagers had previously sought refuge in Thailand and were not issued a Thai identification card, preventing them from accessing the local healthcare system. The villagers converse primarily in Lahu, with a minority capable of speaking Thai, which served as a significant barrier to communication. Fortunately, the team included a group of outstanding interpreters who were well-versed in Lahu, Thai and English, allowing for efficient delivery of care.

Every clinic session, which ran from 9.30am to 4.00pm daily, was met by overwhelming demand,

Aims of The Trip Project Beyond Borders aimed to establish a good relationship with local communities of Chiang Mai, Thailand, with the long-term goal of providing 54

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sustainable medical relief, which could be tracked through collection and analyses of quantitative health outcomes, such as blood pressure and blood glucose levels.


dents performed and taught the traditional Lahu dance around the campfire, typically performed for the first seven days of the New Year. The night ended with a sing-along session. A Fulfilling Experience With such an amazing opportunity for learning and self-discovery, the team conducted reflection groups to conclude each day. As Mahatma Gandhi said, “The best way to find yourself is to lose yourself in the service of others.”. This humanitarian aid trip had no doubt been a fulfilling experience for all members of the team – for those in their clinical years, this trip served as a timely reminder of why they chose to pursue Medicine; for those in their pre-clinical years, they were given the opportunity to work in a team to deliver healthcare in a low-resource setting. Overall, this served as a first step towards the path of global health advocacy, and the fuel that would light the passion of service and volunteering in order to achieve global health equity. The Project Beyond Borders 2018 team would like to extend our gratitude to Dr. M, Dr. E, Pastor A and Pastor A’s family who provided guidance throughout this journey. We would also like to thank our fellow team members who worked tirelessly over the past few months to make this project possible. Lastly, we would also like to thank the locals for graciously accepting us into their community, for as it is said, ‘Patients are the best teachers’. Thank you for being part of our medical journey.

with approximately 60 patients each day, commonly presenting with musculoskeletal conditions, viral infections, hypertension, and reflux disease. Clinic operations were run entirely by the team, which included registration, triaging and ushering of patients. Clinical students were also given the chance to run their own consults, taking histories and performing various physical examinations, which were closely supervised by Dr. M and Dr. E. Students would then present their case and management plan to the supervising doctor for approval.

Acknowledgements The Project Beyond Borders 2018 team would like to extend our gratitude to Dr. M, Dr. E, Pastor A and Pastor A’s family who provided guidance throughout this journey. We would also like to thank our fellow team members who worked tirelessly over the past few months to make this project possible. Lastly, we would also like to thank the locals for graciously accepting us into their community, for as it is said, ‘Patients are the best teachers’. Thank you for being part of our medical journey.

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Post-op After each clinic session, the team would pack up and conduct a stocktake to ensure all equipment were accounted for. The team would often find themselves enjoying the company of the residents of the orphanage and a tight bond was formed through playing soccer and exploring various parts of the village together. Despite the language barrier, friendships were forged through daily activities, which was truly heart-warming to witness. At the end of our stay at S Orphanage, the residents prepared a farewell campfire for the team. The resi-

Conflict of Interest None declared Correspondence Image Buffing Q. Child luang prabang laos tribe [Internet]. 2018 [cited 26 October 2019]. Available from: child-luang-prabang-laos-tribe-3532961/

Armed with a greater understanding of the barriers to health access and the challenges associated with health provision in developing countries, future doctors may champion the cry for global health equity.

References 1. Kickbusch I. The need for a European Strategy on Global Health. Scandinavian Journal of Public Health. 2006;34(6):561-5.


AMSA Journal of Global Health

CLINICAL CHALLENGE Presented by AMSA MedEd Chair Samuel Smith1,2



hours, his psychosis worsened, and he was moved to the high dependency unit, and medical opinion requested. The medical registrar confirmed the history and performed a neurological exam. On examination, he was generally confused. There was no muscle wasting, but there was generalised weakness of all four limbs with reduced power and reduced reflexes in the upper and lower limbs. He was generally hypoaesthetic with no sensory modality preference. There was no lateralising lesion to either side, however he noted particular numbness to the soles of his feet. There were no signs of meningism. He was ataxic, but Rombergâ&#x20AC;&#x2122;s sign was negative. Cranial nerve examination was unremarkable, other than his ophthalmic exam. This revealed anisocoria with a right and left pupil size of 2mm and 3mm respectively. There was no reaction to light, however there was prompt constriction to accommodation. Visual acuity was 6/6 in both eyes, and there were no abnormalities of the lids, conjunctiva, iris, and there was no discharge or scleral injection. His visual fields were normal and ocular pressure 20 in both eyes.

M, a 54 year old Aboriginal male, presented to the emergency department of a North Queensland Hospital with increasing agitation, paranoia, and auditory hallucinations. According to family members, this began approximately 2 years prior, though now increasing in frequency and severity. When interviewed, SM reported feeling like an unknown agency was watching him and telling him to do things. There were no bizarre delusions, delusions of control or thought broadcasting. He had recently begun thinking his family were involved in a conspiracy, prompting them to seek medical attention for him. He did not endorse any suicidal ideation and had no plan or intent. His previous medical and surgical history was unremarkable, apart from an unknown infection during a prison stay for assault many years ago, treated with oral antibiotics. He was on no regular medications prior to admission and had no allergies. SM has been a heavy smoker since the age of 16 and drank only a moderate amount of alcohol.

Which of the following tests (or sets of tests) would be most likely to confirm the suspected diagnosis? A. Brain CT-angiogram. B. CSF IgG against GluN1 subunit of the NMDA receptor. C. Treponema palladium serology + CSF TPHA. D. Thyroid function tests + folate/ Vitamin B12 E. MRI brain. F. No further testing in necessary as psychiatric evaluation and diagnosis sufficient.

The provisional diagnosis was an initial presentation of schizophrenia, and he was admitted to the psychiatric ward. However, over the next 24

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On examination, his vital signs were normal. MSE revealed an unkempt man with poverty of speech and spoke in low tones. There were no needle track marks, or smell of alcohol. His affect was restricted, and this was congruent with his mood. He was seen to respond to unseen stimuli and endorsed command auditory hallucinations. His thought content was linear, if difficult to assess, and he had little insight into his condition.


There are several aspects of this case that should prompt the reader to search for alternative diagnoses. The following features suggest organic brain pathology: • • • •

Atypical age of first presentation. Lack of symptoms specific to schizophrenia (bizarre hallucinations, thought broadcasting, etc.). Rapid progression of psychosis upon admission. Neurological signs on examination.

All of these suggest an underlying disorder. The neurological exam suggests a neurological pathology, however the general examination is non-specific: reduced power, reflexes, sensation, etc. which could be any number of diagnoses. However, the ophthalmic exam is most revealing. The combination of small, irregular pupils, absent light reflexes, and intact accommodation reflex (light-near dissociation) is a clinical entity known as the Argyll-Robertson pupil.[1] This strongly suggests the diagnosis of tertiary neurosyphilis. The most appropriate test to diagnose this is testing for Treponema palladium serology + cerebrospinal fluid (CSF) Treponema palladium hemagglutination assay (TPHA), or TPPA, thus the correct answer is C.

In conclusion, this was the case of a 53-year-old male with new, unexplained psychoses. It highlights the importance of a thorough history and neurological examination, and to consider organic (and often treatable) causes of psychiatric symptoms in all patients presenting to mental health units. It also highlights the importance of sexual histories in patients who have been incarcerated, and in different ethnic groups.

This patient contracted syphilis whilst he was incarcerated >20 years ago. He was inadequately treated in prison with an oral antibiotic, when the accepted first line management in Australia is benzathine penicillin 1.8g IMI.[2] As the initial infection spontaneously resolves (and 50% of patients will be entirely asymptomatic), it is common for patients who are not tested to develop latent syphilis. Around one third of untreated patients will develop tertiary syphilis, which most commonly presents as cardiovascular (e.g. aortitis), neurological (e.g. tabes dorsalis) or dermatological (e.g. gumma) disease. Neurosyphilis can take a variety of forms, including psychosis and tabes dorsalis, as seen in this case. The clincher in this case was the Argyll-Robertson pupil, a highly specific sign of neurosyphilis characterised by near-light dissociation and unequal anisocoria.[3] This rare, but specific finding alone should lead the reader to diagnose neurosyphilis. This is supported by his history of incarceration, Aboriginal status in Queensland, and likely organic cause for his psychosis.

Author 1 AMSA Medical Education Committee, Australian Medical Students’ Association, Canberra, Australia 2 Queensland Research Centre for Peripheral Vascular Disease, James Cook University, Townsville, Queensland, Australia. Acknowledgements None Conflicts of interest None declared Correspondence Image Pixabay. Madness psycho fear [Internet]. 2013 [cited 26 October 2019]. Available from: References

In terms of diagnosis, syphilis is typically diagnosed using EIA screening of serology to detect T. palladium IgG, which, if positive, is followed by RPR (Rapid Plasma Reagent) and TPHA (Treponema pallidum Hemaglutination Assay) /TPPA (Treponema pall58

1. Dichter SL, Shubert GS. Argyll Robertson Pupil. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2019. Available from: Accessed September, 2019. 2. Australasian Sexual Health Alliance (ASHA). Australian STI Guidelines. Syphilis. 2018. Available; au/sexually-transmissible-infections/syphilis#management. Accessed September, 2019. 3. Timoney PJ, Breathnach CS. Douglas Argyll Robertson (1837– 1909) and his pupil. Irish J MedSci. 2010;179(1): 119-121. 4. Dalmau J, Lancaster E, Martinez-Hernandez E, Rosenfeld MR, Balice-Gordon R. Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis. Lancet Neurol. 2011;10(1):63– 74. doi:10.1016/S1474-4422(10)70253-2

AMSA Journal of Global Health

idum Particle Agglutination Assay) testing to determine the age of the infection. In this case, testing of the CSF is indicated, which was positive. A brain CT angiogram is not warranted in this case as there is little indication of a vascular pathology (A). NMDA subunit IgG (B) is indicated for NMDA receptor encephalitis. Whilst this is another organise cause for psychosis, this case does not align with the typical history of this disease, with no flu like symptoms 2-4 weeks before the psychotic episode or language symptoms like echopraxia.[4] Whilst hyper and hypothyroidism screening (D) is important to consider in ruling out organic vs. psychiatric disease, this man does not complain of any symptoms suggesting these as potential diagnoses. An MRI (E) would potentially show some signs of cerebral damage in neurosyphilis, it is not the most specific test in this case and should also include the spine to examine for signs of tabes dorsalis. Finally, as discussed, this case has many features suggestive or organic pathology, meaning accepting a psychiatric diagnosis is not appropriate, and potentially disastrous.

Answer key

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