Issue 10 November 2009
The Official Student Publication of the AMSA Global Health Network
Non-communicable diseases edition Stroke and Heart Disease Impacts the Developing World
Global Health Conference 2009
Talking with the Indian Consul General
Medical student experiences from PNG and Cambodia Also inside: Creative stories from the medical profession on global health issues!
issue 10 november 2009 3
What Lurks in the Shadows: noncommunicable disease in the developing world Heart Disease and Stroke Threaten Developing World Tipping the Scales: the ‘expansion’ of the global community Smoking and Tobacco’s Impact on the Developing World: the worlds top health priority A Conversation with the Indian Consul General The Nageri Misiion Mental Health Crisis in China Medicine and Mosquitoes: a medical student’s month in Papua New Guinea Stories from Cambodia
9 10 11 12
14 Global Health In The News
13 the non-communicable diseases edition
Global Health Network Update 15 Welcome to the GHN 15 A Year in the GHN: Looking back and Looking Forwards 16 The Global Health Conference: Challenging the world after Brisbane 17 Global Health Series - University of Sydney 17 Student Involvement - Helping VSAP to help others Creative Pieces 18 The Boy who Jumped off the Bridge 19 Noor 20 at a Glance: India
Kruthika Narayan Vikram Joshi Rami Subhi
he golden arches of McDonalds have become a ubiquitous metaphor for globalisation; previously in the economic sense, but perhaps now as a symbol of the global epidemic of ‘lifestyle’ diseases. There is an inherent irony in that the very symbols of prosperity and growth have become emblems for illness, in the developed world with growing incidence of chronic non-communicable diseases (NCDs). The picture is both similar and different in the less developed world. Instead of representing the dangers of excess, the rampant increase in NCDs in less-developed countries
Added to this are high rates of smoking and the long standing struggle against chronic infections. The World Health Organisation estimates that NCDs, including cardiovascular disease, diabetes, cancer and respiratory diseases, are responsible for over half of all deaths and 46% of the global disease burden. Health issues in the developing world have thus far concentrated on communicable diseases; and rightly so, since many of these are preventable and/or readily treatable. But with the rise of NCDs including HIV/AIDS, an emerging concern about the influence of climate change and the environment on health outcomes, and the appreciation of the economic implications of chronic diseases particularly when compounded with poverty and failing health systems, it is time to promote the complexities of NCDs on the global agenda. In this issue of Vector, we consider the impact of non-communicable diseases in settings least equipped to bear the burden of mortality, morbidity and economic strain they impose. The challenges are immense. The experience of the Western World attests to the difficulty in preventing and treating chronic disease; a difficulty compounded by the resource limitations of low income countries. The multifactorial causes of NCDs require a shift in attitude, not just in local government policies but in the ethics of operation of industries, corporations and nations, and a shift in the perceptions of the global society as a whole.
Non-communicable diseases, with their precursors of high cholesterol, hypertension and obesity, are overwhelming the developing world much faster than the developed reflects the deficiencies of stretched health systems traditionally geared towards relief of acute illness in handling the immense burdens of chronic disease. It also highlights the effects of environmental exploitation limiting access to fresh healthy foods, and the dire struggle of the growing populations of the urban poor for whom chronic disease is yet another force perpetuating the vicious cycle of poverty. Non-communicable diseases, with their precursors of high cholesterol, hypertension and obesity, are overwhelming the developing world much faster than the developed.
Vector: The Official Student Publication of the AMSA Global Health Network
Editors Design & Layout
Catherine Pendrey Kruthika Nayaran Vikram Joshi Rami Subhi Alexander Murphy
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We welcome your written submissions, letters and photos on any global health issue or topic. Please limit submissions to 500 words or less. Cover Photo: The locals in Papua New Guinea // Image by Georgia Ritchie, Medical Student, University of Sydney
non-communicable disease in the developing world Words Fred Hersch, Medical student, University of Sydney
hen we think about the global burden of disease and the plight of the poorest of the poor our minds often turn to the scourge of HIV/AIDS, malaria and tuberculosis - after all, that’s where all the attention is. Yet in the shadows lurks an uneasy truth: the rise of noncommunicable disease (NCD). Historically thought to be a disease of the “developed world”, NCD is in fact a worldwide pandemic of devastating proportions. In 2005 alone there were an estimated 35 million deaths from heart disease, stroke, cancer and other chronic diseases - approximately 50% (17.5 mil-
lion) due to cardiovascular disease(1). Of these, 80% occurred in low- middle- income countries– (LMIC) twice as many deaths as from HIV, malaria and tuberculosis combined(1, 2). Cardiovascular disease (CVD), responsible for 30% of the total deaths worldwide(1)1, is the second leading cause of death in Africa, and the leading cause of death in those aged 30 or older(3). The fastest growing region for CVD is in the African region (27%) and it is estimated that over the next 10 years the burden from NCD will rise by 17% whilst those from communicable diseases will fall by 3% which translates to approximately 28 million deaths due to NCD over that period(1). The consequences of this are profound and far-reaching. Consider this: In contrast to our experience of NCD
1.Tunstall-Pedoe H. Preventing Chronic Diseases. A Vital Investment: WHO Global Report. Geneva: World Health Organization, 2005. pp 200. CHF 30.00. ISBN 92 4 1563001. Also published on http://www.who.int/chp/ chronic_disease_report/en. Int J Epidemiol. 2006 Jul 19. 2.AD Lopez CM, M Ezzati, DT Jamison and CJL Murray, Editors. Global burden of disease and risk factorsnext term, Oxford University Press, New York2006. 3.Gaziano TA. Economic burden and the costeffectiveness of treatment of cardiovascular diseases in Africa. Heart. 2008 Feb;94(2):140-4. 4.Leeder Sea. A Race Against Time: The Challenge of Cardiovascular Disease in Developing Countries (New York: Trustees of Columbia University)2004. 5.Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004 Sep 11-17;364(9438):937-52. 6.Steyn K, Sliwa K, Hawken S, Commerford P, Onen C, Damasceno A, et al. Risk factors associated with myocardial infarction in Africa: the INTERHEART Africa study. Circulation. 2005 Dec 6;112(23):3554-61. 7.Thomas A. Gaziano KSR, Fred Paccaud, Susan Horton, and Vivek Chaturvedi. 2006., editor. "Cardiovascular Disease."2006. 8.Joshi R, Jan S, Wu Y, MacMahon S. Global inequalities in access to cardiovascular health care: our greatest challenge. J Am Coll Cardiol. 2008 Dec 2;52(23):1817-25. 9.Greenberg H, Raymond SU, Leeder SR.
Cardiovascular disease and global health: threat and opportunity. Health Aff (Millwood). 2005 Jan-Jun;Suppl Web Exclusives:W-5-31-W-5-41. 10.Gaziano TA. Reducing the growing burden of cardiovascular disease in the developing world. Health Aff (Millwood). 2007 Jan-Feb;26(1):13-24. 11.Beaglehole R, Ebrahim S, Reddy S, Voute J, Leeder S. Prevention of chronic diseases: a call to action. Lancet. 2007 Dec 22;370(9605):2152-7. 12.Lim SS, Gaziano TA, Gakidou E, Reddy KS, Farzadfar F, Lozano R, et al. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: health effects and costs. Lancet. 2007 Dec 15;370(9604):2054-62. 13.Gaziano TA, Galea G, Reddy KS. Scaling up interventions for chronic disease prevention: the evidence. Lancet. 2007 Dec 8;370(9603):1939-46. 14.Beaglehole R, Epping-Jordan J, Patel V, Chopra M, Ebrahim S, Kidd M, et al. Improving the prevention and management of chronic disease in low-income and middle-income countries: a priority for primary health care. Lancet. 2008 Sep 13;372(9642):940-9. 15.Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and financial costs of strategies to reduce salt intake and control tobacco use. Lancet. 2007 Dec 15;370(9604):2044-53. 16.Gaziano TA, Opie LH, Weinstein MC. Cardiovascular disease prevention with a multidrug regimen in the developing world: a cost-effectiveness analysis. Lancet. 2006 Aug 19;368(9536):679-86.
being a disease of old age, in LMIC, it is often men and women in their most productive years (40‘s and 50‘s) who are most affected(4). On a personal level this is a tragedy for a family struggling for survival. At a societal level this lost productivity further compounds the challenges of economic growth. Inattention, rather than complexity contributes to the lack of action to date. A common set of known risk factors: hypertension, elevated lipids, smoking, obesity, sedentary lifestyles, and diabetes accounts for about 80% of clinical cardiovascular disease in every region of the world(5, 6). As developing countries, particularly those in sub-Saharan Africa move to the next stage of the epidemiological transition greater numbers of people are being exposed to diseaseproducing risk factors (2, 4, 7-11). The challenges are vast yet not insurmountable. We know from our experience that prevention works and there is a growing literature pointing to opportunities for scaling up low cost interventions. Tobacco control measures and dietary interventions can lead to small but significant changes in large groups of people(12-15). Health systems in LMIC traditionally oriented towards communicable disease will require re-orienting to address the chronic nature of NCD(1, 8, 12-14, 16). As we struggle towards goals such as “health for all” it would be nice to think that we can address the challenges of disease in a linear fashion - communicable then non-communicable. The inconvenient truth in all of this is that health, like life, is more complex than that. It is time that we lift the spotlight off to reveal the true picture of the global burden of disease and direct our efforts at addressing the health needs of communities as a whole.
// Image by xymonau (sxc.hu)
What lurks in the shadows:
Heart disease and stroke
threaten developing world Words Stephen R. Leeder and Angela Beaton
eart attack and stroke, thought to be typically western diseases, are fast becoming major threats in developing countries. Four times as many deaths in mothers occur in most developing countries than do childbirth and HIV/AIDS: HIV/AIDS causes three million deaths a year; stroke and heart attack cause 17 million. Yet heart disease and stroke have attracted virtually no interest from international agencies committed to improving global health. It is time for that to change.
Stephen Leeder is a Professor of Public Health and Community Medicine at the University of Sydney and Director of the Menzies Centre for Health Policy. He has a long history of involvement in public health research, educational development and policy. His research interests as a clinical epidemiologist have been mainly asthma and cardiovascular disease. His interest in public health was stimulated by spending 1968 in the highlands of Papua New Guinea. Dr Angela Beaton is a Research Officer at the Menzies Centre for Health Policy.
Developing economies are seeing the kind of devastation to their workforces that Western countries experienced 50 years ago. Troubling as these patterns are, they are but the first rumbles of the storm. The worldwide shift of working people from rural to city living has paralleled rising levels of prosperity and with it, greater consumption of food. A worldwide epidemic of obesity, even where under-nutrition persists in poorer quarters, presages high levels of diabetes, heart disease and stroke ahead. Fortunately, we can prevent and treat much heart disease and stroke. Treatment of raised blood pressure and blood lipids with drugs radically reduces risk and smokers who quit halve their risk of heart disease and stroke within two years. The World Health Organization has shown commendable leadership in relation to global tobacco control and now has its sights set on nutrition and exercise. Governments can assist by taxing tobacco and promoting good lifestyle habits, ensuring that all citizens have easy access to clinics, and plan
healthier cities. Poor urban environments exacerbate physical and mental illnesses, now a major burden of global illness, at the expense of the economies of developing countries and our planet. To wait until heart disease and stroke decimate workforces before we take the global epidemic of heart disease and stroke seriously, would be both a health and economic tragedy. Heart disease and stroke are already propelling families into poverty in developing countries as young breadwinners and mothers die. Many developing countries have yet to create programs to control these diseases through long-term changes in macroeconomic policies, and by providing effective clinical care. Prevention programs must be locally sustainable for an indefinite future, and so developing countries should be encouraged to take the first step themselves, now. There is a responsibility for Australian medical students in advocating for action. Medical professionals have an important role in educating the public and lobbying governments to take up the challenge. Countries need the encouragement that stronger vocal advocacy for change can provide, to prod governments and donors into action, and international aid agencies should add to their agendas efforts to work with developing countries to contain these urgent and heavy threats to global health, national prosperity and family life in the developing world. Commitment from the highest levels of government in these countries is essential for comprehensive heart disease and stroke prevention. It will be important to graduate medical practitioners that have the capacity to deal with the consequences of an increased burden of chronic illness and an ageing population, and to assist communities to help themselves.ďƒ˝
tipping the scales the ‘expansion’ of the global community Words Rhea Pserickis, Medical student, University of Tasmania
looked up from the desk and watched as my next patient walked in through the door. She was a middle-aged obese woman and beads of sweat had formed along her forehead in spite of the cooler weather. It took her a while to shuffle in, navigate the chair and find a comfortable sitting position. I noticed her heavy breathing. This patient was presenting with back and knee pain and had come in hoping for some analgesia. As I continued the consult, I pondered how to broach the fact that her weight was probably contributing to, if not directly causing, her pain. Just another obese patient with more chronic disease. Right? Well, not
quite. The disparity is that this patient wasn’t in Australia nor was she a white Caucasian. I had in fact been working at a mobile clinic in remote Western Kenya, and this was a native Kenyan; more alarming, she was not the first or last obese Kenyan I came across during my time in Africa.
Once considered a problem only in wealthy countries, the number of overweight and obese individuals has escalated in low and middle income countries. As risk factors for cardiovascular disease, type 2 diabetes, stroke and other chronic diseases, the rising prevalence of overweight and obesity in less developed countries is a hallmark of the now increasingly recognised ‘global society’ (1). Furthermore, the morbidity and mortality associated with these chronic diseases are significantly higher
Right: Influences on the energy equation in developing countries (3). Below and facing page: One can appreciate the irony in all this when you see both the malnourished and obese side by side in a Gambian hospital (2).
in less developed countries due to lack of education and understanding, as well as the age-old problem of resource insufficiency. In sub-Saharan Africa case-specific mortality rates for diabetes are more than 10 times higher than in the UK (2). The WHO indicates that globally, greater than 75 percent of women over the age of 30 are now overweight (1). Estimates are similar for men. In the Pacific islands of Nauru and Tonga nine out of every 10 adults are overweight (1). Obesity is even spreading rapidly through many an African countryside, along with its bevy of chronic disease burden which is both devastating and costly (2). Indeed, the existence of obesity and malnourishment within the one community presents an unintelligible paradox (see figure 1) (3). The increase in obesity in developing nations is due to â€˜a global shift in diet towards increased energy, fat, salt and sugar intake, and a trend towards decreased physical activity due to the sedentary nature of modern work and transportation, and
increasing urbanisation.â€™ (1) The developing world is now more than ever a target of many food companies and less developed countries present the largest growth markets for soft drink producers (4). Even where the Global Financial Crisis has tainted the US and European markets, consumption of soft drinks has increased in countries as diverse as Mexico, Egypt and China, encouraged by aggressive marketing campaigns, often aimed at children and youth (4). It is estimated that by 2015, 1.5 billion individuals globally will be
overweight (1). At this point, non-communicable diseases associated with the overweight and obese will surpass malnutrition as the leading cause of death in low-income communities (5). The contribution of chronic disease on the health status of the global community may paint a bleak picture, but it is our responsibility to take action to combat it. And where obesity is such a paradox to concurrent poverty, malnutrition, environmental instability and development, this responsibility becomes even more urgent. ďƒ˝
1.Anon. The World Health Organization warns of the rising threat of heart disease and stroke as overweight and obesity rapidly increase. (Media release). Geneva: September 22 2005. Article retrieved online on September 17 2009 from, http://www.who.int/ mediacentre/news/releases/2005/pr44/en/ 2.Prentice A and Webb F. Obesity admist poverty. Int J Epidemiology. 2006; 35:24-30 3.Witkowski TH. Food Marketing and obesity in developing countries: analysis, ethics and public policy. J Macromarketing. 2007; 27(2):126-137 4.Anon. Soft drinks and obesity: global threats to diet and health. (online article). Retrieved online on September 17 2009 from, http://www.dumpsoda. org/health.pdf 5.Tanumihardjo SA, Anderson C, Kaufer-Horwitz M, Bode L, Emenaker NJ, Haqq AM, Satia JA, Silver HJ and Stadler DD. Poverty, obesity and malnutrition: an international perspective recognising the paradox. J Amer Dietetic Assoc. 2007; 107(11):1966-1972
Smoking and Tobacco’s Impact on the Developing World: The World’s Top Health Priority Words Cam Hollows, Medical student, University of Sydney
“In the 20th century, the tobacco epidemic killed 100 million people worldwide… during the 21st century, it could kill One Billion.” “Reversing this entirely preventable epidemic must now rank as a top priority for public health and for political leaders in every country of the world.” Dr Margaret Chan, WHO Director-General (1)
// Image by Vivekchugh (sxc.hu)
1. Organization WH. WHO Report on the Global Tobacco Epidemic, 2008: the MPOWER package. Geneva: World Health Organization2008 Contract No.: ISBN 9789241596282. 2. The Global Fund to Fight AIDS TaM. The Global Fund to Fight AIDS, Tuberculosis and Malaria: Annual Report 2008. Vernier, Switzerland: The Global Fund to Fight AIDS, Tuberculosis and Malaria2008 2008 Contract No.: 92-9224-163-X (ISBN). 3. UNAIDS. UNAIDS Report on the global AIDS epidemic: 2008. Geneva, Switzerland: UNAIDS2008 August 2008 Contract No.: 978 92 9 173711 6. 4. Organization WH. WHO Report 2009: Global Tuberculosis Control Epidemiology, Strategy, Financing. Geneva, Switzerland: World Health Organization2009 Contract No.: 978 92 4 156380 2. 5. Organization WH. WHO 2008 World Malaria Report. Geneva, Switzerland: World Health Organization2008 Contract No.: 978 92 4 156369 7. 6. Nations TU. The Millennium Development Goals Report 2208. New York, USA: United Nations2008 August 2008 Contract No.: 9789211011739. 7. Chapman S. Public Health Advocacy and Tobacco Control: Making Smoking History. Oxord: Blackwell Books; 2007.
hese statements are on the opening page of the World Health Organization Report on the Global Tobacco Epidemic, 2008. Tobacco use is recognized as harmful throughout the medical profession. The links of smoking with increased incidence of cardio-vascular disease, peripheral vascular disease, respiratory diseases, many cancers, as well as effects on reproductive health (to name but a few) have also been clearly established. Recently, new data have made clear just how harmful smoking is in a global epidemiological sense and the disproportionate impact it has on health in developing countries.
Tobacco use currently kills around 5.4 million people every year. To put this in perspective, in 2005 HIV/AIDS, TB & Malaria (the diseases targeted in Millennium Development Goal 6) killed approximately 4.2 million together (2-6). Whilst I am aware of the dangers of impetus splitting, and I would not for a second want to detract from the importance of programs combating these diseases (particularly having had falciparum malaria myself!), the huge impact of tobacco related disease cannot be ignored. It is estimated that smoking related deaths will rise to as much as 8 million every year by 2030. These mortality data are of course not the full picture and as medical students our own clinical experience should allow us to extrapolate the burden of associate morbidities. We should also pause for thought
as to the resource demands imposed by smoking in already stretched systems. Whilst the individual circumstance is often tragic and coupled with physiological and psychological addiction, the reality is that diseases occurring due to tobacco use are entirely preventable. Tobacco is the only product on the planet which if used according to the manufacturer’s instructions kills half of the people who use it (7). The unfortunate reality for those of us working in global health is that over 80% of smoking related deaths are occurring in the developing world (1). But the burden goes further than the morbidity, mortality and economic impact. For the poor, money spent on tobacco means money not spent on basic necessities such as food, shelter, education and health care. In one study in Bangladesh low-income families were spending as much as ten times on tobacco as they were on their children’s education (1). Given our awareness of the importance of education in health and sustainable development, and the prevalence of extreme poverty, this sort of study should chill us to the very core. In Australia, tobacco control is a public health success story. That our rates of smoking are so low and rates of tobacco related disease are dropping is to be lauded (7). Most other countries in the world are much worse off than we are in terms of what they can spend on tobacco control. Whether we are interested in it or not, the problems of tobacco related illness cannot be ignored; the numbers and impacts are simply too large. So where and when we can, we must remember to add tobacco control to our list of priorities as we try to address the challenges of equitable and sustainable health in the developing world.
any of you may recognise the painting as Van Gogh’s Wheatfields with Crows. Each of you will be struck by some aspect of the painting and form your own impression of it. What if you were then told that this was Van Gogh’s last painting before his suicide? Given this key piece of information, do your perceptions then change? The flying birds perhaps, are crows, harbingers of death; the chaotic landscape a reflection of his inner turmoil. In reality, Wheatfields is not Van Gogh’s last painting. Does this fact once again completely alter the perceptions proceeding from the previous one?
Indian Consul General Words Kruthika Narayan, Medical student, University of Sydney Van Gogh’s Wheatfields was a poignant illustration of how essential pieces of information shape the way we perceive a situation and how these perceptions may not always be correct. As the Consul-General emphasised, this is particularly important in addressing the various issues of international health. It highlights that a health model which works in one developing country situation, may not necessarily be transplanted with equal effectiveness to another. In India, as the Consul-General explained, the diversity in language, culture and
the health interventions implemented by the Government to counter this increase in chronic illness. Recognising that a centralised approach to health policy would be less effective, one strategy has been to empower village councils or ‘Panchayats’, funded by, but not accountable to, the Government. Composed of local villagers and an elected leader, these Panchayats have a better picture of the cultural and social characteristics of a region, and are in a position to know what policies would be most suitable. Another includes the health edu-
customs within states, let alone between them, makes the implementation of health policy a complex issue, requiring a different approach in each region. The burgeoning of chronic disease in India highlights the importance of targeted health intervention programs. According to 2009 WHO statistics, the age–standardised mortality rate for cardiovascular disease is 382/100 000 and studies suggest that chronic diseases, particularly cardiovascular, are fast becoming the main cause of mortality in urban and rural populations. Not to mention diabetes, the prevalence of which was estimated to be greater than 31 million in 2005 and growing. The Consul-General spoke of some of
cation programs, run by the Central Health Education Bureau, focusing on the education of women and children and taking into account the differences in beliefs between regions. These two strategies mentioned by Mr Dasgupta reiterate that approach is the key message. Health interventions need to be tailored and not run as an identical franchise from state to state, or as the Consul General put it, ‘McDonalised’. It comes back to how we interpret the picture of chronic disease in India, or in any country; ensuring the individual characteristics of that particular picture are what shape our perceptions and actions.
This was the eloquent example with which the ConsulGeneral of India, Sydney, Mr Amit Dasgupta, commenced his talk to medical students at the University of Sydney. As part of the Global Health Stream, the Medical Faculty’s international health curriculum, we had the valuable opportunity of speaking with the Consul-General on Thursday 17 September about health issues in India. Prior to his appointment in Sydney, Mr Dasgupta has held various diplomatic positions across the world, from Cairo to Kathmandu. His wide experience is reflected in the numerous books he has edited and written in both fiction and non-fiction. Caught up as we are in the world of medical facts, the Consul-General’s talk was an important eye-opener into the more philosophical issues surrounding health policy.
a conversation with the
The Nageri Mission Words Jennifer Prince, MS Gen Surgery trainee, CMCH Vellore
aving been in Christian Medical College (CMC), a tertiary hospital throughout my training, I entered with a sinking feeling into the Church of South India (CSI) hospital Nageri, located on the Andhra PradeshTamilnadu border in South India. This was a part of a rural service obligation. In contrast to CMC's state-of-the art facilities, the Nageri hospital was a single storied building with a minimum of amenities.. The hospital was located 100km from Chennai, the capital city of the state of Tamilnadu and 70km from Tirupati, one of the large pilgrimage centres of the neighbouring state of Andhra Pradesh. It was a cultural potpourri of the two states yet, development came slowly to this region. The hospital itself was conceived by Dr Fanny Gibbens, a missionary doctor, and begun in the front yard of her house. She was in a land of strangers with just the will to serve the sick. I find it hard to imagine the depth of commitment that step would have asked of her. A new building sprung up as the workload increased and in a few years, the hospital reached the zenith of its development, with long queues of outpatients stretching into the night and inpatients awaiting their turn for admission on the floor between the cots. But with Dr Gibbens' death the hospital joined the ranks of Mission Hospitals started by committed individuals but struggling to remain open. The reasons were many- lack of doctors, paramedical staff, equipment and a committed leadership. And here I was, fresh from Internship, full of hopes, and plans and apprehension. There was a small medical staff at the hospital, including the Medical Superintendent, a Paediatrician, an auxiliary nurse midwife in charge of obstetrics and a senior from medical
school. We catered to a patient profile that varied from those who could not afford a 5 day course of Amoxycillin for their children, to affluent businessmen presenting for follow up between their regular reviews in private city hospitals. As the days passed into months, the other doctors left Nageri and my senior and I were left to care for the hospital. As a primary evaluation centre, the spectrum of cases was wide, from respiratory infections and viruses to the common emergencies of traffic accidents and poisonings. Organophosphorous pesticides were readily available to the farming community of Nageri and were the poison of choice for suicidal attempts. As we did not have access to monitoring equipment like an ECG monitor or a pulse oximeter, or to a ventilator, the patients were given a gastric lavage and atropine. If there was any suggestion of respiratory compromise, the patient would be intubated and taken by relatives to the nearest city. What can I say? It was far from the ideal in my head; some made it and some did not. But occasionally, we were rewarded in the form of a patient who returned for follow up after being on a ventilator for almost a fortnight. We did have a functional Operating Theatre. However, in the absence of an Anaesthetist, most of the surgeries we performed were those that could be done under spinal or local anaesthesia. On some days, the city hospitals would oblige us with the services of an Anaesthetist for more complex cases. As I mentioned earlier, we had a section of patients who were from an affluent background. They often presented with chronic illnesses such as Diabetes Mellitus, Hypertension and Obesity. In fact, infected trophic ulcers constituted one of the most common as well as dreaded complications of poorly controlled Diabetes Mellitus resulting in amputations and numerous visits for wound care. The patients were provided advice on lifestyle modification and were offered the services of the visiting Physician and an Oph-
thalmologist whenever possible. My favourite part was the weekly outreach clinic in a selected village around the hospital, aided by a NonGovernment Organisation. There was a social worker who supervised four female workers, each of whom collected the Health Statistics from areas around the hospital. Regular Medical and Ophthalmology camps were a unique feature of this programme, as well as health education and preventive medicine. We worked towards understanding their beliefs and perceptions on health as well as addressing some superstitions. Notable examples of these included the avoidance of food or water during diarrhoea or that a febrile illness with rash was due to divine visitation. These clinics provided the ideal perspective of a patient's illness, allowing us to see firsthand his or her usual environment, lifestyle and beliefs. I will treasure the friendships that I have with many of the families through these interactions. What did I learn from my experience? That what mattered most was that you did the best you could with the situation rather than looking at the
What can I say? It was far from the ideal in my head; some made it and some did not.
flaws. I learnt not to take resources for granted: indeed the hardest problems were the lack of resources and expertise. Gloves and sutures were hard to come by and are to be used carefully. In the absence of a senior doctor, I learnt to do what I could in a given situation, often performing surgical procedures with an open book for my guide. It did add to my self confidence and I learnt to rely on myself in the absence of supervision. It was also a lesson in administration. I hope to go back to Nageri after my General Surgery training. We have a new administrative team, operations are being scheduled on a regular basis and things are indeed looking up. The Nageri hospital was started with the vision of service to the ailing. What this requires is consistent work, vision and money. Sometimes I question if one person will be able to make a difference. But the reality is that there is often only one person and he/she is the one who makes the difference. ďƒ˝
Mental Health Crisis in China Words Ron Cheung Medical student University of Sydney
// Image by Ringoc2 (sxc.hu)
familiar with local expressions and culture were selected, so they could adapt questions in order for patients to understand.
Seventeen percent (17%) of the population had a form of mental illness (this is 173 million people!). Eleven percent (11%) of men had issues with alcohol abuse: an increasing problem that has thus far not received attention. Of those with mental illness, 25% were so severely disabled by it that they were unable to work. Among all those with mental illness, only 5% have ever seen any mental health professional. Unfortunately, China’s health care system is plagued by systematic issues. There are no mental health services in rural areas. There is a stigma towards mental illness and even though people
realize they have it, they refuse to seek treatment. There is a lack of knowledge - 60% of people interviewed had never heard of the word depression, even though they had full blown symptoms. In China, GP’s do not offer mental health services, only large psychiatric wards in large hospitals do so. It is not seen as part of a GP’s duties to address mental health. Closing the gap in mental illness and services in China is challenging. The culture of medicine will need to be changed: barriers will need to be overcome, medical school curriculums redeveloped, effective reimbursement patterns in hospitals introduced, and the makeup of the health care workforce that includes a consideration of the mental health agenda.
ental health is a substantially underestimated problem in China. In a four province study, 63 000 people were screened in random urban and rural sites. A trained psychiatric nurse screened-out those at high risk of mental illness, or those with a pre-existing diagnosis of a severe mental illness. Those at moderate to low risk were administered a Chinese version of the Structured Clinical Interview for (DSM)-IV axis I disorders by a psychiatrist. Importantly, clinicians who spoke the local dialect and were
was fortunate enough to spend a month of my Christmas holidays in Papua New Guinea (PNG). The people of PNG have the lowest health status in the Pacific region. Despite this, life in PNG is full and the people embrace it with all their might. I was welcomed with huge smiles and all around kindness. I was often invited back into people’s homes to meet their families and be shown their village life.
MEDICINE and MOS QU I TOE S a medical student’s month in papua new guinea
Words and Photos Georgia Ritchie Medical student University of Sydney
One particular day in the town of Goroka, I was invited to a Christmas party by the surgical team. For Christmas the staff often prepare a ‘mumu’, a traditional way of cooking in PNG where a whole pig or goat is killed, wrapped in banana leaves and cooked in the ground with hot rocks. For this Christmas party they had decided that they would prepare a pig for the mumu. So they brought the pig to the hospital, where it waited on the first floor balcony until they could kill it and prepare the mumu. The pig, however, had other ideas and was last seen running frantically around the hospital grounds followed closely by the entire theatre staff, leaving an empty theatre and a rather bewildered looking surgeon. I was later informed that pigs are highly valued in PNG and are a symbol of wealth and social standing. In fact they
are so important that women will often breastfeed the piglets when they are born. Now after they had caught the pig and it was prepared for the mumu I sat down with the theatre staff and surgical team to enjoy the feast. However, this was not for long as the surgical resident and myself were called to emergency to assess a patient. Having been in PNG for over 3 weeks I was not easily shocked by anything I saw, but this still did shock me! On entering the ED I was directed to a young man sitting on the edge of a bed with three arrows protruding from his body. He had been shot four times in total; the first arrow was in the ninth intercostal space on the left, the second entered the superficial tissue on his right flank, the third was embedded in his groin and the fourth he had removed himself from his right triceps. Despite
the wounds, he sat perfectly still and appeared not to be in any pain. Despite much effort the radiographer at the hospital could not be contacted that evening so the young man had to wait until morning for his X-rays and surgery to remove the arrows. This meant he had to sleep on his front with three arrows protruding form his body! When he eventually went to surgery, it was found that the arrow entering the chest had passed through the spleen, the duodenum and the transverse colon. After 7 hours of surgery, the arrow was removed, the spleen saved and the puncture wounds to the bowls closed and he was sent to the ward for recovery. I have a story about each day I spent in PNG. Whether it is about the amazing people I met or the interesting medical cases I saw, I was constantly in awe of the country. Although at times a hard place to comprehend, I feel that I understood by the end of my trip and fell in love with the PNG, its culture and the people.
Behind these smiles are stories of great sadness and tragedy
uring my summer holidays last year, I spent a few weeks volunteering at an orphanage and medical clinic in rural Cambodia in a town called Neak Leung on the banks of the Mekong River. Cambodia has some of the worst health statistics in the world – 1 in 7 children will die before the age of 5.
from the photos, the children here are all smiles, but behind these smiles are stories of great sadness and tragedy. Some of the children in the permanent centre had been sold into child prostitution and child labour in Thailand’s notorious Pattaya district before they were rescued, some are AIDS orphans, some are mentally or physically handicapped and thus abandoned by their families who cannot afford to take care of them, and others were the victims of domestic violence. The medical clinic here provides a vital service for the rural poor. The government healthcare system is expensive ($20 US for a consultation) and underresourced. The poor, many of whom earn less than $1 a day, simply cannot afford it. In contrast, the medical clinic costs 12 cents (including medication). People would travel several hours to receive affordable medical care. I also spent much of my time doing social work in the
community. One day we went to followup a child who hadn’t been turning up to school, which surprised us because he loved going to school and hadn’t missed a day. When we arrived at his home we discovered that his older brother had died of AIDS, and now he had to stay at home to take care of his younger brother. Stories like his are a prime example of the “cycle of poverty” – now he is likely to miss out on the opportunity of education. Living with a local family, I was able to immerse myself in the language and culture of the Khmer people. Having fallen in love with the people of Cambodia, I will be returning this year to Damnok Toek.
The charity I visited was called Damnok Toek, which means ‘a drop of water’ in Khmer. Ironic, given that the area is surrounded by flooded rice paddy fields, and the houses are built up on stilts to avoid the floodwaters during rainy season. Damnok Toek houses 60 orphans, provides schooling for a further 150 children and has a social work program and medical clinic. As you can see
Words and Photos Nilru Vitharana Medical student, University of Sydney
global health in the news Copenhagen Climate Change Summit will be held in December 2009. For the health impacts of climate change, refer to the editorial published by the Lancet and BMJ and University College London in September 2009. http://en.cop15.dk
World Diabetes Day 14th November 2009 WHO estimates that more than 180 million people worldwide have diabetes, according to 2005 figures. This number is likely to more than double by 2030 without intervention. Almost 80% of diabetes deaths occur in low and middle-income countries. www.worlddiabetesday.org
A trial of a vaccine to prevent infection by HIV involving 16,000 participants in Thailand this year has shown modest results with 26% reduction in rates of infection compared to placebo controls. Refer to the October 20th 2009 issue of the New England Journal of Medicine.
Indonesia’s official death toll stands at 650, with a 672 people missing, following the devastation of the recent earthquake. Damage to roads, disruption to electrical power and sources of clean water could make the situation much worse in the coming weeks. There is similar concern in Samoa about the spread of infectious diseases, such as causes of acute watery diarrhoea, typhoid fever and dengue fever following the Tsunami.
PNG’s Liquid Nitrogen Gas (LNG) Project will officially open in 2010, is expected to double the country’s GDP, and will have a profound impact on trade and health in the Pacific region. Refer to a series by Jo Chandler of The Age published September this year.
2nd November 2009 commemorates renewed efforts to promote pneumonia on the global health agenda by 2011. Wear blue jeans on the 2nd of November (signifying the 2 million deaths of children every year due to pneumonia) and support this cause. www.worldpneumoniaday.org
global health network update
A Year in the GHN: Looking back and looking forwards
Welcome to the GHN Trung Nghia Ton WakeUp! GHN Officer, University of Newcastle AMSA GHN Chair 2009 - 2010 With much enthusiasm, the newly elected GHN committee for 09/10 are getting right onto the task. Realising this year’s GHN National project, the South East Asian Libraries Project, will be a challenging undertaking but with the experience and motivation of each global health group (GHG) we hope to exploit the growing momentum and make a longstanding impact by helping our fellow medicos in the developing world (watch this space!). We also hope to strengthen our collective voices and to bring truly pressing global health advocacy issues to the fore in our chosen active advocacy campaigns, especially in regards to the crucial Millennium Development Goals, and the treatment of refugees and asylum seekers. The GHN remains an avenue for medical students to bring ideas, issues and action to a national level, but it is vitally important for us all to look at developing our own Global Health Groups (GHG) and individual initiatives – there are so many opportunities available to bring grass roots ideas and projects to fruition and collaborate on a local, regional and national level. I invite you all to become active members of your local GHG as they grow into dynamic student organisations. It is incredibly exciting to see the initiatives of GHGs around the country in 09/10 and I look forward to working with an exceptional and motivated GHN Committee and witness medical students making a real difference in our global community.
As the outgoing Chair of the Global Health Network (GHN), I am delighted to report on our successful year of global health group development and support; our wildly successful National Project, the Red Party, which raised over $88 022 for HIV/AIDS support and research; and our advocacy working party, which developed the Millennium Development Goals policy that in February became AMSA’s first-ever global health-based policy document. It’s been a great year for medical students in global health, with new and exciting work happening in global health groups, in the GHN, at GHC09, and at AMSA level. It has been my privilege to serve as GHN Chair during the last twelve months. Along with the other outgoing GHN Representatives and officers, I am delighted to be handing over the reigns to a new committee, as I know Trung and his team will be dedicated and enthusiastic in promoting and supporting global health activities around Australia. And, looking back on the various global health events of the past year, I look forward to seeing what the next twelve months will bring.
A very warm welcome to you all on behalf of the AMSA Global Health Network Committee! This issue of Vector marks the start of yet another Global Health Calendar year (kicked off by a truly rousing Global Health Conference in Brisbane). We look forward to adding to the monumental efforts of the GHN Committee of 08/09 who have worked tirelessly to bring together students from all over the country to collaborate in common interests in global health awareness and action. This culminated in the very first GHN National project, the Red Party concept, which raised national funds and awareness for HIV/AIDS, and was a huge success. This is a tangible example of how our efforts at a local level can be part of a global impact. Additionally, The GHN began its first national advocacy movements, further highlighting the GHN’s increasing ability to inform, represent and advocate for medical students in matters of global health. I would like to extend heartfelt congratulations and thanks to the outgoing GHN Committee for their successes this last 12 months. It is without a doubt that their efforts have made a real and tangible difference, and has set up a national framework for us to continue to grow and mature as an organisation. Their efforts continue to reflect on the new committee as they mentor us through a very steep learning curve.
Tamara Vu AMSA GHN Chair 2008-09
The Global Health Conference: Challenging the world after Brisbane
Meg Scott Deputy Convenor GHC 2009
As I think back over the 4 days of the Global Health Conference 2009 (GHC), certain events and lessons I learned remind me to do more with my life and challenge my world! Our biggest achievement, the event we put the most blood, sweat and tears into was challenge day. The 10 station, half-day workshop challenged the delegates to work through various situations one might come up against in an overseas medical aid situation. Delegates planned a refugee camp and were marked on the appropriateness of their toilet selection, as well as deciding how many farms they would have. Groups got to try talking their way into a prisoner of war camp past cheeky guards, and the guards were also marked on their ability to stick to their guns. The triage station allowed the clinical years delegates to shine, using their ability to interpret vital signs to save many a paper doll life. We made nutritional food packs, delivered babies (and placentas) in emergency situations, learned about the difficulties in communicating with non-English speaking patients, allocated sparse resources to those who needed it the most, and perhaps most importantly, enjoyed the Brisbane sunshine! The inspiring opening plenary from Dr. Sujit taught me a couple of things. One, if you want to add prestige to a product, print the label in English; if the people can’t read it, they’ll want it more. Two, having nothing is no excuse; start where you are and the financial support will come. There is no reason why one person can’t start making
a difference in the community. Personally, I was amazed at how easy Dr. Sujit made it all sound! Starting at a farm, negotiating the use of a barn for a clinic, to shortly thereafter running numerous hospitals and schools! He definitely challenged my idea that one needs money to make a difference. Tania Major continued the unintended theme to get out there and start doing, with her challenging Australians’ attitudes towards the Indigenous population. She spoke of her work increasing awareness of Indigenous issues, which she has been doing for the majority of her life. She reminded us that whether Indigenous or non-Indigenous, we are all Australian, and we must look after our own. We all know of the 17 year age gap between the two populations, and the barriers towards proper healthcare for those in remote communities are not new. Tania showed us that grassroots action is vital in making a change. As Tania so eloquently stated, “just fucking do it!” Carolyn Hardy showed us what has been done so far in combating HIV/AIDS, and we are sadly nowhere near meeting the Millennium Development Goal. Again we were shown how to challenge the problems in bringing healthcare to those who need it, and how to overcome these obstacles. Carolyn spoke of the potential for conducting HIV tests remotely via mobile phone and picture texts! With unbelievable solutions like this in the works, I was reminded to look outside the box for solutions to decade-old problems. Dr. Nick Coatsworth gave me wanderlust
recounting his missions with MSF to such places as Darfur and the Sudan. He also spoke of getting in there and working at a grassroots level and somehow managed to make immunising hundreds of children a day for 4 weeks straight sound exciting! He’s definitely an inspiration for all medical students, showing us that it is possible to have a life, train in a specialty and work overseas all at once. Gabi Hollows, on behalf of the Fred Hollows Foundation (FHF), taught us that enthusiasm is enough; that having passion for a cause will make things happen. She also reminded us of the need for medical aid in Australia. Sure, while the FHF now have clinics and factories all over the world, Fred Hollows’ work started in rural/remote Australia, and Gabi reminded us we cannot overlook our own country. Also, what struck me from the Fred Hollows story was that one persons’ passion and hard work can continue indefinitely. After all that energy spent learning and inspiring, I wouldn’t have thought anyone had enough energy for a party, but boy, was I wrong! Perhaps the memory burned into my mind the most was the monkey dancing with the genie, or was it seeing 2 sumo wrestlers trying to get onto a bus? Check out the pictures on our website to decide for yourself… Thank you everyone for coming to Brisbane, for participating so fully in the program (both day and night!), and for challenging yourself and your peers to do more and be more. I look forward to seeing you in Hobart for GHC 2010 and hearing about how you have challenged your world this year. Left: The GHC is a ‘hands-on’ event. Far left and above left: Dr Sujit inspires the audience to make a difference. Images: www.amsa.org.au/ghc09
Helping VSAP to help others
What is VSAP?
The Victorian Students’ Aid Program (VSAP) is a student initiative run by medical students at the University of Melbourne, which delivers much needed equipment and health resources to disadvantaged communities globally. Our vision is that all doctors worldwide will have essential medical supplies and equipment to treat their patients. Recently, VSAP has elected to broaden its scope and fulfil the role of being the University of Melbourne’s global health group. This financial year we will be taking on additional projects as well as expanding into the areas of education and advocacy. Check out our website for more information on: our Teddy Bear Hospital community project, our Global Health Short Course being held in collaboration with the Nossal Institute for Global Health, and our Red Party fundraising event that raises money for HIV/AIDS research and awareness. One of our main, ongoing projects is the Wishlist Project.
What is the Wishlist Project?
The Wishlist Project aims to contribute to global health equity by sending targeted aid to hospitals in poorly resourced areas via medical students completing their elective placements there. To ensure that we are supplying appropriate and effective equipment, the hospitals are asked to compile a ‘wishlist’ of the sup-
plies and equipment that they require. VSAP works with hospitals and medical suppliers in Australia to fulfil these wishlists and these donations are delivered with the medical student when they leave for their elective placement. Since its inception in 2005, VSAP has delivered over $30000 worth of equipment and monetary donations to countries as diverse as Guatemala, Tanzania, East Timor and Vietnam.
How can you be involved?
Student involvement – Helping VSAP to help others We are always looking for travelling students who can deliver donated supplies to areas where health care professionals are in need of medical supplies. We are also looking for students to get involved in our various projects. Please contact us by email.
institutions have been the main contributors of equipment particularly when they reorganise, close down, have excess supplies, or upgrade. VSAP is also responsible for the logistics of delivering donated supplies to destination hospitals. Assistance with airfreight, packaging, and transport would also be very welcome. We are always looking for sponsors of medical equipment and supplies. If you would like to donate, please contact us by email.
General enquiries: email@example.com Sponsorship enquiries: firstname.lastname@example.org For more information, visit http://www. vsap.org.au
Equipment and financial contributions for Wishlists VSAP relies on the generosity of sponsors to obtain equipment to send to underresourced communities. In the past, health
Right: Sanka Amadoru delivering supplies to Kibosho Hospital, Tanzania. Far right: Alexandra Bryson using a donated anaesthetic machine, Papua New Guinea
Global Health Lecture Series - The University of Sydney Nilru Vitharana, Acting Chair, USyd GlobalHOME [Global Health Group]
indigenous health. This series will equip students with the necessary clinical and public health skills to understand global health issues that they may encounter whilst on elective or in their future careers. The lecture series will feature case studies, scenarios, interactive discussion and is designed to appeal to students from across all years of the medical program. The lectures will be held on Tuesday evenings in March and May. Students from other universities are most welcome to attend. Please sign up to our Yahoo Group (http:// groups.yahoo.com/group/globalhome/) to join our mailing list and keep up to date with details of our lecture series.
After attending the Global Health Conference, students from globalHOME (Sydney University’s global health group) were inspired to educate their fellow students about global health by developing a lecture series to improve the global health awareness and skills of medical students. The 8-part lecture series will be delivered by leading experts in the field, from doctors, public health personnel, and NGOs. The topics to be covered include: aid and poverty, healthcare in conflict settings, emergency response to natural disasters, tropical infectious diseases, climate change and its impact on health, malnutrition and
It was in the news. He jumped off the bridge last qweek. He died.” My old school friend told me in tears on the phone. The sunlight is so bright. I sit, feeling a little nauseous. In that country, it is the coldest time of the year. Did he drown or freeze to death?
“Does anyone know why he killed himself?” We used to go to the same primary school. We were in the same class although he was 3 years older than the rest of the class. Kids used to laugh at him, because his legs looked funny. He had poliomyelitis. He would never catch anyone after being teased. It would only cause more laughs. And he walked in the most awkward way, too. “They said he was a psycho, he went to see a shrink a few times.” The last time I heard about him was last year. He published an article on a famous magazine, named “A sad river”. I can just remember the words he used in that book. That unbearable sense of sorrow floods my heart even now. “Was he depressed?” He never really spoke to anyone. I supposed we were all immature and didn’t want to hang out with a kid who couldn’t play with us. He dropped out of school after high school. It was simply too far away. His parents couldn’t afford anything after paying for his expensive medications. “Depression. Emm… Maybe. But it is not a problem for poor people. People have enough trouble paying for food, it’s not at the top of their agenda.” It is true. Who would pay money to see a psychologist when that same money was enough for a month’s worth of food. He didn’t have a job as far as I know. So many people who had good legs were still unemployed.
The boy who
jumped off the
Words Mengying Su Medical student, University of Tasmania
// Image by OmirOnia (sxc.hu)
“Couldn’t he apply for government support?” “The government? Are you kidding? I don’t think it is rich enough to look after everyone here. The hospital wouldn’t treat anyone who can’t pay the bill up front.”
Outside the window, children walk across the street after school. They are young, healthy and happy. Just like how we were like. I feel sorry for that boy. I wonder if it would be any different if we were young today or if he lived somewhere else.
his morning, with thanks to the Australian Cricket Team, morale seems particularly high in Michael's Care Home, New Delhi. The staff and clients of the AIDS hospice and mini hospital, squash up on the old cast iron beds of the main ward and watch Australia (32 for 3) squirm live on TV.
The details of how Noor went from staff member at the men's rehab centre to patient at Michael's Care Home are foggy. It happened around Christmas time. Alcohol was involved. A fall. Brain haemorrhage. Emergency surgery.
of in India, has someone with him 24 hours a day. One of the volunteers, a handsome and talented soccer player (also, along with his brother, a refugee from Iran and witness to his own father's execution) sits with his patient by night. He speaks in Persian to Noor and translates what little anyone can offer in encouragement. Another, onetime street child, shaves Noor with gentleness that cuts directly to the heart. And still another, stands beside me this morning, bashfully holding a clean piece of paper on which his recently written letter of reference is printed. We read together slowly. 'Mr. Satish, 27 years old has been working with us as a care worker from 2003–present. He is diligent, committed and his performance is satisfactory in every way ... We wish him every success in future undertakings ...' It is signed by Sahara 's Director of Medicine. His hard yards in heroin rehab and then as a volunteer care worker are coming to an end and he has applied for a job in a hospital outside Michael's Care Home. He plans to continue to live at Sahara and help out where he can around the hospice, caring for people such as Noor, but build a life and a career in the world outside also. In mixed Hindi and English. 'I just like to care for people.' I feel the heat of tears rising. Satish has never had a letter of reference before. His job interview is at 10am tomorrow morning. No doubt he'll be sighted in a borrowed shirt and freshly pressed pants, reference in hand. The Cricket score is Australia 155 for 5. A roar erupts throughout Michael's Care Home. Noor is sleeping.
NOOR Now a piece of his skull is missing and a thick line of cable stitching closes the place where his brain was exposed. His long black hair is shorn and the jagged greying crop makes him look vulnerable as a lamb. Occasionally his eyes respond to words. The care workers have been trying to help him walk. At night he sits up and mutters a little in his first language. The rest of the time his hands are bandaged to the bed sides and he sleeps. They tell me he needs further surgery, but for now, rest and healing. Michael's Care Home first came into being in 1998 to care for those marginalised by addiction and ostracised from society by HIV. Public hospitals in Delhi, were too scared to touch them. So were their families. So, rather than let people die on the path outside the emergency departments (as was happening) Michael's Care Home was born. There still aren't many family visitors to Michael's Care Home. Blood relatives don't cook special convalescent cuisine or send cards. But a care force has been formed to look after Noor. Sporting tattoos and track marks and the signature Sahara combed hair and worn but washed clothes, they take turns at occupying the uncomfortable plastic chair at Noor's bedside, by day and night, anticipating his every need. His meals are prepared by an exclient of the rehab centre (now the hospice cook) and spoon fed to him by a team of young men (all ex-injecting drug users) who, having completed some or all of their own rehabilitation, have volunteered to be with Noor in his. Noor, with no family to speak
'The world is full of suffering, it is also full of overcoming it.' –Hellen Keller Cara is a registered Division 1 nurse who undertook the PHC Jamkhed Course with the University of Melbourne in 2005. She has since lived and worked in India in the area of HIV / Aids, heroin rehabilitation and Public Health and in the process of writing about many of these experiences.
Between overs, one of the care workers disentangles himself from the jubilant add break highlights recap, and bounds up to me with a piece of paper in his hand. The paper, though of creamy, freshly minted quality, is already softening along the fold, a sign of being read and re-read many times over. We stand next to the bed of Noor, the patient who I came today to visit, and share the contents of the page. On this day of victory, its contents make me cry. Before that though, let me tell you about Noor. Noor is about 45. Tall. Muscled. My earliest memory of Noor is in the kitchen of 'Sahara', the heroin rehabilitation centre to which Michael's Care Home is attached. Long hair in a ponytail, white singlet with sweat crescents under the arms. Hoisting kilo upon kilo of rice or hovering above the perpetual dhal pot, bini (local cigarette) smoke trailing from his lips as he tossed in onions. A tomato. He ran a slick kitchen. Vital, sunnywindowed place. The sort of kitchen you feel drawn to. I remember leaning against the bench top, sipping water and listening to Phantom of The Opera on his radio in one ear and instalments from his 15 year saga with the Afghani Embassy in the other. Noor was an Albanian refugee, somehow made it through Afghanistan to India where he wound up in heroin rehab. Despite the smallness of the Sahara kitchen, Noor never shooed me away. He churned out three meals a day for all present at mealtime, the aroma of his cooking as reliable as the sun. Brown and ambiguous, we made jokes about 'The Noor Curry' then.
Words Cara Munro
at a glance india
India has had significant economic growth in the past decade from which the general health of the population has benefitted in many ways. The following summarises many of the facts regarding health in the world’s second most populous nation.
// Image by asifthebes (sxc.hu)
Target by 2015
Proportion of population below poverty line
Proportion of population undernourished as whole
Proportion of children undernourished
Under five mortality rate (per 1000 births)
Maternal Mortality Rate (per 100 000 births)
Deaths due to AIDS
Arrest the spread of HIV. The estimated adult prevalence of AIDS in 2007 was 0.3%
Deaths due to TB (per 100 000)
Reverse the number of deaths due to TB
Deaths due to Malaria (per 100 000)
Reverse the number of deaths due to malaria
Healthcare investment (proportion of GDP)
Approximately 3% (1990)
Approximately 5% (2000)
Ischaemic Heart Disease
Most Recent Date
Adapted From: Government of India. (2005). Millennium Development Goals India Country Report 2005. New Delhi: India. Indian Council of Medical Research. (2005). Assessment of Burden of Non-Communicable Diseases. Ansari Nagar: India.
Rural Weighted average prevalence /1000 (+20y.o.)
As of 2004, India had: • 503 900 doctors • 737 000 nurses • 350 000 chemists • 15 000 hospitals India has a three tiered healthcare system with 23 000 Primary Healthcare Centres (urban), 137 000 subcentres (semi-urban and rural) and 3000 community health care centres.
Increased economic growth is expected to reflect a greater investment in health care
Urban Weighted average prevalence /1000 (+20y.o.)
Total Number of entire population affected
// Image by barunpatro (sxc.hu)
18 600 984 (1998) 22 367 840 (2004)
Expected to be single greatest cause of mortality in India by 2015.
792 628 (1998) 930 985 (2004)
Total number of DALYS attributable to stroke approximately 6.37 million in 2004
37 768 402 (2004)
Rates of diabetes incidence are expected to increase significantly within the next two decades Total contribution of hypertension in combination with other risk factors, as it occurs, would prove worse outcomes than shown here.