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The Official Journal of AMSA Global Health

CULTURE & HEALTH

Reflections from a Rwandan Refugee & Australian Medical Student

Vol 10

ALSO IN THIS ISSUE A Global Approach to Combating Antibiotic Resistance Non-Communicable Diseases in Africa War on the Female Body: Rape and Sexual Violence during Conflict vector journal

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Editor’s Note

Contents Culture and Health: Reflections from a Rwandan Refugee and Australian Medical Student................................................................4 A Global Approach to Combating Antibiotic Resistance.............10 Non-Communicable Diseases in Kenya.........................................16 Multidisciplinary Health Practice for Indigenous Communities......................................................................................22 War on the Female Body: Rape and Sexual Violence during Conflict................................................................................................27 Keeping the Promise: A Review of the Millennium Development Goals....................................................................................................33 An update on HIV Technology: What’s the latest? Are we far from a cure?........................................................................................38 Professor Hilleman: The Man Behind Half of our Vaccines........43 The Australian Delegation’s Experience at the East Asian Medical Students’ Conference (EAMSC) 2015.............................................45 Don’t Trade Our Health Away: Reflections from a Workshop on Trade and Health................................................................................49 Global Health Group Spotlight........................................................52 Bonus Insert: Australian Refugee and Asylum Seeker Policy

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Welcome to Issue 17 of Vector Journal! 2015 has been a year of growth and change for Vector thus far. Our efforts have focused on helping Vector to evolve into a reliable and professional academic journal. I’m proud to say that for the first time in Vector’s history, all of our review articles are peer-reviewed. I believe this added review process, as well as the hard work of our authors and input from our talented associated editors, has been a positive step towards our latest vision for Vector. This year, Vector has accepted articles on topics that authors want to write about and care about. We have also streamlined our guidelines with the Australian Medical Student Journal, which has allowed authors to choose the style of articles they wish to produce. Naturally, Issue 17 has developed into an exciting and colourful depiction of the global health topics that matter to medical students. Some articles provide up-to-date reviews on topical issues, for instance Joyce Shi’s article on non-communicable diseases in Africa; Aaron Kovac’s review of the Millennium Development Goals; and Hayleigh Chiang and Rukaiya Malik’s discussions on the quest for HIV treatments and cures. Finally, don’t miss the insert from AMSA for Refugee and Asylum Seeker Mental Health (AFRAM) at the end of the issue which contains various expert opinions on Australia’s refugee and asylum seeker policies. Other articles are an attempt to bring to the fore largely forgotten, albeit important, global health issues including Swetha Prabhakaran’s article on antibiotic resistance, and Carrie Lee’s article on gender-based violence against women during times of war and conflict. Furthermore, Samuel Ognensis has created a touching news article to pay tribute to the late Professor Maurice Hilleman who created some of the most important vaccines that we largely take for granted. Several of our articles have also enabled medical students to present their unique views and experiences. Emmanunel Ndayisaba’s feature article, which provides invaluable insights that we can all take away now and into the future to improve the care we provide to patients of culturally and linguistically

diverse backgrounds. In addition, Ayesha Aziz, Hadrian Pranjoto, Mingkun Guan and Rahul Rane have presented their multidisciplinary views when approaching the central topic of primary healthcare for Indigenous communities. Other personal experiences are presented in post-conference reports from the East Asian Medical Students’ Conference and International Federation of Medical Students’ Association General Assembly, which we hope will inspire medical students to get involved in these and other great opportunities in global health. Although much of Vector has changed in 2015, there are some Vector traditions we have maintained – the Global Health Group (GHG) Spotlight. In this issue, Stormie De Groot, the current AMSA Global Health Representative for ASPIRE at the University of New England, has shared the unique challenges and successes of their rural GHG. The accomplishments of ASPIRE are truly inspiring given the restraints brought about by their location. We hope that the GHG spotlight will continue to bring a finale to Vector Journal that grounds us and reminds us of the endless opportunities to be directly involved in global health, day-to-day. I would like to thank our authors who have worked tirelessly on their articles and congratulate them on the quality of work they have produced. I also express by sincerest gratitude to the Associate Editors, Infographic Designer and Design and IT officer. I will always treasure the opportunity I’ve had to work with this hard-working and talented group of medical students. Furthermore, I thank AMSA Global Health for their endless support in providing the resource and opportunities for Vector to grow. Finally, I would like to thank our readers, old and new, without whom Vector wouldn’t be worth creating. I truly hope our current issue brings all that you had hoped for and more.

Jackie Hara-Crockford Editor-in-Chief, Vector Journal

Associate Editors

Infographic Designer

Designer & IT Officer

Aurora Killey Faye Liu Freya Berenyi Nicolas Soputro Rose Brazilek Ross Penninkilampi Rukaiya Malik

Rebecca Kelly

Aryan Firouzbakht

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Feature Article

Culture and Health: Reflections from a Rwandan Refugee and Australian Medical Student Emmanuel Ndayisaba

About the author Emmanuel Ndayisaba was born in Rwanda. In 1994 during the genocide he became a refugee in different East African countries. In 2011, Emmanuel’s family was resettled to Australia through the offshore humanitarian refugee program. After completing a Bachelor of Health Science at Adelaide University, he was admitted to the post-graduate medical program at the University of Notre Dame Sydney, class of 2018. Having lived as a refugee all his life, he closely observed the issues related to health inequity and how they affect communities and individuals. Today, as a medical student in Australia, he sees himself as having a duty to give back to marginalised communities, like the ones in which he grew up. He advocates for refugee health and wellbeing through education of the Australian community and believes it is especially important for other medical students to be aware of these issues.

Introduction Australia prides itself on being a multicultural country. Multiculturalism continues to gain attention in medical school curricula as it becomes increasingly recognised as an important constituent of good health care delivery. Multiculturalism is used to describe ‘the cultural and ethnic diversity of contemporary Australia’.[1] Understanding how different cultures shape the view of health and acceptance of its delivery is a step towards improving the quality of healthcare in Australia. In this article I present personal reflections from the perspective of an African refugee in Australia, who is also a current medical student at an Australian university. These reflections aim to shed light on the complexity of cultural influences on the health of African refugees in Australia. In particular, I have focused on sharing reflections which are centred around three broad themes: that culture is identity and identity is everything; the importance of effective communication; and not to shy away from discussing confronting cultural norms. I hope that the piece will provide insight into some of the challenges healthcare providers are faced with when working with patients from a different cultural background and encourage readers to consider ways to address these difficulties in their medical practice. Culture is identity, and identity is everything I was born in Rwanda, a small country in East Afvector journal

rica in which I lived peacefully for 9 years. In the year of 1994, my family survived the genocide that claimed more than a million civilian Rwandan lives, which forced us to flee our country. Running with nothing, we ended up in many different countries and refugee camps. The political regime in Rwanda meant my family could no longer live there safely, without constant fear of persecution. We were forced to endure a life of uncertainty for almost two decades. Throughout this time, my parents’ emphasis on culture was clear: they did not want their children to lose any part of their culture, as they constantly reminded us, “culture forms our identity”. In 2011 we were lucky enough to receive Australian offshore humanitarian visas, allowing us to finally have a place to call home; a place where we could live, study and cease to exist as refugees and become Australians.

Not long after we reached the Australian shores, I quickly realised that we had brought our culture with us. However, younger refugees like myself felt these cultural differences less strongly. Since I was nine years old, I had lived amongst other

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cultures, including those cultures in Burundi, Tanzania, and Kenya. I had friends whose parents were Congolese and Senegalese. When I was in primary school, my Congolese friends would teach me how to dance their Congolese dance, while I taught them how to do the Rwandan dance. At the same time I was part of a drumming group made of refugees from East Africa, the Horn of Africa, as well as the Great Lakes region of Africa. For my generation, multiculturalism has always had a strong presence. Many African countries share similarities and these similarities are amalgamated by Australians to create a socalled ‘African culture’. However, it is difficult to define what this really means, as it is a mixture of so many different beliefs, languages and traditions. Despite the absence of a well-defined African culture, when we arrived in Australia there were instances which caused me to reflect upon the differences between the Australian and African cultures. For example, I was confronted by the idea of a person putting their parent in a nursing home. My cultural upbringing meant that leaving my parents in a nursing home would cause me to feel significant guilt and to believe that I had failed as a son. Yet, the culture here is one that makes aged care facilities for end of life care almost compulsory and inevitable. It may be naïve to think that I will still take of care my parents when they are older, however this cultural belief is still strong. My parents remind me everyday that when that time comes, my responsibility as a son is to take care of them. Given the career that I have chosen to pursue, I will inevitably lead a very busy life. The culture in Australia accommodates this well, as it allow individuals the freedom to choose their career path and lifestyle. My culture allows this too, but it also expects you to follow the dreams of the whole community and culture. This worries me. Specialty training is incredibly demanding and it is often difficult for trainees to balance studying with having families. For someone in my culture, our sense of oblivector journal

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gation to take care of our parents, and in many instances beyond the nuclear family, is strong. I am concerned that employers will not understand my cultural perspective and thus won’t allow me the flexibility to look after my parents – a practice which is foreign to most Australians but is an important part of my culture. This will be an important consideration when I need to decide which specialty to choose. I know that I love intensive care medicine, but cultural obligations might force me to look into something else. There are significant differences in how ‘family’ is defined in my culture compared with Australian culture. Although there is significant variation between African cultures, they all define family the same way and believe that the responsibility of the younger generation is to take care of their aging parents. The importance of extended family in African culture is worth emphasising, as it has significant impacts in terms of immigration. I have heard of cases where refugee parents are denied the right to be reunited with their adult children who were left behind, because the Australian immigration does not consider them to be ‘immediate relatives’. In my culture your mother’s sister is considered your ‘other mother’, your father’s brother is your ‘other father’ and their children are your brothers and sisters. So for a mother to be denied a family reunion with her biological son is often very distressing for families and I found it very difficult to understand. These and many other differences serve as a reminder that we have moved to a culture where we were a minority and our ways of seeing life and doing things was no longer the only ‘right way’. Few environments, such as workplaces or education systems, accommodate for our beliefs. I have therefore come to understand what it really meant ‘to adopt’ the Australian culture. While there are some cultural values that can’t be maintained, it is difficult to disregard them without facing inner confrontations and turmoil. For younger generations like myself, this change and adaptation to a new culture is inevitable because it is necessary for survival. The move to Australia was a great opportunity to create a successful future and the chance to start again is one of the main drivers behind the courage to embrace the changes. For my siblings and myself, Australia has rescued us from a life without a future, without a name other than ‘refugees’, to a life volume 10, issue 17

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with opportunities and hope. This means we are ready to do whatever we can to embrace whatever comes with it, for we have so much to gain, but most importantly, we have the time, resources and support needed to successfully make the transition. But for my parents who came from a different generation, their culture is in many ways, the only thing they have that has not been taken away. It forms their identity, their way of thinking and reasoning. Sometimes, it is all they have to offer to the Australian community itself.

I believe it is important for medical students to remember the magnitude of importance culture and identity has on people. When confronted with patients from different cultural backgrounds, there may be resistance to ideas and other difficulties. It is essential to keep in mind that culture is everything to the identity of a refugee and therefore is linked to our self-worth and understanding of the world, our bodies and our health. For this reason, I urge medical students to open their minds, practice patience in understanding how culture impacts the ways of life and decisions made by your patients, and adjust the biomedical management of your patients to fit their needs. In dealing with people from other cultures, young or old, I ask that there may be a consideration for the adjustments they are making to fit into the Australian culture, and as such, a reciprocated effort to understand our roots so that you may be able to meet us halfway in our cultural journey.

lar comment by a guest, “They have no respect for the anus, they don’t mind sticking fingers inside.” This was followed by a loud laughter. It was not until a year later, when I was doing my Bachelor of Medical Science that I understood what the conversation was all about – digital rectal exams. My own father was at retirement age, putting him in the high-risk age group for colon and prostate cancer. [2] I became curious about how he perceived this issue, and whether he understood what digital rectal exams are all about and why they are important. As I expected, he was not comfortable having this conversation with his fifth born son. However, I insisted. It turned out that my father and many other African-Australian men were horrified by the prospect of such a test. “After all, what has my anus got to do with prostate cancer?” My father asked me uncomfortably. This made me realise that patients with these concerns like my own father’s, need more than just ‘doctor’s orders’ to accept such medical procedures. In the case of my father and his peers, the initiative that I took to explain the anatomy and why the rectal digital examination is related to the prostate helped to alleviate these fears and increase understanding and therefore compliance. It was not easy for me to explain this sensitive issue to these men, nor was it easy for my father to accept such so-called ‘strong words’ from his son. However, it was worth broaching this topic because it helped dispel the fears of my father and his friends and gave them a chance to ask further questions. Doctors in Australia may not have the time to explain such details to uninformed, but at-risk patients. However, recognising the issues surrounding

Take the time to communicate and communicate effectively During our first week in Australia a group of African Australians came to visit to see how we were settling in. As the conversation heated up, the subject of ‘how different the Australian society is’ came up. My ears were attracted to one particuvector journal

knowledge about health, and acknowledging how this can act as a barrier to accessing health services might reshape the way we, as health care providers, communicate with them and approach them as patients.

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ry to her doctors, in fear of telling it to the whole Rwandan community in her area. This limited her ability to get an accurate and complete diagnosis and likely had a negative effect on her mental well-being, as she was limited by what she felt comfortable sharing in front of another person from her community.

Language barriers can present another key obstacle to clear communication. One of the major strategies to distribute better healthcare to minority groups is through facilitating translating services. However, in my experiences, the use of interpreter services can be problematic. When we arrived in Australia, my parents needed to use translating services to access health care. But it did not take long before my mother started complaining. The translators they brought her were all people she had met before in our little Adelaide Rwandan community. These were the same people who would invite her to weddings and other social events. They were the last people to whom she wanted to disclose her medical history. It took me a while to understand the magnitude of this barrier. However, once I observed the close relationship my parents had with the Rwandan community in Adelaide, it became apparent why my mother felt the way she did. For older people, moving to a new country with a new language and culture is a challenging and frightening journey. [3] My parents had to do it because they were refugees, which meant they could not plan or choose where to go. They just went to a country that would be safe for our family. My parents quickly formed a community with other refugees of a similar age, which helped them feel connected. To them, this small community is their functional community. Within it cultural beliefs remain strong. One of these beliefs is the importance of never exposing vulnerabilities. My mother therefore felt exposed to her community and was concerned about losing respect every time she knew her translator. She felt reluctant to disclose her whole medical histovector journal

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The eventual solution for my mother was having a translator from a different community. Refugees and other migrants speak more than one language. This was luckily the case for my mother, who also happened to speak French. After considerable advice and encouragement, she asked her doctor to book a French translator instead. She was fully satisfied and at ease to disclose her whole medical history, without worrying about meeting the translator in her intimate Rwandan community. However, many patients of non-English speaking backgrounds might be too shy to ask for a different translator or may not speak another language. A doctor’s initiative in recognising this potential problem may help patients who are refugees and migrants, especially in the early stages of their resettlement process. In my view, having an opening discussion about which languages they speak, and whether or not they prefer someone from another community or country of origin is one of the most important and simplest steps to providing appropriate health care to these populations. Don’t shy away from confronting cultural norms It is important for health care providers to understand possible vulnerabilities that may be disguised in relationships when it comes to new arrivals in Australia. One of the well-hidden issues that I have observed in refugee communities is domestic violence and abuse, whether it is physical, verbal or emotional abuse, with both female and male perpetrators. Surprisingly, these tend to go unreported or undisclosed. When I have conversations about this topic with my parents or other community members, it is often shrugged off as a cultural norm. The issue of gender roles is one that can be a source of conflicts when comparing cultures. [4] For example, many African cultures still believe in strict gender roles, in which the man is the breadwinner while the woman stays at home and volume 10, issue 17

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looks after the children. This is not an issue specific to African people, it has been seen in almost all civilisations across the globe. In Rwanda the mixture of the traditional Christianity and African traditions such as dowry payments, where the man has to give a payment before they take a woman for marriage, means these roles have been further validated. Daily Kinyarwanda language for example still refers to a wife as ‘Umufasha’, which translates to ‘helper’ and husband as ‘Umutware’, which translates to ’boss’ or ‘leader’. In my culture a woman’s merit is based on things like how many children she has (especially the number of sons) and how happy her husband looks. This has cemented strong gender roles that are sometimes incompatible with the mainstream Australian culture. While my culture openly condemns gender violence, it does not necessarily recognise other forms of abuse besides physical abuse or unequitable standards. For example, speaking down to a woman with an aggressive tone is permissible for the husband, but not for the wife. It is important to note however, there are differences between cultures within Africa. For example, Congolese women are known to be vocal and can express themselves towards men. The same norm is seen in the West African countries like Nigeria. During our move to Australia, one of the stages of the long journey was cultural orientation. This emphasised cultural differences to expect when settling in Australia, such as the fact that both women and men have equal rights and that they are both expected to share household and societal responsibilities. The trainer, an African lady, put it like this, “In Australia, the woman is the boss!” At the time this seemed like a laughing matter for me and my brothers. But as soon as we got in Australia, I realised how much fear that cultural difference had evoked in some men. They feared their wives ‘taking over’ their male role, the role of a ‘boss and a leader’ and abandoning their female role of ‘helper’. As a consequence, these men undertook measures to keep all women at home. This is one of the reasons that some women have babies continuously, even though they may not actually want more children. The same cultural upbringing may influence the woman’s actions, as she might believe that disclosing such a situation will make her lose her husband. Sometimes, this partner abuse occurs in the context of power imbalance, when vector journal

one partner is dependent on the other for their visa, leaving them vulnerable to hidden forms of abuse. There are numerous cases in the community and further research may be important in providing further insight in the future.

au/our-responsibilities/settlement-and-multicultural-affairs/programs-policy/a-multicultural-australia/national-agenda-for-a-multicultural-australia/ what-is-multiculturalism

pants in this dialogue. Conclusion

Through my exposure to many cultures and different living situations, I have observed that the cultural norms and customs that create such large gender divides are misguided and that it is in a person’s best interest that these barriers are broken down. For example, a female Rwandan refugee in Kenya could obtain employment when their husbands could not. The husbands then took on the role of looking after young children, allowing these families to survive as a result of looking beyond the cultural expectations. Furthermore, Rwanda currently has the highest number of female parliamentarians in the world. [6] With globalisation and increasing awareness about the importance of gender equality, more and more cultures are shifting towards this ideal. It is important for Australian doctors and medical students to realise that cultural norms can be changed, even within the home countries of refugees. While cultures may be different, practices that are not acceptable in the Australian society tend to be universally unacceptable and based on respect for human rights, individual freedoms and dignity. Some of these partner abuses that I have observed, although they stem from long lasting traditions, do cause harm to individual victims, and are therefore not to be tolerated in the name of ‘protecting cultures’. Refugee communities themselves are becoming aware of this and do all they can to intervene where such abuses are noticed. I believe the purpose of cultural pluralism is to take and share what is good, while we learn to reject what is harmful.

Moving to a foreign country is not easy and it is especially difficult for refugees, as they do not choose their destination or have time to prepare themselves for the culture shocks they will encounter. These significant changes in their lives often translate to challenges that can be seen in the healthcare sector. As medical professionals it is important to consider the cultural background of patients because, as the problems described in this article exemplify, access to health care on many levels can be difficult for these groups of patients.

2. Prostate Cancer Foundation. Prostate Cancer Risk Factors. Prostate Cancer Foundation (PCF) [Internet]. 2015 [cited 2015 March 25]. Available from: http://www.pcf.org/site/c.leJRIROrEpH/b.5802027/k.D271/Prostate_Cancer_Risk_Factors.htm 3. Jerzy J. Smolicz , Margaret J. Secombe , Dorothy M. Family Collectivism and Minority Languages as Core Values of Culture among Ethnic Groups in Australia.Hudson Journal of Multilingual and Multicultural Development .[internet] 2001. [cited 2015 March 10]; 22(2):152-172. Available from: http://www.tandfonline.com/doi/ pdf/10.1080/01434630108666430#.VWpqJVmeDGc 4. Milne, K and Khawaja, NG. Sudanese Refugees in Australia: The Impact of Acculturation Stress. Journal of Pacific Rim Psychology [Internet]. 2010 [cited 2015 March 25]; 4(1): 19-29. Available from : http://eprints. qut.edu.au/32943/ 5. Inter Parliamentary Union. Women in Parliaments: World Classification [Internet]. 2015 [cited 2015 April 21]. Available from: http://www.ipu.org/ wmn-e/classif.htm

These shared reflections are based on my own observations and may therefore vary from person-to-person and patient-to-patient. Being aware that these problems exist and having an open and respectful approach to them will assist in resolving many of these issues. People from diverse cultural backgrounds, refugees in particular, are vulnerable and it is our duty as doctors and healers to help them access health care which is matched with their cultural understanding, needs and values. References

1. Australian government; Department of Social Services. What is multiculturalism? Australian Government Department of Social Services [Internet]. 2014 [cited 2015 April 10]. Available from: https://www.dss.gov.

As health professionals we need to dig deeper and ask the right questions. I encourage health professionals to have conversations surrounding difficult and sensitive topics like gender-based violence. In having these conversations, we may have a chance to overcome adversities that are justified under the cultural banner. Culture is malleable and ever evolving, as are norms and values. Desired change in culture starts with discussions and open dialogue between members of different cultural backgrounds. I believe that doctors are ideally positioned to be active partici-

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Review Article

tion pressure that contributes to the development of resistance.[4]

A Global Approach to Combating Antibiotic Resistance Swetha Prabhakaran Abstract Globally, the medical profession is increasingly facing the problem of antimicrobial resistance. As antibiotic therapy continues to be a mainstay of curing infections, both developed and developing nations are dealing with the hard reality that its effectiveness is decreasing. A comprehensive global approach is thought to be the most effective way of slowing the progression of antimicrobial resistance. Broadly, there is a need to have stricter controls on the use of antibiotics not only in clinical practice, but also in the wider community, and in animal husbandry. This review focuses on the importance of developing a multifaceted solution that considers healthcare delivery, public health measures, pharmaceutical research, agriculture and global advocacy. The incorporation of antibiotic stewardship programs into hospital guidelines, the introduction of regulations dealing with non-prescription access to antibiotics and monitoring or banning the use of antibiotics in animal husbandry are necessary strategies to assist in combating antimicrobial resistance. Further, this article explores existing national and international campaigns that aim to raise awareness of antimicrobial resistance, and discusses current approaches in encouraging research and the development of new antibiotics.

Introduction The discovery of antibiotics in the 20th century heralded dramatic changes in clinical practice. Among others, antibiotics were able to contain and treat infections in a more effective manner, and provided prophylactic cover when needed, allowing for complex procedures to be conducted in a safer environment.[1] Yet, as a consequence of such extensive antibiotic use, resistance to these very drugs is a public health problem that the medical profession is increasingly facing.[2] The threat of moving towards an era where the effectiveness of these drugs on which modern medicine is premised, could be permanently compromised, is a concerning one. [3] Resistance that develops in one part of the world, often rapidly spreads to others, causing difficulty in infection prevention and control.[1] Judicious use of antibiotics is imperative in halting the current trend of increasing antimicrobial resistance, and the solution should be multi-faceted, in recognition of the contributions of various stakeholders. Drivers of antimicrobial resistance include improper use of antibiotics in clinical practice, non-prescription access to antibiotics globally and the use of antibiotics in agriculture. [1] The introduction of antibiotic stewardship programs into clinical practice has been associated with significantly reduced rates of antimicrobial resistance in some instances, and should be implemented globally where possible. Additionally, while non-prescription access to antibiotics vector journal

is often endemic in developing nations, solutions which take into account the unique social, cultural and political context of these countries are likely to lead to the desired outcome of reducing the driver for resistance. Regulations for antibiotic use in other sectors are important, as are measures to encourage the pharmaceutical industry to invest in antibiotic research and development. The Phenomenon of Antibiotic Resistance Globally, the widespread use of antibiotics by doctors and health professionals has become a true characteristic of modern medicine. The implications of a “post-antibiotic era� due to the development of antimicrobial resistance would truly be far-reaching. Research currently suggests that there may be upwards of 20,000 potential antimicrobial resistance genes in the world.[3] The overuse of antibiotics is the major driver of selec-

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The rates of antimicrobial resistance development around the world are concerning, particularly for the treatment of common bacterial infections, such as respiratory, gastrointestinal and urinary tract infections. From an Australian perspective, the main antibiotic resistant organisms found are vancomycin-resistant enterococci, methicillin-resistant Staphyloccocus aureus (MRSA), multi-resistant Escherichia coli (E. coli), multi-resistant Streptococcus pneumoniae and multi-resistant Neisseria gonorrhoeae.[5,6] For instance, the incidence of MRSA in comparison to all reported S. aureas infections within the Australian community has doubled from 10 to 20% between 2001 and 2010.[7] Globally, antimicrobial resistance is even more concerning. A study in Bolivia found that 76% and 44% of commensal E. coli from healthy children was resistant to nalidixic acid and ciprofloxacin respectively.[1,8] A study on Shigella isolates conducted in the Andaman and Nicobar Islands in India found that the number of drug resistance patterns, including resistance to newer generation antibiotics, had more than tripled between 2000 and 2011.[4] Furthermore, fluoroquinolones, a synthetic antibiotic, which heralded promising results in relation to overcoming resistance has shown reduced efficacy in less than 30 years after its introduction.[8] According to the World Health Organisation, there is quantitative evidence available regarding the harm caused to patients as a result of drug resistance in the treatment of tuberculosis – a common infection in developing countries.(8) Among the number of TB cases notified worldwide in 2010, it was estimated that there were 290 000 new cases of multi-drug resistant tuberculosis (MDR-TB).[9] A study conducted in Mozambique using data from the National Tuberculosis Referral Laboratory detected 58.3% resistant strains to at least one anti-tuberculosis drug and 43.7% MDR-TB strains isolated in culture during 2011.[10,11] Furthermore, extensively drug-resistant tuberculosis (XDR-TB) has emerged, which is resistant to second-line drugs and its prevalence is estimated to be approximately 10% worldwide.[12] These are but a few of the many examples of the implications of antimicrobial resistance. These vector journal

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show the immense speed at which antimicrobial resistance can develop, and they highlight the need for a concerted global effort to respond to it. Addressing Antibiotic Use in Clinical Practice The clinical environment, be it hospital or clinic, plays an important role in the management of antimicrobial resistance. These environments are responsible for the appropriate provision and prescription of antibiotics, as well as for proper infection control. The first priority in managing any infection in a clinical environment is to control the transmission and spread of infection. This is essential since hospitals may sometimes contribute to the spread of nosocomial infections, through cross-infection between patients, and also through the horizontal transfer of antimicrobial resistance. [13,14] The cornerstone of managing infectious patients in an environment such as this is curing the patient, while including the implementation of appropriate infection control measures, such as appropriate isolation and hand-disinfection practices.[13] Once these measures have been implemented satisfactorily, the focus turns to antimicrobial treatments. Often, there are guidelines for the appropriate use of the antibiotics, with variable levels of evidence for the recommendations.[15] However, there is evidence that guidelines may be inappropriately adopted, as evidenced by the poor application of them with regards to urinary tract infections.[16] In Australia, the Online Therapeutic Guidelines for antibiotics guides clinicians. [15] Inappropriate prescribing can lead to increased antimicrobial resistance, more wastage of health resources, and a greater risk of adverse effects for patients.[17] Misuse of antibiotics is particularly common with respiratory presentations, where they are often wrongly prescribed for viral illnesses.[18] As a result, it has become essential to establish hospital or clinic-based antimicrobial policies, which may be known as antimicrobial stewardship programs. Various hospital antibiotic policies have been implemented globally since the threat of antimicrobial resistance emerged; however it was McDougall and Polk who formally defined the aim of antimicrobial stewardship programs in 2005.[19] The aim of the program is to regulate and monitor the prescription of antimicrobials in order to reduce further development of antimivolume 10, issue 17

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evidenced by a significant reduction in antibiotic prescribing by GPs and non-medical prescribers in Derbyshire, England following a four-year initiative including educational seminars, antibiotic audits and ongoing GP support. The outcome was a lower than national average level of prescribing cephalosporins and quinolones. These programs are easy to organise and should continue to be encouraged.[17] Empowering prescribers to make informed choices about antibiotic use is ultimately the aim of these initiatives.

crobial resistance, provide optimal patient care and decrease health costs.[19] These policies are premised on the education of healthcare professionals; to empower them to prescribe antibiotics appropriately, and to support them in their practice. Occasionally these policies may be extended to restrict the availability of certain antibiotics. [13] Antimicrobial stewardship programs have been recommended by various international and national healthcare organisations. In 2007, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) developed comprehensive recommendations regarding optimal antimicrobial use in acute care hospitals, in the form of antimicrobial stewardship programs.[20] In 2014, the Centres for Disease Control and Prevention (CDC) recommended all acute hospitals to implement an antibiotic stewardship program.[21] From an Australian perspective, the first National Antimicrobial Resistance Strategy was published in June 2015, and aims to guide governments, healthcare institutions and agricultural sectors, among others, in reducing the development of antimicrobial resistance.[22] Additionally, every Australian hospital and day procedure service is now mandated to implement infection prevention and antimicrobial stewardship programs following the implementation of the National Safety and Quality Health Service Standards in 2013. In doing so, Australia is a global pioneer in mandating requirements for better infection prevention and control.[22,23] Antimicrobial stewardship programs are important initiatives that are highly recommended by experts in the field.[1,5] Education programs about antimicrobial stewardship can be used to great effect. This is vector journal

The effectiveness of policies such as the antimicrobial stewardship program depends on the co-operation of the entire healthcare institution, including multi-disciplinary support. Hospitals and primary care establishments both seek to gain from integrating these policies to be a core aspect of current accreditation programs.[1] Research has shown that codifying stewardship programs can successfully lead to a decrease in antibiotic use, while simultaneously reducing the burden of morbidity and mortality of infections. Evaluating the impact of existing antimicrobial stewardship programs is difficult, with no unifying metric to assess their effectiveness.[24] Furthermore, primarily observational studies have been conducted to assess the effectiveness of antimicrobial stewardship programs, which are Level III evidence according to Australian Government National Health and Medical Research Council NHMRC evidence hierarchy.[25] Studies have shown a statistically significant immediate reduction in the use of broad-spectrum antibiotics following the implementation of formal antibiotic policies and programs, such as antimicrobial stewardship programs.[26] For instance, a prospective 7-year study showed a statistically significant decrease of 22% in parenteral broad-spectrum antibiotic use within a single teaching hospital.[27] Furthermore, a 2005 Cochrane systematic review showed that hospital-based interventions aimed at improving antibiotic prescribing through stewardship programs successfully reduced both antimicrobial resistance and the development of nosocomial infections. Within this review, 77% of studies included showed a significant improvement in at least one clinical outcome (such as in-hospital or 28 day mortality), and multiple studies showed over 10% reduction in resistance development between intervention and control groups.[28] A retrospective cohort study conducted in a teach-

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ing hospital in North East Scotland found that implementation of antibiotic stewardship with fluoroquinolone and cephalosporin use resulted in a statistically significant decrease of prevalence of MRSA bacteraemia.[14] A well-rounded stewardship program may be associated with decreased use of broad spectrum antibiotics, a reduced risk of infection transmission within the hospital and a decreased level of antimicrobial resistance. Healthcare workers in hospitals and clinics are therefore encouraged to be aware of antimicrobial stewardship programs and help promote its aims. Monitoring Antibiotic Use in the Community Globally, access to antibiotics is not always governed by prescriptions from medical facilities. Pharmacies, friends and family can also be sources of drugs for those seeking self-medication. Non-prescription access to antibiotics is present worldwide, but most commonly in nations outside of Europe, North America and Australia.[29] Developing nations in Asia and Africa have been shown to have some of the highest rates of non-prescription access in the world. For instance, the rates of antibiotic self-administration have been found to be as high as 74% in Sudan [30], 60% in China [31], and as low as 3% [32] in Northern European nations. The strongest driver behind the prevalence of non-prescription access to antibiotics is the scarcity of medical resources in developing nations. As a result, minimally trained or unskilled personnel often act as healthcare workers, and take on the role of antimicrobial prescribing.[33] There are numerous problems associated with this status quo. Often, those dispensing the medications have little medical knowledge to guide them, which may lead them to select inappropriate antibiotics in light of local resistance patterns.[34] Rates of adverse effects due to antibiotics are also more common, and are associated with the lack of medical screening for allergies in less than 17% of cases, as well as with a lack of knowledge of potential side effects. [29,35] In addition, many studies have shown consistently that these antibiotics are more likely to be administered as single dose therapies, as opposed to the full course. Potentially due to financial concerns, these drug regimens are popular in developing nations, but are associated with greater resistance potential.[32] vector journal

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Regulation and legislation are pivotal in combating this issue. Limiting access of non-prescription antibiotics within the community is likely to reduce the rate at which antimicrobial resistance develops. Yet developing nations pose unique challenges. Often, the regulatory capacity of the nation might be limited, and legislation unenforceable. Indeed, non-medical prescribers may well be the only access point to life-saving drugs that members of society with poor access to formal healthcare have. As a result, an outright ban on non-prescription sales is likely to cause more harm in the short-term.[2] Hence, measures must be taken to ensure that drug restriction does not come at the expense of the health of patients.[1] Advocacy and political leadership to ensure the incorporation of an antibiotic stewardship program into existing health infrastructure could be an effective start to safer antibiotic use. In addition to addressing non-prescription antibiotic use, the key issues of infection control and prevention must also be addressed. For example, improving primary health care and basic health infrastructure may reduce the prevalence and spread of infections, thereby reducing the need for antibiotic use. Furthermore, vaccination programs remain as a key prevention strategy to avoid unnecessary antibiotic use in the future. In the United States for instance, the use of the pneumococcal conjugate vaccine against the drug-resistant Streptococcus pneumoniae has significantly reduced rates of infection, and as a consequence, the use of antibiotics as well.[36] Yet, with high numbers of unvaccinated children in developing nations, there is a greater range of bacterial infections that require antibiotic use. [2] Finally, developing nations may lack social infrastructure, such as access to clean water and sanitation, which contributes to the spread of infections.(2) Addressing antimicrobial resistance at the community level needs to consider the social, economic and political structure unique to countries so that the best solution be identified and implemented. Antibiotic Use in Animal Husbandry The development of antimicrobial resistance does not only occur in humans. The animal industry is also an important stakeholder in this global phenomenon. Widespread use of antibiotics in animal husbandry poses the risk of volume 10, issue 17

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transmission of resistant bacteria from animals to humans. In many countries around the world, antibiotics are authorised for use in animals, and are available over the counter. Transmission from animals to humans may occur through exposure to animal products, or less commonly through environmental routes such as exposure to manure and biological solids.[1] In the past two decades, increasing legislation has been introduced in specific countries to restrict the use of antibiotics in animal husbandry to address this problem.

For instance, the use of antibiotics in animal rearing was phased out in the European Union in 1999[37] and was associated with a reduction in antimicrobial resistance among faecal enterococci in animal populations, which proved that it was potentially possible to reverse the effects of antimicrobial resistance. In fact, rates of multidrug resistant Enterococcus faecium in US poultry declined from 84% to 17%, after organic feed was implemented.[38] Furthermore, international organisations such as the World Health Organisation, the United Nations Food and Agriculture Organisation and the World Organisation for Animal Health are currently working together to create guidelines regarding the appropriate use of antibiotics in animal rearing.[37] The creation of a “No-Feed Antibiotics” label on consumer products could provide an incentive for the agricultural sector to reduce their use of antibiotics, particularly if this certification is produced in association with governmental departments of agriculture.[39] Antibiotics – The Way Forward in Antibiotic Development In the 20th century, antibiotic discovery was at an all-time high. More than 20 classes of antibiotics were discovered in a span of just over 30 years[40], in what can be characterised as vector journal

“the golden age of antibiotic discovery”.[1] Since then however, antibiotic development has stalled dramatically. Indeed, there was a 32-year gap (1968 - 2000) between the discoveries of two novel antibiotic classes.[41] During this time, the focus for pharmaceutical companies moved from discovering new classes of antibiotics to instead developing analogues, a decision associated with the reduced side effect profile of analogue drugs. Additionally, a new antibiotic has a relatively low profit potential, as compared to a drug of a different therapeutic class.[41] This too, likely contributed to the decrease in interest in the pharmaceutical industry to fund and invest in antimicrobial research, especially as the regulations for approval for new classes of antimicrobials have become stricter.[40] As a result of this decline in research and development into new antimicrobials, there has been a significant loss of knowledge and infrastructure in the industry with regards to antibiotic development and this is predicted to take time and effort to re-build.[40] There is a need for antibiotic development to begin anew. Suggestions currently being proposed and discussed at international conferences include revisingz the regulatory requirements for approval of medications, offering pharmaceutical-friendly patent protection and even providing direct financial investment.[42] The European Medicines Agency has relaxed its current guidelines for clinical antibiotic trials and the US Food and Drug Administration (FDA) is considering altering their regulations with regards to generic antibiotics.[1,39] Other potential approaches include considering value-based pricing of new antibiotics, which could incentivise pharmaceutical companies to invest in drug development. This particular approach promises developers a cut of the savings to healthcare costs that would be achieved if the current burden of morbidity and mortality of resistant infections is reduced by new drug discovery. [39] Increasing Awareness Globally Awareness about antimicrobial resistance is certainly building worldwide, with national campaigns such as the European Antibiotic Awareness Day, US Get Smart About Antibiotics Week, Canadian Antibiotic Awareness Week, and the Australian Antibiotic Awareness Week being established as annual traditions.[43] Aiming to tar-

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get both consumers and healthcare professionals, initiatives such as these impart knowledge on the necessity of using antibiotics prudently and judiciously, as well as on the need for co-operation to halt the trend of increasing resistance. Conclusion If left unchecked, the current trend of antimicrobial resistance suggests that a post-antibiotic era is not far off; a world where infections currently treated with antibiotics may carry a high level of morbidity and mortality. As discussed in this article, it is imperative that a multifaceted solution be raised where possible. These include incorporation of antibiotic stewardship programs into hospital guidelines, introduction of regulations to deal with non-prescription access to antibiotics, monitoring or banning the use of antibiotics in animal husbandry, global advocacy, and incentivisation of the pharmaceutical industry to engage in new antibiotic research. Ultimately, if access to life-saving antibiotics is not to be compromised by the development of resistance, global co-operation is essential to this end. As the WHO World Health Day 2011 proclaimed, when it comes to antimicrobial resistance, “no action today, no cure tomorrow” – the time to act is now. References

1. Laxminarayan R, Duse A, Wattal C, Zaidi AK, Wertheim HF, Sumpradit N, et al. Antibiotic Resistance-The Need For Global Solutions. Lancet Infect Dis. 2013;13(12):1057-98. 2. Laxminarayan R, Heymann DL. Challenges of Drug Resistance in the Developing World. 2012. 3. Davies J, Davies D. Origins and Evolution of Antibiotic Resistance. Microbiol Mol Biol Rev. 2010;74(3):417-33. 4. Bhattacharya D, Bhattacharya H, Sayi DS, Bharadwaj AP, Singhania M, Sugunan AP, et al. Changing Patterns and Widening of Antibiotic Resistance in Shigella Spp Over a Decade (2000-2011), Andaman Islands, India. Epidemiol Infect. 2015;143(3):470-7. 5. McKenzie D, Rawlins M, Del Mar C. Antibiotic Stewardship: What’s It All About? Aust Prescriber. 2013;36(4):116-20. 6. Lahra MM, Ryder N, Whiley DM. A New Multidrug-Resistant Strain of Neisseria Gonorrhoeae in Australia. N Engl J Med. 2014;371(19):1850-1. 7. Australian Group for Antimicrobical Resistance. Staphylococcus Aureus Programme 2010: Community Survery Antimicrobial Susceptibility Report. 2010. 8. Bartoloni A, Pallecchi L, Riccobono E, Mantella A, Magnelli D, Di Maggio T, et al. Relentless Increase of Resistance to Fluoroquinolones and Expanded-Spectrum Cephalosporins in Escherichia Coli: 20 Eears of Surveillance in Resource-Limited Settings from Latin America. Clin Microbiol Infect. 2013;19(4):356-61. 9. World Health Organisation. The Evolving Threat of Antimicrobial Resistance Options for Action. 2012. 10. Pires GM, Folgosa E, Nquobile N, Gitta S, Cadir N. Mycobacterium Tuberculosis Resistance to Antituberculosis Drugs in Mozambique. J Bras Pneumol. 2014;40(2):142-7. 11. World Health Organisation. Global Tuberculosis Control. World Health Organisation, 2011. 12. Dheda K, Gumbo T, Gandhi NR, Murray M, Theron G, Udwadia Z, et al. Global Control of Tuberculosis: From Extensively Drug-Resistant to Untreatable Tuberculosis. Lancet Respir Med. 2014;2(4):321-38. 13. Paterson DL. The Role of Antimicrobial Management Programs in Optimizing Antibiotic Prescribing Within Hospitals. Clin Infect Dis. 2006;42 Suppl 2:S90-5. 14. Lawes T, Edwards B, Lopez-Lozano JM, Gould I. Trends in Staphylococcus aureus Bacteraemia and Impacts of Infection Control Practices Including Universal MRSA Admission Screening In a Hospital in Scotland, 2006-2010: Retrospective Cohort Study and Time-Series Intervention Analysis. BMJ Open. 2012;2(3). 15. Therapeutic Guidelines Limited. Therapeutic Guidelines Antibiotics Version 14: Therapeutic Guidelines Limited; 2014 [cited 2015 15 April ]. Available from: http://www.tg.org. au/?sectionid=71. 16. Rotjanapan P, Dosa D, Thomas KS. Potentially Inappropriate Treatment of Urinary Tract Infections In Two Rhode Island Nursing Homes. Arch Intern Med. 2011;171(5):438-43. 17. Harris DJ. Initiatives to Improve Appropriate Antibiotic Prescribing in Primary Care. J Antimicrob Chemother. 2013;68(11):2424-7. 18. Llor C, Moragas A, Bayona C, Morros R, Pera H, Plana-Ripoll O, et al. Efficacy of Anti-Inflammatory or Antibiotic Treatment in Patients with Non-Complicated Acute Bronchitis and Discoloured Sputum: Randomised Placebo Controlled Trial. Bmj. 2013;347:f5762. 19. MacDougall C, Polk R. Antibiotic Stewardship Programs In Health Care Systems. Clin Microbiol Rev. 2005;18(4):638-56.

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20. Dellit TH, Owens R, McGowen J, Gerding D, Weinstein R. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clin Infect Dis. 2007;44(2):159-77. 21. Fridkin SK, Baggs J, Fagan R, Magill S. Vital Signs: Improving Antibiotic Use Among Hospitalized Patients. MMWR. Centers for Disease Control and Prevention, 2014. 22. Commonwealth of Australia Department of Health and Department of Agriculture. Australia’s First National Antimicrobial Resistance Strategy 2015-2019. Commonwealth of Australia, 2015. 23. Australian Commission on Safety and Quality in Health Care. Hospital Accreditation Workbook. Sydney: Australian Commission on Safety and Quality in Health Care, 2012. 24. Dodds Ashley ES, Kaye KS, DePestel DD, Hermsen ED. Antimicrobial stewardship: philosophy versus practice. Clin Infect Dis. 2014;59 Suppl 3:S112-21. 25. National Health and Medical Research Council. NHMRC Additional Levels of Evidence and Grades for Recommendations for Developers of Guidelines. National Health and Medical Research Council, 2009. 26. Cairns KA, Jenney AW, Abbott IJ, Skinner MJ, Doyle JS, Dooley M, et al. Prescribing Trends Before and After Implementation of an Antimicrobial Stewardship Program. Med J Aust. 2013;198(5):262-6. 27. Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable Impact of a Multidisciplinary Antibiotic Management Program Conducted During 7 Years. Infect Control Hosp Epidemiol. 2003;24(9):699-706. 28. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to Improve Antibiotic Prescribing Practices for Hospital Inpatients. Cochrane Database Syst Rev. 2005(4):5-6. 29. Morgan DJ, Okeke IN, Laxminarayan R, Perencevich EN, Weisenberg S. Non-Prescription Antimicrobial Use Worldwide: A Systematic Review. Lancet Infect Dis. 2011;11(9):692-701. 30. Awad A, Eltayeb I, Matowe L, Thalib L. Self-Medication with Antibiotics and Antimalarials in the Community of Khartoum State, Sudan. J Pharm Pharm Sci. 2005;8(2):326-31. 31. Bi P, Tong S, Parton KA. Family Self-Medication and Antibiotics Abuse for Children and Juveniles in a Chinese City. Soc Sci Med. 2000;50(10):1445-50. 32. Grigoryan L, Haaijer-Ruskamp FM, Burgerhof JG, Mechtler R, Deschepper R, Tambic-Andrasevic A, et al. Self-Medication with Antimicrobial Drugs in Europe. Emerg Infect Dis. 2006;12(3):452-9. 33. Okeke IN, Lamikanra A, Edelman R. Socioeconomic and Behavioral Factors Leading to Acquired Bacterial Resistance to Antibiotics in Developing Countries. Emerg Infect Dis. 1999;5(1):18-27. 34. Okeke IN, Klugman KP, Bhutta ZA, Duse AG, Jenkins P, O’Brien TF, et al. Antimicrobial Resistance in Developing Countries. Part II: Strategies for Containment. Lancet Infect Dis. 2005;5(9):568-80. 35. Taylor RB, Shakoor O, Behrens RH. Drug Quality, A Contributor to Drug Resistance? Lancet. 1995;346(8967):122. 36. Dagan R, Klugman KP. Impact of Conjugate Pneumococcal Aaccines on Antibiotic Resistance. Lancet Infect Dis. 2008;8(12):785-95. 37. Casewell M, Friis C, Marco E, McMullin P, Phillips I. The European Ban On Growth-Promoting Antibiotics and Emerging Consequences for Human and Animal Health. J Antimicrob Chemother. 2003;52(2):159-61. 38. Pruden A, Larsson DGJ, Amézquita A, Collignon P, Brandt K, Graham D, et al. Management Options for Reducing the Release of Antibiotics and Antibiotic Resistance Genes to the Environment. Environ Health Perspect. 2013;121(8):878-85. 39. Metz M, Shlaes D. Eight More Ways To Deal with Antibiotic Resistance. Antimicrob Agents Chemother. 2014;58(8):4253-6. 40. Coates AR, Halls G, Hu Y. Novel Classes of Antibiotics or More of the Same? Br J Pharmacol. 2011;163(1):184-94. 41. Powers JH. Antimicrobial Drug Development--The Past, The Present, and The Future. Clin Microbiol Infect. 2004;10:23-31. 42. Bergstrom R. The Role of the Pharmaceutical Industry in Meeting the Public Health Threat of Antibacterial Resistance. Drug Resist Updat. 2011;14(2):77-8. 43. Earnshaw S, Mendez A, Monnet DL, Hicks L, Cruickshank M, Weekes L, et al. Global Collaboration to Encourage Prudent Antibiotic Use. Lancet Infect Dis. 2013;13(12):1003-4.

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Review Article

Non-Communicable Diseases in Kenya Joyce Shi

Abstract Non-Communicable Diseases (NCDs) stand as one of the world’s most challenging health, social and economic issues. [1] The speed at which NCDs have risen has created a mammoth global problem, and it is predicted that by 2030 they will overtake infectious diseases as the leading contributor to disability adjusted life years in LMICs. [2] Astonishingly, almost three quarters (28 million) of NCD deaths globally now occur in low- and middle-income countries each year [2]. Fighting NCDs is intrinsic to improving the lives of all people, however, it is also an incredibly complex issue that is entrenched within a country’s social, economic and physical environments. Kenya is one such low-income country that is experiencing rapid NCD growth. Throughout this piece, I draw upon some personal experiences I had during a 4 week elective in Kenya to highlight the complex issues at play and identify some barriers against improvements being made.

Non-Communicable Diseases (NCDs) stand as one of the world’s most challenging health, social and economic issues. [1] The speed at which NCDs have risen has created a mammoth global problem, and it is predicted that by 2030 they will overtake infectious diseases as the leading contributor to disability adjusted life years in LMICs. [2] During a 4 week elective in Kenya in December 2014, I was prompted to reflect on my own perception of NCDs in the global context. This short exposure, although neither extensive nor comprehensive, inspired me to learn more about the issue of NCDs in low to middle income countries (LMIC) and has helped me understand the many factors complicating the global fight against NCDs. Throughout this piece, I will draw upon some experiences I had in Kenya to highlight the complex issues at play and identify some barriers against improvements being made.

globally and impacting on many other areas of human and economic development. While the traditional understanding of NCDs portrays it as a problem of the old and wealthy, the new reality is that the burden of diseases from NCDs lies disproportionately in LMICs. [4] Contrary to popular opinion, available data demonstrate that nearly 80% of NCD deaths occur in LMICs. [2] Since the landmark 2011 UN Summit, [5] there has been a greater appreciation of the emerging burden of NCDs in LMICS. However, despite repeat calls for action, the NCD burden is increasing unchecked.

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In Kenya, health expenditure remains less than 5% of gross domestic product (GDP) [8], with curative rather than preventative health continuing to receive the highest share of the total health sector budget. [8] As a comparison, Australia spent 9.67% of GDP on health in 2012 – 2013. [9] Importantly, Kenya’s figure sits significantly less than the 15% goal set out in the Abuja Declaration of 1989. [10] A 10 year review of the Abuja Declaration, which was signed by heads of state of African Union countries to improve the health sector, revealed that there has not been appreciable progress in terms of the commitments that African Union governments, including Kenya, make to health, or in terms of the proportion of gross national income the rich countries devote to official Development Assistance. [11] This disproportionate economic commitment to tackling health, and subsequently NCDs, is disparaging and highlights the lack of action in this key area. The transformation of the food sector is another example of how the economic environment has perpetuated the rise of NCDs. Studies have shown how food environments and access to convenience foods in developed countries have contributed to higher rates of obesity, diabetes and cardiovascular disease. [12] What is concerning is that the harmful habits that stubbornly resist public health measures in HICs

What are NCDs? NCDs can be defined as chronic diseases that are not transmissible. They constitute a large group of diseases that are of long duration, and generally slow to progress, with the 4 main types of noncommunicable diseases being cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes. [3] Common risk factors for developing these chronic diseases such as poor diet, a sedentary lifestyle, exposure to tobacco and harmful use of alcohol are near ubiquitous, contributing to the rapid rise of NCDs

services and products that protect them from the greatest risks while lower-income groups can often not afford such products and services. [6] A recent report identified four broad reasons chronic disease are on the rise in the African region. These were rapid unplanned urbanization, little understanding of the risks that come with a chronic condition like heart disease, lack of access to healthcare and cost of treatment. [7]

The social, economic and physical environments in developing countries afford their populations much lower levels of protection from the risks and consequences of NCDs than in high income countries (HIC). [6] In many countries, harmful drinking and unhealthy diet and lifestyles occur both in higher and lower income groups. However, high-income groups can access volume 10, issue 17

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The effect of this food environment transformation can be seen in the modern paradox that many developing countries suffer from undernourishment on the one hand, and obesity and diet-related diseases on the other. The lack of investment in nutrition [15] has also created a burgeoning challenge that complicates an already difficult issue. A UN taskforce mission in 2014 revealed that, alarmingly, 18% of Kenyan pre-school children are now obese, with around 30% of Kenyan adults overweight and around 9% obese, [6] while malnutrition statistics from 2009 showed 35% of children under five years were still stunted (defined as being less than -2 standard deviations from the height-for-age of the WHO Child Growth Standards median), 16% were underweight, and 7% were wasted. [16] In the African region, the rate of stunting remained at 39% in 2013. NCDs in Kenya In Kenya, NCDs account for 27% of deaths suffered by those aged between 30 and 70 years, with the potential to reduce productivity, curtail economic growth and trap the poorest people in chronic poverty. Prevalence and mortality data is either unavailable or have a high degree of uncertainty due to lack of national NCD information. [17, 18] However, 50% of all hospital admissions and 55% of hospital deaths in Kenya are estimated to be due to NCDs. [19] As with many developing countries, medical care is not readily accessible to the majority of the

Social Determinants of Health

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are shared between all countries, shaped in part by national and global food production and a variety of marketing forces that drive global epidemics of NCDs. The sale and promotion of tobacco, alcohol, and ultra-processed food and drink (unhealthy commodities), transnational corporations [13] are all driving factors. In Kenya, the fight against these diseases is further complicated by cultural factors, including the perception of overweight and obesity as signs of prosperity. [7] Whilst the transformation of the food sector and concurrent growth of supermarkets has shown to provide some financial benefits to rural farmers, [14] ready access to cheaper, higher calorie but not necessarily healthy food options presents a growing challenge.

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citizens, with primary health care implementation since the Alma-Ata Declaration in 1978 lagging behind despite government level commitments. [20] On top of the pervasive economic factors at play, the impacts of this are broad, as inability to access affordable and safe primary care services leaves little opportunity for health promotion and preventative medicine which are cornerstones in the fight against NCDs.

paying steeply out of your own pocket, and travelling 300 km to the national hospital, management of cancer was a helplessnessinducing experience for all. A sobering fact is that 80% of the women affected by cervical cancer live in developing countries. [22] This reality, and the numbers of women dying all over the world due to this potentially vaccine preventable disease is simply unacceptable.

Many aspects of the underfunded and underresourced healthcare system that struggles to deal with NCDs became apparent during my stay. The multitude of barriers stacked up against the provision of basic healthcare, not just NCDs were apparent. Immersed in the hospital’s organised chaos, I watched on with admiration as the staff worked tirelessly without complaint and access to basic equipment (including CT machines and reliable supply of blood for transfusions). Day to day, as doctors worked within the constraints of a system stretched to its limits, it seemed that NCDs had fallen on the wayside of their priorities. However, the devastating effects of NCDs though could not be denied and were a frequent encounter during my 4-weeks there.

Since it’s introduction in Australia through the HPV school vaccination program in 2007 there has been a 77% reduction in the HPV types responsible for cervical cancer. [23] Although we will not expect to see reduction in cervical cancer for a few more years, since cervical cancer usually develops over 10 years or more, health experts are confident of a decline and all current evidence is supportive of this. [23] Despite its effectiveness, cost remains one of the greatest barriers against introducing this vaccine, among others, in developing countries including Kenya. [24] Other barriers include the underlying weakness of the health system in developing countries, lack of political commitment, weak information system, severe shortage of adequately trained health workers, lack of information about vaccines and the fear of vaccines. [24] It is clear that the issues at play at complex, but the injustice of not taking action against this is clear: with every 5-year delay in bringing vaccination to developing countries, 1.5 million to 2 million more women will die. [22]

The case of cervical cancer, a noncommunicable disease with an infectious origin, is just one example of health disparity resulting from inequitable access to life saving technology, such as vaccines. In sub-Saharan Africa, cervical cancer remains the leading cause of cancer death among women. [21] Encounters with patients suffering from cervical cancer were unfortunately not rare during my elective. In a system where receiving palliative care involves vector journal

In the face of a highly complex issue incorporating multiple diseases, there is a definite need for stronger health investment and public health programs to address awareness of the broad range of disease represented by NCDs. Resources, dedicated government bodies and funding are all necessary to improve knowledge of their risk factors, enable the implementation of programs to support prevention and initiate early management. These are all essential elements in the mitigation of NCDs. Action Against NCDs There are signs that awareness of NCDs is translating into action. The great levels of illness and death associated with NCDs has lead the Kenyan government to prioritise NCD prevention

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and control in its National Medium Term Plan 2014-2018;[25] the United Nations Development Assisted Framework 2014-2018 for Kenya; [26] and the Kenya third generation WHO Country Cooperation Strategy (2014-2019). [27] The need for a ground-up approach has also been recognised. A few groups involving Kenyan young professionals (including medical students) have been developed to help change the mindset of the population through free health screening initiatives and school based educational programs. [28] Their experience in Kenya highlights how such a network can empower the youth to have a substantive impact on the prevention and mitigation of NCDs in their local context. It is clear that that fighting NCDs is intrinsic to improving the lives of all people, but it is also clear that the issue of NCDs in LMICs is incredibly complex. While some countries are making progress, the majority are off course to meet the global NCD targets. [21] The role of policy change, taxation, mass media and regulation of foods in targeting NCDs and their risk factors are all pivotal when NCDs are seen as part of an industrial epidemic. [13] As such, only by addressing the issues through a multisectorial response against NCDs and their risk factors can we make any real progress towards reducing or attenuating the occurrence of NCDs.

11. World Health Organization. The Abuja Declaration: Ten Years On. 25 March 2011, World Health Organization. 12. Babey, S.H., et al., Designed for Disease: The Link Between Local Food Environments and Obesity and Diabetes. 2008. 13. Moodie, R., et al., Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet, 2013. 381(9867): p. 670-9. 14. Chege, C.G.K., C.I.M. Andersson, and M. Qaim, Impacts of Supermarkets on Farm Household Nutrition in Kenya. World Development, 2015. 72(0): p. 394-407. 15. UNICEF, Nutrition strategies and programmes in Kenya. 2011, UNICEF. 16. Macro, K.N.B.o.S.a.I., Kenya Demographic and Health Survey 2008-2009. KNBS and ICF Macro: Calverton, Maryland. 17. World Health Organization. NCD Country Profiles. 2011. 18. World Health Organization. NCD Country Profiles. 2014. 19. World Health Organization. Non Communicable Diseases: An overview of Africa’s New Silent Killers. [cited 2015 26 April 2015]; Available from: http://www.afro.who.int/en/clusters-a-programmes/dpc/ non-communicable-diseases-managementndm/npc-features/1236-noncommunicable-diseases-an-overview-of-africas-new-silent-killers.html. 20. World Health Organization. Report on the review of primary health care in the African Region. WHO regional office for Africa. 2008, World Health Organization. 21. World Health Organization. Global status report on noncommunicable diseases. 2014, World Health Organization. 22. Agosti, J.M. and S.J. Goldie, Introducing HPV vaccine in developing countries--key challenges and issues. N Engl J Med, 2007. 356(19): p. 1908-10. 23. Vaccine, H. “Has the Program Been Successful?” Success of National HPV Vaccination Program. [cited 2015 1 April]; Available from: http://www.hpvvaccine.org.au/the-hpv-vaccine/has-the-program-beensuccessful.aspx. 24. World Health Organization, U., World Bank, State of the world’s vaccines and immunization. 2009, World Health Organization: Geneva. 25. African Development Bank Group. Country Strategic Paper 2014-2018. 26. United Nations Development Group. United Nations Development Assistance Framework for Kenya 2014-2018. 2013. 27. World Health Organization. WHO Country Cooperation Strategy 2014 - 2019. 2013. 28. Matheka, D.M., et al., Young professionals for health development: the Kenyan experience in combating non-communicable diseases. Glob Health Action, 2013. 6: p. 22461.

References 1. United Nations. High-level Meeting on Non-communicable Diseases. 2011; Available from: http://www.un.org/en/ga/president/65/ issues/ncdiseases.shtml. 2. World Health Organization. Global status report on noncommunicable diseases. 2010, World Health Organization. 3. World Health Organization. Noncommunicable diseases factsheet. 2015. 4. Hosseinpoor, A.R., et al., Socioeconomic inequality in the prevalence of noncommunicable diseases in low- and middle-income countries: results from the World Health Survey. BMC Public Health, 2012. 12: p. 474. 5. United Nations, Resolution 66/2. Policatal Declaration of the High-level Meeting of the General Assembly on the Prevnetion and Control of Non-communicable Diseases. In: Sixty-sixth session of the United Nations General Assembly. . 2011, United Nations: New York. 6. United Nations. Kenya’s fight against noncommunicable diseases aims to improve health, strengthen development. 6 October 2014 8 June 2015]; Available from: http://www.who.int/nmh/ncd-taskforce/unf-kenya/en/. 7. Dealing with the spread of chronic disease in Africa. Available from: http://novartis.com.bd/newsroom/feature-stories/2014/09/noncommunicable-diseases-in-africa.shtml. 8. Group, W.B., Decision Time: Spend More or Spend Smart? Kenya Public Expenditure Review. 2014, World Bank Group. 9. AIHW, Health expenditure Australis 2012-13. , in Health an welfare expenditure series no. 52. 2014: Canberra. 10. Alwan, A.D., G. Galea, and D. Stuckler, Development at risk: addressing noncommunicable diseases at the United Nations high-level meeting. Bull World Health Organ, 2011. 89(8): p. 546-546a.

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Review Article

Multidisciplinary Health Practice for Indigenous Communities

Ayesha Aziz, Hadrian Pranjoto, Mingkun Guan, Nicolas Adrianto Soputro & Rahul Vivek Rane Abstract The complex interaction of behavioural risk factors, historical events, and social determinants of health, compounded by barriers to accesses for health services, have been recognized as the causes of gaps in Indigenous health. The relatively poor health status of Indigenous communities demands integration of conventional medicine with local perspectives and cultural values. This article puts forth perspectives of students from different health related disciplines for resolving problems of access to healthcare for Indigenous Australians. It is hoped that the accounts in this article will serve as a starting point for dialogue on the institution of multidisciplinary healthcare teams. Introduction Indigenous health represents one example of community-based practice which demands for a marriage between conventional medicine and an appreciation of local perspectives and cultural values. Medical professionals should appreciate that the increasing levels of complexity means that help from experts from different industries could be fruitful. Hence, one solution is to create a multidisciplinary team comprised of people with medical and other expertise to tailor specific and sustainable solutions towards certain health issues. Multidisciplinary teams have been known to increase the levels of innovation as well as improving implementation in the scopes of knowledge, skills, and abilities. [1] The Royal Australian College of General Practitioners (RACGP) recognises that multidisciplinary care is highly crucial to improve the primary healthcare services for Australians as it helps General Practitioners (GPs) to provide “continuous, close, and respectful therapeutic relationships with patients.” [2, p. 454] However, according to the World Health Organization, the definition of multidisciplinary practice extends beyond the patients themselves. They explained the concept as the provision of the highest quality of care by working together with the patients, families, caregivers, and the surrounding communities. [3] The institution of multidisciplinary teams in healthcare practices has raised numerous questions regarding its efficacy, which is measured by patient satisfaction as well as the hospital admission and re-admission rates for those hospitalized at home. [4,5] The following will present Indigenous health access as a sample case study of how multidisciplinary teams can be utilized to generate some recommendations for the local vector journal

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communities. The Aboriginal and Torres Strait Islander population, which makes up 3% of the total Australian population, [6] has been faced with numerous inequalities over the years, especially in the healthcare sector. Recent surveys show that the median age of Indigenous Australians is 21 years, which is 16 years less than the median age of non-Indigenous Australians. [7] Their life expectancy is also lower by 10 years as compared with non-Indigenous population. Furthermore, the low socioeconomic status of many Indigenous individuals increases their likelihood of engaging in practices that can elevate their risks of major health complications. The Australian Institute of Health and Welfare (AIHW) stated that Indigenous Australians are twice as likely to be daily smokers and 50% more likely than non-Indigenous population to drink alcohol at chronic high risk levels, which are two risk factors that predispose to cardiovascular diseases, chronic kidney disease, and type 2 diabetes. [7] Despite the widespread passion for “Closing the Gap” advocated by the Australian government, the discrepancies in the health outcomes between Indigenous and non-Indigenous communities remain, which means that more work is needed in the area. [8] Various studies illustrate the under representation of Indigenous people across the three tiers of Australian Healthcare System, [9-10] which encompasses preventative medicine, primary accesses represented by GP consultations, and accesses to hospital-based and further treatments. As an example, on the preventative side, the immunisation coverage of Indigenous volume 10, issue 17

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children in 2009 aged 5 years (78.2%) was lower than that of their non-Indigenous counterparts (82.7%). [7,11] In terms of hospital access, 26% of Indigenous Australians aged 15 years and over are faced with difficulties in accessing these services due to their rural and remote residence. [7] Multiple factors, such as financial, linguistic, and cultural barriers also give rise to challenges in accessing primary health services as simple as GP consultations. [12-13] These problems can be considered to be stemming from the differences between Indigenous communities and non-Indigenous health practitioners, especially in terms of cultural values and opinions of a good healthcare system. As an example, health workers and policy makers tend to focus on improving physical environment and the healthcare system, putting aside the issues of trust and respect, which are paramount for Indigenous patients. [14] It is hard not to consider how the historical and intergenerational trauma of the Half-Caste Act, and other historical Government policies, has contributed to Indigenous people’s distrust in health and welfare services. [15] Racial discrimination in policies, institutional structures and social networks has led many Indigenous people to live in closed, isolated communities. [16-17] Even after the National Apology of 2008 and affirmative actions to promote Indigenous health, many Indigenous Australians are being ‘caught between two worlds’ as they live with ambivalent identities. [18-19] The complex interaction of behavioural risk factors, historical events, and social determinants of health, compounded by barriers to accesses for health services have been recognized as the cause of gaps in Indigenous health. [7] Together these issues raise the integral question of how can different perspectives from different disciplines be integrated to improve Indigenous health access? This article presents the various problems related to Indigenous people’s access to primary health care services. It builds on perspectives of students from different disciplines and considers an institution of multidisciplinary healthcare teams as an effective option for collaborative approach to problem solving. It is hoped that the following accounts vector journal

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from students of medicine, molecular biology, social work and business will enrich readers’ thinking about the various approaches to understanding and dealing with problems experienced by Indigenous people. Problems of Healthcare Access – A Medical Perspective For most Australians, primary and community health services represent the frontline of the health care system and are provided by GPs and allied health professionals. General practice services serve as a direct measure of access to primary care. [9] According to the Bettering the Evaluation and Care of Health (BEACH) survey over five-year period from 2001 to 2006, only 1.5% of total GP consultations were with Indigenous patients, even though they account for 2.5% of the total population as of 30 June 2006. In addition, a comparison study conducted in the Townsville Aboriginal Community Controlled Health Services (ACCHS) sector has showed GP cases in Indigenous population are more complicated and challenging compared to mainstream general practice. On average, 1.65 problems were managed per consultation in ACCHS, whereas 1.45 problems needed to be managed in mainstream GP. [20] It is proposed that language and cultural differences have been the main barriers limiting Indigenous people’s access to GP services. [12-13] In 2008, 11% of the Indigenous Australians who spoke a non-English language at home had reported difficulty communicating with English speakers. This rate was markedly increased among older Indigenous people (aged 55 and over), which makes up 24% of the Indigenous population. [7] Additionally, cultural barriers remain a prominent issue in relation to access to healthcare. Indigenous and non-Indigenous Australians hold different perspectives of health and wellbeing. [13] A research study found that non-Indigenous health workers believed that improving the physical environments and the healthcare system would be the most effective ways of breaking the cultural barrier. However, Indigenous Australians consider sincere and open interpersonal relationships that are based on trust and respect to be crucial in medical pracvolume 10, issue 17

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tice. [14] This study concluded non-Indigenous doctors and Indigenous Australians hold very different opinions about health care and many doctors were misguided when it came to how to provide culturally appropriate health care for Indigenous patients. Fortunately, we now have more Indigenous people joining the health care profession [21] and they are a critical source in demonstrating to non-Indigenous health staff culturally appropriate practices. One possible solution to address this issue of cultural differences is early in doctors’ during medical training. Medical schools should integrate this issue into their curriculums and implement Indigenous rotations to give medicals students more exposure to Indigenous health care. In fact, in 2004 the Committee of Deans of Australian Medical Schools (CDAMS) developed an Indigenous Health Curriculum Framework with the purpose to provide medical schools with guidelines for how to successfully implement and deliver indigenous health content in medical education. Specific strategies include recruiting more Indigenous people as medical educators; inviting Indigenous guest speakers; integrating Indigenous elements into case-supported learning (CSL) or problem-based learning (PBL) and community visits. [22] In addition, continued education post-medical schools are equally essential. There are now a considerable amount of workshops and conferences pertinent to Indigenous health available to health professionals, given by organisations such as National Aboriginal Community Controlled Health Organisation (NACCHO). [23] Practising doctors should be encouraged and motivated to regularly attend these conferences that serve as a reminder on how to provide the best care for Indigenous population, as well as keeping them well-informed on the latest trends in Indigenous health care. Over the past decades, through the employment of more Indigenous health workers and culturally competent non-Indigenous staff, health promotion campaigns specifically tailored for Indigenous Australians, and increased utilisation of interpreter services, [12] we are finally “closing the gap” in terms of GP service usage. In 2009-10, the number of GP services vector journal

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reimbursed by Medicare was similar between Indigenous and non-Indigenous populations (approximately 5,630 and 5,550 per 1000 population, respectively). [9] Nonetheless, this is only the tip of the iceberg. Indigenous Australians are still doing poorly in other sectors of the healthcare spectrum such as preventive and hospitalised care. The road ahead is still full of obstacles. From empirical data to solutions: A molecular biology perspective Even though Australia is a pioneer in molecular diagnostics and drug development technologies, there has been a grave paucity of such studies or ventures tailored to Indigenous Australians. This deficiency is particularly exacerbated in the case of genetic studies, [25] mainly due to Indigenous communities finding a lack of benefit and fearing risk of further persecution based on their genetic background, particularly in insurances. One such case was seen in New Zealand with the ‘warrior gene’ fiasco of 2006, which led to an unintended racial discrimination against the Maori community by media incorrectly labeling them as aggressive and prone to risk-taking. [26] Such debacles can however be evaded by implementation of culturally sensitive ethical frameworks and protocols as recommended by Kowal et al., [25] which can help adapt medical researches to benefit Indigenous Australians. In addition, research focus and investments should be targeted towards the factors that can impact Indigenous health access and outcomes. For example, recent research has suggested that Indigenous people with mixed ancestry see increased incidence of rheumatoid arthritis as compared to persons with strictly non-Aboriginal ancestry. [27] In addition, a recent and record first genomic study of Indigenous people also reported a genetic risk for high body-mass index and type 2 diabetes in Indigenous communities. [28] The knowledge of such risk factors and trends in public health can be used to design specific treatment, as exemplified by Anderson et al., [28] by discovery of specific genes found in affected individuals whose genomes they sequence. Each of these studies when combined together can be used to form short-term and long-term treatment goals by clinicians and associated volume 10, issue 17

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organizations. Problems of Healthcare Access – A Social Work Perspective In terms of primary health services, it has been shown that racial discrimination plays a crucial role in hindering Indigenous people from medical consultations as 22% of them reported racism from health providers. [17,29] Hence, there is a need for healthcare providers to establish trust with Indigenous communities at different levels in the Australian healthcare system, which can be done by respecting their social values. As an example, medical and allied health professionals must appreciate Indigenous peoples’ strong association to land, [30-33] extended family/kinship networks and affiliation to local languages that collectively form important aspects of their identities. [3233] Social work practice rests upon the multidimensional approach that appreciates the interactive nature between an individual and various aspects of their environments, such as psychological, spiritual, social, and cultural. [34] In addition, social work practice also encapsulates commitment to values of respect and social justice, which mandates the recognition of historic and racial disadvantages that can adversely affect behaviours, social determinants, access to health care services and health status of Indigenous populations. [35] For medical practices, social workers can facilitate groups engaging in critical reflection to encourage realisation of personal and culturally constructed biases, [36-38] which is deemed to prompt empathetic practice and modification of service protocols to address Indigenous needs. The multiple identities of different generations of Indigenous people calls for working in partnership with them so that they can be included in defining their problems as well as identifying and instituting solutions. [20,34-35] Roles and responsibilities in teams are defined by legal and ethical boundaries, but they are highly influenced by social norms and situational realities. [37] Social workers can contribute by encouraging mutual aid in teams and driving efforts towards affirmative action for Indigenous vector journal

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communities. Strategic Use of Indigenous Health Funding: A Financial Perspective In 2008-2009, healthcare expenditure for the Indigenous population was 1.39 times higher than that for non-Indigenous people. However, high prevalence of certain health problems and geographical challenges raise questions as to whether more spending is required along with the need for a more strategic use of Indigenous health funding to improve health services and accesses for Indigenous Australians. [41] Professor Geoffrey Dobb, the Vice President of Australian Medical Association (AMA), highlighted that it is now the responsibility of all the governments and health service providers to strategically target funding to ensure that Indigenous people get the access to the right health service in the right place at the right time. [42] Decisions made by both the funders and the providers should be based on returns from investments, including individual and community health gain, equity, as well as the incorporation of cultural security, which is defined as “the delivery of health services of such a quality that no one person is afforded a less favourable outcome simply because they hold a different cultural outlook”. [43, p.45] Moreover, to improve the priority setting process by the funders and the providers, there is a need to make use of better evidence and data, especially economic evaluations. It has been suggested that more education on the credibility of economic evaluation by training staff in health economics would improve the use of economic evaluation evidence. [38] Contracts in the context of Indigenous health provision is defined as the arrangements which specifies the services or other activities the government funders are obtaining on the behalf of the community, including the amount of funding, reporting and other accountability required. The currently applied funding and accountability arrangements have been particularly criticised for being excessively fragmented and complex, especially in terms of administrative and reporting requirements. [44] The contracts should accommodate uncertainties, such as the possibility of sudden changes in service demand, while maintaining care quality volume 10, issue 17

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and continuity. As opposed to the old-fashioned classical contracting, relational contracting recognises the contractor-supplier interdependence, and is characterised by greater flexibility and cooperation, as well as reliance on trust and mutual accountability. This approach can potentially reduce administrative costs and improve healthcare performance. [44] So far, the reformation progress from classical contracting to relational contracting has been slow, and it is also still too early to assess on outcomes. But on a positive note, the provision of community governance and delivery on the basis of negotiation and agreed standards represents an important milestone towards an authentic partnership approach between communities and governments. Moreover, it also opens the possibility of a better integration of healthcare provision by both the community-controlled sector and the mainstream health system in a more practical sense, rather than simply in the form of high policy principles. [45] Conclusion Access to primary healthcare for Indigenous Australians presents a complex problem and to yield sustainable and effective solutions, each of the factors contributing to the problems have to be considered by seeking advice from experts in different industries. The four accounts from different postgraduate students in medicine, molecular biology, social work and business, addressed a portion of the problem surrounding Indigenous healthcare access. However, it highlights the varying perspectives and approaches that exist which are outside the scope of practice for medical practitioners. For example, it is important to acknowledge the roles of social worker in taking care of the patients’ wellbeing post-treatment and ensuring that they have the access to various supporting facilities crucial to their treatment. The roles of financiers and accountants are also important in providing financial access as well as creating cost-effective solutions that can be easily adjusted for different circumstances. Lastly, molecular biology represents an important part of science towards the health industry for specific targeted treatments that can be provided to patients quickly by knowing their underlying genetic predispositions, hence saving costs and time. Access to primary healthcare for Indigenous Australians presents just one of the many health vector journal

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challenges that calls for experts from different industries to collaborate and formulate sustainable solutions. This collaboration has the potential to create avenues for greater learning, reflections, and knowledge transfer, and ultimately lead to better health outcomes for patients. We hope that the above accounts from students of different disciplines could be a starting point to appreciate the importance in integrating a multidisciplinary team in tackling ongoing local and global health problems. References:

1. Fay, D, Borrill, C, Amir, Z, Haward, R, West, M. Getting the most out of multidisciplinary teams: A multi-sample study of teams in healthcare. The British Psychological Society. 2006;79:553-567. 2. Royal Australian College of General Practitioners 2011. Multidisciplinary Care. The RACGP Curriculum for Australian General Practice 2011. Melbourne: Royal Australian College of General Practitioners. 3. World Health Organization 2010. Framework of action on interprofessional education and collaborative practice. Geneva: World Health Organization. 4. Poulton, B, West, M. Effective multidisciplinary teamwork in primary healthcare. Journal of Advanced Nursing. 2003;18:918-925. 5. Joseph, R, Brown-Manhertz, D, Ikwuazom, S, Santomassino, M, Singleton, J. The effectiveness of structured interdisciplinary collaboration for adult home hospice patients on patient satisfaction and hospital admission and re-admission: a systematic review protocol. JBI Database for Systematic Reviews and Implementation Reports. 2014; 14(7). 6. Biddle N 2014. Data about and for Aboriginal and Torres Strait Islander Australians. Issues paper no. 10. Produced for the Closing the Gap Clearinghouse. Canberra: Australian Institute of Health and Welfare & Melbourne: Australian Institute of Family Studies. 7. Australian Institute of Health and Welfare 2011. The health and welfare of Australia’s Aboriginal and Torres Strait Islander people, an overview 2011. Cat. no. IHW 42. Canberra: AIHW. 8. Pholi K, Black D, Richards C. Is ‘Close the Gap’ a useful approach to improving the health and wellbeing of Indigenous Australians?. Australian Review of Public Affairs. 2009;9(2):1-13. 9. Australian Institute of Health and Welfare 2011. Access to health services for Aboriginal and Torres Strait Islander people. Cat. No. IHW 46. Canberra: AIHW. 10. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. The Lancet. 2009;374(9683):65-75. 11. Hull B, Dey A, Mahajan D, Campbell-Lloyd S, Menzies R, McIntyre P. NSW Annual Immunisation Coverage Report, 2009. NSW Public Health Bull. 2010;21(10):210. 12. Hayman N, White N, Spurling G. Improving Indigenous patients’ access to mainstream health services: the Inala experience. The Medical Journal of Australia. 2009;190(10):604-606. 13. King M, Smith A, Gracey M. Indigenous health part 2: the underlying causes of the health gap. The Lancet. 2009;374(9683):76-85. 14. McBain-Rigg K, Veitch C. Cultural barriers to health care for Aboriginal and Torres Strait Islanders in Mount Isa. Australian Journal of Rural Health. 2011;19(2):70-74. 15. Herring S, Spangaro J, Lauw M, McNamara L. The Intersection of Trauma, Racism, and Cultural Competence in Effective Work with Aboriginal People: Waiting for Trust. Australian Social Work. 2013;66(1):104-117. 16. Paradies, Y, Harris, R, Anderson, I. 2008, The Impact of Racism on Indigenous Health in Australia and Aotearoa: Towards a Research Agenda, Discussion Paper No. 4, Cooperative Research Centre for Aboriginal Health, Darwin. 17. Bonilla-Silva E. Rethinking Racism: Toward a Structural Interpretation. American Sociological Review. 1997;62(3):465. 18. Fejo-King C. The National Apology to the Stolen Generations: The Ripple Effect. Australian Social Work. 2011;64(1):130-143. 19. Brough M, Bond C, Hunt J, Jenkins D, Shannon C, Schubert L. Social capital meets identity: Aboriginality in an urban setting. Journal of Sociology. 2006;42(4):396-411. 20. Larkins S, Geia L, Panaretto K. Consultations in general practice and at an Aboriginal community controlled health service: do they differ?. Rural Remote Health. 2006;6(3):560. 21. Australian Institute of Health and Welfare 2009. Aboriginal and Torres Strait Islander health labour force statistics and data quality assessment. Cat. no. IHW 27. Canberra: AIHW. 22. Phillips G. CDAMS Indigenous health curriculum framework. Sydney: Committee of Deans of Australian Medical Schools, 2004. [cited 3 July 2015] Available from: http://www.medicaldeans.org.au/pdf/CDAMS%20Indigenous%20Heal th%20Curriculum%20Framework.pdf 23. Healthinfonet.ecu.edu.au. Conferences, workshops and events « Key resources « Australian Indigenous HealthInfoNet [Internet]. 2015 [cited 3 July 2015]. Available from: http://www.healthinfonet.ecu.edu.au/key-resources/conferences 24. Steering Committee for the Review of Government Service Provision (SCRGSP) 2011. Report on Government Services 2011. Canberra: Productivity Commission. 25. Kowal E, Pearson G, Peacock C, Jamieson S, Blackwell J. Genetic Research and Aboriginal and Torres Strait Islander Australians. Bioethical Inquiry. 2012;9(4):419-432. 26. Lea R, Chambers G. Monoamine oxidase, addiction, and the “warrior” gene hypothesis. The New Zealand Medical Journal (Online) 2007 Mar 02;120(1250). 27. Vincent F, Bourke P, Morand E, Mackay F, Bossingham D. Focus on systemic lupus erythematosus in Indigenous Australians: towards a better understanding of autoimmune diseases. Intern Med J. 2013;43(3):227-234. 28. Anderson D, Cordell H, Fakiola M, Francis R, Syn G, Scaman E et al. First Genome-Wide Association Study in an Australian Aboriginal Population Provides Insights into Genetic Risk Factors for Body Mass Index and Type 2 Diabetes. PLoS ONE. 2015;10(3):e0119333. 29. Paradies Y, Cunningham J. Experiences of racism among urban Indigenous Australians: findings from the DRUID study. Ethnic and Racial Studies. 2009;32(3):548-573. 30. Gray M, Coates J, Yellow Bird M. Indigenous social work around the world. Aldershot, Hants, England:Ashgate; 2008. 31. Graham M. Some Thoughts about the Philosophical Underpinnings of Aboriginal Worldviews. Australian Humanities Review. 2008;(45):181194. 32. Bourke E. The first Australians: Kinship, family and identity. Family Matters. 1993;(35):4-6. 33. Grieves, V. 2009, Aboriginal Spirituality: Aboriginal Philosophy, The Basis of Aboriginal Social and Emotional Wellbeing, Discussion Paper No. 9, Cooperative Research Centre for Aboriginal Health, Darwin. 34. Harms L. Understanding human development. South Melbourne, Victoria: Oxford University Press; 2005. 35. AASW Code of Ethics. Brisbane: Australian Association of Social Workers. 2010 36. Bernard D. The use of groups in social work practice. London ; Boston: Routledge and Kegan Paul; 1975. 37. Leonard B. Groups for growth and change. New York: Longman; 1991. 38. Furlong M, Wight J. Promoting “Critical Awareness” and Critiquing “Cultural Competence”: Towards Disrupting Received Professional Knowledges. Australian Social Work. 2011;64(1):38-54. 39. Paradies Y. Defining, conceptualizing and characterizing racism in health research. Critical Public Health. 2006;16(2):143-157. 40. Nakata M, Nakata V, Keech S, Bolt R. Decolonial goals and pedagogies for Indigenous studies. Decolonization: Indigeneity, Education and Society. 2012;1(1):120-140. 41. Korff J. How Aboriginal people use healthservices [Internet]. Creative Spirits. 2015 [cited 13 June2015]. Available from: http://www.creativespirits.info/aboriginalculture/health/how-aboriginal-people-use-health-services 42. Indigenous Health Funding Must be Better Targeted. Targeted News Service 2011 Jun 24. 43. Otim M, Kelaher M, Anderson I, Doran C. Priority setting in Indigenous health: assessing priority setting process and criteria that should guide the health system to improve Indigenous Australian health. International Journal for Equity in Health. 2014;13(1):45. 44. Dwyer J, Lavoie J, O’Donnell K, Marlina U, Sullivan P. Contracting for Indigenous Health Care: Towards Mutual Accountability. Australian Journal of Public Administration. 2011;70(1):34-46. 45. Dwyer J, Boulton A, Lavoie J, Tenbensel T, Cumming J. Indigenous Peoples’ Health Care: New approaches to contracting and accountability at the public administration frontier. Publi Management Review. 2013;16(8):1091-1112.

Review Article

War on the Female Body: Rape and Sexual Violence during Conflict Carrie Lee Abstract: Sexual violence has an enormous burden on individuals and communities worldwide. Women and girls are particularly vulnerable, with one in three women globally estimated to experience physical or sexual violence in their lifetime. Rape and sexual violence has severe physical and psychological consequences in any circumstance. This article focuses on rape as a weapon of war, the sociological impacts of which can be widespread and long-lasting. This is especially due to the ensuing terror and disruption to livelihoods, relationships and morale. A recent example explored in this article was the rapes of over 200 women and girls in October 2014 by Sudanese military forces. Doctors and health workers can provide sensitive medical care to victims of sexual violence. However, medical care is only a fraction of the individual’s healing; the coordination of psychological and community support is integral to addressing their needs holistically, and can help potentially bridge barriers in accessing services.

Introduction In October 2014, over 200 women and girls in the town Tabit, Sudan were raped by Sudanese government troops, according to Human Rights Watch report.[1] Witnesses described uniformed soldiers systematically looting, beating residents, and raping women and girls in their homes and on the streets.[1] The civilian attacks and mass rapes were denied by the Sudanese government, and the town intimidated and repressed against speaking out about the crimes, with some even restricted access to medical care following rape. [1]

and girls. One in three women globally will experience physical and/or sexual violence by an intimate partner or non-partner, according to the World Health Organisation (WHO).[4,5] Women and girls are especially vulnerable to violence and discrimination in societies and cultures which limit their social status and control. Violence against women is an expression as well as reflection of gender inequitable norms, and disparities in opportunities and empowerment. Thus, if violence against women is ever to be eliminated, it is imperative to address the root issue of gender inequality.

Sexual violence is a major human rights and public health issue worldwide.[2] It causes serious physical and psychological suffering, and can have long-lasting and widespread impacts on individuals and communities.[2] Sexual violence is broadly defined as any sexual act, attempted sexual act, unwanted sexual comments or advances against a person’s sexuality by means of coercion such as physical force, intimidation, or blackmail.[2] Sexual violence encompasses a spectrum of manifestations including rape by intimate partner or non-partner, forced abortion and female infanticide, sexual abuse of children and people with intellectual disabilities, female genital mutilation, forced prostitution and sexual trafficking.[2,3] Another form of is that which occurs during armed conflict [2], such as the use of rape as a weapon of war. Rape in conflict settings is used as a militarised strategy to weaken and dehumanise enemies, attacking identity and social bonds. It is also employed as a means of terror and ethnic cleansing.[3]

This article is a response to the mass rapes in Tabit, exemplifying the intertwinement of health and human rights issues associated with rape in conflict settings. For such a horrific act of brutality, it has been met with relative silence and response nationally and internationally. This reiterates that sexual violence remains an under-recognised issue, despite its devastating effects and widespread prevalence. In addition, this article examines medical and social implications for victims of sexual violence, barriers in accessing services and the role of doctors, health workers and communities in providing appropriate care and preventing the perpetuation of violence.

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Sexual Violence During Conflict: Rape as a Weapon of War Rape and sexual violence occurs during times of peace, however it escalates during armed conflict and humanitarian crises.[6] This causes extensive physical and psychosocial trauma not only to the individual victims, but to their families and communities. This amplification of damage throughout communities contributes to the rationale and effectiveness of militarised rape in volume 10, issue 17

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inflicting widespread, long-lasting harm. The female body is thus more than mere spoils of war; when considered communal property, they serve as strategic targets through which to weaken morale and debilitate community bonds. History shows us examples of women and girls targeted for sexual violence during conflict. During World War II, Japanese soldiers abducted and forced into sexual slavery an estimated 100 000 to 200 000 women from Korea, China and the Philippines.[3,7] For centuries, sexual violence was considered an inevitable side effect of war, rather than a preventable or punishable human rights violation. This changed following the recognition of rape as a war crime, following post-WWII Tokyo war trials.[3] However, rape and sexual violence occurred during armed conflict throughout the late 20th century, including in Bangladesh, Uganda, Sierra Leone and the Democratic Republic of Congo.[3,8] Rape was also used as a means of ethnic cleansing, with mass rapes of Tutsis by Hutus in Rwanda [9], and systematic rapes of women in the former Yugoslavia to terrorise civilians into fleeing.[3] Since the Rome Statute of the International Criminal Court in 1998, rape and other forms of sexual violence are considered crimes against humanity.[10] During conflict and humanitarian crises, sexual violence manifests in two major forms. The first is militarised sexual violence, distinguished as strategic, systematic and perpetrated partly or fully by government and/or state military forces. Examples include systematic rapes of civilians, such as those in the former Yugoslavia and Tabit, Sudan in 2014. The second form is opportunistic sexual violence, the abuse of women and girls at increased vulnerability due to conditions attributed to conflict and insecurity.[6] This includes sexual assault of women and girls collecting firewood, food or water. This is a particular issue in camps for internally displaced persons (IDP) and refugees in Sudan and neighbouring Chad during the ongoing conflict in Sudan.[8] Due to vector journal

limited resources in heavily populated camps, families are forced to venture beyond the confines to forage for food and supplies, despite the risk of assault. Under such conditions, some families perceive that women and girls collecting firewood risk ‘only’ rape by Janjaweed militias, whereas men will almost certainly be killed.[8] It is also reported that women and girls at IDP or refugee camps may be forced to exchange sexual favours for food and necessities, including to peacekeepers and authorities supposedly responsible for their protection.[6]

were not spared from the violence, with victims and witnesses describing rapes of girls under 18.[1]

Humanitarian Crisis in Sudan and Mass Rapes in Tabit Conflict between government and rebel forces in Sudan has spanned over a decade since 2003. This has been driven by political and ethnic tensions, as well as long-standing struggles for scarce land and resources.[8,11] Villages have been destroyed, with inhabitants slaughtered and terrorised. Many attacks are racially targeted due to Fur, Masalit or Zaghawa ethnicity, predominant groups composing rebel forces known as the Sudan Liberation Army (SLA) and the Justice and Equality Movement (JEM).[8] These form a resistance against a government they feel marginalises interests of non-Arab populations. Ongoing issues with insecurity, loss of livelihoods and mass displacement have resulted in over 300 000 deaths due to direct violence, disease and starvation, with around 2 million internally displaced persons and refugees fleeing to neighbouring Chad.[11,12]

In addition to severe physical and psychological trauma inflicted on the village, intimidation from government authorities has contributed towards ongoing fear and repression. Residents have allegedly been deterred against speaking out about the crimes under threats including beatings and imprisonment. One interviewee likened the situation to “living in an open prison”, with military presence day and night and the prevention of female residents from exiting or visitors from entering.[1] The Government of Sudan and local authorities have publicly denied the crimes, as have some local traditional leaders, possibly under coercion. Members of the community have been instructed not to speak about the incident, especially not to Human Rights Watch or African Union United Nations peacekeepers.[1] This silencing and deprival of justice, with the crimes left unpunished, has been a further insult overshadowing the attacks.

Attacks against civilians in the village Tabit in the Darfur region of Sudan over three days commencing October 30th, 2014 are a brutal example of rape used as a weapon of war. According to over 130 witness interviews conducted and cross-referenced by Human Rights Watch, the attacks – including rapes, beatings and detainment – were perpetrated systematically by armed, uniformed Sudanese government soldiers. [1] Witnesses reported that soldiers entered houses, accused residents of links with rebels, detained or removed men and raped women and girls in their homes. During night attacks, men were reportedly forced out of households and taken to distant locations, leaving women extremely vulnerable. Most victims were raped multiple times, often by multiple men, and in front of their families or friends. Even children

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“They said, “You killed our man. We are going to show you true hell.” Then they started beating us. They took my husband away while beating him. They raped my three daughters and me. Some of them were holding the girl down while another was raping her.”

Extract from witness interview: a mother’s description of the rape of her and three daughters, two under the age of 11.[1]

“Imagine that people are raping your wife in front of your eyes and you can’t do anything. Or you see your sister is being raped and you are incapable of stopping it. After all this if you want to look for justice and there is no justice… What happened to us is unimaginable. One feels ashamed to talk about it.” Extract from witness interview in Tabit, Sudan [1]

Another serious issue has been the deterrence and prevention of sexually assaulted women and girls from receiving medical care at clinics and hospitals. According to the report, some women have not sought help due to fear of arrest and further abuse as punishment for disclosing the rapes. There is also the belief that many doctors work for the government or that clinics are observed by intelligence staff. Others describe local authorities refusing to assist victims to access medical doctors, intimidating health professionals vector journal

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and punishing families attempting to bring rape victims for medical attention.[1] Medical Implications of Rape Survivors of rape and sexual violence often suffer various physical and gynaecological problems as well as psychological distress. Substantial evidence exists regarding adverse health consequences. These include gynaecological complications [13,14], sexually transmitted infections [15,16], unwanted pregnancies [14], unsafe abortions [16], post-traumatic stress disorder and depression (Table 1).[16] Victims may also experience fear and shame [3], and face ostracism from their partners, families or community. [2,9] Their suffering may also be exacerbated by limited access to health services, or social taboo surrounding sexuality and sexual violence. Fistula, chronic pelvic pain and infertility are gynaecological complications caused by rape. [13,16] Conflict-related sexual violence is significantly more likely than non-conflict sexual violence to cause fistula (traumatic or obstetric) or chronic pelvic pain, according to a study in the Democratic Republic of Congo.[14] Traumatic gynaecological fistula is an extremely debilitating injury involving abnormal communication between the reproductive tract and internal organ, usually bladder or rectum.[17] Due to resulting urinary and/or faecal incontinence, women are often shunned and alienated by their communities. Particularly violent sexual assault such as gang rape or the use of foreign objects during rape leads to such fistulas.[17] Unwanted pregnancy and unsafe abortions are also possible consequences of rape. In their inability to access medical care during conflict, desperation may drive women to endanger their lives with unsafe abortion [6], especially in countries where abortion is illegal. Abortion may also be an urgent matter in order to prevent the manifestation of rape as a visible, socially taboo pregnancy, particularly in cultures where female chastity is linked with family honour. In addition, pregnancy may serve as a distressing physical reminder of assault to the mother, and children born out of rape are at higher risk of neglect and malnutrition [6]. Another medical consequence of rape in conflict is sexually transmitted infections including human immunodeficiency virus (HIV). Risk of HIV transvolume 10, issue 17

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mission is increased in violent, forced rape due to the likelihood of tearing and breaching the vaginal or anal mucosa.[2] It has been speculated that mass rapes contribute to increased HIV epidemics in conflict-affected countries with high HIV prevalence. Limited evidence is available, however one study investigating the impact on HIV incidence in African countries estimated increases of 5 infections per 100 000 females per year in four out of seven countries studied, including Sudan.[15] Medical Complications of Rape and Sexual Violence Physical injuries Gynaecological complications: Fistula (traumatic or obstetric) Infertility Vaginal discharge Chronic pelvic pain Genital lacerations, bruising, mutilation Sexually transmitted infections including HIV Unwanted pregnancy, unsafe abortion

position to provide medical care to victims of sexual violence, as well as facilitate access to appropriate psychological and social support services (Table 2). In addition, documenting evidence such as sperm and DNA samples can assist legal proceedings, including identification of attackers where appropriate and with consent. [2,7] Victims should be approached with utmost care, dignity and sensitivity, with awareness that their injuries may be deeper and more extensive than tangible physical complications. Care should be taken to ensure consultation and physical examination causes as little distress as possible. Furthermore, underreporting of rape and sexual violence is common due to innate sensitivity and other personal or social factors, and victims of sexual violence may present with injuries, infections or pregnancy without initially disclosing they have been raped. Thus, medical professionals should be vigilant for signs of aggression or sexual assault, including genital bruising, lacerations or mutilation; missing patches of hair; and bruising on the arms, chest or forehead.[3] Medical response to sexual violence

Psychological: Depression, suicidal ideation Post-traumatic stress disorder, anxiety Social dysfunction, isolation Substance abuse

Consultation and examination Documentation, full description of incident Gynaecological and contraceptive history Full physical examination Assess risk of pregnancy Emergency contraception, abortion counselling (if legal) Screening and treatment for sexually transmitted diseases including HIV Reassurance, communication, informed consent, safe environment Follow up

Table 1: Medical complications of rape and sexual violence [3,13,17] Sexual violence in any context causes severe physical, emotional and psychological suffering for victims. Depression, suicidal thoughts, post-traumatic stress disorder, anxiety, feelings of humiliation and fear, social withdrawal, inability to fulfil maternal roles and substance abuse are all adverse outcomes related to rape and sexual abuse.[9] Overall poorer physical and mental health, combined with stigma of sexual violence, contribute to the difficulty victims face in accessing healthcare and support. Furthermore, these issues may be exacerbated in conflict settings, especially in situations where victims endure or witness more extreme forms of violence. Medical care and mental health services, difficult for victims of sexual violence to access even during times of peace, become more inaccessible during conflict due to strain on resources or destruction of infrastructure. Doctors and other health workers are in a unique vector journal

Referral for psychological services and social support Counselling/therapy Support groups Rape crisis centres, helplines Non-government/community organisations, women’s groups Training of health workers and students on reproductive health issues, sexual violence and sociocultural factors Providing/facilitating access to information about sexual health and preventing sexual violence Table 2: Medical response to sexual violence [2]

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Whilst medical attention has valuable role in caring for victims of rape and sexual violence, it forms only a fraction of the individual’s process towards healing. The implications on mental health may be long-lasting, and social consequences such as blaming, fear and stigmatisation are a profound cause of suffering, as well as contributing to difficulty in breaking silence about sexual violence and seeking help. Integrated health, legal and community services are a potential means of increasing ease of access to support services. For example, rape crisis centres may provide various services including immediate and follow up medical care, counselling, forensic evidence, legal assistance, community support and education programs.[2]

are not merely isolated incidents. Systematic raids of non-Arabic villages by Janjaweed militants, at times in combination with Sudanese government troops, appear to have occurred on a mass scale.[8] A consistent pattern indicative of the systematic nature of these attacks has been described by survivors: raiding forces surround villages, their arrival often signified by sexual assaults of women and girls gathering firewood or water. Men and boys are killed, women and girls raped by attackers entering house to house or gathering groups at a central location. Finally, fleeing survivors, mostly female, are pursued and assaulted as they seek safety in the surrounding mountains, towns or entering IDP or refugee camps.[8]

Social Impacts of Rape During Conflict The prominent social aftershocks of rape drives the use of militarised sexual violence, a weapon intended to shame and debilitate populations. The intimate link between female chastity, marriage and family honour is viciously exploited when rape is perpetrated on a mass scale.[6] It is used during conflict as a strategic act of terror, humiliation and dehumanisation, a means of destroying community bonds and morale. Local leaders, male community members and parents of children assaulted may feel extremely disempowered or unable to protect their families. Many victims are killed during the assault, others that survive may be blamed, stigmatised or rejected by their communities.[9]

The aftermath of fear and terror from rape during conflict can have dire and long-lasting consequences. Women and girls in fear of sexual abuse may be reluctant to leave home and participate in normal routine, crippling the ability of households and communities to function and thrive. Education may be affected when children are afraid to walk to or attend school. Household malnutrition and poverty may be intensified when women are afraid to collect firewood, food or water in fear of assault. Economic status and employment is similarly compromised when men are afraid to work or unwilling to leave wives and daughters alone at home.[16] Such sociological impacts are amplified on a mass scale when sexual violence is enacted against large populations. This principle of widespread incapacitation contributes to the continued use of rape as a militarised weapon of war.

Systematic rape is also employed as a brutal means of ethnic cleansing.[12] Women’s bodies, perceived as communal property, are targeted for impregnation in order to extinguish or pollute blood lines and cultures. This has been exemplified by racially targeted sexual violence during conflict in Darfur, Sudan. Friction between Arab and non-Arab ethnic groups contributes to targeting of civilian populations of Fur, Masalit and Zaghawa ethnicities. Surveys from a retrospective study revealed increased use of racial epithets during combined attacks by Sudanese government soldiers and Arabic Janjaweed militia against ethnic African women (p<0.001). Racial terror and sexual violence is compounded in statements such as, “We will kill all men and rape the women. We want to change the colour…Arabs are the husbands of those women”.[12] Moreover, ethnically targeted attacks in Sudan vector journal

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Ethnic tension and discrimination is also a major barrier in the provision of and access to medical care in Sudan. Under the former Criminal Procedure Act, in order for patients to legally receive treatment, they were required to obtain a medical evidence form from police, known to withhold forms from individuals of certain non-Arabic tribes.[18] Health workers have also been pressured and intimidated as a deterrent against caring for these ethnic populations. An example is the harassment, detainment and interrogation of health workers at the Amel Centre for Treatment and Rehabilitation of Victims of Torture in Darfur. The centre is a non-government organisation providing free legal and clinical services to those affected by human rights violations, including volume 10, issue 17

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numerous victims of violence (beatings, gunshot wounds) and rape, mainly from tribes of non-Arabic ethnicity. As many as 1 in 2 women who attended from 2004-6 disclosed sexual assault (49.3%), most commonly gang rape (86.1%), and this was potentially an underestimation of the true scope of sexual violence as the majority of patient records at the time were male (252/325 = 77.5%).[18] Broadly speaking, community involvement is vital in fostering an environment where victims can safely access services and support they need and taking action to prevent perpetuation of sexual violence. Having the support of their community can have a profound influence on healing and protection against further stigmatisation and discrimination. Communities have the capacity to implement measures to prevent the perpetuation of sexual violence, for example through education in schools, support for women’s groups, inclusion of women in decision-making and public awareness campaigns to reduce stigma and acceptability of sexual violence (billboards, radio and television, theatre, public meetings).[2] Integration of sexual violence education with other health and social issues such as reproductive health, HIV, and general violence issues may also help to ease into discussion of sexual violence in settings, especially in situations where it is a sensitive issue.[2] Community activism contributes towards reducing stigma and changing public acceptability of sexual violence. Conclusion Sexual violence causes an enormous burden on individuals and communities worldwide, however it remains highly stigmatised and under-recognised. Victims of rape and sexual violence may endure a magnitude of physical and psychosocial consequences. This burden may be deepened by barriers accessing health services and community support, as well as victim blaming, stigmatisation and ostracism. Rape and sexual violence in conflict zones can be particularly debilitating due to weakened social infrastructure, widespread violence and presence of arms, mass displacement and loss of livelihoods, and increased baseline levels of violence against women throughout the population. The mass rapes of women and girls in Tabit, Sudan are a gross violation of human rights and an unspeakable act of cruelty. It is unspeakable vector journal

on multiple levels, from the silencing of victims and traumatised communities, to the silence of the international community about the atrocities and others committed throughout the decade of conflict in Sudan. Women and girls continue to be targets of sexual violence, especially due to disparities in opportunities and social status. If we ever hope to reduce the occurrence of sexual violence, it is absolutely crucial that we empower communities and take local and international action to address root causes of gender inequality. As current and future doctors, it is important to maintain awareness that sexual violence is intrinsically linked with personal factors and sociocultural issues. Medical attention is only a part of the individual’s healing process, with psychological and social factors equally as important. Coordination of appropriate health and community support can help address the individual’s needs holistically as well as bridge potential barriers in accessing services. Victims commonly encounter difficulties in accessing care for various reasons, and even those able to access care may not initially disclose sexual violence, and may need careful prompting once a safe environment and trust has been established. Thus a level of vigilance for signs of sexual violence should be maintained to help identify women at risk. Sexual violence may be silenced at first, however by seeking to understand, listening for warning signs and taking appropriate measures, doctors can help to heal and give victims a voice. References 1. Loeb J. Mass Rape in Darfur. United States: Human Rights Watch, 2015 February 2015. Report No. 2. Grug EG, Dahlburg LL, Mercy JA, Zwi AB, Lozano R. World Report on Violence and Health. Geneva: World Health Organisation (WHO), 2002. 3. Swiss S, Giller JE. Rape as a crime of war: A medical perspective. JAMA. 1993;270(5):612-5. 4. World Health Organisation/London School of Hygiene & Tropical Medicine/South African Medical Research Council. Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and non-partner sexual violence. 2013. 5.World Health Organisation/London School of Hygiene and Tropical medicine. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva: 2010. 6. Marsh M, Purdin S, Navani S. Addressing sexual violence in humanitarian emergencies. Global Public Health. 2006;1(2):133-46. 7. Watts C, Zimmerman C. Violence against women: global scope and magnitude. The Lancet. 2002;359(9313):1232-7. 8. Gingerich T, Leaning J. The use of rape as a weapon of war in the conflict in Darfur, Sudan: Program on Humanitarian Crises and Human Rights, Franc̦ois-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health; 2004. 9. Stark L, Wessells M. Sexual violence as a weapon of war. JAMA. 2012;308(7):677-8. 10. Kivlahan C, Ewigman N. Rape as a weapon of war in modern conflicts. BMJ. 2010;340:c3270. 11. Olsson O, Siba E. Ethnic cleansing or resource struggle in Darfur? An empirical analysis. Journal of Development Economics. 2013;103(0):299312. 12. Hagan J, Rymond-Richmond W, Palloni A. Racial targeting of sexual violence in Darfur. Am J Public Health. 2009;99(8):1386-92. 13. Frljak A, Cengic S, Hauser M, Schei B. Gynecological complaints and war traumas. Acta Obstetricia et Gynecologica Scandinavica. 1997;76(4):350-4. 14. Dossa NI, Zunzunegui MV, Hatem M, Fraser W. Fistula and other adverse reproductive health outcomes among women victims of conflict-related sexual violence: a population-based cross-sectional study. Birth. 2014;41(1):5-13. 15. Supervie V, Halima Y, Blower S. Assessing the impact of mass rape on the incidence of HIV in conflict-affected countries. AIDS. 2010;24(18):2841-7. 16. Clifford C, Slavery SM, editors. Rape as a Weapon of War and it’s Long-term Effects on Victims and Society. 7th Global Conference Violence and the Contexts of Hostility Budapest(5-7 May 2008); 2008. 17. Salim F. Holdstock-Piachaud Prize essay. War and the systematic devastation of women: the call for increased attention to traumatic gynaecological fistulae. Medicine, Conflict & Survival. 2012;28(2):125-32.

Review Article

Keeping the Promise: A Review of the Millennium Development Goals Aaron Kovacs

Abstract: If there’s one quality the United Nations cannot possibly be accused of lacking, it’s ambition. The Millennium Development Goals stand as one such product of the UN’s idealism, eight limited and yet very well intentioned targets for global health progress by the year 2015. And now that 2015 has finally rolled around, how close have we actually come to meeting any of those goals? The unfortunate reality is that while many nations have made remarkable health and social progress, a minority of countries will fail to meet any of the goals at all. Many of the most heavily affected constituencies lack the political will to strive for such changes, perhaps because it is the louder voices of developed nations that drives dialogue surrounding the MDGs. However, regardless of the apparent naivety of such ambitious targets, the Millennium Development Goals have been necessary because they provide exactly what its name suggests: a goal that we have to continually keep striving for. It hasn’t been fifteen years without significant and measurable progress, and perhaps that is more important than whether or not the UN is aiming too high. If there’s one quality the United Nations cannot possibly be accused of lacking, it’s ambition. The Millennium Development Goals stand as one such product of the UN’s idealism, eight limited and yet very well intentioned targets for global health progress by the year 2015. Adopted in September 2000, the MDGs have aimed to address many of the indisputably pressing health and environmental issues of the 21st century, and have been described by the University of Manchester’s Professor David Hulme as ‘the world’s biggest promise.’[1] The eight MDGs are as follows: 1. To eradicate extreme poverty and hunger 2. To achieve universal primary education 3. To promote gender equality and empower women 4. To reduce child mortality 5. To improve maternal health 6. To combat HIV/AIDS, malaria, and other diseases 7. To ensure environmental sustainability 8. To develop a global partnership for development

18. Tsai AC, Eisa MA, Crosby SS, Sirkin S, Heisler M, Leaning J, et al. Medical evidence of human rights violations against non-Arabic-speaking civilians in Darfur: a cross-sectional study. PLoS Med. 2012;9(4):e1001198.

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The nature of the goals being set wasn’t exactly unprecedented, but the international community’s financial commitment to attempting to meet them has been; in 2005, the G8 nations 32

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agreed to cancel US$40 to $55 billion in debt owed by some of the world’s poorest countries. [2] The UN’s secretary-general Ban Ki-Moon has hailed the MDGs as ‘the most successful global anti-poverty push in history’[3], though some would argue otherwise; some view the MDGs as a warm, fluffy and ultimately hollow gesture with good intentions, while other more radical critics feel the MDGs actively distract the international community from more effective measures and issues of greater importance, such as finding working alternatives to capitalism.[1] So now that 2015 has finally rolled around, maybe we can begin to put the debate to rest when we finally have some more concrete statistical evidence. But therein lies one of the biggest problems with assessing the effectiveness of the MDGs. The reality is that it’s very difficult to track the exact extent of progress in many countries where data is limited, or entirely absent[4] – countries that are often the ones most desperate for change. And it hasn’t always been a straightforward fifteen years for governments and humanitarian organisations. Since the turn of the millennium, we have seen Timor-Leste become a sovereign state following years of occupation, a war-torn Sudan splintered into two separate nations, and the Arab’s world’s pursuit of democracy leave a steadily growing trail of death and destruction in its wake. Much of India and Southeast Asia was left to pick up the volume 10, issue 17

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pieces following the catastrophic 2004 Boxing Day tsunami, while Haiti is still recovering from the devastation of the 2010 earthquake. According to UN data, the number of newly displaced persons has tripled since 2010, with developing nations shouldering the greatest burden.[5] There have been setbacks, some manmade and others natural, and ones that truly highlight that we can’t possibly achieve the MDGs without peace and international cooperation. So in spite of these shortcomings, how close have we actually come to meeting any of these goals? There has legitimately been some remarkable, if uneven, change over the last fifteen years. According to the UN’s 2014 MDG progress report[5], as well as the African Development Bank[6] and Center for Global Development[4], a number of their targets have indeed been met, while others still face significant challenges. Goal 1: Eradicate extreme poverty and hunger While ‘eradicate’ might not be the right word, UN data suggests that we have actually met the first component of goal 1: to halve the proportion of people living in ‘extreme poverty’, defined as those living on an income of less than US$1.25 a day, between 1990 and 2015.[5] In 1990, 36% of the world lived under such conditions, in comparison to the 18% in 2010.[5] It’s an extraordinary statistic at first glance, though much of the apparent success is owed to China, a country that has witnessed a veritable social revolution over the last two and a half decades. Today, 12% of its 1.35 billion inhabitants live in extreme poverty, in contrast to the 60% of China in 1990.[5] Certainly, the numbers overlook those that aren’t necessarily living in extreme poverty, but regardless, it is significant change. However, the statistics don’t look nearly so good in other parts of the globe; the UN’s most recent estimate of the proportion of people living on less than $1.25 a day in Sub-Saharan Africa remains at 48%, just 8% down from the corresponding figure in 1990.[5], With Africa’s dramatic population growth, the number of people living in extreme poverty has actually increased, rising to 410 million in 2010 from 290 vector journal

million in 1990 (excluding North Africa).[6] Even worse is knowledge that the proportion of people living in extreme poverty has worsened in eight African nations: Central African Republic, Nigeria, Madagascar, Zambia, Kenya, Guinea Bissau and Côte d’Ivoire.[6] It may be some improvement in terms of percentage, but it’s evidence that the international community’s current approach to tackling poverty in many parts of Africa isn’t working well enough. Goal 2: Achieve universal primary education The second MDG has aimed to address the less than complete rates of primary education throughout the world, particularly aiming to reduce the gap in education between that of males and females. The last fifteen years have marked some dramatic increases in enrolment rates throughout the developing world, with an average improvement of 7%.[5] Most significant is the improvement in Sub-Saharan Africa[6], increasing to 78% in 2012 from 60% in 2000[5], though there are still significant disparities between individual countries, with eleven countries having net enrolment rates of less than 75%.[6] Once again, however, the apparent improvement in the numbers somewhat obscures a less favourable reality; with booming birth rates worldwide, the 60 million children out of school in 2007 stood at a similar 58 million in 2012.[5] A disproportionate 50% of these children live in conflict-affected areas[5], feeding that vortex of poverty and violence much of the developing world knows too well. Goal 3: Promote gender equality and empower women It’s too easy to think of the MDGs as being only applicable to developing nations, but reducing inequality between women and men stands as equally critical in the developed world. It’s another area where progress is being made, but the disparity is still apparent.

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Women still remain underemployed in comparison to men in non-agricultural sectors, modestly improving worldwide from a 35% share to a 40% share of paid positions.[5] The global time-related underemployment rate, a measure of those willing and able to work more hours, stands significantly higher amongst women in most regions of the world, including developed countries.[5] Wage disparity is also a significant problem in much of the world, and particularly Africa; of the 54 African countries, only in Egypt, Uganda, The Gambia, Ghana, Malawi, Zambia Burundi, Botswana and Benin do women earn at least 75% of what men in similar positions are paid.[6] Women’s political involvement still remains poor worldwide, though some parts of the world have shown dramatic improvement. As of 2014, women hold 24% of political seats in national parliaments in North Africa, in stark contrast to 3% in 2000.[5] Five countries still remain with no female representation whatsoever: Palau, Qatar, Tonga, Vanuatu and Yemen.[5] Of all the seats in the developing world, 21% are now occupied by women, only 4% behind the alarming 25% of seats in developed nations.[5] It may be the 21st century, but the glass ceiling remains firmly in place for many women worldwide. Goal 4: Reduce child mortality The sad reality is that the MDGs’ target to reduce the under-five mortality rate from 1990 to 2015 by two-thirds has appeared to fall short. It hasn’t been without significant progress, however; the global under-five mortality rate dropped to 48 per 1,000 in 2012 from 90 per 1,000 in 1990.[5] This improvement has coincided with far higher rates of measles vaccination worldwide, although recent progress appears to be stagnating. Most regions, barring Sub-Saharan Africa and Oceania, reduced mortality rates by at least half, resulting in 17,000 fewer under-five children dying everyday.[5] Interestingly, improvements have been noted at all income levels and in both developed and developing nations.[5] It’s no small consolation, but there is still so much more to be done. vector journal

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Goal 5: Improve maternal health Going hand in hand with goal 4, goal 5’s aim to reduce maternal mortality rates by three-quarters has also failed to be met. In spite of this, as of 2012 we have seen a 45% reduction worldwide since 1990[5], with 68% of births in the developing world being assisted by a trained professional, in contrast to only 56% in 1990.[5] Sub-Saharan Africa remains the most heavily affected region in the world, accounting for 62% of maternal deaths in 2013.[5] Sierra Leone is the most heavily burdened country in the world, with a staggering 1,100 deaths per 100,000 live births – in plain terms, more than one in a hundred live births results in the death of the mother. This stands in contrast to Belarus, Israel and the Scandinavian nations, countries that have amongst the lowest rates worldwide at between 1 and 4 deaths per 100,000 live births.[7] Few of the goals so well illustrate the shocking disparity between developed and the most disadvantaged nations. Goal 6: Combat HIV/ AIDS, malaria and other diseases While HIV incidence has declined significantly since 2001, many parts of Africa remain crippled by devastating infection rates. As of 2012, a record 35.3 million people are living with HIV worldwide, with new infection rates continuing to exceed AIDS-related deaths. [5] Condom use amongst males and females engaging in higher-risk sex in Sub-Saharan Africa remains very poor, at an estimated 57%, in contrast to the 95% target set by the UN General Assembly in 2001.[8] However, access to antiretroviral therapy has been dramatically improving annually, with an unprecedented 1.6 million additional patients receiving treatment in 2012. The UN estimates that, given current trends, the target 15 million patients receiving ART by 2015 could be a reality.[5] Closely tied to HIV/AIDS prevalence, reducing rates of tuberculosis has been another significant volume 10, issue 17

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MDG target. 1.1 million of the 8.8 million patients diagnosed in 2013 were also HIV-positive, and 75% of the 8.8 million from Africa.[6] Despite this, worldwide, the number of new cases of TB per 100,000 is dropping, with 87% of newly diagnosed patients in 2011 being treated successfully.[5] Whether or not these trends can be maintained in the face of the rising threat of multidrug-resistant tuberculosis remains to be seen. With increased use of anti-malarial interventions, the world has seen a 42% decline in malaria mortality rates between 2000 and 2012. [5] Over that period, an approximate 700 million insecticide-treated bed nets were distributed throughout Sub-Saharan Africa, once again the most heavily affected region in the world. However, only an estimated 36% of the inhabitants of these countries have access to a bed net[5], highlighting the enormous gap that still needs to be bridged. Goal 7: Ensure environmental sustainability In terms of progress, Goal 7 arguably stands as the most disappointing of the MDGs. It’s 2015, and millions of hectares of forest continue to be destroyed annually, while carbon emissions continue to rise dramatically as parts of the developing world begin to industrialise. Though developed regions have observed a slight reduction in carbon emissions, dropping from 14.9 billions of metric tons in 1990 to 13.3 billions of metric tons in 2011, emissions in the developing world have spiked, now contributing more emissions than the developed world with 18.9 billions of metric tons in 2011.[5] Perhaps it’s one of those things that have to get worse before it can get better, but it’s still a pressing concern being entirely overlooked by too many countries, Australia included. Goal 7 also includes the specific target to halve the proportion of the population without consistent access to basic sanitation and clean drinking water, and there has been some remarkable global progress made in that field. In 1990, an estimated 24% of people worldwide did not have access to clean water, in comparison to 11% vector journal

in 2012, achieving the target before schedule. [5] Despite this, 45 countries will still fail to meet those targets, twenty of which are from Africa[6], again emphasising the considerable disparity between different countries and regions of the world. Moreover, the sanitation target will fail to be met, 2.5 billion people worldwide still without access to adequate facilities, a very modest 7% improvement from the 2.7 billion in 1990.[6] Goal 8: Develop a global partnership for development The final MDG focuses on maintaining strong and functional ties between nations, and admittedly suffers from some of the MDGs’ most poorly defined targets; target 8A is a prime example of this, supposedly aiming to ‘[d]evelop further an open, rule-based, predictable, non-discriminatory trading and financial system’.[5] The Organisation for Economic Co-operation and Development (OECD) states that as of 2013, developed countries net ‘official development assistance’ sat at an all-time high of US$134.8 billion, or a combined 0.9% of the developed world’s gross national income.[9] Impressive figures, perhaps, but equally ones that remind us of the MDG’s dependence on foreign aid that can only reach so far. A more enduring change is the significantly decreased debt burden on developing countries; in 2000, 12% of exports from developing nations were external debt payments, in contrast to 3.1% in 2012.[5] On another positive note, the UN notes that Internet access throughout the developing world is rapidly increasing, with two-thirds of the world’s Internet users living in developing regions. An estimated 20% of Africa’s population are online, as of 2014, up from 10% in 2010.[5] Even still, more than four billion people worldwide are yet to use the Internet, a likely consequence of insufficient access and affordability for many individuals. 2015 and beyond So the results are in – or at least as much of it as we’re going to get with incomplete data – and

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the findings are somewhat mixed. The unfortunate reality is that while many nations have made remarkable health and social progress, as we can see, at the opposite end are nations such as the Democratic Republic of Congo and Côte d’Ivoire, countries that will fail to meet any targets at all.[4] The MDGs may be eight undoubtedly worthwhile targets, but they also fail to address the root causes of poverty and social inequality. Moreover, many of the most heavily affected constituencies lack the political will to strive for such changes, perhaps because it is the louder voices of developed nations that drives dialogue surrounding the MDGs.

continually remind us of the promise we’ve made ourselves and the fact that we are determined to keep it.

Another question that stands is whether or not these positive trends will be able to continue in the face of fluctuating foreign aid, although 2013 marked a rebound from two years of diminishing volumes.[9] The Guardian’s Liz Ford has described the MDGs as essentially ‘targets for poor countries to achieve, with finance from wealthy states’[10], while the Center for Global Development called them ‘overly-ambitious goals’ with ‘unrealistic expectations’ on foreign aid.[11] It’s very easy to be a cynic, and maybe understandably so; even the UN have acknowledged the ‘gaps and disparities’ between their idealised vision of 2015 and the projected reality.[5] But it hasn’t been failure without measurable progress, and perhaps that is more important than whether or not the UN is aiming too high.

4. Center for Global Development. MDG Progress Index: Gauging Country-Level Achievements [Internet]. Washington, D.C.: Center for Global Development; 2011 [accessed 2015 Apr 4]. Available from: http://www. cgdev.org/page/mdg-progress-index-gauging-country-level-achievements

In September of this year, the United Nations will aim to finalise the specifics of the Sustainable Development Goals, the proposed successors to the MDGs. The SDGs will purportedly aim to ‘[b]uild upon commitments already made’ by the MDGs, but with an additional focus on implementing ‘action-oriented’ strategies that support long-term, sustainable development.[12] It’s a topic that cannot possibly be explored in an adequate level of detail here, and certainly warrants an essay of its own. Perhaps the SDGs will be able to address the shortcomings of the MDGs’ programs and 2030 will be the year we eliminate inequality for good – or at least we’ll be closer to making that dream a reality. Regardless of the apparent naivety of such ambitious targets, the Millennium Development Goals have been necessary because they provide exactly what its name suggests: a goal that we have to continually keep striving for. We’ve needed the MDGs to vector journal

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References 1. Hulme D. The Millennium Development Goals (MDGs): A Short History of the World’s Biggest Promise [Internet]. Manchester: Brooks World Poverty Institute, University of Manchester; 2009. Available from: http:// www.bwpi.manchester.ac.uk/medialibrary/publications/working_papers/ bwpi-wp-10009.pdf 2. Mutume G. Industrial countries write off Africa’s debt. United Nations Africa Renewal [Internet]. 2005 Oct [cited 2015 Mar 4]. Available from: http://www.un.org/africarenewal/magazine/october-2005/industrial-countries-write-africas-debt 3. United Nations. The Millennium Development Goals Report 2013. New York: United Nations; 2013. Available from: http://www.un.org/millenniumgoals/pdf/report-2013/mdg-report-2013-english.pdf

5. United Nations. The Millennium Development Goals Report 2014. New York: United Nations; 2014. Available from: http://www.un.org/millenniumgoals/2014%20MDG%20report/MDG%202014%20English%20web.pdf 6. African Development Bank. MDG Report 2014: Assessing Progress in Africa toward the Millennium Development Goals. Addis Ababa: Economic Commission for Africa; 2014. Available from: http://www.afdb.org/fileadmin/uploads/afdb/Documents/Publications/MDG_Report_2014_11_2014. pdf 7. World Health Organization, UNICEF, UNFPA, The World Bank & United Nations Population Division. Trends in Maternal Mortality: 1990 to 2013. Geneva: WHO Press; 2014. Available from: http://apps.who.int/iris/bitstre am/10665/112682/2/9789241507226_eng.pdf 8. United Nations General Assembly. Declaration of Commitment on HIV/ AIDS. New York: United Nations; 2001 Jun 27. Report no.:S-26/2. Available from: http://www.un.org/en/development/devagenda/hiv.shtml 9. Organisation for Economic Co-operation and Development. Aid to developing countries rebounds in 2013 to reach an all-time high [Internet]. Paris: OECD; 2014 Apr 8 [accessed 2015 Apr 4]. Available from: http:// www.oecd.org/newsroom/aid-to-developing-countries-rebounds-in2013-to-reach-an-all-time-high.htm 10. Ford L. Sustainable development goals: all you need to know. The Guardian [Internet]. 2015 Jan 20 [cited 2015 Mar 25]; Global Development. Available from: http://www.theguardian.com/global-development/2015/jan/19/sustainable-development-goals-united-nations 11. Clemens M, Moss T. CDG Brief: What’s Wrong with the Millennium Development Goals? Washington, D.C.: Center for Global Development; 2005 Sep. Available from: http://www.cgdev.org/files/3940_file_WWMGD. pdf 12. United Nations. Sustainable development goals [Internet]. New York: United Nations; 2015 [accessed 2015 Mar 20]. Available from: https:// sustainabledevelopment.un.org/topics/sustainabledevelopmentgoals

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Review Article

An update on HIV Technology: What’s the latest? Are we far from a cure? Hayleigh Chiang & Rukaiya Malik Abstract: HIV/AIDS has wreaked havoc across the globe since its discovery in 1981, when patients were first clinically identified with the disease. Since then, medical advances have enabled improved antiretroviral therapy (ART) and management protocols. Furthermore, a significant number of global health organisations highlight HIV/AIDS as a priority area for research and global management. Even though there is no current HIV vaccine, there is significant research occurring into the development of an effective vaccine. However, there are a variety of challenges with creating a vaccine that needs to be addressed. The HIV prophylactic methods that are being implemented in parts of the world include male circumcision, topical microbicides, oral pre-exposure prophylaxis (PrEP) and the use of ART as prevention. Novel treatments for HIV such as neutralising antibodies, ‘shock and kill’ approaches and gene modification are currently being researched through pre-clinical phase trials and small clinical trials. The preliminary evidence is promising for such novel treatments and hence with further research they have the potential to be used as viable treatment options. With the advent of new technologies, finding a cure for HIV is slowly becoming a more realistic goal but despite all of these progressive measures, the global burden of HIV remains immense. Introduction The cure for HIV/AIDS remains evasive since the discovery of the condition in 1981, however there have been several major breakthroughs in HIV treatment and prevention interventions over the years.[1] For instance the breakthrough of mother-to-child transmission prevention in 1994 and the introduction of triple combination antiretroviral therapy (ART) in 1996 following the Vancouver 11th International Conference on AIDS. [2,3] Triple combination ART is still the main form of treatment today. In addition, the degree of protection medical male circumcision provided against acquiring HIV infection is well-supported by Randomised Control Trials (RCTs) from 2005 onwards,[4] and topical microbicides having a role in reducing HIV acquisition is supported by RCTs such as the 2010 trial by Karim et. al.[5]. Furthermore, the introduction of oral PrEP occurred following strong supporting evidence from RCTs since 2010,[6,7,8,9] and lastly treatment with ART used as prevention has been highly supported by the 2011 landmark study by Cohen MS et. al.[10] Evidently, there has been extensive ongoing research into HIV treatment and prevention. However there is currently no cure for HIV or any vaccine that works effectively in humans and hence research continues today into newer technologies such as gene modification and the ‘shock and kill’ approach. This article will explore vector journal

the epidemiology of HIV/AIDS and then delve into the recent advances in HIV/AIDS prevention and treatment including potentially promising future therapies. The current statistics and epidemiology According to statistics published by the World Health Organisation, approximately 35 million people worldwide were living with HIV/AIDS in 2013.[11] It was estimated that 1.5 million people had died from AIDS in that year alone.[11] Sub-Saharan Africa continues to be the most severely affected region, accounting for 71% of the global population living with HIV/AIDS. Fortunately, the expansion of the HIV/AIDS epidemic has steadied in recent years, as have the number of AIDS related deaths.[11] The Kirby Institute’s latest Annual Australian Surveillance Report of HIV, viral hepatitis and sexually transmissible infections, revealed that the HIV rates in Australia are the highest they have been in twenty years.[12] The report further stated that there are now more than 26 000 people living with HIV in Australia and that one in seven Australians are unaware they have the infection.[12] This increase in Australia’s HIV rates has been attributed to casual unprotected sex between male partners.[12] As of the end of 2013, the number of new cases of HIV on a state/territory basis indicated that New South Wales, Victoria

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and Queensland have the greatest numbers in descending order respectively.[12] On a positive note, the number of HIV cases caused by unsafe intravenous drug usage is now down to 2% in Australia. This achievement was reached through the widespread introduction of the safe disposal of needles and syringe programs.[12]

An update on HIV vaccinations The development of a vaccine that can be prophylactic or therapeutic is one of the major methods considered and heavily researched for managing the HIV epidemic.[13] This section will focus primarily on the research surrounding preventative vaccines and also the potential for vaccines to provide a ‘functional cure’. The pursuit for a safe and efficacious preventative vaccination has been challenging and limited by a variety of factors. Importantly, immune correlates of HIV control are currently not clearly defined.[14] Thus, success of the vaccine is difficult to determine. The importance of identifying immune correlates of HIV is necessary for future research on vaccinations, to ensure that outcomes in efficacy trials can be measured and compared. Various markers have been considered previously, including virus-specific T-cells and humoural immune responses, however confounding factors prevent a direct causal relationship from being identified. [14] To date, there have been six vaccine efficacy trials conducted. Of these trials, only one study was able to demonstrate efficacy with the vaccine.[15] This is the RV144 study which used the canarypox vector vaccine. This trial was a community-based double blind, randomized and placebo-controlled trial conducted in Thailand. [16] Participants of this study were at risk of contracting HIV infection heterosexually. Whilst vector journal

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efficacy with this trial was established, there are many limitations with broadening the results of this study to the wider community. The population sample size was small and thus the study is low in power. Despite this, the RV144 study enabled further research for identifying immune correlates of HIV infection risk.[17] A case-control analysis conducted by Haynes & Gilbert et al, aimed to identify cellular and antibody correlates of HIV infection risk.[17] This correlates study was hypothesis-generating and suggested that IgA antibody binding to envelope proteins is inversely related to the rate of HIV infection. In addition it was found that IgG antibody binding to variable regions 1 and 2 of HIV enveloped proteins, may be directly correlated with the rate of HIV infection. Whilst these findings may inform future research in the area, the study rightly recognised its limitations and highlighted that further clinical vaccine efficacy trials or animal models must be developed in light of this information for true identification of correlates of HIV infection risk.[17] Up until now several strategies have been trialled in developing a preventative HIV vaccine. The use of live attenuated vaccines for HIV has been discussed and is a contentious issue. The major concern was that any attenuated vaccine has the potential to result in infection.[18] Examples such as the live attenuated polio vaccine causing paralytic poliomyelitis were stressed.[18] Additionally, a study on gay men who became infected with a naturally attenuated form of HIV, were later found to have compromised immune function over time.[18] These observations support the view that live attenuated HIV vaccines have a capacity to cause HIV infection. The current strategy in developing a vaccine is to create an immunogen and vaccination protocol that induces both a broadly reactive and cell mediated immunity as well as a neutralising humoural response. The aim behind this, is to ensure that the vaccine is active at potential infection sites and post-infection.[15] Presently, there has been discussion surrounding the use of vaccines in establishing a ‘functional cure’ in people already infected with HIV. Between 2008 and 2010 a trial using a peptide based therapeutic vaccine known as ‘Vacc-4x’ was conducted.[19] This was a phase 2 randomised and double blinded placebo controlled volume 10, issue 17

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trial which recruited 136 participants across multiple sites in Europe and USA.[19] One group was assigned to receive the vaccine, whilst the other received a placebo. An article by Pollard and Rockstroh et al, explored the efficacy and safety of this vaccine.[19] It was established that there was no significant difference between groups in terms of efficacy.[19] Overall, whilst there was no benefit from the vaccination, it was established that Vacc-4x was generally safe and is worth considering for further investigation into a ‘functional cure’.[19] At this point in time, a vaccine for prophylaxis or a ‘functional cure’ remains elusive.[15] Unfortunately, the majority of vaccines that initially seemed promising in the laboratory and then even in animal studies, eventually fail in human trials. However, research that delves into the discovery of potential HIV immune correlates will facilitate prediction of outcomes in future HIV vaccine efficacy studies. Current methods of HIV prophylaxis As there is no current vaccination that effectively prevents HIV transmission, antiretroviral medications are currently being used as prophylaxis in high-risk populations. In addition, new HIV prevention interventions including male circumcision, topical microbicides (e.g. tenofovir 1% gel) and oral pre-exposure prophylaxis (PrEP) are currently being implemented.[20] PrEP and ART for prevention especially, are two methods which are currently being considered for widespread global use due to their efficacy and safety.[10] A 2011 study explored the prevention of HIV infection with commencing ART immediately once HIV positive status was recognised (early) rather than delaying therapy until CD4 count decreases below 350 or HIV related symptoms begin.[10] This study was conducted across nine different countries and observed couples whereby one partner was HIV positive and the other HIV negative.[10] Results of the study highlighted that early administration of ART was successful in reducing rates of HIV transmission via sexual transmission by a relative reduction of 96%.[10] However, the study also mentioned that there was an increase in drug-related side effects in those couples that commenced ART early.[10] The results further demonstrate that both the infected and uninfected individual benvector journal

efit from this approach, thus ART for prophylaxis may be an appropriate public health strategy in managing the HIV pandemic.[10] This study has prompted a number of recent trials, two of which revealed favourable results, however some were terminated as non-adherence to antiretroviral regimes rendered the programs ineffective.[20] Hence, whilst the use of ART for prevention of HIV appears promising, drug stock outs, the cost of ART, adverse drug reactions and subsequent poor adherence to treatment regimes remains a challenge in implementing such programs globally. PrEP is a daily oral pill consisting of tenofovir and emtricitabine for people who are HIV negative but with a substantial risk of contracting HIV infection.[21] The ART used in PrEP are effective in blocking the pathways used by HIV to initiate an infection. The PrEP needs to be taken daily to ensure the levels of the medications remain at an appropriate level to prevent HIV infection. Several PrEP trials have demonstrated efficacy. The 2013 Bangkok Tenofovir randomized and double blinded study demonstrated that PrEP was effective in preventing transmission of HIV in people who inject drugs.[9] In addition, a 2012 study based in Botswana demonstrated that PrEP was successful in preventing HIV infection amongst sexually active heterosexual adults.[7] Recently, the US Public Health Service released ‘clinical practice guidelines for PrEP’ recommending that it be considered for all people who are HIV negative and at a high risk of contracting HIV.[22] Similar to using ART for prevention, PrEP adherence remains a challenge and adherence to the once daily pill is essential for efficacy.[22] The ‘clinical practice guideline for PrEP’ emphasizes the importance of adherence counselling and provides various strategies to improve adherence, including education.[22] Some recent studies have even considered the use of PrEP in the form of a long-acting injection every three months.[22] Novel approaches to treating HIV/AIDS Currently the mainstay of treatment for HIV involves the combination of at least three medications – i.e. ‘triple combination therapy’. The classes of these medications include; protease inhibitors, non-nucleoside and nucleoside reverse transcriptase inhibitors, fusion inhibitors and integrase inhibitors. The underlying mechanism of these medications combined, is to prevent HIV

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from entering CD4+ T-lymphocytes and from replicating.[23] These drugs do not provide a cure but are able to reduce the viral load, increase the CD4 cell count and thus keep clinical signs and symptoms at bay.[23] There is continual research into reducing the cost and adverse effects of ART as well as research into the cure for HIV. Two common research approaches are a sterilizing cure, where all HIV infected cells are eliminated, and a functional cure, whereby the individual does not require the use of ART in order to have life-long control of HIV. [24] The 2014 AIDS conference discussed a new ‘shock and kill’ approach, which is a potentially promising sterilising cure for HIV. Its aim is to eliminate the barrier that our current antiretroviral medications have because of their inability to kill latent HIV infected cells. As ART currently stands, it is a life long medication regime for HIV positive individuals since HIV is able to remain latent in cells.[25] If the patient stops taking the medication, these latent viruses are able to activate and spread throughout the body.[25] Unfortunately ART does not have the ability to eliminate the inactive viruses because they are unable to recognise cells, which have been infected with dormant HIV.[25] The ‘shock and kill approach’ has been tested with a mice model and was successful.[25] The study involved injecting mice containing human immune cells with HIV and treating them with ART, latency reversing agents, broadly neutralising antibodies or an amalgamation of these treatments.[25] Latency reversing agents are medications that have the ability to activate latent viruses.[25] Neutralising antibodies, such as ones that neutralize AMV reverse transcriptase has been shown to significantly reduce viral load and markedly increase CD4+ T lymphocytes on immunological testing.[26] This vector journal

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seems encouraging, however the pilot study on neutralising antibodies of AMV reverse transcriptase is limited by its sample size and inability to be transferred to the general HIV population.[26] The mice in the ‘shock and kill approach’ study were treated with a combination of three different latency reversing agents and the broadly neutralising antibodies and consequently had no sign of viral rebound in blood levels after the treatment was ceased.[25] Based on this result, it is clear that preventing HIV from creating and maintaining an inactive reservoir will be a key component in finding a sterilizing cure.[25] However, it is important to contextualise this research as being evidence from mice models and appreciating its low predictive value for humans. Incidences such as the famous ‘Berlin patient’ who is the only person reported to have been functionally cured of HIV in 2008,[26] have been extensively analysed and inspired avenues for research into novel treatments such as gene modification. The ‘Berlin patient’ had HIV and later was diagnosed with acute myeloid leukaemia and hence underwent stem cell transplantation with a donor who was homozygous for the CCR5Δ35 mutation.[26] Current research into gene modification involves the removal of key cells from people infected with HIV and genetically modifying these cells to resist HIV infection, then returning the modified cells to the infected individual.[27] The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health is funding the research behind this technique.[27] The scientific reasoning behind this method of treatment is based on observations that individuals who possess a genetic modification to the CCR5 protein are naturally resistant to HIV and when exposed to HIV these individuals progress to AIDS at a slower rate.[27] The CCR5 protein is a surface cell receptor that most variants of HIV use to invade the CD4+ T-lymphocyte. A recent trial involved genetic modification of CCR5 in 12 HIV infected individuals.[27] The protein was made non-functional and multiplied so that each individual had ten billion of their own CD4+ T-lymphocytes re-infused.[27] When measuring the outcome of this treatment all participants ceased their ART. Results indicated that all modified CD4+ T-lymphocytes remained protected from HIV. It is hoped that using this technology will allow individuals to control the virus without the use of volume 10, issue 17

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medications.[27] Conclusion This article only captures a snapshot of the evolving technologies surrounding HIV prevention and management. The current safety status and efficacy of prophylactic HIV vaccines is yet to be established and remains controversial. However, research is now focussed on elucidating immune correlates of HIV, which will enable greater accuracy in efficacy vaccine trials. A HIV vaccine that can produce a ‘functional cure’ is also under consideration. There have been exciting breakthroughs with HIV treatment and prevention over the years that are well supported by strong RCT evidence. This includes HIV prophylactic methods that are implemented around the world such as prevention of mother to child transmission, male circumcision, topical microbicides, oral PrEP and the use of ART as prevention. Triple combination antiretroviral treatment remains the mainstay of management of HIV today. There is much less evidence for novel treatments such as the ‘shock and kill approach’ and gene modification in comparison to well-established preventative and treatment measures. However the preliminary evidence for such novel treatments is promising and the research is working towards discovering functional and sterilising cures for HIV. This is a rapidly growing field. Hence, medical students and practitioners alike should be encouraged to remain informed about new advances in HIV treatment and prevention to ensure patients receive the most evidence-based and optimal care. This is particularly crucial given the continuing global burden of HIV/AIDS. With the ongoing advancement of medical technology, it is hoped a cure for HIV will become a reality in the not so distant future. References 1. Gallo RC, Montagnier L. Discovery of HIV as the Cause of AIDS. N Engl J Med. 2003;349:2283-2285. 2. Connor EM, Sperling RS, Gelber R et. al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS clinical trial group protocol 076 study group. N Engl J Med. 1994;331(18):1173-80. 3. The XI international conference on AIDS, Vancouver 7-12 July, 1996. A review of clinical science track B. Genitourin Med. 1996;72(5):365-369. 4. Auvert B, Taljaar D, Lagarde E et. al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005;2(11):e298. 5. Karim QA, Karim SSA, Frohlich JA et. al. Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science. 2010;329:1168-1174. 6. Grant RM, Lama JR, Anderson PL et. al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med.

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2010;363:2587-2599. 7. Thigpen MC, Kebaabetswe PM, Paxton LA et. al. Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana. N Engl J Med. 2012;367:423-434. 8. Baeten JM, Donnell D, Ndase P et. al. Antiretroviral prophylaxis for HIV-1 prevention among heterosexual men and women. N Engl J Med. 2012;367(5):399-410. 9. Choopanya K, Martin M, Suntharasamai P et. al. Antiretroviral prophylaxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomized double-blind, placebo-controlled phase 3 trial. Lancet. 2013;381(9883):2083-90. 10. Cohen MS, Chen YQ, McCauley M et. al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6). 493-505. 11. World Health Organisation. HIV/AIDs Global Health Observatory Data. [Internet] 2014 [cited 2014 Sept 9]. Available from: http://www.who.int/ gho/hiv/en/ 12. The Kirby Institute for infection and immunity in society 2014. HIV, viral hepatits and sexually transmissible infections in Australia Annual Surveillance Report. [Internet]. 2014 [cited 2015 Mar 27]. Available from: http:// www.kirby.unsw.edu.au. 13. Wang N, Li Y & Niu W, Sun M, Cerny R, Li Q, Guo J. Construction of a live-attenuated HIV-1 vaccine through genetic code expansion. Angew Chem. 2014;53(19):4967-4971. 14. Prado JG, Carrillo J, Blanco-Heredia J, Brander C. Immune correlates of HIV control. Curr Med Chem. 2011;18(26):3963-70. 15. Tomaras GD, Haynes BF. Advancing Toward HIV-1 Vaccine Efficacy through the Intersections of Immune Correlates. Vaccines. 2014;2:11535. 16. Rerks-Ngarm S, Pitisuttithum P, Nitayaphan S et.al. Vaccination with ALVAC and AIDSVAX to prevent HIV-1 infection in Thailand. N Engl J Med. 2009;361(23):2209-2220. 17. Haynes BF, Gilbert PB, McElrath MJ, et al. Immune-correlates analysis of an HIV-1 Vaccine Efficacy Trial. N Engl J Med. 2012;366(34):12751286. 18. Blower SM, Koelle K, Kirschner DE, Mills J. Live attenuated HIV vaccines: Predicting the tradeoff between efficacy and safety. Proc Natl Acad Sci USA. 2001;98(6):3618-3623. 19. Pollard RB, Rockstroh JK, Pantaleo G, et al. Safety and efficacy of the peptide-based therapeutic vaccine for HIV-1, Vacc-4x: a phase 2 randomised, double-blind, placebo-controlled trial. Lancet Infec Dis. 2014;14:291-300. 20. Alistar SS, Grant PM & Bendavid E. Comparative effectiveness and cost effectiveness of antiretroviral therapy and pre-exposure prophylaxis for HIV prevention in South Africa. BMC Medicine. 2014;12(46). 21. Pre-Exposure Prophylaxis (PrEP). Centres for Disease Control and Prevention [Internet]. 2014. [updated 2014 Sept 30; cited 2014, Oct 12]. Available from: http://www.cdc.gov/hiv/prevention/research/prep/index. html. 22. Department of Heath and Human services USA and Centres for Disease Control and Prevention. Pre-exposure prophylaxis for the prevention of HIV infection in the United States. [Internet] 2014. [cited 2014 Oct 12]. Available from: http://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf. 23. Salah S, Hajjar B & Essam R. A novel approach to inhibit HIV-1 infection by actively neutralizing the antibodies of reverse transcriptase system. J AIDS Clin Res. 2014;5(310). 24. Rennie S, Siedner M, Tucker JD, Moodley K. The ethics of talking about ‘HIV cure’. BMC Med Ethics. 2015;16:18. 25. Haler-Stromberg, Lu CL, Klein F, Horwitz JA, Bournazos S, Nogueira L, Eisenreich TR, Liu C, Gazumyan A, Schaefer U, Furze RC, Seaman MS, Prinjha R, Tarakhovsky A, Ravetch JV, Nussenzweig MC. Broadly Neutralising Antibodies and Viral Inducers decrease rebound from HIV-1 latent reservoirs in humanised mice. Cell. 2014;158(5):989-999. 26. Yuki SA, Boritz E, Busch M et. al. Challenges in dectecting HIV persistence during potentially curative interventions: a study of the Berlin patient. PLoS Pathogens. 2013;9(5):e1003347 27. National Institute of Allergy and Infectious Diseases (NIAID). Genetic Modification of Cells Proves Generally Safe as HIV Treatment Strategy. [Internet] 2014. [updated 2014 Mar; cited 2014 Oct 5]. Available from: http://www.niaid.nih.gov/news/newsreleases/2014/Pages/CCR5mutation. aspx

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News Article

Professor Hilleman: The Man Behind Half of our Vaccines Samuel Ognensis

Measles. Mumps. Hepatitis B. Varicella. Haemophilus influenzae. Just a handful of the diseases for which we have an effective vaccine. They are also a handful of diseases for which vaccines have been developed (either solely or primarily) by one man, the late Professor Maurice Hilleman. Arguably the world’s greatest ever vaccinologist, Prof. Hilleman is, responsible for around half of the current schedule of childhood vaccinations. Despite this lofty title and all his pioneering achievements, Prof. Hilleman remains a relatively unknown figure. Not only to the general public, but also amongst many in the medical and broader scientific community. This is surprising given his incredible public health achievements, and that he has received a number of significant honours, including the U.S. ‘National Medal of Science’. In 2007, Paediatrician Prof..Paul Offit wrote an enthralling biography about Prof. Hilleman’s life works and achievements, short titled ‘Vaccinated’. As part of the AMSA International Australia (AIA) interview series, I discussed the life of Maurice Hilleman, as well as vaccines more generally, with Prof. Offit, undoubtedly one of the eminent figures in this field. Describing his achievements as ‘other worldly”’ and ‘“unprecedented’”, Prof. Offit explains a possible reason for why Prof. Hilleman’s name and legacy remains a relative secret: “He worked for a company. We don’t like our heroes to come from industry. We like them to come from academia. That seems pure, more wholesome.”

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In a time when there is growing discussion around the encroachment of ‘Big Pharma’ into both academic and clinical medicine, and the negative impacts that often follow. It is interesting to consider that as an employee of Merck, Prof. Hilleman, through an incredible scientific mind, was able to save more lives each day, than almost all of us as individual doctors would save over many lifetimes. Whilst Prof. Hilleman, with millions of lives saved each year, is clearly an outlier, it raises question of our perceptions of public academia versus private industry. Indeed, it may help remind us of the fact that most Australian medical professionals tread a balance of public and private employment over their careers, and that both help provide significant benefit to patients, and the wider community. To clarify, Prof. Offit also points out that Prof. Hilleman did have an extensive career as an academic scientist, including discovering Chlamydia was a bacteria (not a virus as previously believed), and performing extensive “seminal” research into interferon. “But (Hilleman) would’ve never have been able to have done what he did if he worked solely in academia”, Prof. Offit notes. Had Prof. Hillman done so his achievements may not have been so incredible, although he would have likely achieved far more public awareness and credit for his work. “Jonas Salk got a ticker tape parade down the centre streets of New York when he made his vaccine. Maurice Hilleman essentially made 9 vaccines.” Yet he remains unrecognised by many in the scientific community, and indeed by the public at‒large. And when it comes to the prospect of a Nobel Prize, Prof. Offit has a similar explanation, from an experience with someone who is part of the Nobel decision process: “I said, “Why not Maurice Hilleman?” And he said, “Because he works for a company.”” Despite this, Prof. Hilleman was by all reports not someone who sought the spotlight, or to garner volume 10, issue 17

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support and compliments for his work. His drive was to find a new project to pursue. A new disease to eradicate. One vaccine at a time. And over many decades, Prof. Hilleman achieved this target, time and time again, to the point where his life’s work seems more a work of fiction, of hyperbole.

The Australian Delegation’s Experience at the East Asian Medical Students’ Conference (EAMSC) 2015

Velasco, Dannica, Luong, Suzanne, Kuk, Nathan, Zhang, Victor, To, Joanne, Him, Nicholas, Lam, Joey (Chau), Lee, Bryan, Im, Luke, McBride, Caroline & Betts, Nicky time. Introduction The 28th East Asian Medical Students’ Academic Program Conference (EAMSC) was held in Jakarta, Keynote Lectures Indonesia, between the 10th and 15th of Lectures on various January, 2015. Approximately 300 delegates aspects of sexual from all across the globe converged on the health were given city for the 6-day long program. It aimed to on day two of the bring medical students together to discuss conference. They the pervasive global health issue of sexually were delivered by transmitted infections (STIs), with the theme esteemed specialists of the conference being “Sexually Transmitted from around the world, with topics ranging Infections – Halt the Disease, Help the People”. from the global epidemiology of STIs to their Organised by the Asian Medical Students’ clinical presentation and treatment. Each Association International (AMSA International), lecture was followed by a brief Q&A session the conference in which delegates were given the opportunity aimed to achieve the to draw from the lecturers’ expert knowledge organisation’s vision on the topics discussed. The lectures not only of “Knowledge, Action provided a good overview of the theme, but also and Friendship”. highlighted the large role that culture can play in the way medicine is practised. After arriving at the hotel and checking Academic Workshops & Group Discussion into our rooms, the A critical aspect of AMSA International first item on the conferences are the workshops that detail schedule was to meet our groups. Each group had between 16 and 18 important skills and knowledge pertaining to the conference theme. delegates, led by two group moderators from Indonesia. General introductions were followed by ice-breaking activities such as celebrity heads Circumcision, a common practice in some religions, has also been shown to reduce and clapping games - a great opportunity to rates of STI transmission. Far less common get to know the people with whom we would in the Australian health system, the Australian be spending the majority of time during the delegation were fortunate enough to participate conference. in an interactive clinical workshop where they were wowed by the technicality of this Moving to the Universitas Pelita Harapan procedure. Students were taught surgical skills (UPH) main campus for the opening ceremony including aseptic practices, incision methods and dinner, a warm welcome was given by and suturing. Furthermore, advice on postvarious speakers, including leaders from the circumcision care was taught, especially the Organizing Committee of the conference and importance of dressings and adequate cleaning the UPH Faculty of Medicine, amongst others. of the surgical site. Ultimately, the Australian This was followed by a performance of Reog, delegation walked away from this workshop upa traditional Indonesian dance demonstrating skilled with a new appreciation for STI protection. physical strength and included a lion-peafowl mask and costume. Amazingly, at the end of the performance it was revealed that the extravagant, Another workshop that delegates undertook enormous and presumably very heavy mask was involved appropriate sexual health history taking. The 5 Ps of the sexual health history held between the performer’s teeth the entire

But sometimes reality is stranger, or in this case more wonderful, than fiction. And for this, we all owe a great deal of thanks to the dedicated Microbiologist from Montana, who saw a problem, and needed to fix it. When not writing books, Prof. Offit is the Director of the Vaccine Education Center at the Children’s Hospital of Philadelphia. He is regarded as a ‘go‒to’ expert on vaccine development, vaccine safety and disease outbreaks, regularly interviewed on television and radio. In recent times, Prof. Offit has been extensively consulted and interviewed in the wake of the ‘Disneyland’ Measles outbreak. He is also the receiver of much ‘hate mail’ from anti‒vaccination individuals and groups, for his dedication to the vaccine cause. Fittingly, Prof. Offit now serves as the Maurice R. Hilleman Professor of Vaccinology, and, like Prof. Hilleman, as a Professor of Paediatrics at the University of Pennsylvania. In our interview, Prof. Offit and I covered a range of issues around vaccines, and also around the ban he helped introduce on vaccine supplementation at the Children’s Hospital of Philadelphia. We discuss why, and what impacts this policy has had. To watch the full interview with Prof. Offit, visit: https://www.youtube.com/watch?v=WijMo8qexeE For all AIA interviews, visit our Channel: https:// www.youtube.com/channel/UCLmFGTw2A2m3zggcTwuV6PA

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fine, but instead, ‘checking’. were discussed – partners, practices, protection from STIs, past history of STIs, and prevention of pregnancy – and mock cases were devised. For the junior students who had little clinical experience, this proved to be a challenging but valuable session. For clinical students, this session allowed them to refine their own history taking technique and to provide mentorship for the younger students. Delegates then divided into small discussion groups that were conducted like a standard Problem Based Learning (PBL) class. In line with the conference theme, the case discussed was on vaginitis and trichomoniasis. Fascinating discussions on different health systems and medical education around Asia took place as the demographics of each group were very diverse in terms of country of origin, year level and health system. There were not many differences in the approach to diagnosis and treatment but there were points of cultural shock and amazement when discussing different health systems. For example, many were surprised that the UK and Australia had a HPV vaccination program that provided young girls with free vaccination because in other countries this was fully privately financed. Despite some differences, we were all united by the focus of wanting to help and treat our patients. Overall, it was an invaluable insight into various medical systems; it was also helpful revision for senior students and a productive learning experience for those in lower year levels. Hospital Visits Hospital visits were organised for all delegates to gain an appreciation of the Indonesian health system. Hospitals visited included the Siloam Hospital Lippo Village – the teaching hospital of UPH – and Bethsaida Hospital in Tangerang. Delegates were also taken on a tour of the Mochtar Riady Institute for Nanotechnology, which is co-located with the medical campus of UPH, and learned about research currently being undertaken at the facility. vector journal

Community Service The community service program gave delegates the opportunity to educate members of the community on what we had learned throughout the conference. The organising committee had devised a plan involving a flash mob in the middle of the UPH cafeteria, followed by the handing out of pamphlets containing general information about STIs and how best to prevent them. The flash mob certainly drew attention from cafeteria lunch-goers, while the sizeable crowd of delegates handing out pamphlets were greeted with some surprise and plenty of interest from the rest of the UPH population. Conference Competitions Scientific Paper The scientific paper competition aimed to educate the public on pertinent health issues, with a specific focus on the role of medical students, clinicians and government on public health. With STIs being a leading cause of morbidity and economic detriment in Australia, the scientific paper team aimed to determine whether a positive HPV vaccination status increased the risk of unsafe sexual health practice in Australian women. Having achieved enormous success in previous competitions, the Australian team once again embarked on a scholarly journey, holding high hopes of emulating the success of our predecessors. The presentations took place over 15 minutes, which included 7 minutes of answering questions directed by the judges. Our excellent systematic review, analysis, originality and presentation garnered us a well-deserved 2nd place. Once again the Australian scientific paper team are to be congratulated on their

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The public poster was evaluated by both judges’ scoring and chapters’ voting, and we successfully placed fourth overall.

academic endeavour. Scientific Poster A culmination of almost half a year’s work by medical students from across the country, our entry for the scientific poster vcompetition was a systematic review investigating the relationship between knowledge and awareness of, and Human Papillomavirus (HPV) vaccine uptake, in Australian females. Australia was one of the few countries present at the conference to have a nationally funded HPV vaccine program; this sparked interest from competition judges and medical students alike, leading to enlightening exchanges regarding international public health policy. Important findings from our study included the need for more research into the reasons behind vaccination refusal and poor uptake, as well as studies that focus on Indigenous and minority groups. Though we faced some tough competition as always, Australia’s entry was ultimately a great success, being awarded first prize in its category. Public Poster In line with the sexual health focus of the conference, the Australian delegation developed a public poster titled “Don’t guess. Check”. In Australia, research has shown that even though individuals understand that STIs often have serious health implications, few believe they are personally susceptible to contracting them. Moreover, the majority of individuals that do have STIs are asymptomatic, therefore misleading sexually active persons to avoid screening despite their high risk. The public poster is designed to address the issue of stereotyping and presentation of STIs in Australia, with the aim of encouraging all sexually active individuals to be screened for STIs – not ‘guessing’ that they’re vector journal

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Public Video We know that young people are vulnerable to STIs, especially in areas where sexual health education is poor or incomplete. We therefore wanted to create a video that would appeal to this population. Given the recent spate of post-apocalyptic, survival-genre movies, we decided that a zombie-themed video would be most effective. The idea of a zombie-creating virus would serve as the metaphor for the troubles faced by those infected, with the means of combating the zombie virus (knowledge, protection, and screening) being strangely reminiscent of how we would encourage people to protect against STIs. The video was split into two parts. The first showed a world ravaged by the zombie-virus where people are scared and unsure of what to do. The second part was the more direct publicservice announcement, showing people visiting their GP, getting STI screens, and talking about barrier protection and vaccinations. Although the other entries were of an exceptional standard, our team secured third place in this category.

Cultural & Social Program Sightseeing & cultural workshops On day four, delegates visited the “Beautiful Indonesia Miniature Park” to see and feel the rich diversity of Indonesian culture. Brief histories volume 10, issue 17

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of different provinces were provided during the tour and enlightened the delegates. Delegates were invited to dance the Tari Enggang alongside performers, who also demonstrated hunting skills.

A variety of cultural workshops were arranged for delegates to engage in Indonesian cultural history and activities on the day. Delegates were involved in learning the traditional Saman dance, playing musical instruments (angklung) and tasting great local dishes (such as tumpeng), amongst others.

This year, we also constructed a photobooth encouraging other delegates to get into the ‘Aussie spirit’ by dressing in one of the many accessories we had prepared – did someone say koala or kangaroo onesie? Cultural night and farewell party The last night of the conference was held at the Spring Club Royal Ballroom, a majestically beautiful white hall, making it the perfect place to have many of our final farewells. The cultural performance is an opportunity for chapters to display the fascinating culture and talents of their delegates. Since the start of the conference, the Australian delegation had been practising their cultural performance into the early hours of the morning. On the night, each chapter had ten minutes in the spotlight to entertain the delegates. The Australian delegation danced to an array of Australian songs, whilst our comrade the solo New Zealand delegate, was brave enough to sing on her own. It was definitely the perfect way to end a full week at the EAMSC, despite the sadness we all felt at parting.

At night, the delegates visited the Museum Bank of Indonesia. It began with a tour that explored the history of the museum. It was then followed by “Historia Fun Games,” which was like a mini ‘amazing race’ within the museum. It ended with a magical musical performance at the museum that was the highlight of the day. The bonds between delegates and groups solidified and the time spent together was very memorable. Conclusion This wonderful global conference has given the entire Australian delegation food for thought. Through an inspirational academic program, immersive cultural activities and entertaining social events, the 28th EAMSC Indonesia has helped us learn more about the pressing issue of STIs, instilled us with an urge to act whilst forging new long-lasting friendships across the globe. Cultural Booths The cultural booth session is always a highlight of any EAMSC conference, giving an opportunity for chapters to display what is unique about their countries. This year, the Australian delegation did not disappoint with a booth that showcased all the delicious foods (Vegemite, Tim Tams and much more!) and drinks Australia has to offer. vector journal

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Don’t Trade Our Health Away: Reflections from a Workshop on Trade and Health Jade Lim and Claire Ferguson The International Federation of Medical Students’ Association (IFMSA) holds two General Assemblies (GAs) annually, bringing together medical students from 126 countries. The Federation holds several capacity building pre-GA workshops in the days leading up to the event, facilitated by students and externals covering a myriad of topics, aiming to provide skills and knowledge to the participants for their work both within the Federation, and in their own endeavours. The Pre-GA workshops aim to deliver information, and build the capacity of members by cultivating a contemporary understanding of health. Medicine, health, and global health, are affected by biological and individual determinants – as well as wider social, economic and environmental determinants. These include economic and environmental policies, both of which are affected by trade negotiations, including the Trans-Pacific Partnership (TPP) Agreement. As an international organisation of which AMSA Global Health is an active member, IFMSA policy states that “We, the International Federation of Medical Students’ Associations, affirm our belief that trade agreements should promote public health and expand access to medicines. We believe that trade agreements, such as the Trans Pacific Partnership and the Transatlantic Trade and Investment Partnership, should not prioritize multinational corporate profits over patients and consumers around the world. We think it is unacceptable that trade agreements create barriers to access treatment and ultimately a healthy life. We believe as future health professionals that it is our mandate and duty to use our voice to improve health of populations around the globe by positively influencing the global economic system.” [1]

From the coordinator’s perspective (Jade)

We would like to extend our warmest appreciation to AMSA Indonesia for organising an exciting EAMSC. The next thrilling and stimulating AMSA International conference will be the 36th Asian Medical Student Conference (AMSC) 2015 in Singapore in July.

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This year, I had the privilege of acting as a coordinator for the Trade and Health pre-GA held in Istanbul, Turkey for the 64th March Meeting of the IFMSA. Along with medical students and IFMSA alumni from Denmark, Germany, the USA and Belgium, I worked in the months leading up to the event to provide our delegates with information on every aspect of trade 48

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and health we could find. Based on my past participation with AMSA, AMSA Global Health and the IFMSA, there has been growing passion and enthusiasm around this topic, which led to the formation of a Trade and Health student group, and a call for positive and decisive action from the General Assembly of the IFMSA in August 2014. As a member of this student group, which was formed by members of the IFMSA, UAEM (Universities Allied For Essential Medicines), and others, I was involved in the preliminary discussions of student action on trade and health, leading to the opportunity to co-ordinate this event. For the pre-GA workshop, we focused on the current trade negotiations, namely the Transatlantic Trade and Investment Partnership (TTIP) and the Trans-Pacific Partnership (TPP) Agreement, of which Australia is party to. We discussed what these agreements entailed and how these agreements can directly and indirectly affect health. The IFMSA engenders energy, enthusiasm and camaraderie amongst its delegates, and we hoped to harness these assets, and provide support to our peers in advocating on trade and health issues. Action in Australia, and particularly within AMSA Global Health, around trade and health has always been inspiring, ensuring that the student voice was heard and represented. However, secrecy around the new generation of trade agreements, and difficulties in communicating the technicalities of the possible consequences made the topic difficult to discuss. In developing this workshop we aimed to address these barriers both within, and external to, our organisation. The purpose of this workshop was to illustrate how trade agreements and the current negotiations may impact health, the key actors in these negotiations, why it matters to the medical student community, and what action we can take. A key endeavour was to be neutral in our presentation of the topic, providing as many perspectives as possible. We also emphasised the uncertainty around these trade negotiations, and discussed what the outcomes of some particular clauses may be. To the best of our ability, we aimed to make a difficult and technical topic, approachable and volume 10, issue 17

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By providing input from multiple parties, from the trade negotiators, to students who coordinated side events at the negotiations, we encouraged everyone to think broadly. Introductions to the Social Determinants of Health by Boyan Konstantinov from the United Nations Development Programme, discussion around the action that has been taken in the Access to Essential Medicines movement from James Love, and how this fits into trade agreements, as well as advocacy and campaigning training from Dr. Elizabeth Wiley and Kiti Phillips aimed to facilitate this. We aimed to encourage our peers to speak to each other, and the public, about the issues that mattered most to them. Now, as the buzz of the most recent IFMSA GA starts to dwindle, and having seen the conversations and contacts made in the last weeks, I hope that we, as a co-ordinating team were able to achieve our goals. Personally, the participants of this workshop undoubtedly inspired me to get excited about this topic, to up-skill, and to take what we’ve created even further.

From the participants perspective (Claire) I chose the pre-GA workshop “Trade and Health” because I knew nothing about the topic. I enjoyed the idea of exploring unfamiliar intellectual territory in an unfamiliar city with unfamiliar people, with the different dimensions of unfamiliarity uniting to yield a globalised sense of adventure. I anticipated that learning about how trade impacts health would be interesting in the same way intricate physiological mechanisms are interesting: it’s pleasing to chip away at the many mysteries of how the world works. What I did not expect was to walk away with such an enduring zeal for the issues and their social justice implications. It was like learning a new language, in that I had to master a new vocabulary and work at being able to speak coherently about things like the TPP, Investor State Dispute Settlements, intellectual property and access to essential medicines.

"The workshop expanded my mind in the following four directions....

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die by these agreements.”

encompassed within the influence of trade agreements; 3. The existence of concepts like delinkage, which challenge the current unjust system of pharmaceutical company monopoly; 4. The power of stories, which is a power every medical student can harness.

engaging.

One of the most meaningful outcomes of this workshop was seeing people at my level engaging in advocacy to a degree that expanded my own notions of what is possible. Two of the European facilitators shared their story of attending a TTIP stakeholder consultation session, which is currently being negotiated between the US and the EU. As lone representatives of the health sector amidst the huge list of people representing business or financial interests, they may have seemed like fish out of water. As it transpired the TTIP negotiators were genuinely interested in their perspective. Following a Skype session with a TTIP negotiator, we received feedback from that negotiator saying he had found the dialogue “extremely useful.” While humility and being realistic about our current capacities as medical students is important, such an experience empowers one to ignore that inner voice a lot of us have, the one that quietly insists we are not important or knowledgeable enough to contribute yet, or that our efforts are futile and nobody will listen. I soon found myself embedding other issues discussed throughout the General Assembly into a trade and health context. For example, a policy on ‘Prioritising Sugar in Combating the Obesity Epidemic,’ proposed by Medsin-UK. [2] Essentially, the universality of rising obesity rates reflects obesogenic environments [3], especially the underrecognised omnipresence of high sugar foods, rather than poor individual choices. High fructose corn syrup is a potent in this regard, particularly in the US, and I wondered whether trade agreements could enable its spread. [3-5] Sure enough, Mexico now owes USbased food producer Cargill nearly 100 million dollars for attempting to limit the import of high fructose corn syrup, thanks to an Investor State Dispute Settlement provision in the North American Free Trade Agreement. [5] Being able to speak the language of trade systems makes you realise how many public health issues are shaped or caused by them. The week before the trade and health workshop, we learnt about Sofosbuvir in class, the infamous Hepatitis C drug that costs up to $70,000 for a

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full course. [6] At the time, I remember thinking that this was a tragic but inevitable sequela of the amount it costs to research and develop (R&D) new medicines. I have since learnt that the dichotomy between the current system of pharmaceutical company monopoly, and no innovation at all, is a false one. While the cost of medications are justified by pharmaceutical companies as reflecting the cost of research and development, allegations have been made that only as little as eight cents in the dollar is fed back into R&D. Delinkage is the concept of finding ways to separate the R&D process from the cost of drugs, for example by using grants and prizes to incentivise innovation. Soon after hearing the word delinkage for the first time I found myself participating in discussions about how to make it a reality. During the workshop, Director of Knowledge Ecology James Love enumerated several steps to this end; the first one being to propagate awareness of the reality that the pharmaceutical monopoly system is inefficient, unfair and people die by it. As well as reiterating the importance of voicing the health perspective on broader issues, and on a personal level, the workshop reminded me of the power of stories. Another facilitator shared the story of a man she met at the AIDS2014 conference; this man is HIV positive, as is his wife, but thanks to generic HIV medication sourced from India, he and his wife do not suffer from AIDS and their children are HIV negative. This story illustrated better than any other the importance of ensuring that trade agreements do not enshrine intellectual property policies that prevent access to generic medicines, due to strengthened patenting. Medical students have access to stories like these and our advocacy can be more powerful for it - it is not about appealing to emotion, but sharing stories to anchor rational debates to better human health. In the words of James Love, “people live and vector journal

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Finally, being in a room with people from all over the world discussing how to establish target audiences, find allies and know and combat opposing arguments made me feel like a true global citizen, connected by shared passion. I felt like together we could build a world where Hepatitis C drugs do not cost $1000 a pill, and where HIV drugs do not cost $20 more in South Africa than in Norway. Our world is built from these very legal and economic structures that this workshop taught me to view not as the natural order, not irrevocable, but manmade. However, we can’t fix what we don’t know is broken. To spread this knowledge, we need to speak coherently, loudly and often. Overall, my experience at the workshop helped me realise the importance of being open-minded about the many different sorts of knowledge that are relevant to health. It opens my eyes to opportunities to advocate for better health outcomes, both directly and indirectly. Our collective involvement in the IFMSA pre-GA, and GA this March was a truly unforgettable experience. Interested in getting involved? No experience required! If you are interested in the IFMSA, and events such as this, keep a look out for information on the next General Assembly, which will be held in August 2015, in Ohrid, Macedonia – applications for the AMSA delegation, are open in April. If you would like to express your interest, or for more information on AMSA Global Health and the IFMSA, please contact AMSA Global Health Co-Chairs Josh Monester and Hui Ling Yeoh via global@amsa.org.au. References: 1. International Federation of Medical Students’ Associations. Policy Statement on Trade and Health. March 2014. Hammamet, Tunisia. Available from: http:// www.ifmsa.org/content/download/413075/4718203/file/2014MMPS_12_ POLICY%20STATEMENT%20ON%20TRADE%20AND%20HEALTH.pdf 2. International Federation of Medical Students’ Associations. Policy Statement on Prioritizing Sugar in the Global Obesity Epidemic. March 2015. Antalya, Turkey. Available from: http://www.ifmsa.org/content/download/666685/8080208/file/ PS_2015MM_Prioritising_Sugar_in_the_Obesity_Epidemic.pdf 3. Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, et al. The global obesity pandemic: shaped by global drivers and local environments. The Lancet.378(9793):804-14. 4. Fugloni V (3rd) High-fructose corn syrup: everything you wanted to know but were afraid toask Am J Clin Nutr. 2008 Dec;88(6): 5. Tappy, Luc, and Kim-Anne Lê. “Metabolic effects of fructose and the worldwide increase in obesity.” Physiological reviews 90.1 (2010): 23-46. 6. State.gov. Cargill, Inc. v. United Mexican States [Internet]. 2015 [cited 15 March 2015]. Available from: http://www.state.gov/s/l/c42198.htm 7. 2014 [cited 15 March 2015]. Available from: http://www.abc.net.au/ news/2014-10-23/rejection-of-costly-new-cure-a-death-sentence-for-hep-csufferer/5837484

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Article

ASPIRE Now

Global Health Group Spotlight

Stormie De Groot, AMSA Global Health Representative, ASPIRE This year marks an incredible five years since the start of ASPIRE (Armidale Students Promoting International Rights and Equality), the University of New England’s (UNE) global health group (GHG). I’m sure that you, like almost everyone who hears about UNE for the first time, is surprised by its existence. In actual fact, Armidale is home to a small but passionate group of medical students of approximately 60 to 70 students per cohort. With the growing attention of regional, rural and remote medicine amongst medical schools and policy makers, we have seen a dramatic growth in the number of rural and remote medical schools and opportunities for rural placements. Medical students are spending more time in rural and remote contexts then ever before vand for this reason, we felt it was important to discuss some of the ways that ASPIRE has continued to develop the presence of global health our medical school and community. Lessons from a Rural GHG A rural context for ASPIRE has meant that we are a smaller and ‘fun sized’ GHG, with a committee of 12 students and approximately 75 members, it means ASPIRE has had to make the most of its limited funding and resources. However, this hasn’t stopped us from organising numerous successful global health projects and initiatives. Below are some of the steps that have been taken through ASPIRE’s development across the years:

what we can access in Armidale. As our university lacks a School of Public Health, and there is little global health content in our medical curriculum, initiatives such as the AMSA Global Academy and Global Health Conference (GHC) are essential in providing avenues for our members to keep abreast of global health issues. Step 3: Recognising the opportunities for global health involvement and partnerships in our own backyard has helped ASPIRE to grow beyond our small medical cohort. We have had the pleasure of working with numerous local organisations including Armidale Rural Australians for Refugees, Sustainable Living Armidale, and our local Zonta International Branch. This work has been incredibly rewarding and many of these groups have become generous sponsors and supporters of our projects across the years.

Step 1: Having a group of dedicated and enthusiastic medical students has been pivotal in helping us develop our GHG in a rural context. Also as a smaller cohort learning how to recruit motivated students has been essential in ASPIRE’s development.

We’d like to thank AMSA, AMSA Global Health and all the GHGs that have supported us over the last five years and look forward to continuing working with you for many more years to come. We hope our insights into ASPIRE’s experience as a GHG has shown that no matter how small in number in you are or where you are geographically you can still be active and valued participants in global health.

ASPIRE has also expanded our executive committee to include Code Green, Red Party and Crossing Borders representatives. Two of our students participated in the AFRAM Advocates program and we are excited to see how our continued involvement in the AFRAM and Crossing Borders projects can increase throughout the rest of the year.

Despite our small size and limited resources we’ve still managed to organise a large range of events including saving the tops of aluminium cans for the creation of prosthetic limbs; signing petitions to get more Fair Trade chocolate in supermarkets; hosted

Having close associations with AMSA Global Health and GHGs has also given our members the opportunity to get involved in global health beyond amsa global health

ASPIRE’s success has been the result of the incredibly hard work of our past and present members and executive teams. We’ve fought against unique rural challenges to provide UNE students with the wonderful opportunity to become involved and learn more about global health. We hope that ASPIRE continues to grow, inspire and educate more people into the future.

Our motivated students have also gone on to hold some important positions outside ASPIRE. These include: · Publications and Promotions on the AMSA Global Health Management Team in 2014 · Deputy Convenor for the GHC 2014 Executive · Logistics Officer for the GHC 2016 Executive

Step 2: Becoming involved with AMSA Global Health and other GHGs has allowed us to expand the achievements of ASPIRE. This has included our involvement in the AMSA projects and initiatives including AFRAM, Code Green and Red Party.

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In the last five years ASPIRE has grown rapidly. We’ve gone from the development of our constitution to organising UNE’s largest on campus club night. We’ve also pioneered and continued to develop a Maternal Skills and Birthing Kit weekend on the Mother’s Day Weekend, which was runner up in the project pool last year at GHC and this year. We have since increased the number of birthing kits made from 600, in our first year, to 1000. Our size also hasn’t stopped us from winning three Live Below the Line AMSA Global Health challenges – a feat only made possible through the enthusiasm and strong participation of our entire cohort. Furthermore, we saw our largest delegation attend GHC Sydney in 2014. Naturally, we are all incredibly excited to attend this year’s GHC in Perth.

many bake sales; and continuing our participation in Live Below the Line. Our fundraising events have also been extremely successful. In our first year we raised $3,500 for the Burnet Institute of Medical Research. In 2014 we were able to raise $2879 to the Ashwood Memorial Hospital in Daund, India and $4522 to the Barbra May Foundation.

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Australian Refugee and Asylum Seeker Policy Concerns for health and well-being

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Table of Contents Foreward from AMSA Abridged Review of the Literature

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Articles Children in Immigration Detention 8 Health Concerns Regarding the Re-Introduction of Temporary Protection Visas 10 Conditions on Christmas Island 12 Changes to the Immigration Act 14 Border Force Act - implications for doctors’ code of conduct 18 AMSA recommendations

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For those who’ve come across the seas we’ve boundless plains to share...” - - Australian National Anthem

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Abridged Review of the literature: Collated by Tom O’Neill, Alyssa Pradhan and Tim Martin

From the president

Includes excerpts of work by Nicky Betts, Elise Buisson, Piyush Grover, Abbirami Linghanathan, Timothy Martin, Anju Roy and Devaki Wallooppillai and others.

During my time as a part of the Australian Medical Students’ Association (AMSA), I’ve been privileged to meet medical students from all over the country – there are 17,000 of them from Australia’s 20 medical schools.

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Amongst all of the issues they raise with me, the health of refugees and asylum seekers is always amongst the most frequent. Medical students believe that the government’s current policies of indefinite mandatory detention and offshore processing are cruel, shameful and detrimental to health. Refugees and asylum seekers are already more likely to have been exposed to a range of conditions that predispose them to poorer health, including time spent in refugee camps or detention facilities; history of persecution and armed conflict; and the threat or occurrence of physical violence. Exposure to these conditions puts refugees and asylum seekers at an elevated risk of mental and physical illness, and may lead to self-harm or suicide. Under our current policies, asylum seekers are indefinitely detained, which has a profound mental health impact on some of the world’s most vulnerable people. This booklet has come about to share some of the nation’s leading experts on mental health, as well as those who focus on the health of refugees and asylum seekers. The evidence is clear that our policies are directly responsible for significant mental and physical harm to vulnerable people. Improvements to Australia’s immigration policies would draw public support from the AMSA and the broader medical community. It is up to our government to take its responsibility as a global citizen seriously.

James Lawler President Australian Medical Students’ Association

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he health impacts of Australia’s immigration detention policies, including but not limited to, indefinite mandatory detention, offshore detention, temporary protection visas (TPVs) and children and families policy, have been well established. The evidence has been compiled by a large number of reports by independent bodies and peer-reviewed studies by health practitioners. AMSA has compiled numerous summaries of the data available, included in multiple submissions to official bodies, and these reviews have painted a concerning picture of the wellbeing of vulnerable people under Australia’s care.

“In response to the suicide attempt of a 9 year old child in detention, the Australian Medical Association (AMA) stated “detention of asylum-seeker children and their families is a form of child abuse”

It is known that “prolonged mandatory detention compounds past trauma and abuse, leading to a demonstrated negative effect on health, particularly mental health” [1]. An assessment pertaining to the mental health of detainees held in an Australian detention facility for more than two years concluded that every adult had

et al noted a lack of infectious diseases screening in children, in a context where over 50% are likely to be infected with tuberculosis and several likely to have blood borne diseases such as hepatitis B [3.] The recent death of Hamid Khazaei due to septicaemia from a foot wound is a stark indicator of the poor provision of medical care [4].

Drawing by a 9 year old girl detained on Christmas Island, given to the Australian Human Rights Commission as part of the National Inquiry into Children in Immigration Detention 2014

major depressive disorder and 82% of adults had PTSD [2]. However, prior to detention only half reported having PTSD, 21% had comorbid depression and no adults had self-harmed or had experienced suicidal ideation [2]. Subsequent to detention, most expressed suicidal ideation with a third having physically harmed themselves during their detention [2]. Substantial risk of physical illness has also been reported. Procter

Furthermore, there is “significant and ongoing risk of child abuse, including physical and sexual abuse” in Australia’s offshore detention centres [3]. The recent Moss review found further evidence of inadequate standards of safety, including the alleged rape of two women and female one minor (currently being investigated by Nauru authorities) and a culture of under-reporting due to cultural reasons and fear of adverse effects on asylum claims [5]. Incidents of

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References:

Mental Health Effects of Immigration Detention on Adults 100

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2. Green J, Eagar K. The health of people in Australian immigration detention centres. Med J Aust [Internet]. 2010;192(2):65–70. Available from: https://www. mja.com.au/journal/2010/192/2/ health-people-australianimmigration-detention-centres.

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% with Major Depression

% with PTSD

Before Immigration Detention

uncontrolled and widespread physical violence have been well-documented, for example by the independent Cornall report into rioting on Manus Island which saw at least 69 injuries including one detainee wounded by shooting, another losing their eye and Mr. Reza Berati killed [6]. Finally, the effect of prolonged detention on children is perhaps the most concerning aspect of current policy. In response to the suicide attempt of a 9 year old child in detention, the Australian Medical Association (AMA) stated “detention of asylum-seeker children and their families is a form of child abuse [7]. Indeed, 81.1% of Australian paediatricians responding to a recent survey agree or strongly agree with this statement [8]. The Forgotten Children Report found that children were spending and average of 231 days in detention.

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1. Australian Commonwealth Ombudsman. Immigration detention review reports. Commonwealth Ombudsman. 2014 [cited 2015 Jan 27]. Available from: http://www.ombudsman.gov.au/ reports/immigration-detentionreview/

% self harmed

3. Procter N, Sundram S, Singleton G, Paxton G and Block A. Physical

and mental health subcommittee of the joint advisory committee for Nauru regional processing arrangements Nauru site visit report. 16-19 Feb 2014. 4. http://www.abc.net.au/ news/2014-09-06/hamidkehazaei/5724800 5. Moss P. Review into recent allegations relating to conditions and circumstances at the Regional Processing Centre in Naru. 6 Feb 2015. 6. Cornall R. Review into the Events of 16-18 February 2014 at the Manus Regional Processing Centre. 23 May 2014.

7. http://www.theaustralian. com.au/national-affairs/ immigration/mandatorydetention-of-asylum-seekers-likechild-abuse-ama-tells-inquiry/ storyfn9hm1gu-1226146845917 8. Corbett E, Gunasekera H, Maycock A and Isaacs D. Australia’s treatment of refugee and asylum seeker children: the views of Australian paediatricians. Med J Aust 2014; 201 (7): 393-398. 9. Australian Human Rights Commission (AHRC). The Forgotten Children: National Inquiry into Children in Immigration Detention 2014.

After 2 years of Immigration Detention

The prolonged detention of children has profound negative impacts on their mental health and development with 34% being assessed as having a mental health disorders of a severity experienced by only 2% of children in Australia [9]. There is an significant body of evidence demonstrating the incompatibility of current immigration detention practises and respect for human well-being and dignity. In a context where the health consequences of particular policies are well known, it is unacceptable for a wealthy democratic nation such as Australia to continue to enact such policies. Genuine reform is needed and AMSA’s recommendations regarding this matter can be found at the end of this booklet.

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Children in Immigration Detention By Dr Jon Jureidini

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t is hard to envisage a more toxic environment for the well-being of children than Australia’s Immigration Detention system. Part of it is about the horrible environments; historically Curtin, Woomera, Baxter; currently Christmas Island, Nauru. But even when the environments are more physically comfortable (for example the recently closed Inverbrackie Centre near Adelaide), children are severely damaged by the experience.

The main contributors are as follows:

1. Being in a culture where there is a lack of hope.

The impact here is particularly from the effect on parents. The strongest determinant of children’s emotional survival of traumatic experiences is how well their parents deal with the trauma. In our experience, because of the toxic effect on adults in this environment, previously competent parents often fail in the detention environment; that is they become unable to provide reasonable levels of structure and predictability in their children’s lives and keep safe their children and are unable to attend to and help make sense of their emotional needs.

2. Lack of space to play.

This is not just about having a friendly, safe play environment; children can play with a few rocks in a scruffy yard. This is about psychological space for play.

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Children use play, especially imaginative play to process emotions. For example, a small child might act out aggressive behaviour between dolls or other figures as a way of processing distressing memories of witnessing violence [1]. Immigration detention is anti-play. For example, frequent arbitrary security checks and searches and officious rules are two of the factors that make immigration detention an unsafe environment for play. This compounds the already toxic environment, because play is an important way in which children cope with distressing experiences.

3. Exposure to violence.

It is a natural and healthy response to mistreatment to protest, sometimes violently. Unfortunately in the toxic immigration detention environment such protest often takes destructive form – lip sewing, cutting, physical violence – and children are exposed to this behaviour from a young age. Of course this is not unique to the immigration detention environment but it is much more prevalent and from my experience has damaging effects on children.

Unfortunately protest often gives way to despair and hopelessness, and we sadly see children with alarmingly high rates of self-harm, developmental regression and mood disorders [2, 3, 4]. Once this occurs, the chances of real recovery after discharge from detention is severely diminished.

Drawing by a child in detention in Darwin, given to the Australian Human Rights Commission as part of the National Inquiry into Children in Immigration Detention 2014

References:

1. Root-Bernstein, M. (2012). The creation of imaginary worlds. In M. Taylor (Ed.), The Oxford Handbook of the Development of Imagination. Oxford: Oxford University Press. 2. Mares S, Jureidini J. Psychiatric assessment of children and families in immigration detention: Clinical, administrative and ethical issues. Aust N Z J Public Health 2004, 28:16-22. 3. Steel Z, Momartin S, Bateman C, Hafshejani A, Silove D, Everson N et al. Psychiatric status of asylum seeker families held for a protracted period in a remote detention centre in Australia. Aust N Z J Public Health 2004,28:520-26. 4. Australian Human Rights Commission. The Forgotten Children: National Inquiry into Children in Immigration Detention (2014)

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Health Concerns Regarding the Re-Introduction of Temporary Protection Visas By Professor Zachary Steele

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Prepared by Professor Zachary Steel, School of Psychiatry, University of New South Wales and St John of God Health Care, Richmond Hospital.

n December 2014, the Australian Federal Government reintroduced Temporary Protection Visas (TPVs) for certain categories of refugees. A TPV provides a three year period of residency to refugees identified as facing a real risk of persecution in their country of origin. TPV holders can work in Australia, access social security benefits and Medicare. The key restrictions include being unable to leave Australia with a right of return, access to family reunion immigration rights and exclusion from many resettlement services. At the termination of the TPV, refugees are required to undertake a full merits review of their refugee claim to re-establish continuing need for protection for a further three year TPV, but under current legislation, are never eligible to apply for permanent residency in Australia.

individualised refugee merits based assessments is not possible [1]. The use of temporary protection for persons already found to be refugees is unique to Australia. These provisions are in direct breach of International principles [2] laid out in the United Refugee Convention of Refugees, including that refugee status should be granted continuously and that refugees who are resident should have a range of rights including the right to travel documents and to be treated with the same rights as other citizens. There are important concerns about the reintroduction of this policy. The permanent restriction on TPV holders from being able to reunite with immediate family, who are often dependent on the TPV holder, is a particularly distressing and is at odds with all accepted international norms in protection and resettlement. In the first implementation of TPV provisions from 1999-2008 there was evidence that the lack of access to family reunion created a perverse incentive leading to a secondary surge in irregular migration.

â&#x20AC;&#x153;TPV holders were two to three times higher to have a stress related mental disorder than refugees with permanent protection visas despite similar levels of pre-migration traumatic exposureâ&#x20AC;? Internationally, temporary protection has historically been used for mass displacement or for countries of first asylum where undertaking

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indicate that TPV holders do not display the normal pattern of recovery and reintegration observed amongst refugees with permanent protection [3-5], suffer significant hardship associated with uncertainty created about the future, lack of access to family reunion, and the inability to travel in case of family emergency, as well as an increase in daily living stressors [6, 7]. More recently, studies comparing the mental health and social outcomes of refugees with permanent and temporary residency have raised serious concerns about the use of this policy [8-11]. Momartin and colleagues [9] found refugees on TPVs experienced substantially higher number of daily living difficulties, anxiety, depression and PTSD than their compatriots with permanent residency as a result of the TPV provision, despite reporting a similar level of pre-migration adversity, which continued at two year follow up of both groups [10]. Resettlement outcomes in the TPV group were also poorer amongst the TPV cohort with no improvement in the very low levels of English language proficiency in the TPV group compared to the permanent protection group, and high levels of living difficulties at the two-year follow up period. A second study confirmed the high levels of mental health impairment amongst an independent sample of 341 refugees and immigrant from Iraq. TPV holders were two to three times higher to have a stress related mental disorder than refugees with permanent protection visas despite similar levels of pre-migration traumatic exposure. A follow up, undertaken after TPVs had been abandoned and most converted to permanent protection visas and found significant improvement in depression, PTSD and mental health related quality of life for these refugees. Collectively, all sources provide a clear picture that TPVs are associated with sustained high levels of daily stress and poor resettlement outcomes across all indices.

References:

1. Fitzpatrick, J., Temporary protection of refugees: Elements of a formalized regime. American Journal of International Law, 2000. 94(2): p. 279-305. 2. Refugee Council of Australia. Temporary Protection Visas. 2013; Available from: http://www.refugeecouncil. org.au/r/pb/PB1324_TPVs.pdf. 3. Bowles, R. and N. Mehraby, Lost in limbo: Cultural dimensions in psychotherapy and supervision with temporary protection visa holder from afghanistan, in Voices of Trauma: Treating Psychological Trauma Across Cultures. 2007. p. 295-320. 4. Procter, N.G., Providing emergency mental health care to asylum seekers at a time when claims for permanent protection have been rejected. International Journal of Mental Health Nursing, 2005. 14(1): p. 2-6. 5. McMaster, D., Temporary protection visas: Obstructing refugee livelihoods. Refugee Survey Quarterly, 2006. 25(2): p. 135-145. 6. Coffey, G.J., et al., The meaning and mental health consequences of long-term immigration detention for people seeking asylum. Social Science and Medicine, 2010. 70(12): p. 2070-2079. 7. Mansouri, F. and S. Cauchi, The psychological impact of extendes temporary protection. Refuge, 2006. 23(2): p. 81-94. 8. Nickerson, A., et al., Change in visa status amongst Mandaean refugees: Relationship to psychological symptoms and living difficulties. Psychiatry Research, 2011. 187(1-2): p. 267-274. 9. Momartin, S., et al., A comparison of the mental health of refugees with temporary versus permanent protection visas. Medical Journal of Australia, 2006. 185(7): p. 357-361. 10. Steel, Z., et al., Two year psychosocial and mental health outcomes for refugees subjected to restrictive or supportive immigration policies. Social Science and Medicine, 2011. 72(7): p. 1149-1156. 11. Steel, Z., et al., Impact of immigration detention and temporary protection on the mental health of refugees. British Journal of Psychiatry, 2006. 188: p. 58-64.

TPVs are associated with a consistent set of adverse mental health and resettlement outcomes. Reports

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socially, become mute or self-harmed. We met children who had been waiting weeks for specialist medical care or assessment and parents so distressed that they could not contemplate a future.

Conditions on Christmas Island

The AHRC report on the National Inquiry – The Forgotten Children – tabled in Parliament on February 11th includes quantitative data from standardised assessments of child mental health and evidence given under oath by health service providers and others. It documents unacceptable levels of mental ill-health in children, providing credible evidence of harm from detention. It leaves the reader in no doubt that mandatory detention is bad for child mental health. Regardless of our politics - and acknowledging the international

By Professor Elizabeth Elliot

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n July 2014, during the National Inquiry into Children in Immigration Detention, I visited Christmas Island with the President of the Australian Human Rights Commission (AHRC) Gillian Triggs, as an expert paediatrician. There I witnessed first-hand the conditions for children and the extent to which they were deprived of their human rights.

challenges of dealing with asylum seekers - we must find a more humane way to treat asylum seeker children. The report has two key recommendations. First, Australia must abolish arbitrary detention of children and release all children detained on mainland Australia and Nauru into community detention, or into the community as soon as possible. Secondly, legislation should be enacted so that in future children may be detained under Migration Act for only as long as is necessary for security, identify and health checks. We must develop methods for timely processing of claims for refugee status and in the meantime must ensure that children in our care are treated humanely, with compassion and provided the opportunities for health and education that are their right.

Families barely existing in small metal rooms in searing tropical heat; absence of clean, cool areas for play and exploration; lack of opportunity to attend school; a restricted diet; no freedom of movement; and limited access - in this remote location - to timely specialised paediatric and child mental health services. We interviewed, heard the experiences of, and brought to everyday Australians, the words of over 200 previously ‘voiceless’ families who had been stripped of their identity during mandatory detention; a practice that contravenes the international conventions to which Australian is a signatory. After more than a year in detention, many had lost hope. Asylum seekers understand the need for assessment of their claims, but cannot understand why this process is so protracted. They reminded us of the fact that a prisoner at least knows his sentence, in contrast to their plight of indefinite limbo.

“As one layer of trauma was piled onto another, children had become more and more mentally disturbed” As one layer of trauma was piled onto another, children had become more and more mentally

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Drawing by a child in detention, given to the Australian Human Rights Commission as part of the National Inquiry into Children in Immigration Detention 2014

disturbed. Many had witnessed brutal events in their homeland, endured a frightening passage by boat to Australia and had now come to the realisation that, according to current policy, they would never be settled in Australia. Some of the teenagers had the flashbacks typical of PostTraumatic Stress Disorder (PTSD), many could not sleep, and some reported feeling depressed and crying every day. One 12-year old summed up her predicament in the words ‘My life is really deth.’ In order to thrive emotionally and physically, young children need a stable environment. Cramped living conditions and traumatised parents are not conducive to this. At the time we visited Christmas Island a dozen women with children aged less than 12 months were deemed at risk of repeat self-harm or suicide and were under 24-hour eye-contact surveillance. Against best clinical practice, they were supervised by security guards rather than by medical staff. We met children who had developed bed-wetting, regressed in their speech, withdrawn

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Changes to the Migration Act passed in the Australian Senate on December 5 2014 Legal Changes Relevant to Refugee Wellbeing By Claire O’Connor SC Katie Milanowicz

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aw Council of Australia’s submission to the Senate Standing Committee on Legal & Constitutional Affairs inquiry into the Migration and Maritime Powers Legislation Amendment (Resolving the Asylum Legacy Caseload) Bill 2014 (Submission 129):

Schedule 2: TPVs and Safe Haven Visas Who this affects • Asylum seekers who arrived by boat • Asylum seekers who arrived by plane without a visa or were not cleared by immigration at the airport • Asylum seekers who have previously held certain types of temporary visas, such as a Temporary Safe Haven Visa or Temporary (Humanitarian Concern) Visa.

Who this does not affect • Asylum seekers who arrived by plane with a valid visa, cleared immigration and then applied for asylum. You will continue to be eligible for a permanent protection visa. What is a Temporary Protection Visa (TPV)? • Valid for up to three years • Able to work • Able to access Medicare • Cannot sponsor family to come to Australia • Will have to reapply up to every 3 years and will not be eligible for permanent protection

“Key amendments relate to: the increase of Executive and non-Executive powers to detain and transfer people at sea and the restriction of the court’s ability to invalidate such actions; the reintroduction of Temporary Protection Visas (TPVs) and the introduction of the Safe Haven Enterprise Visa (SHEV); the introduction of fast track processing for the ‘legacy caseload’, including the removal or restriction of merits review; the removal of most references to the Convention relating to the Status of Refugees (Refugee Convention) in the Migration Act 1958 (Cth) and the requirement to consider Australia’s non-refoulement obligations; clarifying that babies born in Australia or in offshore processing centres will have the same designation under the Migration Act as their parents; and allowing the Minister to cap the number of protection visas issued.”1

What this means A new fast-track process has been developed for people who arrived by boat on or after 13 August 2012. Under the fasttrack process, you will still be interviewed by a department of immigration official; however there will be limited opportunity to appeal a negative decision of your refugee claim.

Schedule 1: Non-Refoulement

Expands the powers of Australian maritime vessels to transfer asylum seekers intercepted at sea (in Australian or international waters) to another ‘destination’. The Bill sets out that the term ‘destination’ will apply to places other than countries, such as a vessel.2

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Schedule 4: Fast Track Processing and removal of access to review before the RRT Who this affects This will affect asylum seekers who arrived by boat on or after 13 August 2012. (Note: around 30,000 people who are still living in the community/on bridging visas/in onshore detention facilities)4

Summary of the changes/issues overall:

Drawing by a child in detention, given to the Australian Human Rights Commission as part of the National Inquiry into Children in Immigration Detention 2014

Ban on family reunion for TPV holders The most concerning aspect of the TPV is the ban on family reunification. TPV holders will not be able to sponsor their families to Australia, and cannot leave Australia to visit their families and then return to Australia. This creates the perverse incentive of encouraging family members to risk their lives on the high seas.

Drawing by a 14 year old girl detained on Christmas Island, given to the Australian Human Rights Commission as part of the National Inquiry into Children in Immigration Detention 2014

This means: • Under fast track, unsuccessful claims will not be reviewed by the Refugee Review Tribunal • Instead, your application may be referred to a new review body called the Immigration Assessment Authority (IAA) • The review will not involve a hearing, instead the paperwork of your case will be reviewed • You will only be allowed to provide new information to the IAA if you are able to explain why it could not have been

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presented in the first instance • You can only appeal the decision at court to test whether the law has been applied properly, not to have the facts or merits of your case re-heard If your claim is successful, you will be granted a temporary protection visa.

Schedule 5: Changes to the definition of a refugee “Schedule 5 of the Bill is described in the Explanatory Memorandum as “clarify(ing) Australia’s international obligations”. It does so by removing references to the Refugees Convention from the Migration Act, an act that seriously undermines Australia’s commitment to its nonrefoulement obligations, the cornerstone of refugee protection.”5 Who this affects All asylum seekers, regardless of mode of arrival. Whether modifying behaviour is reasonable The decision maker assessing your application will determine whether you are able to reasonably modify your behaviour in order to be safe in your home country. This might mean, for example, changing your profession if this is what is putting you in danger. It does not require you to change fundamental things about your identity, such as your religion. The new Bill proposes to change and codify the test for membership of a particular social group (MPSG). At present, when considering MPSG, decision makers must be satisfied that: • there is a relevant social group of which the applicant is a member; and • the persecution feared is for reasons of membership of the group. Under the Bill, section 5L(1)(b) introduces an additional requirement for MPSG, being that the defining characteristic of the particular social group must be either innate or immutable or so fundamental to the member’s identity or

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conscience, the person should not be forced to renounce it. Changes to the test for eligibility for protection aka the 49/51% rule: (Insertion of 6AA to the Migration Act) A person is currently eligible for complementary protection from Australia if there is a “real risk” they’ll face significant harm on return. Australian courts have said the current threshold may be met when the probability of harm is well below 50 per cent. As former High Court Justice Michael McHugh has explained: [A] fear may be well-founded for the purpose of the Convention and Protocol even though persecution is unlikely to occur. ... an applicant for refugee status may have a well-founded fear of persecution even though there is only a 10 per cent chance that he will be ... persecuted. [6] The proposed reforms would increase the risk threshold an asylum seeker is required to meet to “more likely than not”, that is, a probability of greater than 50 per cent. This increases the risk of asylum seekers being returned to an environment in which they will experience mental or physical harm associated with persecution.

References:

1. Law Council of Australia submission 129, Executive Summary page 4. 2. Amnesty International Submission 170. 3. ANU College of Law submission 168 page 5. 4. Department of Immigration and Border Protection, ‘Immigration Detention and Community Statistics Summary’ (31 August 2014). 5. ASRC Submission 131 page 22. 6. Chan v MIEA (1989) 169 CLR 379 per McHugh J at 429. 7. ASRC submission 131 page 25. Drawing by an 8 year old child in detention in Darwin, given to the Australian Human Rights Commission as part of the National Inquiry into Children in Immigration Detention 2014

Schedule 6: Legal status of babies born in detention “Bill sch 6 item 2 inserting ss 5AA(1A) and 5AA(1AA) into the Migration Act 1958 (Cth). The Bill amends the definition of ‘unauthorised maritime arrival’ to include a child born in Australia or a regional processing centre who has at least one parent who arrived by boat, provided that child is not deemed an ‘Australian citizen’ under the Australian Citizenship Act 2007 (Cth). Babies born on Australian soil will be subject to: mandatory detention offshore; resettlement in Nauru or Cambodia, not Australia; or statelessness. This breaches article 3(1) of the Convention on the Rights of the Child49 (CRC) to ensure primary consideration is always given to the best interests of the child.” [7]

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Border Force Act – implications for doctors’ code of conduct By Barri Phatarfod Dr Barri Phatarfod is Cofounder and Convenor of Doctors for Refugees. She is a Sydney GP.

The Australian Border Force Act passed with bipartisan support in May 2015 and states that contracted persons speaking out about conditions in detention centres face penalties of up to two years imprisonment.1 Since then, medical bodies

including the Australian Medical Association (AMA) and the Royal Australasian College of Physicians (RACP) have voiced concerns about the resulting conflict facing doctors working under such conditions.2,3 In clinical practice doctors often have to balance competing ethics; however in this setting the dilemma is one of competing duties rather than ethics, as the ethical course is clearly outlined in the Medical Board of Australia’s Code of Conduct4, which is heralded as “consistent with the Declaration of Geneva and the International Code of Medical Ethics issued by the World Medical Assembly (WMA).” Specific sections of the Code are especially pertinent to the conditions in Immigration Detention Centres. Section 5.3 on ‘Health Advocacy’ states: “Good Medical Practice involves using your expertise and influence to protect and advance the health and well-being of individual patients, communities and populations.”4 Section 6.2 on ‘Risk Management’ describes Good Medical Practice as: “Working in your practice and within systems to reduce error and improve patient safety, and supporting colleagues who raise concerns about patient safety. Taking all reasonable steps to address the issue if you have reason to think that patient safety may be compromised.”4

Drawing by an unaccompanied teenager in detention on Christmas Island, given to the Australian Human Rights Commission as part of the National Inquiry into Children in Immigration Detention 2014

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This is consistent with the WMA which states: “A Physician shall act in the patient’s best interest when providing medical care and owe his/her patients complete loyalty and all the scientific resources available to him/her.”5 It is primarily from doctors and other health workers speaking out that we have learned about the appalling practices rife in the detention

Drawing by a child in detention on Christmas Island, given to the Australian Human Rights Commission as part of the National Inquiry into Children in Immigration Detention 2014

system. This includes lack of basic medication and equipment, dehumanising treatment of patients such as removal of eyeglasses, dentures and other aids including artificial limbs, denying sanitary products to women, sexual assault, trading essential items for sexual favours and unacceptable delays in transferring patients to hospital facilities or offshore, amongst other gross deviations from standard care.6,7,8 Doctors who speak out have so far been threatened with loss of employment and the civil action of breach of the confidentiality clause in their contract. Now they potentially face jail time. ‘Conflict of Interest’ is addressed in Section 8.11 of the Australian Code, confirming: “the doctor’s primary duty is to the patient; doctors must recognise and resolve this conflict in the best interest of the patient”4, all of the Code’s principles are superseded by Section 1.3 which states: “If there is any conflict between this code and the law, the law takes precedence.”4 However while this disclaimer might reassure some doctors fearful they may lose their medical registration by complying with the new Act, it does nothing to hearten the overwhelming majority who chose medicine because of the desire to treat and uphold the rights of vulnerable patients.

Significantly, this caveat is absent from the WMA Code of Ethics. This is hardly unexpected. Founded in 1947 in the aftermath of the Second World War, the WMA states in relation to prisoners and those in detention: “The physician shall not be present during any procedure during which torture or any other forms of cruel, inhuman or degrading treatment is used or threatened.”5 ‘Cruel, inhuman and degrading’ are the words used by Amnesty International9 and the UN10 to describe the routine treatment witnessed while visiting the offshore detention centres, raising the question of whether doctors ought to not work in these environments at all. Currently before Senate is a proposed law which effectively allows detention centre staff to use whatever force necessary to keep ‘good order’.11 There has already been one death on Manus Island last year allegedly caused by a security guard,12 and this law could remove such actions from being criminal. While the issue concerning compliance with registration requirements might be somewhat resolved, the larger question remains as to the type of society we have where the government passes laws contrary to medical ethics ratified by the Geneva Convention. History provides many examples of state-sanctioned human rights abuses

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perpetrated against sections of the population, and when the full extent of the atrocities comes to light the community is understandably horrified at the complicity of doctors. One wonders why Australia’s Medical Board has chosen to make these fundamental tenets subject to the prevailing laws of the day.

References:

1. Australian Parliament House: Australian Border Force Bill 2015 http://www.aph.gov.au/ Parliamentary _Business/Bills_ Legislation/Bills_Search_Results/ Result?bId=r5408 2. Sydney Morning Herald: Doctors and teachers gagged under new immigration laws 4 June 2015 http:// www.smh.com.au/federal-politics/ political-news/doctors-and-teachersgagged-under-new-immigrationlaws-20150603-ghft05.html

The harms being done to asylum seekers and refugees, compounded by this new law, are provoking a range of responses from doctors, all trying to achieve the best outcome for people in detention. Some advocate doctors boycott working in detention centres while others advise doctors not to sign contracts that put the employer’s interests between them and their duty to their patients. Several health professionals have affirmed they will continue to work in the system, advocate for their patients and risk imprisonment for defying an immoral law.

3. Sydney Morning Herald: Doctors must be allowed to speak freely on poor detention centre conditions http://www.smh.com.au/comment/ doctors-must-be-allowed-to-speakfreely-on-poor-detention-centreconditions-20150608-ghih50.html Drawing by an child in detention on Christmas Island, given to the Australian Human Rights Commission as part of the National Inquiry into Children in Immigration Detention 2014

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4. Medical Board of Australia Good Medical Practice: A Code of Conduct for Doctors in Australia. March 2014 5. World Medical Assembly International Code of Medical Ethics http://www.wma.net/ en/30publications/10policies/c8/ index.html

6. The Guardian,Christmas Island doctors’ letter of concern – in full. 13 Jan 2014 http://www.theguardian. com/world/interactive/2014/jan/13/ christmas-island-doctors-letter-ofconcern-in-full 7. Australian Department of Immigration and Border Protection. Review into recent allegations at the Regional Processing Centre in Nauru. February 2015. www.immi.gov. au/about/dept-info/_files/reviewconditions-circumstances-nauru.pdf. 8. 2015 Submission to the Select Committee on the Recent Allegations Relating to Conditions and Circumstances at the Regional Processing Centre in Nauru http:// www.theguardian.com/australianews/2015/jun/05/former-asylumseeker-worker-tells-of-abuse-of-twoyear-old-children-on-nauru

10. UN report: Australia’s detention of 46 refugees ‘cruel and degrading’. http://un.org.au/2013/08/27/ australias-detention-of-46-refugeescruel- and-degrading/ 11. Australian Parliament House: Migration Amendment (Maintaining the Good Order of Immigration Detention Facilities) www.aph.gov. au/Parliamentary _Business/Bills_ Legislation/Bills_Search_Results/ Result?bId=r5415 12. ABC News, Reza Barati: Trial of two men accused of killing asylum seeker on Manus Island to start next week. www.abc.net.au/news/201502-26/two-men-to-stand-trialover-reza-barati-death-on-manusisland/6265212

9. ABC News, Manus Island detention centre inhuman, violates prohibition against torture: Amnesty International 12 Dec 2013 Dufy, Stevens http://www.abc.net.au/news/201312-11/manus-island-violatesprohibition-against-tortureamnesty/5150664

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AMSA Recommendations: Given the evidence supported by the scientific and medical literature as well as experts, AMSA has 6 key recommendations for Australia’s humanitarian program: ONE

FOUR

This limit was recommended by the Joint Select Committee on Australia’s Immigration Detention Network and would reduce the health impacts of indefinite, mandatory detention. The sole purpose of detention should be to perform refugee status, health and security assessments. After this 90 day period refugees and asylum seekers would be moved to and processed in community detention.

FIVE

TWO

This must be a genuine regional agreement solution that is efficient and humane. A key component of this framework must be the guaranteed resettlement of refugees in the region (including, but not limited to, Australia) within a specific time period. This removes the uncertainty compelling asylum seekers to board boats for Australia, truly preventing deaths at sea.

Immigration and Border Protection’s consent. Doctors and other professionals contracted or employed by the Department are subject to this legislation. Although the Public Information Disclosure Act provides some protection, this is only in cases where there is a “substantial and imminent” threat to an individual.

Thus the PIDA does not provide protection to health professionals who advocate regarding chronic conditions leading to non-life threatening mental illness, environment conditions et cetera. Furthermore, the PIDA may not protect health professionals reporting instances outside of Australia’s jurisdiction; for instance within offshore detention centres.

Implement a legally binding limit of 90 Move all individuals on temporary days for refugees and asylum seekers protection visas (TPVs) to permanent in onshore and offshore detention. protection visas and abolish TPVs. This will provide certainty to these AMSA is opposed to offshore processing on health refugees, facilitating integration and grounds. However in the context of this occurring, a contribution to Australian society and legal restriction on the duration of detention would avoid unnecessary mental harm. minimise harm.

Introduction of independent oversight of Australia’s processing of refugees and asylum seekers, including offshore centres. In particular the establishment of an independent national health body to investigate and advise on the health needs of refugees and asylum seekers under Australia’s care. Parliamentarians must be accountable to the Australian public with respect to the conditions and services for refugees in detention and processing centres to whom Australia has a duty of care.

THREE

Move all children out of detention with their guardians. Implement the findings of the Australian Human Rights Commission’s The Forgotten Children report and the Moss Review to ensure that no child under Australia’s duty of care is at risk of sexual, physical or mental abuse. 22

AFRAM

Facilitate a regional processing and resettlement framework in which Australia, and other countries in our region, accept and process refugees in a manner consistent with international obligations.

As part of this framework, Australia would further support UNHCR process refugees in the region, and act as a leader by encouraging countries with capacity to become a signatory to the Refugee Convention and Protocol. AMSA understands this is a medium to long term solution involving complex international relations.

SIX

Ensure that medical and other health professionals are not at any risk of criminal prosecution for publically advocating for their patients.

Drawing by an 11 year old girl in detention in Darwin, given to the Australian Human Rights Commission as part of the National Inquiry into Children in Immigration Detention 2014

The Border Force Bill (2015) allows for the imprisonment of “entrusted persons” who release information without the Department of

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Vector Journal Issue 17  

Vector Journal is the official publication for AMSA Global Health and is a medical student run journal with the purpose of engaging medical...

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