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Issue Issue13 13July aug 2011

The Official Student Publication of the AMSA Global Health Network Committee

DISASTER ZONE


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Contents 4 editorial update

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5 Global Health in the News 6 AMSA Global Health Update

feaTures 7 CSI: 9/11 8 A World on the Run 10 The Health Burden of Climate Change

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12 A New Killer Disaster 15 Help is on its Way

opinion 17 An Important Distinction in Times of Crisis

electives 18 Electives for Dummies 20 Fondues in Geneva

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22 Patients Ahoy!

CONFERENCE REPORTS

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24 A Bright Idea 25 Time for a Paradigm Shift in Medical Education

26 GLOBAL HEALTH QUIZ

8 Dadaab, Kenya 14. 30; 14% 15. Carteret Islands 10. 15 million 11. Smallpox 12. 8 million; Pneumonia 13. Dagahaley camp in Sudan 6. 2015 7. US $1.25 (PPP)/day 8. China 9. Post-partum haemorrhage 1. Al Gore 2. Ischaemic heart disease 3. October, 2011 4. Pandemic 5. South


SUBSECTION

Editorial W e have been overwhelmed recently by scenes of modern cities at the mercy of Mother Nature, towns toppling under the ferocity of water despite adhering to the strictest building codes, and historic heatwaves and cold snaps paralysing foolproof transport networks. In spite of the death, destruction, and economic woes that have abraded the Western World, it has cast a debilitating shadow over the predicaments besieging millions in some of the poorest corners on Earth. On the 20th of July, the UN echoed vestiges of the past, declaring famine for the first time in over three decades. The crisis, encroaching upon twelve million victims in the Horn of Africa, is a product of a truculent drought, political unrest, and economic instability. According to UN figures, one billion dollars is required to meet immediate needs including food, clean water, and basic sanitation. However, the response of the international community can be at best described as ‘apathetic’ with a commitment of less than 200 million so far to match. The unfolding crisis is as much a result of people and policies, as other extenuating factors, and could have been mitigated in severity if pre-emptive action was taken. Developing countries, chiefly the poorest, endure the brunt of the world's disasters and suffer disproportionately from them (an estimated ninetyseven per cent of natural disaster related deaths occur in developing countries), as a result of marginalisation and lack of investment. The long-term repercussions of disasters are often equally as devastating as their acute effects, plunging many into new crises. A year on, Pakistan is still reeling from its prodigious floods, as hundreds of thousands remain displaced and in need of food assistance. This is compounded by the threat of further flooding due to the approaching monsoon season, stifling recovery efforts and perpetuating the lack of contingency planning. Similarly, Haiti is still in a tumultuous state and has succumbed to a Cholera epidemic. Clearly, a lack of long-term disaster management, such as early warning

Vector: The Official Student Publication of the AMSA Global Health Committee AGH Publicity Officer Alyssa Fitzpatrick Editor-in-Chief Saion Chatterjee

www.ghn.amsa.org.au

Co-Editors Maheshie Dayawansa Katherine O’Shea Design & Layout Annjaleen (Anjie) Hansa Webmaster Rungrueng (Tommy) Kovitwanichkanont

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SAION CHATTERJEE Editor-in-Chief Monash University

systems, tackling underlying social inequality, and emergency relief coordination is leading to futile loss of life and thwarting wider development goals. Whether disasters are essentially natural or man-made in origin, their consequences derive from a combination of human action and interaction with nature’s cycles or systems. UN officials warn that natural disasters will increase in intensity and frequency in coming years if unplanned urbanisation and environmental degradation continue. By 2015, on average over 375 million people per year are likely to be affected by climate-related disasters (fifty-four per cent greater than an average year during the last decade). Economically the cost of disasters is set to escalate as well. The devastation wrought by the earthquake in Japan, along with other disasters, made 2011 the costliest year ever recorded in terms of damages caused by nature. The global cost of natural disasters is anticipated to top 300 billion dollars annually by the year 2050, if the likely impact of climate change is not stemmed with aggressive disaster reduction measures. Future emergency responses need to be better aligned with a longer term perspective, looking at key socioeconomic investments, infrastructure, and preparedness and planning for disasters. Consequently, this issue of Vector takes a wideranging look at disasters, from the principles of disaster management to the links between health, disasters, and climate change. In addition, our guide to elective placements aims to provide a starting point for the world of opportunities that exist. We are in unprecedented times. It is essential that we adopt a proactive approach to address the potential challenges we face rather than the reactive one which has developed through complacency. The 21st century is the first time in history that we are able to eradicate famine, yet famine has returned with an uncompromising vengeance due to quick fixes and global inaction.

Editorial enquiries: Email vector@agh.amsa.org.au AGH enquiries: publicity@agh.amsa.org.au For past issues of Vector and AGH information visit: Visit www.ghn.amsa.org.au Call for submissions: Issues 14 of Vector, Refugees, Asylum Seekers

and Internally Displaced Persons, is now seeking submissions. We welcome letters, feature and opinion articles, elective stories, conference reports, and creative pieces. Please refer to the website for submission requirements.


SUBSECTION UPDATE

Global Health in the News SO LONG POLIO Eradication Update The past 2 decades have seen a 99% reduction worldwide in the prevalence of polio, but the virus is still endemic within 4 countries; India, Pakistan, Afghanistan and Nigeria. Recent reports suggest that the virus could be eliminated in India in the next 2-3 years, with this year’s case numbers hovering close to zero! If (when) this program succeeds, polio will go down in history as the second human virus to be eradicated form the face of the earth. WHO–GATESFOUNDATION.ORG

SEVEN BILLIONTH BABY ON WAY The United Nations Population Fund (UNFPA) has recently announced that the world’s population will reach 7 billion on the 31st October, this year. This is a significant milestone and represents both challenges and opportunities in regard to global health care. UNFPA Executive Director, Dr. Babatunde Osotimehin stated, ‘the population projections underscore the urgent need to provide safe and effective family planning to the 215 million women who lack it,’ highlighting the fact that population growth rates are not globally uniform. ‘Reducing inequities and finding ways to ensure the well-being of people alive today–as well as the generations that follow–will require new ways of thinking and unprecedented global cooperation.’ A seven day countdown is planned to start on the 24th of October, with the UNFPA using the week to raise awareness of the implications of a 7 billion strong global community. The week will also see the launch of the State of World Population report, which will be released to coincide with the birth of the world’s 7 billionth child.

CHOLERA RAVAGES HAITI More than 5,000 Haitians have now died in the post-earthquake cholera epidemic that continues to shake the most impoverished country in the Americas. Over 302,000 people have been affected by the disease throughout the outbreak, which shows no signs of abating.

This year marked the 60th anniversary of the UN Refugee Convention, yet 2011 sees more people than ever before being forced to flee their homes in search of asylum. The United Nations High Commission for Refugees’ (UNHCR) latest report states that there are currently 43.3 million people forcibly displaced worldwide. (This figure includes 15.6 million registered refugees and 27.1 million internally displaced people (IDP).) On the 20th of June every year, the UNHCR celebrates World Refugee Day as a sign of solidarity and to recognise the immense courage and resilience that millions of displaced people around the world exemplify. This year the theme is ‘1 refugee without hope is too many’ and the UNHCR encourages everyone to ‘do 1 thing’ to support refugees in their community and around the world.

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‘1 REFUGEE WITHOUT HOPE IS TOO MANY’ World Refugee Day–20th of June

CEDRIC GERBEHAYE–AGENCE VU, LIGHTBOX.TIME.COM

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SUBSECTION UPDATE

Global Health in the News SAY NO! TO NOMA

Life-Saving Rotavirus Vaccine Launched

We are going to take a small liberty here, and showcase something specifically because it is not in the news. Noma (cancrum oris) is a horrifically destructive disease that devours the faces of those it infects. It is a disease of abject poverty, with malnourished status being a key risk factor in the development of the disease. Rotaviruses are a leading cause of severe diarrhoeal disease and dehydration in The United Nations Food and Agriculture Organization (FAO) estimates that 925 infants and young children worldwide. It is million people are currently undernourished, with an overwhelming majority living expected that the Rota vaccine in Sudan, in the developing world. Almost all cases of Noma occur in children under the age the first African country to have the vaccine, of 6. If they survive, they are subjected to a life of social and educational exclusion, will significantly reduce the country’s infant unemployment and ongoing health concerns. mortality rate. The WHO estimates that of the 140,000 new cases of Noma per year, only 10% at most will survive. The vast majority of the 126,000 Noma deaths each year occur in sub-Saharan Africa, between Senegal to Ethiopia in what is now known as ‘the Noma belt’. If Noma is something new to you, we highly recommend checking out websites such as Facing Africa, No Noma and Harar Project amongst others, because this disease does not receive the attention it should. So, what needs to happen? • Adequate global nutrition–the world currently has the resources to feed every single inhabitant, we need to ensure those in need receive access to daily nutrition. • Making poverty history–Noma is both caused by poverty and a cause of poverty. • Improving dental hygiene–the causative pathogens are common commensal oral flora. • Increase access to antibiotics–if treated early on, the disease’s progression can be halted before its disfiguring and debilitating effects occur. • Increase access to reconstructive procedures for survivors– maxillofacial surgery is prohibitively expensive for survivors given that Noma is a disease of poverty; most survivors cannot afford reconstructive surgery. Charitable organisations provide a limited yet increasing number of free surgeries in high prevalence areas, but require constant donations.

AMSA GLOBAL HEALTH COMMITTEE

UPDATE

FROM GHN TO AGH AND BEYOND

From July 2011, you might notice a few differences when you head to the GHN webpage. First of all, we are not called the GHN anymore. For the fourth time in its history, the GHN will undergo a name change, this time to the AMSA Global Health Committee (AGH). This change reflects an underlying restructure which has been designed to make the AGH more effective, dynamic and streamlined in its approach to engaging medical students from across Australia in issues of global health. Where previously the Executive Committee, who oversaw the day to day running of the AGH, consisted of the students who had been elected to represent their global health group on the AGH Committee, these two committees have been separated. The AGH is now composed of two individual committees who function together to better represent the collective needs of Australia’s global health groups. The Representative Committee is composed of students elected by their Global Health Group (GHG) to represent them on the AGH; the Representative Committee then elects the Executive Committee who serves the needs of the Representative Committee. By distinguishing the functions of the committees, the individual voices of GHGs will be better heard and a more collaborative approach able to engage students in global health.

WHAT DOES THE AGH DO?

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For many students, the AGH is somewhat of a mysterious entity. It exists, but many are unsure of how it can impact on their student lives. The AGH primarily exists as a network to support individual GHGs in their work, provide educational materials for students and offer avenues for further involvement in global health. The AGH is rapidly becoming one of the premier resources for Australian medical students with an interest in global health, and as it continues to evolve, its reach and impact can only continue to grow.

NATIONAL PROJECT AND GLOBAL HEALTH LIBRARY

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The AGH runs a National Project every year in which GHGs may become involved. In 2011, the National Project is the Project Pool, which encourages submission of initiatives which have been successfully run at each university to allow for information sharing and the exchange of ideas. GHGs present their most successful initiative at the Global Health Conference, with prizes available for the most outstanding submissions. The Global Health Library is also currently being developed, which will provide students with high quality resources on issues of global health.

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SUBSECTION FEATURE

Dr Richard Jones

Forensic Pathologist Wales Institute of Forensic Medicine

‘At 8.45 am a Los Angeles bound American Airlines 747 from Boston, USA crashed into the upper half of the north tower of the World Trade Centre with a terrific explosion. Workers arriving into downtown lower Manhattan could only stare in disbelief. Within eighteen minutes, United Flight 175 crashed into the south tower sending a fireball and debris down to the crowded streets below. Panic took hold, and the city’s emergency services flooded into the area from all over the island. As part of my elective, I was working at the City of New York Office of Chief Medical Examiner at East 30th Street, 1st Avenue, at the time of the crashes–just 11/2 miles away.’ or several hours supplies came into the office in a steady stream and we were told to get some rest before the expected delivery of bodies of the victims from ‘Ground Zero’. The streets around the Office of the Chief Medical Examiner (OCME) were sealed off to civilians within hours of the incident, and NYPD and Fire Department officials began converging on the area, their faces grim in the knowledge that up to 350 of their colleagues were still missing, presumed dead. The federal agencies such as the FBI were also well represented. That night, the work of the OCME began in earnest and I was assigned to one of the four teams that began the harrowing job of identifying the bodies of the victims. From a practical point of view, the process of identifying whole or partial bodies involved searching through clothing for personal papers, credit cards, and identity cards or driving licenses, etc. Where there were no such papers, the investigation focused on clothing, which is documented in detail, from the colour, style and make of the items, to the size of the garment. Tattoos and jewellery were also of immense importance, particularly where there were inscriptions of any kind. Where there were no readily available features, teeth and DNA were vital, and each body or part was routinely sampled for DNA profiling. Over the next twenty-four hours the grim reality of the total devastation of the incident was clear. The

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Smoke billows from ‘Ground Zero’ (right) HALINA MALONE –THE ELECTIVES NETWORK

Article supplied by The Electives Network.

www.ghn.amsa.org.au

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pathological details meticulously gathered at the OCME would be perhaps the only manner in which many relatives would be able to receive definitive information about their missing relatives, and it was immensely satisfying to be part of the efforts to find and document identifying features. Within the next few days I was given the role of identifying and cataloguing body parts, so that the Medical Examiners could focus on the whole bodies. As the days drew on, the team structures changed and eventually I found myself being assigned to ‘triage’ the large amount of incoming body parts. By introducing an additional ‘sorting’ stage into the process, it was hoped that the pathologists and their identification teams would not be overloaded by fragments that were too small to catalogue in detail, but which could still be sampled for DNA. The triage process was very successful. There were a large number of non-human remains, and I found that my prior training in meat inspection and comparative anatomy held me in good stead. We removed beefsteaks, lobster tails, ‘rack-of-ribs’ and hot dogs from the already over-crowed system, and allowed the identification teams to concentrate on their more important work. Towards the end of our elective, we were given tours around ‘Ground Zero’. The sight was surreal–having seen images of the devastation on CNN the reality of the scale of the situation was far more horrible to contemplate. There were huge mounds of twisted steel girders as far as the eye could see, and there was a mist of steam and smoke hanging in the air. Several buildings on the perimeter of the central area had huge girders sticking out at strange angles from their sides–where they had pierced their facades during the collapse of the World Trade Centre towers. The whole scene looked just like an extremely expensive Hollywood film set and not what we initially thought could be the tomb of nearly 50,000 missing people. Despite the horror of seeing ‘ground zero’, it was extremely useful to visit the site to put the rest of our elective experiences into some sort of context. As medical students we were fully integrated into the identification process and accepted without question as being ‘part of the team’. The whole experience was extremely rewarding because of this, and I found it difficult to leave after working so closely with my other colleagues.

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FEATURE

A WORLD

ON ON THE THE RUN RUN O

The plight of ‘climate refugees’

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ur Earth is not ready to deal with another 250 million refugees, but that is where our current state of climate chaos is taking us. The plight of ‘climate refugees’ is perhaps one of the most frightening and difficult issues of the climate change debacle, one that seems to be making no progress and one that is simply not going away. Increasingly, climate change is being recognised as the cause of the displacement of individuals, communities and in some cases, entire nations, as its effects become more widely and intensely felt across the world. To add to the problem, climate-displaced persons are not currently recognised under the UN Refugee Convention and no protocols currently exist to ensure that these vulnerable populations are protected. Estimates of anticipated rises in sea levels are still up in the air. A report commissioned by the Australian Government earlier this year predicted a 100 cm increase over the next century.1 Less conservative estimates have predicted the loss of Greenland and the west Antarctic ice sheets, and a 13 m rise in sea level.2 Despite precise figures, however, population displacement due to rising seas is inevitable given that over 1/3 of the world’s population lives within 100 km of the coastline.3 We are already seeing the effects. In early 2009, after battling decades of worsening storm surges

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and king tides, the 2,700 inhabitants of the Carteret Islands in the Pacific were hailed the first climate change refugees when they began the largescale relocation to Bougainville, some 80km away.4 Global increases in sea level will not be uniform. Many small island states are likely to suffer disproportionate land loss consequences.5 Maatia Toafa, the former Prime Minister of Tuvalu, has said that based on current predictions, his country will not exist in 2050 because all of the islands are low-lying. Indeed the highest peak in Tuvalu is only five metres above sea level.6 Naturally, the threat is even more pronounced in regions of high population density. A rise in sea levels of 45 cm would submerge over 10% of Bangladesh and displace 5.5 million people; a rise of 1 m could see almost 30 million become displaced.3 It is no surprise that representatives from these countries voice grave concerns every time the Conference of the Parties (COP) summits fail to deliver any meaningful global promises on climate change. It is becoming increasingly obvious that displacement due to climate change is about more than just the insidious rise of sea levels. 42 million people were forced to flee their homes due to natural disasters in 2010.7 90% of these were climate-related disasters7, and current evidence suggests that these

figures will only increase as climate change causes an increase in the frequency and severity of extreme weather events and natural disasters worldwide. Last year hundreds died and thousands more were displaced on the slopes of Mount Elgon in Eastern Uganda after heavy rains led to landslides on the mountain. In the Himalayan region, glacial lake flooding has been responsible for extensive fatalities and property damage. From cyclones in the USA to earthquakes and floods in Pakistan and furious bushfires here at home, climate change is likely to leave nobody unaffected. Coastal erosion, storm surges and unpredictable weather patterns will all play a part in mass displacement.5 Food security is a less conspicuous but equally concerning cause of climate change displacement. Storm surges deplete and degrade crop production, and drought and salination can devastate previously arable land.5 Coral bleaching extinguishes stocks of natural marine resources and supplies of clean water can become threatened due to changing rainfall patterns.5 Such environmental tragedies have the capacity to create huge numbers of displaced people, forcing both temporary and permanent migration in order to escape uninhabitable conditions.5 All in all, the population of ‘climate refugees’ is


FEATURE Erica Parker

Year 4 Medicine University of Western Australia, Vice-Chair of AGH & Co-Chair of Interhealth

arrived on our shores last year, they will be beside themselves when they are arriving in their thousands. So what needs to happen? • An official agreement must be formed safeguarding the basic human rights of people displaced by climate change, whether it be an adjustment to the Refugee Convention or a completely new agreement. • Australia, along with the rest of the world, needs to switch to a lowemissions economy to minimise the effects of climate change. • Money needs to be invested to help those nations most at risk to adapt to environmental changes and the potential for mass displacement. • We all need to become more educated and push our elected representatives to fight for this important issue and the formation of better, more sympathetic policies. Refugees of climate change highlight a humanitarian issue that transcends debate regarding the man-made contribution to climate change. Our seas are rising and vulnerable peoples are being displaced. The time to act is now. References 1. Climate Commission Secretariat. The Critical Decade: Climate Science, Risks and Responses. Commonwealth of Australia. 2011. Available from: http://climatecommission.gov.au/wp-content/uploads/The-CriticalDecade_final_low-res.pdf. 2. Greenpeace International. Sea level rise. 2006. Available from: http:// www.greenpeace.org/international/en/campaigns/climate-change/ impacts/sea_level_rise/. 3. Belt D. Bangladesh: The Coming Storm. National Geographic. 2011. Available from: http://ngm.nationalgeographic.com/2011/05/ bangladesh/belt-text/1. 4. Morton A. First climate refugees start move to new island home. The Age, Australia. 2009. Available from: http://www.theage.com.au/national/ first-climate-refugees-start-move-to-new-island-home-20090728-e06x. html. 5. Williams A. Turning the Tide: Recognising Climate Change Refugees in International Law. Law & Policy. 2008. 30(4). Available from: http://www. cerium.ca/IMG/pdf/Turning_the_Tide-_Recognizing_Climate_Change_ Refugees_in_International_Law.pdf. 6. Gemenne F. Climate Change and Forced Displacements: Towards a Global Environmental Responsibility – The Case of Small Island Developing States in the South Pacific Ocean. Centre for Ethnic and Migration Studies, Belgium. 2006. Available from: http://www.cedem.ulg. ac.be/m/cdc/12.pdf. 7. Internal Displacement Monitoring Centre. Displacement due to natural hazard-induced disasters. Norwegian Refugee Council, Norway. 2011. Available from: http://www.nrc.no/arch/_img/9570202.pdf. 8. Kenny Z. Global warming refugees – left to drown? Green Left. 2007. Available from: http://www.greenleft.org.au/node/37255.

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“...based on current predictions, his country will not exist in 2050...”

expected to swell to 250 million by mid-century.3 Internal displacement (within the same country) and transnational displacement (crossing borders) both raise many issues. In Bangladesh, one of the most densely populated nations, millions of internally displaced people would overwhelm not only the limited land and resources, but the governments, institutions and borders.3 Similarly, geopolitical chaos would ensue if millions of refugees were to flee to neighbouring India, with problems stemming from widespread disease, religious conflict, chronic shortages of food and fresh water, and heightened tensions between India and Pakistan, well-known nuclear-armed adversaries.3 Indeed, the sheer number of climate refugees will be a huge issue for national security globally. The peaceful settlement of 250 million refugees is no easy task. In a majority of cases, these people will have lost everything: their homes, their communities, their livelihoods and their material goods, perhaps even their families. However, in the current state of international affairs, people displaced by climate change would have zero protection. Indeed, the term ‘climate refugee’ doesn’t even really exist. There are two core elements to the United Nations’ Refugee Convention that must be satisfied in order to grant legal refugee status: 1. There must be a ‘well-founded fear of being persecuted’. 2. The reasons for persecution are limited to ‘race, religion, nationality, membership of a particular social group or political opinion’.5 There is no obvious provision for refugees created by environmental change within this definition. The essence of the idea is the same: the forced relocation of individuals due to external (and largely unmanageable) factors, but the fact remains that there are no doctrines, treaties, agreements or promises to protect the basic human rights of these people.5 Attempts to extend the Refugee Convention definition to be more sympathetic to the plight of environmental refugees have faced severe opposition from governments concerned that such a move would open the “refugee floodgates” given the sheer enormity of the problem.5 And let us face it: our beloved xenophobic Australia does not have the best track record with refugees. In 2007, the Howard government embarrassingly refused to meet with the Tuvaluan Prime Minister on two occasions when he came pleading for generosity with refugee intake.8 New Zealand then made us look even worse by agreeing to take on all 8,000 of the remaining Tuvaluans when their country becomes uninhabitable.8 Preventing official migration will not stop desperate people seeking asylum any way they can. And if our leaders are scared of the 134 boats that

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www.ghn.amsa.org.au

FEATURE

A

Rohan Church

Year 4 Medicine University of Tasmania & National Students’ Representative of Doctors for the Environment Australia (DEA)

THE HEALTH BURDEN OF CLIMATE CHANGE Influencing social change 10

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long with biological, psychological, and socioeconomic determinants of health, it is undeniable that the environment in which a person lives is a major driver of their health outcomes. This is clearer than perhaps anywhere else when we consider the potential impacts of natural disasters. Along with direct injuries or deaths resulting from events such as earthquakes, cyclones, or floods, health problems may be exacerbated by the breakdown of infrastructure, and in the intermediate-term, problems associated with access to clean water and sanitation. In the longer term, mental health conditions such as depression and anxiety may persist well after every brick has been relaid following a natural disaster. The year of 2010 was a record-breaking year for extreme weather events around the world. Cold weather in Western Europe and the UK shut down air travel and stranded thousands. Floods in Pakistan and China displaced millions of people. Heatwaves and wildfires in Russia and Eastern Europe killed tens of thousands of people, and NOAA (National Oceanic and Atmospheric Administration) ranked the North Atlantic hurricane season as one of the most severe of the last century.1 While no single event is climate change, Bates and Kundezwicz2 write that it is expected that global warming will lead to an increase in the frequency and severity of natural disasters around the world. This applies to both developed and developing nations, with Satterthwaite et al.3 noting that cities such as Alexandria, Dhaka, Mombasa and Port Harcourt are particularly at risk from flooding and sealevel rise. The Climate Institute points out that developed nations such as Australia are also at risk, with climate change set to bring more extreme weather patterns to Australia in the coming century.4 One form of extreme weather event, particularly pertinent to Australia, are heatwaves. A report prepared by Victoria’s Chief Health Officer, Dr John Carnie, reported that during the same period as the tragic Victorian bushfires, there were over 300 more deaths than average.5 Heatwaves contribute to morbidity and mortality through dehydration and heat-stress, as well as through precipitating acute presentations of cardiovascular and respiratory diseases. Sterl et al.6 report that some studies predict Australian summer temperatures to peak at over 50°C by the end of the century. Thus climate change will increasingly be a cause of ill-health in Australia unless greenhouse gas emissions are curtailed rapidly.


FEATURE

‘The rich will find their world to be more expensive, inconvenient, uncomfortable, disrupted and colourless; in general, more unpleasant and unpredictable, perhaps greatly so. The poor will die.’7 Despite the Australian Bureau of Meteorology reporting a repeated increase in global temperatures as well as the increasing frequency and severity of extreme weather events,8 there continues to be much misrepresentation of the relationship between climate change and extreme weather. A recent headline by journalist Graham Lloyd in the Australian lead with ‘Summer of disaster ‘not climate change’’, but went on to quote Dr Rajendra Pachauri, the chairman of the Intergovernmental Panel on Climate Change (IPCC), as saying:

‘…these events…are taking place at much higher frequency and intensity all over the world. On that there is very little doubt; the scientific evidence is very very strong.’9 The rest of Lloyd’s article said nothing to back up the sweeping headline, and predictably, the article went on to cast aspersions at those Australian politicians who are seeking strong action on climate change. Fiona Armstrong, founder and convenor of the Climate and Health Alliance, writes that the mainstream media has also failed to question the relationship between extreme weather events and global warming. In her article ‘Levies, wild weather and global warming’, she points out that talking about climate change, for example in the wake of the recent Queensland floods, is not always politically expedient:

‘…the Queensland Premier has an election to fight next year and her government has recently endorsed an ongoing commitment to industries responsible for causing climate change, such as coal.’10 More broadly, at the time this article was written, the Australian government, whilst now taking some steps in the right direction, has as yet far failed to aim above a greenhouse reductions target of more than 5% by 2020. Whilst the Multi-Party Committee on Climate Change has made some important recommendations

so far, it is alarming that the conservative side of politics seems to be increasingly more persuasive with its arguments against serious action on climate change. Never in human history have the livelihoods of future generations depended so strongly on the actions of the current generation. Medical students, health professionals, and citizens of the world have the ability, and perhaps even the responsibility, to call for serious action on climate change. AMSA’s policy on climate change, calling for a 25-40% reduction in carbon emissions by 202011, is an excellent specific and measurable target for Australia to work towards. However, to secure a healthy climate for the future, strong voices are needed to advocate policy at a community and political level. In 2011, student members of Doctors for the Environment Australia (DEA) continued with their ‘Climate Code Green’ campaign, aimed to highlight the devastating health impacts of climate change and call for serious and urgent action on the issue. Medical students around the country helped work towards a healthy climate by participating in ‘Code Green’ Action Week, from August 1st-5th. For further information or to get involved in future events, please contact deastudents@ gmail.com.

References 1. National Climactic Data Centre. Top 10 Global Weather/Climate Events of 2010 [Internet]. Ashville, NC (USA): National Oceanic and Atmospheric Association and National Climactic Data Center (US); 2011 [updated 2011 Jan 12; cited 2010 May 18]. Available from: http:// www.ncdc.noaa.gov/special-reports/global-top-ten-2010.html. 2. Bates BC, Kunderwicz ZW, Wu S, Palutikof JP. Climate Change and Water, Technical Paper of the Intergovernmental Panel on Climate Change [Internet]. Geneva: IPCC Secretariat (SW); 2008 [updated 2008 Jun; cited 2011 May 17]. Available from: http://www.ipcc.ch/pdf/ technical-papers/climate-change-water-en.pdf. 3. Satterwaite D, Hug S, Pelling M, Reid H, Lankao PR. Adapting to climate change in urban areas: the possibilities and constraints in low and middle-income nations [Internet]. London: International Institute for Environment and Development; 2007 [cited 2011 May 17]. Available from: http://pubs.iied.org/10549IIED.html. 4. The Climate Institute. Climate change and extreme weather events [Internet]. Sydney: The Climate Institute (AU); 2011 [updated 2011 Feb; cited 2011 May 17]. Available from: http:// www.climateinstitute.org.au/images/reports/tci_extremeweatherfactsheet_feb2011.pdf. 5. Department of Human Services. Heatwaves in Victoria: an assessment of health impacts. Melbourne: Victorian Government Department of Human Services; 2009. 6. Sterl A, Sverjins C, Dijkstra H, Hazeleger W, van Oldenborgh GJ, van den Broeke M, et al. When can we expect extremely high surface temperatures? Geophys Res Lett [Internet]. 2008 [cited 2011 May 17];35(14):1-5. Available from: http://www.knmi.nl/publications/ fulltexts/sterl_extreme_grl_2008.pdf. 7. Smith K. Symposium introduction. Mitigating, adapting and suffering: how much of each? Annu Rev Public Health [Internet]. 2008 [cited 2011 May 17];29:11-25. Available from: PubMed. 8. Australian Bureau of Meteorology. Climate Change [Internet]. Canberra: BOM; 2011 [updated 2011; cited 2011 May 18]. Available from: http://www.bom.gov.au/climate/change 9. Lloyd G. Summer of disaster ‘not climate change’. The Australian [Internet]. 2011 May 17 [cited 2011 May 17]; National Affairs:[about 2 screens]. Available from: http://www. theaustralian.com.au/national-affairs/summer-of-disaster-not-climate-change-rajendrapachauri/story-fn59niix-1226057100026. 10. Armstrong F. Levies, wild weather and global warming [Internet]. Australia: Climate and Health Alliance; 2011 [updated 2011 Mar 22; cited 2011 May 17]. Available from: http:// caha.org.au/wild-weather-and-global-warming-links-being-ignored/. 11. Australian Medical Students' Association (AU). Climate Change and Health Policy [Internet]. Australia: AMSA; 2009 [updated 2009; cited 2011 May 17]. Available from: http:// www.amsa.org.au/sites/default/files/Climate%20Change%20and%20Health%20Policy.pdf.

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However, it is important to note that those living in developed nations are more likely to be shielded from the worst impacts of extreme weather events due to the existence of stable governments, high quality emergency services, and plentiful resources. As with climate change in general, the following quote from Smith is applicable to the health impacts of more extreme weather:

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FEATURE

‘For the first time ever, we have confronted in reality the sinister power of uncontrolled nuclear energy.’–MIKHAIL GORBACHEV, Soviet Premier, May 26, 19861 ‘The unfortunate truth is we are likely to see more such disasters. The world has witnessed an unnerving history of nuclear accidents.’–BAN KI MOON, UN SecretaryGeneral, April 20, 20112

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n the 26th of April, 1986, an experiment run on Reactor Four at the Chernobyl Nuclear Power Plant in Ukraine descended into chaos. The chain of events that followed resulted in a fire and explosion which released over one hundred radioactive elements into the environment, a release which would alter the lives–in terms of health and relocation–of hundreds of thousands of people.3 And on the 11th of March, 2011, as the 25th anniversary of Chernobyl drew near, a deadly 9.0 magnitude earthquake and tsunami compromised the power supply, and thus the cooling mechanism, of multiple reactors at the Fukushima I Nuclear Power Plant in Japan, sending them spiralling towards disaster. As the disaster’s rating on the International Nuclear Event Scale (INES) was raised from 4 to the maximum of 7, radioisotopes spilled out of the plant into the atmosphere and water. While the long-term effects of this radiation remains unclear, Japan has already seen first-hand the potential effects, given the aftermath of the Hiroshima and Nagasaki bombings which indiscriminately killed more than 210,000 people within a year and caused thousands of malignancies, particularly leukaemias, long after the event.4 Chernobyl and Fukushima join the Three Mile Isle accident in the United States and the Kyshtym Disaster in Soviet Russia on a growing list of significant nuclear disasters.

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THE HEALTH IMPACT

The Chernobyl meltdown has been the most widely researched civil nuclear energy disaster. The explosion and initial release of radiation claimed the lives of thirty workers and firefighters.5 Moreover, one hundred fifty individuals were treated for acute radiation sickness, and forty-eight of these individuals’ deaths were linked to radiation.6 The aftermath saw a significant spike in the prevalence of thyroid cancer due to iodine-131 lodging in the thyroid. Estimates vary, but UNSCEAR (United Nations Scientific Committee on the Effects of Atomic Radiation) in 2005 associated Chernobyl with 6,000 such thyroid cancer cases in children residing in Russia, Belarus and Ukraine.5 Another study associates 16,000 fatal cancers to Chernobyl.6 These figures do not include the psychological impact (including suicides) or the potential for long-term genetic changes via mini-satellite instability (an area of continuing research).2, 6 Our understanding of Chernobyl remains incomplete. Thirty years after Hiroshima and Nagasaki, new radiation-related cancer threats were emerging.6 Strontium and caesium radioisotopes have a long half-life and are linked to malignancies. The effect of whole body radiation versus tissue-specific radiation also needs to be investigated.6 Thus the true impact of these accidents may yet be unknown. Given this, the impact of Fukushima remains largely a mystery. In the shorter term, there were cases of injury and acute radiation sickness amongst workers and nearby residents. The long-term effects will be a major study focus over the coming years.7 Nuclear weapons explosions have far more varied and profound effects, with immediate death and destruction combining with long-term malignancies and birth defects. The differences are partially due to the fact that weapons explosions emit mainly gamma rays and neutrons, while Chernobyl and Fukushima mainly emitted radioactive isotopes.6

MANAGING THE AFTERMATH OF A NUCLEAR DISASTER

Nuclear energy and nuclear accidents cannot be viewed simply from a health perspective. Rather, this issue is mired in far deeper ethical, economic, environmental, and political contexts. The fact that nuclear accidents can originate in one nation but transcend national boundaries adds another dimension to management efforts. In Chernobyl, there was a perceived lack of understanding as to which nation ought to take the lead. Some claim that the Chernobyl aftermath was downplayed and the response was unreasonably reassuring in spite of legitimate health risks, even suggesting that inadequate action was taken to control long-term effects, leading to what the UNDP terms a ‘progressive downward spiral of living conditions’.6, 8 Attempts to suppress fires in the reactor and bring the reactor under control posed great health risks


FEATURE later extended to 30 km, and was then morphed into an irregular area of land which extended beyond 30 km in the north-west direction, as winds had carried radioisotopes to these regions. The United States argued that a larger zone of evacuation was required.10, 11 A high dose of radiation was detected in the town of Iitate 40 km away from the reactors, and even the town of Kanagawa 300 km to the south had been noted as a ‘hotspot’.12 Tsunami victims found within the 30 km zone had received excessive doses of radiation.13 Soil contaminated with caesium radioisotopes, which present a long-term cancer risk, has to be removed and some areas may have to be permanently evacuated. Schools around the region have been the site of community decontamination efforts after perceived government inaction.14 The Japanese government quickly moved to ban agricultural produce from contaminated areas.15 Produce grown within vast tracts of land within and outside the Fukushima prefecture are now deemed unsuitable for human consumption.15 Leafy vegetables and milk in particular had high levels of iodine. Contaminated food and drink was a major issue in Chernobyl, particularly in relation to cows grazing on iodine-contaminated pasture and then producing milk with iodine-131 which can accumulate in the thyroid.15 Criticism has been attributed to the degree of improvisation in the efforts to control the reactors.16

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to the firefighters and workers involved. As a result of a phenomenal engineering effort, a sarcophagus was constructed around the fourth reactor which still presented a radiation danger.2 In the long-term, ‘liquidators’ have continued the decontamination process, and finally in 2000 the decommissioning of the reactors began. Buses were sent to the town of Pripyat (population around 50,000) the day after the radiation release to begin the evacuation process. Over the following weeks and months, around 200,000 people were relocated.2 A 30 km exclusion zone still exists around the disaster site, however, even individuals outside the exclusion zone received high radiation doses.2 Winds carried radioisotopes over the rest of Europe, usually in fairly insignificant amounts.2 Japan has been the most recent demonstration of a nuclear accident recovery effort, and has been both praised and criticised. The reactors were brought under control by around 800 workers who were exposed to high radiation doses.7 The Japanese government made the somewhat controversial decision to increase the maximum allowed radioactive dose for workers to allow them to continue working.9 Peripheral blood stem cells were collected from workers so that haematopoietic stem cell rescue would be possible.9 At first an evacuation zone with a 20 km radius around the disaster site was established, which was

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FEATURE Some claim that worker safety was ignored; that workers were not informed of their radiation doses or were otherwise given incentives to take greater risks.16 By March 29, nineteen workers had received doses above 100 mSv (the original maximum dose allowed).17 The United States and France had to deliver equipment to help restore functionality to the cooling apparatus in the plant. A nuclear disaster has an impact on populations and tracts of land decades and perhaps even centuries into the future. Even decommissioning a reactor takes decades. This draws one to consider the potential for such a disaster to affect a developing nation. Nuclear energy and weapons are, in spite of regulations, spreading to new nations and regions. This places developing regions, particularly in Asia, at risk. The capacity of such regions to coordinate a largescale evacuation and clean-up effort is not as certain as that of a nation like Japan. Furthermore, in 1991, 22.3% of the national budget of Belarus was associated with Chernobyl.18 It is unclear whether other nations could afford such a burden.

WHAT DOES THE FUTURE HOLD?

In the long-term, Chernobyl indicated the necessity of secondary containment and heightened attention has since been given to the safety mechanisms in all reactors in Central Europe.6 Despite this, Fukushima suggests that there may be no way to guarantee that a nuclear accident will never occur, and thus plans for disaster management are vital. Fukushima has stimulated a desire for further research on management of a nuclear accident including medical management, training personnel to deal with meltdowns, and managing the requirement for equipment, clothing, and masks.19 Reinforcing backup energy systems to ensure the integrity of cooling in case of natural disaster is also important.19 Furthermore, many nearby nations were unprepared for the sudden demand for iodine tablets to protect the thyroid from the iodine-131 radioisotope. In Japan, potassium iodide tablets were provided to children.15 Fukushima shocked the world. In its aftermath, Germany announced that it would phase out its nuclear energy program by 2022.20 This move may be a starting point in stimulating other nations to take a similar route. The Comprehensive Test Ban Treaty of 1996 brought an end to nuclear testing, which was having health effects on nearby populations, while the Nuclear Non-Proliferation Treaty of 1970 stipulated disarmament via negotiation. However, achieving nuclear disarmament, perhaps by means of a Nuclear Weapons Convention (NWC), is still years away. The role of the medical profession in achieving this goal, and in particular IPPNW (International Physicians for the Prevention of Nuclear War), is significant, as doctors move towards safeguarding the health of future generations by advocating for action on nuclear weapons and civil nuclear energy. The health impacts of nuclear disaster are profound, and it is evident that a policy of prevention, whatever form that may take, is the most prudent pathway forward.

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The disaster management cycle (above): GOVERNMENT OF INDIA–HAZARDS, DISASTERS, AND YOUR COMMUNITY, A PRIMER FOR PARLIAMENTARIANS, MINISTRY OF HOME AFFAIRS, NATIONAL DISASTER MANAGEMENT DIVIDION, INDIA

References 1. Greenwald J. Moscow struggles to limit the damage of the Chernobyl disaster. Moscow: TIME Magazine; 1986 [cited 2011 3 July]; Available from: http://www.time.com/time/daily/chernobyl/860526. gorbachev.html. 2. IAEA. Frequently Asked Chernobyl Questions. Vienna: International Atomic Energy Agency; 2011 [cited 2011 3 July]; Available from: http://www.iaea.org/newscenter/focus/chernobyl/. 3. Tsukanova A. UN chief issues nuclear warning on Chernobyl visit. Sydney: Sydney Morning Herald; 2011 [cited 2011 3 July]; Available from: http://news.smh.com.au/breaking-news-world/un-chief-issuesnuclear-warning-on-chernobyl-visit-20110421-1dp5r.html. 4. Imanaka T. Casualties and radiation dosimetry of the atomic bombings on hiroshima and nagasaki. NATO Security through Science Series B: Physics and Biophysics: Springer; 2006. p. 149-56. 5. UNSCEAR. UNSCEAR's assessments of the radiation effects. Vienna: United Nations Scientific Committee on the Effects of Atomic Radiation; 2008 [cited 2011 July 3]; Available from: http://www.unscear.org/ unscear/en/chernobyl.html. 6. Baverstock K WD. The chernobyl accident 20 years on: An assessment of the health consequences and the international response. Environ Health Perspect. 2006;114(9):1312-7. 7. Normile D. Tohoku-Oki earthquake. Fukushima revives the low-dose debate. Science. [News]. 2011 May 20;332(6032):908-10. 8. UNDP. Crisis Prevention and Recovery. Belarus: United Nations Development Program; 2011 [cited 2011 July 3]; Available from: http://un.by/en/undp/focus-areas/crisisprevention/. 9. Tanimoto T UN, Kodama Y, Teshima T, Taniguchi S. Safety of workers at the fukushima daiichi nuclear power plant. The Lancet. 2011;377(9776):1489-90. 10. Sanger DE. U.S.: Reactor may spew radiation. New York: New York Times; 2011 [cited 2011 July 3]; Available from: http://www.newsobserver.com/2011/03/17/1059140/japan-races-to-get-power-toreactors.html. 11. Travel Warning. American Citizen Services; 2011 [cited 2011 July 3]; Available from: http://japan. usembassy.gov/e/acs/tacs-travel20110317.html. 12. Krolicki K. Radiation 'hotspots' hinder Japan response to nuclear crisis. The Star; 2011 [cited 2011 July 3]; Available from: http://thestar.com.my/news/story.asp?file=/2011/6/14/worldupdates/2011-0614T153803Z_01_NOOTR_RTRMDNC_0_-576864-1&sec=Worldupdates. 13. Hundreds of corpses believed irradiated, inaccessible. Kyodo News; 2011 [cited 2011 July 3]; Available from: http://search.japantimes.co.jp/cgi-bin/nn20110401a2.html. 14. Tabochi H. Angry Parents in Japan Confront Government Over Radiation Levels. New York Times; 2011 [cited 2011 July 3]; Available from: http://www.nytimes.com/2011/05/26/world/asia/26japan.html?_r=1. 15. Butler D. Fukushima health risks scrutinized. Nature. [News]. 2011 Apr 7;472(7341):13-4. 16. Hackenbroch V, Meyer C, Thielke T. A Hapless Fukushima Clean-Up Effort. Spiegel; 2011 [cited 2011 July 3]; Available from: http://www.spiegel.de/international/world/0,1518,754868,00.html. 17. Hall K, Makinen J. Workers suffer hardships in effort to stabilize Fukushima plant. Los Angeles Times; 2011 [cited 2011 July 3]; Available from: http://articles.latimes.com/2011/mar/29/world/la-fg-japanworkers-20110329. 18. IAEA. Chernobyl's Legacy: Health, Environmental and Socio-economic Impacts2005 [cited 2011 July 3]: Available from: http://www.iaea.org/Publications/Booklets/Chernobyl/chernobyl.pdf. 19. Cai J. Effect of fukushima nuclear plant accident on human health and the medical protection. Academic Journal of Second Military Medical University. 2011;32(4):349-53. 20. Cole D. Fukushima fallout: Germany abandons nuclear energy Sydney: Fairfax Newspapers; 2011 [cited 2011 3 July]; Available from: http://www.smh.com.au/world/fukushima-fallout-germany-abandonsnuclear-energy-20110530-1fczb.html.


FEATURE

H E LP

I S O N I T S W AY Dr Jagbir Singh,

Former Member of the Academic Council University of Delhi, India

The role of medical students in disaster management medical students can play a very important role in the initial stages of helping and coping with a disaster. In developed countries such as Australia, planes are always on standby to carry medical aid, tents, water, and other supplies to the necessary areas. The use of remote sensing satellites nowadays can give warnings and estimates of the size and scope of any disaster anywhere in the world. An impending tsunami warning is given in waves that can be measured in time and speed to a coastal community. This is a great aid in organising a medical team and other rescue personnel such as fire and rescue workers with equipment, sniffer dogs, and electronic searching devices.

DEFINITION OF DISASTER

A disaster is a reality recognised as the greatest challenge for societies in the 21st century. Although in recent years important advances have been made in reducing the losses in the face of associated hazards, their impact continues to be considerable with almost ninety percent of deaths in disasters today resulting from an absence of preparedness and mitigation. The World Health Organization defines a disaster as a: ‘sudden ecological phenomenon of sufficient magnitude to require external assistance.’ The American College of Emergency Physicians (ACEP) states that a disaster has occurred, ‘when the destructive effects of natural or man-made forces overwhelm the ability of a given area or community to meet the demand for health care.’ Other definitions exist, but the common denominator calls for a disruption of such magnitude that the organization, infrastructure, and resources of a community are unable to return to normal operations following the event without outside assistance. Disasters happen when the forces of a hazard (an extreme disruptive event) impact on vulnerabilities (physical & socioeconomic) and overwhelm the ability of the affected community to cope on its own. Remember not all communities are at risk of every type of disaster, but every community is at risk of some particular disaster.

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disaster occurs somewhere in the world almost daily. However, to most people, disasters of the type discussed in this article are unusual events. A group of disasters, including the 9/11 terrorist attacks, the 2004 Indian Ocean tsunami, Hurricane Katrina in 2005, the 2010 Haitian earthquake, the New Zealand Christchurch earthquake in September 2010, the Australian flood disasters in Queensland and Victoria in February 2011, and the earthquake and tsunami that ensued at the Fukushima Daiichi Nuclear Power Plant in Japan of March 11 this year have focused people's attention on this topic. As recently as the 20th of June 2011, extreme flooding hit China causing a major disaster. Australia experiences a range of ‘natural disasters' including bushfires, floods, cyclones and severe storms, and seldom earthquakes and landslides. These events cause great financial hardship for individuals and communities, and can result in the loss of life. Natural disasters occur regularly across the Australian continent. They cause billions of dollars worth of damage each year to homes, businesses and the nation’s infrastructure, along with serious disruptions to communities. Scientific research indicates that more extreme weather events and large-scale single events, with more severe cyclones, storms and floods, are expected in the future. Nearly three million people worldwide may have been killed in the past twenty years due to natural disasters such as landslides, earthquakes, floods, snow avalanches, cyclones, etc. Ninety per cent of the natural disasters and ninety five percent of the total disaster related deaths worldwide occur in developing countries in which India has the second largest share. There is no disaster of any kind in the world, be it flood, earthquake, cyclone, fire, tsunami, or tornado, where there are no injuries and it is in this field where the role of medical doctors, nurses and

Hazard X Vulnerability Community Coping Capacity

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FEATURE The Disaster Management Cycle

• Disaster stage–the phase during which the event of the disaster takes place. This phase is characterized by profound damage to human society. This damage/loss may be that of human life, property, environment, health, or anything else. In this phase, the population is affected by profound shock. • Response stage–this is the period that immediately follows the occurrence of a disaster. It includes the mobilization of the necessary emergency services and first responders in the disaster area. The paramedics and medical personnel arrive, remove the injured for transportation to medical camps or hospitals and provide first aid and life support. The public also takes part in the relief work. One can even find injured victims who help other injured ones. Almost everyone is willing to help. The needs of the population during this phase are immediate. They need medical help and this is where the role of medical students can play an important part in helping with first aid. • Rehabilitation stage–when the immediate needs of the population are met and when all medical help has arrived, the people have settled down from the hustle and bustle of the event and they begin to enter the next phase. This is called the recovery stage which is the most significant, in terms of the long-term outcome. It is during this time that the victims actually realize the impact of the disaster. It is now that they perceive the meaning of the loss that they have suffered. They are often housed along with other victims in a camp or in some place which is often not their house. During this time, they need intensive mental support so as to facilitate a recovery. When the victims have recovered from the trauma both physically and mentally, they realise the need to return back to a normal routine, that is, to their predisaster life. • Reconstruction stage–during this stage, the population has returned to some form of a pre-disaster standard of living. It is in this stage that they recognize the need for certain measures which can reduce the extent of damage during any future disaster. For example, after an earthquake which has caused significant damage to poorly built houses, the population begins to rebuild stronger houses and buildings that give way less easily to earthquakes. In the case of a tsunami, one must avoid building houses very close to the shore and the development of a ‘green belt’ (a thick stretch of trees adjacent

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to the coastline which helps to reduce the impact of a future tsunami) is most necessary. • Mitigation stage–in this stage scientists perform a risk assessment involving hazard mapping and structural/nonstructural measures towards the prevention of such damage in the future. • Preparedness stage–this stage involves the development of awareness among the population on the general aspects of disaster and on how to behave in the face of a future disaster. This includes education on warning signs of disasters, methods of safe and successful evacuation, and first aid measures.

THE ROLES A MEDICAL TEAM CAN PLAY A DURING A DISASTER CRISIS:

1. Assessing the situation of a disaster and responding with the necessary medical aid. 2. Doctors, nurses, and medical students can instinctively provide psychological support to injured and traumatised people. 3. Medical teams can provide immunisation to stop the spread of disease, with Cholera being the main threat arising from damage to the sewerage system. 4. The triage work of the doctor-in-change is very important and each helper must work in cooperation with him/her, with a strong sense of communication and team spirit; conditions are changing all the time. 5. Sufficient numbers of medical personnel must be sent to a disaster so that they can maintain the physical and mental energy levels, in order to give the best service to the injured. 6. It is a great help when some doctors can speak more then one language or have even a basic knowledge of sentences in a foreign language, requiring a simple answer to questions such as the following. Pain? Yes/ No. Where? Here, etc. 7. Knowledge of other cultures is very important as some cultural or religious groups cannot be put together in the one tent, even though they should be grateful for their medical aid. 8. It would be an advantage to the medical students themselves to form a Disaster Management Committee or Society, where they can speak openly about their knowledge and experiences. 9. It is also important for medical students to volunteer at organisations from other countries throughout the world in order to help and share their medical knowledge. This could be done through their own website. In India, for example, The All India Foundation for Peace and Disaster Management (AIFPDM) formed in 2001 works throughout India in the field of disaster management and allows medical students to join if they wish and volunteer their help in India during a disaster crisis. The Red Cross or SES in Australia both seek volunteers for similar situations.

CONCLUSION

Medical Students are a big asset to the world community to save many lives during and after a disaster. By volunteering for such work, they will gain first hand knowledge of the difference between the medical assistance required for flood victims compared with fire, or earthquake victims. Their reports from the victim and their experience can help all doctors in the posttraumatic phases of any disaster.


OPINION

ould h s n e h W top s s t s i l a journ and g n i t r o p re of d i a e h t go to ed? e n n i e thos Famine stricken child (above): 1994 Pulitzer Prize winning photo by Kevin Carter

AN IMPORTANT DISTINCTION IN

TIMES OF CRISIS the welfare of others is one of the over-riding reasons we have chosen our profession. When assistance is needed in natural disasters or conflict zones, it is often doctors and nurses who are delivering care and aid to the unwell. However, when people’s lives are endangered or when the opportunity to help others arises and is urgent, surely there must be journalists who challenge their profession’s old adage to only ‘report on events, not intervene in them’; yet this has not been the case during recent video footage of the spate of disasters that have taken place. To illustrate my point in the extreme, consider the 1994 Pulitzer Prize winning photo taken by Kevin Carter (above, middle) during the Sudan famine. The stark image depicts a malnourished Sudanese child, with the characteristic swollen belly of Kwashiorkor, dragging himself along the ground with his skeletal arms. He is still a few kilometres from the nearby refugee camp and yet, stalking him in the background, a vulture eyes its next potential meal. The tragedy of this image is multiplied when you learn that the photographer and his team did not assist the child in any

Mark Hassall

Year 5 Medicine University of Adelaide way. Surely this represents a clear example which beckons a journalist to relinquish his camera and notepad and take up the common cause of humanity’s well-being. Such examples are fortunately in the minority, but nonetheless represent an important moral distinction about where journalists should draw the line between reporting and intervening. There is no doubt that raw journalism in conflict zones or from the epicentre of an earthquake relays important information to the outside world. It ensures transparency, it highlights breeches of human rights, and it links us to the human suffering and challenges of these disasters. Journalists, however, should be wary that whilst reporting on and connecting humanity they do not become disconnected themselves.

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ince the beginning of this year, the media cycle has been filled with disasters, both man-made and natural. In Australia, we are all familiar with the aftermath of Cyclone Yasi, the extensive Queensland flooding, and the impact of Cyclone Carlos in the Top End. Moving further abroad, the tectonic events in Christchurch, Japan, and China, as well as the mammoth floods in Brazil, have generated a continuous stream of breathtaking video footage, emotional live interviews, and defining photos that have become omnipresent in everyday radio, print media, and television. Further still, the social unrest visible in Egypt, Libya, and the broader Middle East region has only further flooded our lives with images of suffering, oppression, and bloodshed. Consequently, some of the moving moments captured by the media have been so raw and the need for immediate assistance so great, that I have wondered aloud how some journalists are comfortable with their decision not to put down their camera and go to the aid of victims. As future doctors, our impulsive desire to intervene in

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ELECTIVES

ELECTIVES

Alyssa Fitzpatrick &Katherine O’Shea

for dummies

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hinking about a developing world elective, but not sure where to start? Try the following sites and organisations for some inspiration! (Note: These are not endorsements of the companies but merely a suggestion of organisations previous students have found useful.)

IVHQ

International Volunteer Headquarters (IVHQ) is a New Zealand based non-profit company with incountry partners around the world. IVHQ liaises with local volunteer organizations to offer a wide range of programmes and is by far the cheapest option, with all programme fees reaching the local projects. Medical electives are available in both remote clinics and larger hospitals in Kenya, Peru, Nepal, Tanzania, Costa Rica, India, Ghana, Guatemala and Uganda. The medical electives available are suitable for both an overseas elective placement and co-curricular volunteering. IVHQ requires that you have completed at least 2 years of a medical course to be eligible for their medical placements, however, if you are interested in volunteer teaching or orphanage work, there is no prerequisite qualification. (A further 7 countries are available for nonmedical placements.) Some countries do require volunteers to speak some level of Spanish (variable), however, language lessons are available to

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A beginner ’s guide to planning your elective

volunteers in all countries, so the fact that you do not speak the local language should not be a deterrent. (Make sure you do check any language requirement!) There is a 2 week minimum stay on most of the projects, with a maximum of 6 months. To find out more about IVHQ and their programs, check out: http:// www.volunteerhq.org/.

Work the World

Work the World provides a range of medical, dental, nursing, midwifery and physiotherapy placements in Africa, Asia and South America. A UK based company, Work the World provides in-country support as well as preparatory assistance on matters such as visas and acclimatisation. Accommodation and meals are additionally provided in a sharehouse. A range of clinical specialities are available to study. If you choose to study in an African country for more than four weeks, you are able to undertake a Village Healthcare Experience to gain a richer experience of the healthcare system in the chosen country. Medical electives are available in Argentina, Tanzania, Ghana, Nepal and Sri Lanka. Visit: http://www.worktheworld.co.uk/.

Projects Abroad

Founded in 1992, Projects Abroad provides a diverse range of experiences in developing communities across the globe. The program offers pre-departure advice through a dedicated website to aid

in preparation, and accommodation through host family programs. Volunteers are met upon arrival and assisted in returning to the departure airport. Medical electives are available in Argentina, Bolivia, China, Ghana, India, Mexico, Moldova, Mongolia, Nepal, Peru, Sri Lanka, and Tanzania. For those who are unable to commit to a month or more, twoweek options are available for some electives. For more information, check out: http://www.projects-abroad.org/.

The Electives Network

But what if you do not want to go with an organisation, and choose something that specifically suits you by organising it yourself? In that case, The Electives Network is for you! The Elective Network provides reviews and insight into electives in a variety of programs, hospitals and other medical centres across the globe, incorporating both developed and developing nations. The database also includes student reports from people who’ve actually been there, as well as a wealth of information regarding travel, health and visa requirements. Go to: http://www. electives.net/services.


ELECTIVES An essential companion–AMSA and the AMA-CDT have recently released a publication for medical students undertaking electives and other overseas work, which aims to provide advice on the best way to avoid negatively impacting on the communities in which we learn and practise. The Guide to Working Abroad for Australian Medical Students and Junior Doctors offers invaluable practical advice about all aspects of your prospective journey--from preparation to managing personal and professional affairs, and things to be done upon returning home. The guide also provides background on the nature of global health endeavours, including the particularities of different regions of the world, and aims to ensure that students’ work abroad is rewarding for both their own personal and professional development, and more importantly, their host community. You can find a copy of the guide via the AMSA website: www.amsa.org.au.

MJA–AMSA.ORG.AU

Things to know before you go! Check out the Australian Government’s Smart Traveller website prior to your departure! It provides an indication of any major concerns you may run into, embassy information, and a guide to the do’s and don’ts in the country you visit. Go to: http://www.smartraveller. gov.au/. Register your details with DFAT before you travel in case of an emergency overseas or at home: http://australia.gov.au/service/ register-of-australians-travellingoverseas. Make sure you carry copies of your passport, passport photos and flight itinerary with you, in case of loss or theft. Leave copies of all important details with someone at home as well, and make sure at least one person in Australia knows in detail where and when you will be travelling.

Get the low-down

Talk to students who have been to the country you are visiting before. There are often cultural expectations that you may be unaware of, and they may have useful tips regarding interesting places to go, tourist traps to avoid, safety, money and what to bring across with you. Particularly if you are travelling to a very underdeveloped community, you may need to bring items with you for yourself you hadn’t previously

considered. For example, the hospital may not be able to provide you with facemasks for your use during surgery.

Health

Consider your vaccination needs and organise these early! Malaria prophylaxis is essential in some parts of the world. In addition, in some countries it may be advisable to bring HIV post-exposure prophylaxis with you in case of a needle-stick injury. Referral to a travel medicine or infectious diseases specialist may be your best bet for getting all of this in order.

Preparation

Make sure you pack everything you might need, as some unexpected things, (such as zip-lock bags!), may not be available in your chosen location. More obvious things such as mosquito nets and insect repellent are more likely to be found, but you don’t want to be caught out, so purchase all essentials in Australia beforehand. Most adventure/ camping stores will be able to give you a good checklist of the basics to take if you are going to an underdeveloped country.

Travel insurance

Something you never want to need, but it is truly invaluable in times of crisis. Be it for medical evacuation of replacement of lost or stolen items, this is something you should seriously consider as an important investment. Another important consideration is travel insurance that includes returning home for supplementary exams. One such insurance company that students have found provides adequate cover in the event of a re-sit is CoverMore (http://www.covermore.com.au/1/ home.aspx). Their policies may not be appropriate to all exam re-sit conditions, so please look into the fine print and alternative options!

Finances

Don’t forget that a number of organisations offer student grants, both to help you get to your elective and to assist any developing communities that you may be visiting. For example, the student company MIGA offers $3,500 grants for students travelling to developing or Indigenous communities. Applications are now open.

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Safety

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ELECTIVEs Andrew D. K. Nguyen

Year 3 Medicine Australian National University

fondues in

Environment to Noncommunicable Diseases and Mental Health, employees work on a wide range of pertinent issues.2 Videoconferencing, teleconferencing, blackberries and regular deployments make up the mainstay of translating talk to action between colleagues in the world of international health. My role was to aid in work on disaster preparedness– drafting policy documents and researching resources for use by hospitals and government agencies around the world. My role encompassed a wide range of topics–from practical notes on Mental Health and Structural preparation against disasters, to helping improve the public face of the Unit. My role was similar to many internship positions at the WHO, due to its large publishing output within the UN system. There are approximately 200-500 interns at any one time, out of worldwide applications approaching 10,00020,000 each intake. They represent a myriad of countries–Portugal, Holland, Australia, Germany, South Korea and the United States of America to name but a few. Developed countries are mostly represented, since internships are unpaid and so living costs are borne by the interns and their sponsors. This makes it difficult for those from the developing world to take part. Most are mid-20’s graduate students; by far the majority being Masters students in Law, Politics, Economics, Medicine and Public Health. Working in the unit was very much like working in an organ of a much larger body. Workplace aims were often longterm with a flurry of episodic activities to achieve those goals. Partly due to this difficulty in harnessing so many different clusters towards a common roadmap, the actions of the organization itself

Geneva Interning at the Health Action in Crises Unit of the World Health Organization

I

t was the first day, and it was freezing. As I was waiting in line at the security office to receive my identity card and security clearance to begin work, I was greeted by some of the largest snowfalls in a generation. Six months earlier, I received the opportunity to take up an internship at the World Health Organization (WHO) Headquarters in Geneva, Switzerland. What followed was a prompt welcome by my supervisor in the Health Actions in Crises (HAC) Unit and my first meeting in that department. Much like the United Nations (UN) Security Council layout, the meeting room was in a U-shaped pattern with microphones and the names of individuals on each seated station. I was briefly introduced as the new intern before an intimate yet formal briefing on the regular workings of the WHO. It is an institution which employs approximately 3,000 employees with backgrounds from all over the world. Being in the HAC Unit, it was appropriate that global crises dominated the session. In short, we were briefed in detail on the Haiti cholera epidemic sweeping from the north to the south of the country, and the unfolding tense political situation in Cote D’Ivoire that was beginning to trigger WHO intervention.1 It was a startling first day of work. In the meantime, the WHO’s multilingual employees all over the world were working at the same time in their various clusters. Ranging from Health Security and the

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SUBSECTION ELECTIVES

Lost in translation (right): The World Health Organization employs thousands of workers across six regional offices and the headquarters in Geneva. It has six official languages: English, Spanish, Chinese Mandarin, Russian, French and Arabic A hive of activity (left, above): The Executive Board Meeting provides a privileged insight into the workings of the World Health Organization, such as that in passing the Draft Resolution on Disaster Preparedness A world affair (left,below): The World Health Organization meets annually for its World Health Assembly at the Palais Des Nations to vote on resolutions tabled by the Executive Board (all countries of the United Nations are eligible to be represented at the World Health Assembly)

There I saw and met Australians who have made their way to Geneva – former rugby stars turned-human rights commissioners, World Trade Organization representatives, the Immigration Minister and other WHO employees. But all worked towards the common purpose of representing Australia in international affairs. By the end of my short stay I was thoroughly integrated into WHO life. I was in committee hearings evaluating the response to the H1N1 Swine Flu Pandemic during committee hearings with the Director-General and had a tour of the Strategic Health Operations Centre which coordinated the deployment of WHO response teams to far-flung destinations using state-of-the-art technology. I was also part of a pivotal moment in the HAC Unit–passing a draft WHO Resolution on Disaster Preparedness sponsored by Chile at the Executive Board Meeting. Working for such an international organization is a privilege and an opportunity. Taking the initiative and making the most of your time is what is most important. That goes in applying as well; no matter the applicant pool, if you are passionate and driven enough for a global health position, you will succeed.

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often cumbersome and slow; bogged down in bureaucracy. Yet when urgency arose, it was incredibly authoritative and powerful in its response such as that towards the Severe Acute Respiratory Syndrome epidemic. There were also positives to offset the hard work. Access to high level meetings is quite regular, upon invitation. These include that of the Executive Board Meeting in January and the World Health Assembly in May, where country delegations came to meet, debate and pass resolutions. And there is an active Intern Society across all the UN organizations which regularly organise weekly sporting and social events (such as skiing and fondue sessions). During my time I was also personally invited to the Christmas reception at the Australian Mission in Geneva. Such opportunities occur whilst working in an international organisation like the WHO–and are also naturally great networking opportunities.

References 1. World Health Organisation. Health Actions in Crises [Internet]. 2011 [cited 2011 May 20]; Available from: http://www.who.int/hac/en. 2. World Health Organisation. Assistant Directors-General [Internet]. 2011 [cited 2011 May 20]; Available from: http://www. who.int/dg/adg/en.

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ELECTIVES SUBSECTION Clarabella Liew Year 4 Medicine Monash University

Zhi Xuan Quak

Patients

!

A hoy

Year 5 Medicine Monash University

Jibon Tari–a floating hospital in rural Bangladesh

D

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uring the summer holidays in December 2010, we joined a group of doctors (three ENT surgeons, two anaesthetists, and one GP) on their five day ear camp in rural Bangladesh. The objective was to contribute our skills as a team of visiting surgical specialists to a floating hospital called Jibon Tari, (meaning Boat of Life), managed by IMPACT Foundation Banglades. Bangladesh is a riverine country with an estimated 8,433 km of inland waterways, making river transport a common sight.1 After arriving at Dhaka International Airport, we boarded an overnight launch steamer from Sadarghat Launch Terminal. The journey was eight hours long and though exhausted, most of us were kept strikingly awake by the bedbugs.

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Jibon Tari Floating Hospital (below): An essential healthcare service for the remote riverine regions and offshore islands of Bangladesh

Dawn was just breaking when we arrived at Jibon Tari Floating Hospital. A 3-storey floating pontoon, about 40-m long and 10-m wide, Jibon Tari was docked near the small rural village of Mirganj, Barisal. Jibon Tari is equipped with an air-conditioned, three-table operating room, a postoperative recovery area, a 12-bedded inpatient ward as well as laboratory and X-ray facilities. Accommodation is provided for staff, with most spending months on board before returning to urban life. Established in 1982, Jibon Tari is a joint initiative under the United Nations Development Programme (UNDP), World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), and is operated by the international non-profit organisation, IMPACT Foundation.2 Jibon Tari provides medical services to poor remote areas along Bangladesh’s rivers and offshore islands. Launched in April 1999, it has provided primary healthcare to over 200,000 people in these remote areas and has allowed access to specialist surgical services in orthopaedics, plastics, ENT and eye.3


SUBSECTION ELECTIVES

Pre-screening (above): Patients who had hearing loss and perforated tympanic membrane secondary to chronic secretory otitis media, and those suspected of having cholesteatoma were selected for surgery Taxing work (right): A doctor performing one of the many surgeries planned for the day

References 1. Bangladesh: getting there and around [Internet]. 2011 [cited 2011 Apr 1]. Available from: http://www. lonelyplanet.com/bangladesh/ transport/getting-around. 2. Hicks, C. IMPACT: an historical overview [Internet]. 2007 [cited 2011 Apr 1]. Available from: http://www. impact.org.uk/history.asp. 3. IMPACT Foundation Bangladesh: ongoing programs [Internet]. 2002 [cited Apr 1 2011]. Available from: http://www.impactfoundationbd.org/ ongoing_program.html#jibon 4. Louw L. Acquired cholesteatoma pathogenesis: stepwise explanations. J Laryngol Otol. 2010 Jun; 124(6):58793.

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Prior to arrival, patients had packed into the hospital’s only ward to be pre-screened for their suitability to undergo particular ear surgeries by the local doctors. Acute otitis media inadvertently goes untreated in remote villages, and many go on to progress to chronic secretory otitis media resulting in tympanic membrane perforation and hearing loss. Cholesteatomas were also common due to the high rates of untreated middle ear infections.4 These cases were selected for surgery as they would require a relatively straight forward myringoplasty to repair their perforated tympanic membrane, and would potentially improve the patients’ quality of life by restoring hearing. With two operating microscopes available, two concurrent operating tables were used throughout the day as the team took turns to maximise the number of surgeries performed from dawn to dusk. In the end, a total of thirty-six myringoplasties and three mastoidectomies were performed on patients aged between eleven and fifty years of age. As medical students, we had the opportunity to cannulate, scrubbed in and took part where possible under the supervision of the surgeons and anaesthetists, and assisted with simple closing sutures. The opportunity to observe numerous myringoplasties and mastoidectomies up close was also an invaluable learning experience. Moreover, with the endless stream of patients, the pathologies presented in Bangladesh were incredible and once again, demonstrated the intense need for surgical expertise in the rural area. Through the surgeries, we also witnessed the stoic nature of the Bangladeshis, as shown by the minimal sedation used for myringoplasties. It was mind-blowing to initially find a hospital out of nowhere, and a floating one to be exact! Jibon Tari continued to surprise us every day with its medical and surgical facilities. Though limited in resources, it was fully-equipped and enabled the ear surgeries to be performed without a hitch.

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tt SUBSECTION CONFERENCE REPORTS

Anna E. Norris,

Year 4 Medicine University of Tasmania & National Students’ Secretary of Doctors for the Environment (DEA)

A Bright S iDEA

till full of Easter eggs from the weekend before (well, I was), eighty Australian medical students met at the Royal Prince Alfred Hospital in Sydney for the 2011 iDEA (Doctors for the Environment) conference. The ensuing 48 hours, at the end of April, was a mixture of education and planning action, broadly related to environmental conservation, aimed specifically at us as medical students. I know what you are thinking. Is not the Royal Prince Alfred where the programme of compelling theatre, stark truth and nail biting suspense ‘RPA’ is filmed? Indeed it is, well done. iDEA, believe it or not, surpassed that programme in terms of the drama and excitement it contained. Shortly after arrival, Senator Christine Milne reminded us that there is no possibility of being ‘too busy’ to act to minimise global temperature rise. She reminded us we are ‘environmental activists’ even by just sitting in the auditorium in front of her, listening and agreeing with her. This comment fuelled my activist lungs with new breath and energy. Speakers’ words were confronting and stimulating. They demanded action. At this point, it is pertinent to list a number of the other speakers in a list far from exhaustive, but giving some indication of the calibre of the people with whom we talked. They included: Mr Matthew Holt, orthopaedic surgeon and founder of Clean Energy for Eternity; Lindsay Soutar from 100% Renewables; Nic Maclellan, freelance journalist in the Pacific Islands; Associate Professor Mark Diesendorf, environmental scientist and author; and Dr Richard Dennis, executive director of the Australia Institute. ‘Code Green’ is a national environmental action strategy, organised by students from southern Australia. It is DEA’s student response towards the need to prevent climate change from irrevocably damaging our planet for eternity. The premise is that the planet is in an emergency state, and a MET call has been called given the dire need to mitigate global temperature rise. An important outcome of the conference was the reaffirmation that looking after the planet means looking after its inhabitants. An analogy between a sick fish in a tank of putrid water, from which one extracts the sick fish, makes it better and then puts it back into the putrid water, whence it becomes ill again was used by Dr Gary Egger, author of Planet Obesity. It articulated,

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A report on the 2011 iDEA conference, Royal Prince Alfred Hospital, 30th of April-1st of May, 2011

succinctly our dependency on the environment. As medical students, such an analogy was easily understood; it remains, however, exceptionally important that we continue to spread this knowledge across the population. In addition, from the 1st to the 5th of August, Code Green National Action Week was successfully held. Students from across Australia organised and conducted events, wrote media releases and used their educated and intelligent voices to demand more drastic and lasting action to cease the increase in atmospheric carbon particles.


CONFERENCE SUBSECTION REPORTS

Reflections on the Global Community Engaged Medical Education Muster in the Barossa Valley, 18th-21st of October, 2010

TIME FOR A PARADIGM

S H I F T IN MEDICAL EDUCATION T

Year 5 Medicine Monash University

he medical education community last year celebrated the 100-year anniversary of the Flexner report. The report penned by Abraham Flexner in 1910 changed the trajectory of medical education in the Western world. It advocated for a strongly scientific based curriculum and is attributed with improving the quality of medical education, teaching and research. However, it also cast a long legacy of rigidly science focused medical curriculum, which was apparent to Flexner himself as early as 1925 when stating, ‘Scientific medicine in America—young, vigorous and positivistic—is today sadly deficient in cultural and philosophic background.’ The extent to which this critique still holds true in many Western medical curricula today provided an appropriate rationale for the Global Community Engaged Medical Education Muster I attended from the 18th-21st October of 2010. The aim of the conference was to challenge the constructs of contemporary medical education in Australia and ask the question, ‘how can we raise awareness of the diverse global interests of members of the community as key stakeholders in medical education and by doing so strengthen community-engaged medical education both nationally and internationally?’ There is an increased imperative to answer this question given a number of ‘wicked’ problems that are currently facing our health system. There is an inherent need for medical schools to deliver a curriculum that is socially

accountable. The acute lack of well-trained, motivated, and supported health workers is one of the greatest impediments to improving health in a world of unconscionable health inequities. In low and highincome countries alike, medical schools have drifted from their social mandate to serve the most vulnerable. The consensus at the conference was that medical schools need to break out of their ivory towers and bring research, services and learning back to the communities that most need them. Stemming from this first point is the need for a reorientation in the way clinical education is delivered, so students are fostered towards careers in Primary Health Care (PHC), stopping the ‘specialist tsunami’. The answer to the intensifying chronic disease problem in the global North and South lies in community-based, comprehensive PHC. Ironically, our medical schools are producing a greater proportion of hospital-based specialists than ever. Finally, medical education must become more cognisant of the globalised village we now work in and thus strive to create clinicians with truly global perspectives. If doctors are to continue fulfilling our Hippocratic professional ideals we must learn how to lead on the global stage. This increasingly means looking outside the traditional healthcare system to a complex array of social, economic and political determinants of health. The changing dynamic of our community’s health requires medical curricula that are responsive to these 21st century needs. The challenge is in not only defining the appropriate content to be taught, but also the ability to deliver it in a way that emphasises its importance relative to the traditional biomedical content. There is a moral and ethical imperative for medical schools to achieve this responsiveness and social accountability to the communities that we ultimately serve.

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Daniel Yore

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Quiz

! z i qu answers on page 2

EASY (1 point)

1. In 2007, the Intergovernmental Panel on Climate Change (IPCC) and which individual received the Nobel Peace Prize for informing people about anthropogenic climate change? 2. What is the leading cause of death worldwide? 3. When is the world population expected to hit seven billion? 4. What is an epidemic called when it is geographically widespread, occurring throughout a region, continent, or even the world? 5. Which country became the world’s newest independent state and latest member of the United Nations, in July, 2011?

MEDIUM (2 points) 6. What year is the United Nations’ (UN) deadline for meeting the Millennium Development Goals (MDGs)? 7. According to the World Bank, extreme poverty is defined as living on less than what? 8. Which country is the world’s largest emitter of carbon emissions? 9. What causes up to half of all maternal deaths in the developing world? 10. Approximately, how many refugees are there in the world today?

HARD (3 points)

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11. Which disease was declared eradicated by the World Health Organisation (WHO) in 1979? 12. Approximately, how many children under the age of five die globally every year and what is the single largest cause of their deaths? 13. What is the name of the largest refugee camp in the world and where is it situated? 14. How many countries use nuclear power to generate some of their energy needs and what percentage of the world’s electricity does it supply? 15. In 2009, the inhabitants of which group of islands in the South Pacific became the world’s first environmental refugees?

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Australian Medical Association

Your voice in the health system of the future Student MeMberShip iS Free so join the AMA todAy And enjoy A lifetiMe of professionAl benefits Contact details www.ama.com.au/jointheama phone: 1300 133 655 email: memberservices@ama.com.au



Vector Issue 13 August 2011