GLOBAL HEALTH MENTORING PROGRAM

2014 Edition

GLOBAL HEALTH MENTORING PROGRAM

2014 Edition

Global Health Mentoring ProgramThe Global Health Mentoring Program (GHMP) matches Monash medical students from all year levels with experienced global health professionals in Melbourne, for a year-long mentoring partnership.

GHMP was first established in 2011 as a subcommittee of Ignite to fill the gap in opportunity for medical students to truly engage with experts who have made their career in global health. We believe that this opportunity is quite unique, and allows students to apply their passion to a real life context. Each year selected medical students are paired with a mentor to discuss and learn about global health areas of interest, as well as pursue invaluable networking opportunities. We encourage all students to apply!

Interested in being involved?

The application process for the 2016 Global Health Mentoring Program will be in September 2015!

The mentorship runs in the calendar year from January to December, and medical students from all year levels are eligible to apply. The number of places in the program varies from year to year, depending on the availability of mentors.

For more information, please see the website:http://www.ignitehealth.org.au/index.php/about1/global-health-mentoring-program

Thank you to everyone who made this magazine possible:

StudentsJoshua WongEmily NixonEmily JenkinsFrancis HaMingxua FanNaomi AtkinsonKhoa Nguyen CaoShuyu WangJudy ChowClaire FelminghamManissa SufianConnor Rochford

GHMP Team 2014Chair: Stephen SuraceSecretary: Jessica DeitchStudent Coordinator: Ee Lyn ChongEvents Coordinator: Lucia NguyenMentor Communication Coordinator: Isabelle (Izzy) HauAcademic Coordinator: Emily Jenkins & Mingxue FanPublications Officer: Stephen Surace

With thanks to Louise Nixon for editing the magazine

MentorsJames BeesonMike TooleBen CoghlanJenny JamisonMarion CareyRuth GraceGrant BlashkySteve GrahamElissa KennedyKrishna HortAlison MorganJim Black

The concept of Humanitarian Space first came into wide use in the 1990s when former Médecins Sans Frontières president Rony Brauman described an “espace humanitaire” in which humanitarians should be “free to evaluate needs, free to monitor the delivery and use of assistance, free to have dialogue with the people.”[1] Now in common use, the term is interpreted slightly differently by various stakeholders, but is generally understood to represent an operational environment which allows humanitarian actors to provide assistance and services according to humanitarian principles, and in line with International Humanitarian Law.[2] It has been contested over the last decade that humanitarian space is shrinking, and that the blurring of boundaries between humanitarian work and military development work with other political and security objectives, especially during the US intervention in Afghanistan post 9/11, have played a large role in its decline.

The key humanitarian principles of neutrality, impartiality, and independence have traditionally been the cornerstone of the safe and effective delivery of humanitarian assistance by international NGOs. The reconstruction of Afghanistan following the US-led intervention brought military and private corporations further into the humanitarian sphere than previously before.[3] The ‘3D – defence, development, diplomacy’ integrated approach to foreign policy in Afghanistan saw Provincial Reconstruction Teams (PRTs) conducting aid, development and reconstruction with military support, in an effort to “win hearts and minds”; to promote support for Operation Enduring Freedom and acceptance of international military forces.[4] Many among the humanitarian sector believe the blurring of lines between humanitarian aid and broader political and military agendas has significantly impacted on humanitarian space for many NGOs, compromising their ability to act impartially, be perceived as neutral, and to maintain their independence from Western governments.

Afghanistan is just one of many examples in an era of ‘new humanitarianism’ based on a post-cold war coherence agenda where aid is linked to military and diplomatic tools in a conflict-resolution strategy.[3] Many aid agencies had previously accepted the need for coherence between humanitarian and diplomatic and security agendas, as long as they trusted the basic humanitarian intent of the main donor governments. This was the case with many UN integrated peacekeeping missions in the 1990s. But after 9/11, many NGOs became much more concerned about being pulled into the explicit security agenda of the “War on Terror.”[5]

Humanitarian Space and the Impact of Blurring Lines

There is growing concern this strategy of ‘aid induced pacification’ means the delivery of aid is increasingly determined by western foreign policy goals rather than according to need and without discrimination. [3] As NGO work is becoming increasingly integrated with other initiatives, and humanitarian and development work is being delivered by the military and other actors with foreign policy agendas, NGO neutrality and independence is increasingly compromised. Many argue that this compromises their ability to access communities in need of aid. Some also link growing levels of insecurity for aid workers with this blurring of identities and loss of humanitarian neutrality. [6]

Others argue that loss of humanitarian space is a myth; that there is a new complexity to humanitarian work which makes it impossible to compare to the past. They argue that the number of aid workers and the scale of their operations have increased hugely in recent years, [5] with greater involvement in areas of serious conflict being the reason for reduced access and increased aid-worker deaths. Some also argue that coherence with the military has actually increased humanitarian space; improving logistic capability and the security of humanitarian workers, and allowing work in areas which are too dangerous for NGOs. [1]

This debate certainly highlights the complex nature of humanitarian operations, especially in areas of conflict. Humanitarian work will continue to evolve and develop. There will be situations where integration is necessary and effective and other situations where it is harmful and obstructive. While completely neutral space is an unachievable goal, The UN Office of the Coordination of Humanitarian Affairs (OCHA) recognises that “maintaining a clear distinction between the role and function of humanitarian actors and that of the military is the determining factor in creating an operating environment in which humanitarian organisations can discharge their responsibilities both effectively and safely.” [6] With all the complexities taken into account, it is important to remain focussed on the main objective; that humanitarian aid can be delivered to, and accepted by, vulnerable communities on the basis of humanitarian principles.

By Naomi Atkinson

The World Health Organization (WHO) Constitution underlines “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being”. This right to health extends beyond quality health care delivered in a timely fashion, to the underlying determinants of health, such as access to health-related education and information, including on sexual and reproductive health. [1]

Yet, millions of women and girls, especially across the developing world, face challenging barriers that encumber their right to access information and services related to family planning Impediments in health systems, such as inadequate supplies of safe and effective commodities, financial constraints, the medicalised delivery of family planning, human-resource barriers, and poor-quality services, need to be addressed. Similarly, obstacles at the individual level, where a woman’s ability to access contraceptives is compromised, must be targeted; this includes limited knowledge of or exposure to information and services, and any unfounded fears regarding the safety of contraceptives. These barriers contribute to 75 million unintended pregnancies every year; 222 million women and girls, especially those in sub-Saharan Africa, who wish to avoid pregnancy, are not using effective or modern methods of contraception. It is disappointing that in the 21st century, so many lack access to high-quality family planning services, which would empower individuals with the choice to delay, space, and limit pregnancies. [2,3]

The importance of family planning has become increasingly recognised, with an estimated reduction of maternal mortality by a third purely by meeting the unmet need for family planning. [4] Although initially excluded from the eight Millennium Development Goals introduced in 2000, the target to “achieve universal access to reproductive health” was added to MDG 5: improve maternal health, in 2007; key indicators for this target include contraceptive prevalence rate, unmet need for family planning, and adolescent birth rate. [2,5] In 2010, the United Nation Secretary General, Ban Ki-moon, launched Every Woman, Every Child, his Global Strategy for Women’s and Children’s health, which aims to prevent 33 million unwanted pregnancies by 2015. [4]

In July 2012, the UK Government and the Bill & Melinda Gates Foundation hosted the London Summit on Family Planning. Participants from the global community, including national governments, civil society, multi-lateral organisations, donors, the private sector, and the research and development community, united to “support the rights of an additional 120 million women and girls in the world’s poorest countries to use contraceptive information, services and supplied, without coercion or discrimination, by 2020”. [3] This commitment, Family Planning 2020 (FP2020), highlights the benefits of investing in family planning, which ripple out from the individual who accesses it through to their families, and then to their community.

The Global Movement For Family PlanningBy Judy Chow

FAMILY PLANNINGSAVES LIVES

For example, family planning has a rippling effect for child survival by enabling:

• Healthy timing of pregnancy. Family planning reduces the rate of unintended pregnancies. Maternal and child mortality can be reduced, if young women and couples delay their first pregnancy, as mothers who are younger than 18, and their infants, face higher risks of complications6. If all women had access to modern methods of family planning, there would be nearly 100,000 fewer maternal deaths and nearly 600,000 fewer newborn deaths each year.[3]

• Healthy spacing of pregnancy. As the time between one birth to the next pregnancy increases, the risks of death of both the older child and the new infant decreases6. Spacing pregnancies by at least two or three years would reduce child mortality by 13% or 25% respectively.[3]

• Healthy nutrition. By delaying the next pregnancy, mothers can provide their infant with sufficient nutrition during the critical ‘1000 Day Window of Opportunity’ from conception through to their 2nd birthday, which assists the infant in reaching their academic potential.

• Healthy families. Family planning enables a couple to effectively plan when and how many children they will have, so that they can adequately plan the use of their resources and care for every child. [6] Girls who delay pregnancy are more likely to continue their education and secure employment. As mothers, these women are better able to increase their family income and invest in their children’s health and education. Additionally, contraceptive information and services contributes to reducing the risk of mother-to-child transmission of HIV.[3]

• Healthy communities. Communities, and subsequently nations, benefit from investments in family planning. As the fertility rates fall, pressure is relieved on a country’s health, education, water, sanitation and social services. According to the United Nations, “for every dollar spent in family planning, between US$2 to US$6 is saved in interventions aimed achieving other development goals.[2,3,6]

At the Summit, Australia committed to spending an additional USD59.5 million over five years on family planning, with a plan to double our contributions to AUD53 million annually by 2016. Interestingly, the United Kingdom committed to contribute £516 million (USD 800 million) over 8 years.[7] Family planning is often taken for granted in Australia, where access to health information and services is relatively easy. However, in many developing countries around the world, this is unfortunately not the case. Whilst Australians complain about having to wait for their doctor at the clinic, women in the world’s poorest countries struggle to even get to the clinic. Whilst access to contraception is so abundant in Australia that condoms are often given away for free, women and men in the world’s poorest countries encounter barrier after barrier preventing them from family planning.

It is promising that action has been initiated in addressing the lack of access to voluntary family planning globally, especially in light of its ripple effects. However, as 2015 – the target date for the MDGs – approaches, it reminds us that it is important to keep the momentum going as the 2020 deadline of FP2020 also draws closer and closer. It is the right of every individual to decide freely whether, when and how many children they will have; the global movement for family planning empowers each individual to execute this right.

There are a lot of charities. Some dig wells, build schools, and send livestock. In 2000, there were 185,000 registered charities in England and Wales, with an estimated increase of 5,000 per year. [1] So, where should you donate? A simple enough question- isn’t it?

Many of us want to spend on a cause that will do the most good. But in reality, how do we know which intervention is better? Who is to say that a well is better than a school, or a cow, or farming equipment? Few organisations explain what proportion of your donation will actually reach the recipient or highlight what quantitative benefits it will yield. For those who do, the evidence for such claims are dubious.

So a few years ago, four guys- grad students at the time- decided on something simpler- why not give money? In January 2011, GiveDirectly began unconditional cash transfers (UCT) (via mobile phone-linked payment services) to low-income households in western Kenya.[2] These transfers, up to $1,000 USD, had no conditions on use. Based on performance records, 90% of donations were given directly to Kenyan recipients. [3] The impact of their work was measured through a third-party randomised controlled trial (RCT) at the end of a 9-12 month period.

Before we look at the results, some key information should be explained:

Why? The idea is to place the power of choice in the hands of the poor. As one of GiveDirectly’s co-founders told The New York Times Magazine; “… the truth is, I don’t think I have a very good sense of what the poor need.” [4]

In its 2012 annual report, GiveDirectly challenged, “Every organization that asks for money on behalf of the poor should make a clear and compelling case that they can do more good with it than the poor could do for themselves.” [4] Have cash transfers been tried anywhere else? Yes. “After Mexico’s economic crisis in the mid-1990s, Santiago Levy, a government economist, proposed getting rid of subsidies for milk, tortillas and other staples, and replacing them with a program that just gave money to the very poor, as long as they sent their children to school and took them for regular health checkups. … The results were promising; researchers found that children in the cash program were more likely to stay in school, families were less likely to get sick and people ate a more healthful diet. Recipients also didn’t tend to blow the money on booze or cigarettes, and many even invested a chunk of what they received. Today, more than six million Mexican families get cash transfers.” [5,6]

CashTransfers

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Recipients increased asset holdings by 58% primarily through investments in livestock and home improvements (including iron roofs)Income gains implied a 28% annual rate of return on transfers

Increases in nearly every category, but not tobacco, alcohol, or gambling

A 42% reduction in the number of days children went without food

Large reductions in stress and depression and increases in life satisfaction, as measured using validated psychological scales

Little to no impact on health or education over the time horizon considered in the data (9)

Back to GiveDirectly- the RCT (published in October 2013 by the evaluation group, Innovations for Poverty Action (IPA)) found the following results:

Assets

Business & Agricultural Income

Expenditures

Food security

Mental Health

Health & Education

So what does this tell us? The results of the data have shown that UCTs are effective, but they supplied no immediate impact on health or education- key factors that influence earning potential, and cut poverty in the next generation.

That is not to say that cash transfers are inadequate at addressing these issues.

By informal subdivision, there are 3 types of cash transfer programs (10): • Conditional cash transfers (CCTs), where recipients must fulfill requirements such as school attendance or health centre visits. A subset would include conditions, without formal monitoring (so participants receive transfer regardless of compliance)• Unconditional cash transfers (UCTs) e.g. GiveDirectly• Business grant programs- unconditional in-kind or cash grants that are given to micro-enterprises (such as the Uganda government project) Based on a 2013 systematic review, it was found that CCTs with “explicit conditions, monitored compliance, and penalization non-compliance” had a substantially larger effect than UCTs (60% improvement in the odds of school enrollment) (11).

By Josh Wong

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Are cash transfer programs more effective than traditional aid charities? The answer is: yes and no.

There exists no definitive benchmark of an average charity’s cost-benefit, and it becomes less clear when trying to compare specific programs like malaria prevention to cash transfers.

For those few traditional charities that publish their own results, cash transfers are considerably less effective. In simplified calculations (based on the Stanford Social Innovation Review), GiveDirectly yielded “$ 1.03 of additional income over 3 years per donor dollar”. By comparison, KickStart and Proximity Designs (which works to finance and facilitate farm development) generated “more than $10 over 3 years per donor dollar”.[12] VisionSprings, which aims to supply reading glasses to recover lost livelihoods, “turns a donor dollar into $60 of additional income”. [12]

These claims have been controversial and reflect only simplified calculations based on information provided by the charities themselves. In contrast, GiveDirectly’s RCT (along with a decade of research into cash transfers) has provided clear evidence of benefit.

Technically, there is no reason to doubt the claims made by some charities. They provide a theoretical advantage of solving market failures or supply problems. GiveWell, a nonprofit dedicated to analyzing charities, has found many giving opportunities that fulfill these criteria. It compiles its findings and recommends certain organisations. (As a sub note, GiveDirectly is currently deemed as one of its Top Charities.)[13]

So yes, GiveDirectly’s benefit is better evidenced; but no, it may not be more effective overall.

What can we learn from this? There exists a substantial need to measure the impact of international aid charities. In some cases, where lack of capital is perpetuating poverty, cash transfers have a role. That is not to say that they are, or should be, the only option. It becomes far more useful to think of cash transfers as an index of cost-effectiveness.[14] If non-government organisations (NGOs) are able to outperform this index, they can be considered an improvement.[14]

As GiveDirectly describes it: “Every organization that asks for money on behalf of the poor should make a clear and compelling case that they can do more good with it than the poor could do for themselves.”[4]

The arrival of asylum seekers and refugee policies in Australia are currently hot topics for debate in Australian media and politics. However there is a much bigger picture at hand. People are escaping their home countries everyday due to persecution, conflict, violence and human rights violations. Indeed, the UNHCR (Unite Nations High Commissioner for Refugees) estimated that a staggering 16.7 million people were refugees in 2013.[1] Where do these people go to find safety? Usually not to developed countries like Australia, despite what some media views may suggest. The ten countries hosting the most refugees (highest to lowest) are Pakistan, Iran, Germany, Kenya, Syria, Ethiopia, Chad, Jordan, China and Turkey. [2] Many of these countries are developing nations and providing safety and care for refugees can prove difficult.

Refugees often arise from situations of sudden conflict and instability, and the result is an acute mass movement of people across borders, in a short amount of time. This population displacement combined with subsequent food shortages and collapse of basic health services is termed a complex humanitarian emergency. [3] People escaping their countries most often find themselves in impromptu refugee camps that are inherently lacking in resources. In particular, health is an important consideration for the people in these camps.

Refugee CampsRefugee camps conceptually are temporary living areas for refugees before they are resettled; usually back to their home countries once conflict has ceased, or by integration into the local community or resettlement in another country. In reality many refugee camps become permanent, such as the Dadaab complex in Kenya which has hosted over half a million refugees for more than two decades.[4] Necessities that a camp must provide include accommodation, hygiene facilities, healthcare, food, safe water, security, communication, places of worship, activities and administration. These are provided by a combination of local resources, the UNHCR and sister agencies, material and monetary donations from governments, and non-government organisations such as the Red Cross and Médecins Sans Frontières. [5]

Health in Refugee CampsPeople arriving at refugee camps often are in a poor physical and emotional state due to the arduous journey with lack of food and water, and poor living conditions. [4] Infectious diseases (especially diarrhoea, measles, acute respiratory infection and malaria), malnutrition and conflict-related injuries are the most common health problems. These can all be exacerbated by lack of resources in the camps, such as inadequate water supply, poor sanitation, reduced healthcare access, food insecurity, overcrowding and security risks. [6] Public health measures have the largest scale impact on the health of a refugee camp population, such as provision of measles immunisation, drinking water, sanitation, nutritional food, surveillance, basic health care, and addressing specific needs of the people. [7] These health needs are met by local and international health workers, who are often specifically trained in emergency relief. Aside from several Australian organisations that provide aid in complex humanitarian emergencies (such as MSF, CARE and World Vision Australia), the Australian government donates food aid, has delegates amongst UNHCR committees, and financially supports the UNHCR and several targeted programs for protecting refugees overseas. [8] Approximately 10,000 refugees are resettled in Australian each year, which is above the international obligation.

The Bigger PictureWhen confronted with the sheer numbers of refugees living in refugee camps often in developing countries, it is a stark reminder that the arrival of asylum seekers in Australia is merely a fraction of a global issue, and a relatively low humanitarian burden to carry. Refugees often have specific health needs when living in refugee camps, and the last few decades have shown improvements in the understanding and provision of this healthcare.

By Emily NixonRefugee Health: The Bigger Picture

Maternal Child Health - Why We Should All Care

Maternal health relates to the health of women in three different periods, during pregnancy, childbirth and the postpartum period. Oftentimes, motherhood is considered an encouraging and fulfilling experience, however for many more women in several parts of the world it is threateningly associated with suffering, ill health and even mortality. The major direct causes of maternal morbidity and mortality include severe bleeding (haemorrhage), infection, high blood pressure (eclampsia), unsafe abortion and other problems during labour such as obstructed labour. Young adolescent girls, mostly child brides, have the highest risk of mortality because their bodies are not yet fully mature for childbirth.

Millenium Development Goal (MDG) 5 Target 5A calls for the reduction of maternal mortality ratio (MMR, maternal deaths per 100,000 live births) by three quarters between 1990 and 2015. Most countries and regions aspire to achieve the target by 2015 but looking at current trends, it will be realistically unattainable for some countries to achieve this goal.

The challenge is mounting, as it has been thoroughly difficult to assess the extent of progress in developing-country settings due to lack or reliable and accurate maternal mortality data. To add, less than 40% of countries have a complete civil registration system with good attribution of cause of death, which is a critical factor for accurate measurement of maternal mortality.

So far, recent trends have observed a global estimation of 289,000 maternal deaths in 2013, a significant drop of 45% from 1990. But of the total 40 countries with the highest MMR observed, Sierra Leone reports a staggering MMR of 1100. Nonetheless, some encouraging trends shown from the World Health Organisation (WHO) Executive Summary have highlighted 11 countries currently categorized as ‘on track’ with Target 5A, they include countries such as Maldives (93%), Bhutan (87%), Cambodia (86%), Equatorial New Guinea (81%), Lao People’s Democratic Republic (80%), Romania (80%), Timor-Leste (78%), Cabo Verde (77%), Eritrea (77%), Nepal (76%) and Rwanda (76%).

By

Mothers and children are universally known to be the most vulnerable members of any society. The message that losing a mother inherently results in a scarring and dramatic effect on the physical and psychological health of a child should be spread across developing regions. Additionally, the climbing figure of 300,000 dying mothers each year from complications of childbirth ought to spark concern in today’s present and future generations. With enough awareness and active encouragement, efforts can be concentrated towards these specific and simple solutions. The solutions are not only cost-effective but also proven to reduce child deaths by 65 percent and maternal deaths by 80 percent. Briefly, the existing solutions include:

• Childhood immunization against infectious diseases like pneumonia and measles • Insecticide-treated mosquito nets to prevent malaria • Exclusive breastfeeding for six months of life to improve nutrition and immune response • Oral rehydration salt to help prevent death from diarrhoea

• Skilled birth attendants, such as midwives, to assist women during pregnancy and childbirth • Access to nutritious food and provision of micronutrients • Access to clean water and improved hygiene

As well as increasing coverage of these fundamental interventions at the family and community level, health systems need to be strengthened so there are effective hospitals with critical drugs, medical equipment and skilled health workers at their core. Barriers to accessing hospital care must also be overcome such as delivering affordable or free healthcare or appropriate health insurance schemes for poor families, and improving roads, transport and communication systems. It is shamefully only a lack of political will that is preventing the funding for the solutions that are certain to save the lives of millions of children and countless more women.

Tobacco Control

Australia is an international leader in tobacco control. With a myriad of anti-tobacco initiatives over the last three decades, we have persisted in reducing smoking rates and are observing encouraging results. Most recently, the Australian Government has been successful in legislating the Tobacco Plain Packaging Legislation Act 2011. This was part of a comprehensive suite of reforms, others including anti-smoking social marketing campaigns and legislation to restrict internet advertising of tobacco products within Australia.1 This article seeks to summarize Australia’s approach to tobacco control, the efficacy of plain packaging and the implications such legislation has on the global community. The prevalence of smoking in Australia is declining. The proportion of adult Australians who smoked daily has diminished from 35% in 1980 to 20% in 2010. [2] We begin on this more positive note in recognition of the vast policy, legislation and campaign effort poured in by both our Government and Non-Governmental Organisations (NGO) throughout this period. Prominent legislative action that has taken place in Australia include:

• Increase in tobacco tax • Widespread smoke-free areas including all public transport facilities, hospitals, primary and secondary schools and restaurants • Comprehensive ban on advertising, promotion and sponsorship by tobacco-producing corporations including domestic newspapers, magazines, television, radio and outdoor advertising • Introduction of Graphic Health Warnings on tobacco packaging in March 2006 • Introduction of Plain Packaging on Tobacco packaging in December 2012. [3] The effectiveness of such legislative action is highlighted in the immense drop in smoking prevalence during periods of legislative movement such as additional smoke-free legislation and mass-media anti-tobacco advertising. Conversely, during the early 1990s, the lack of legislative activity also saw a correlative stagnation in smoking prevalence.[2] Thus, the enormous strides towards improved health in Australia require persistence over years and coordination between Government and NGOs. More recently, the enactment of the Tobacco Plain Packaging Act 2011 legislation has already demonstrated promising results in the encouragement of tobacco cessation. Results from an interrupted time-series analysis published in the Medical Journal of Australia found a 78% increase in the number of calls to the Quitline associated with the introduction of plain packaging after adjustment for confounding factors. This relative increase is similar to the 86% increase in calls to Quitline when graphic health warnings were implemented in 2006.[4] It is undeniable that the drab colour scheme, the removal of brand loyalty and saliency of graphic health warnings has influenced smokers’ tendency to cessation. This is further highlighted in tobacco corporations’ recent efforts to undermine the legislation through legal action, most especially the Trans-Pacific Partnership (TPP) agreement. The complexity and elusiveness of this free trade agreement remains beyond the scope of this article.

By Francis Ha

However, Philip Morris International’s interest in using the TPP agreement to ultimately introduce higher standards for trademark protection suggests the strength of plain packaging to remove brand loyalty and ultimately reduce smoking prevalence.

But despite the noteworthy mention regarding the decline of smoking prevalence in Australia, such statistics fail to address health inequity that still exists. As with all statistical means across vast populations, a simple average does not explicitly highlight the elevated rates of smoking amongst certain subpopulations. People residing in outer regional and remote areas of Australia were more likely to be daily smokers than those within inner regional areas and major cities. Those in lower socio-economic circumstances were much more likely to be daily smokers compared to areas of least disadvantage. Perhaps most disconcerting is the likelihood of an indigenous adult to be a daily smoker being more than twice that of a non-indigenous adult of the same age.[5] Thus, the overall decline in smoking prevalence is misleading; we, as a country, still face ongoing health inequity that must be acknowledged by ourselves and our Government.

Immense progress has been made since Australia signed WHO’s Framework Convention on Tobacco Control in 2004. This international treaty was developed in response to the growing tobacco epidemic and to provide guidelines for effective tobacco control legislation. Being one of the most widely embraced treaties in United Nations history, the FCTC has been ratified by over 150 countries demonstrating that smoking is a global concern.[6] Australia is currently in a unique position to set new standards worldwide for tobacco control. The introduction of plain packaging has been welcome and supported by the World Health Organisation (WHO) who stands by tobacco consumption as one of the leading preventable risk factors for non-communicable diseases, claiming over five million lives each year.[7] With the preliminary results regarding plain packaging being positive[4], numerous other countries such as New Zealand and Ireland are actively considering the implementation of a similar legislation that would see tobacco brand loyalty diminish. But with the aggressive backlash from tobacco companies threatening with extensive legal action, these legislations are being hampered at every turn. This is not unlike what the Australian Government experienced before plain packaging was finally implemented; what should be recognized is that its eventual legislation is attributed to years of effort from NGOs, campaigners, researchers, bureaucrats and parliamentarians. This easily-preventable risk factor for death and disease should be reason enough for Australia and the global community to push forward in the fight for tobacco control.

In this rapid age of globalisation, health burdens no longer remain the concern of a country alone. Smoking and its health consequences is one such example. As plain packaging has proven a landmark legislation for global standards of tobacco control, it is hoped the global community would encourage one another to take bold stances for the health of their citizens. Although there is much work ahead, the future is promising if we continue to push forward in bold advocacy against an addiction that kills so many.

Non-Communicable Diseases and Health Systems

Non-communicable diseases (NCDs) are the leading cause of global mortality, killing more than 36 million people each year.[1] There are four key groups of diseases responsible for 80% of NCD deaths.[1] These are cardiovascular diseases, cancers, respiratory diseases and diabetes. While NCDs encompass a range of other diseases, we will focus on these four in this paper. These NCDs also share four risk factors, including use of tobacco, unhealthy diets, lack of physical exercise, and harmful use of alcohol.

NCDs are sometimes thought to primarily affect affluent nations, however they disproportionately affect low- and middle- income countries (LMICs) where the premature adult mortality rate is significantly higher than in high-income countries. NCDs are responsible for 36 million deaths globally per year; more than 9 million of which occur before the age of 60.[1] Eighty percent of NCD deaths occur in LMICs.[1] The burden of NCDs is expected to further increase in the next decade and beyond. As shown in figure 1, NCDs are responsible for an increased proportion of loss of disability-adjusted life years (DALYs). Meanwhile communicable diseases, such as HIV/AIDs and diarrhoeal diseases are accountable for an increasingly smaller proportion of illness and premature death.[2]

Figure 1: A comparison of leading causes of burden of disease between 2004 and 2030

Source: WHO 2004 [2]

Components of a health systemAccording to the World Health Organization, a health system ‘consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health’.[3] There are six components that together constitute a health system, these include: Service delivery, health workforce, health information, medical technologies, health financing, and leadership and governance. Health systems and components need to respond to NCDs in the following ways:

Non-Communicable Diseases and Health Systems

NCDs and health systems in LMICs

1. Service deliveryThe organization of health services and how they are provided will have to change due to the shift from treating infectious disease and acute illness to managing chronic disease. Effective long-term management of NCDs will require consistent keeping of health records, whether these be patient-held or on a computer system. Patients will need regular access to health professionals and frequent testing.

2. Health workforceThe health workforce must be trained for prevention and health promotion. They will be required to provide counseling, for example supporting patients quitting smoking. Their role will move away from prescribing medicines and treating episodic illness. There will need to be a greater emphasis on self-management and personal responsibility of the patient, who will be seeing a number of health professionals for their treatment.

3. Health informationAs mentioned above, there will be a serious need for ongoing medical records. There is a lack of information available regarding the behaviours (for example, diets, exercise habits) of people in LMICs.[4] Surveillance and measurement of risk factors would prove helpful in managing and preventing chronic disease.

4. Medical technologiesBetter control over access to health technologies is required. These countries should not invest heavily in complex machines, which are sometimes unnecessary and frequently unavailable to the majority of the population. They should instead invest in simple medicines, with generic prescriptions, so that ongoing treatment will not be an extreme expense for the individual.

5. Health financingNCDs will lead to a greater expenditure on health care, due to the cost of things such as pharmaceuticals and hospital admissions for complications. There is also a detrimental economic impact of NCDs, due to NCDs being a cause for a loss of adult working lives. In order to fund NCDs, governments will need to seek community contribution through insurance schemes.

6. Leadership and governanceInter-sectoral collaboration will be very important. Health promotion and disease prevention policies will require involvement from other areas such as agriculture, transport, urban infrastructure and the food industry.[4] More community involvement will aid self-management and community-based interventions.

By Claire Felmingham

Case Study: Fiji

The Pacific islands have some of the highest rates of obesity and diabetes in the world and suffer from a high prevalence of NCDs due to a recent change in lifestyle.[5] Out of these countries Fiji has the largest population, with an estimation of 837000 in 2007.[6] Fiji has taken some early steps in tackling NCDs.

Governance:In the 2011 and 2012 Budget statements the Prime Minister stressed the importance of tackling NCDs.[5] There is a national NCD committee within the Ministry of Health. Within this committee there are subcommittees focusing on alcohol, tobacco, diet and physical activity and a group working with the food industry. The government has increased funding for the NCD program, increased taxes on alcohol and tobacco and decreased taxes on fruits and vegetables.[5] There is also significant community engagement. In 2012 the annual hibiscus event had the theme of NCDs and there are multiple NCD workplace programs.

Service Delivery:The government is hoping to increase access to specialist services, such as diabetes services. This will mean more specialists in subdivisional hospitals.[7]

Workforce:The Ministry of Health has outlined an aim to increase skills and resources for NCDs in primary health care. Fiji is at an early stage in implementing the Package of Essential NCD interventions (PEN) program with support from the WHO. This includes primary health care programs such as tobacco cessation and support for healthy eating, as well as availability of key medications.[8]

Medical technologies:With over 90% of expenditure on medicines coming from the patient [9] there is low use of medicines in those with NCDs or at high risk. The Ministry of Health is working on price control on a large range of medicines. However, at the moment access remains a serious issue.

Information:The patient record system began in 2011 but is currently only available at large health facilities. Patients with diabetes have used patient-held record cards since 2012.[5]

Financing:The healthcare system is financed through general taxation, with some out-of-pocket payments for private health. A small amount of financing comes from private health insurance and donations. There is still a need to identify how to fund NCDs.

A Developing World Of Mental Health

Earlier this year, I was in Vietnam for a placement at one of Ho Chi Minh City’s largest public hospitals, Benh Vien 115, where I was fortunate enough to follow some of the nation’s top doctors in the fields of cardiology, pulmonology and orthopaedic surgery.

It was during a routine asthma check-up that the mental health culture of Vietnam, a developing country, became apparent. The patient, named Wendy, was in her forties and whilst her asthma was well controlled, she was suffering from severe anxiety symptoms which were clearly impacting her life with family and at work. The doctor remained oblivious to these concerns and once her asthma medication was sorted, she was sent home without a single mention of her mental health issue. I turned to the doctor.

“Did the patient have any mental health issues?”“Yes, I believe she had anxiety.”“Is anything going to be done about it?”“No, not really. We don’t usually treat mental health issues here.”

A Mind of IssuesWith an estimated one in four to suffer from a mental disorder during their lives this century [1], mental illness is rapidly becoming one of the defining global health issues to hit our generation. Mental health spares no country and spares no socioeconomic status yet developing countries shoulder the majority of the burden, with 86% of suicides occurring in low to middle income countries. [2]

The reasons for this are complex. Wars, political instability, natural disasters, diseases and poverty impact the mental health of many around the world.[2] Numerous countries and cultures fail to acknowledge the importance of psychological illnesses and there is a significant lack of funding and human resources directed towards building a better system.

Stigma on the issue is widespread and also leads to discrimination in many developing countries. Being mentally ill can discount an individual from being capable of making their own decisions, carrying out their job, or even being able to look after themselves. In a country where one’s capacity to work may make or break the survival of one’s family, admitting mental health problems may lead to loss of basic necessities such as food, water and shelter.

A Culture of StigmaThe reasons behind mental health stigma are different in every part of the world and for the most part, culturally based. In Asian culture, mental illnesses are seen negatively because of the importance of conformity to the norm. Additionally, it may also shame the family because of the values of family collectivism. In South American culture, men and women are expected to follow the cultural roles of machismo (protective of family, chivalrous and nurturing) and marianismo (kind, unassertive, self-sacrificing) and any contradiction to these roles may result in discrimination. In Middle Eastern culture, concealing emotions is considered an important value and thus many view mental health services and any who seek them negatively.[3]

By Khoa Cao

A Light at the EndThe greatest tragedy of this tale is how preventable and treatable mental health diseases are, due to advances in psychiatric therapy. The greatest barrier that remains is no longer scientific but in fact human. Building an effective mental health system needs interest from both the provider and its users. A system is said to have failed if a depressed patient cannot access help services. Likewise, a system has also failed if services are freely available, yet a depressed patient refuses to access them in fear of stigma, discrimination and community backlash.

Building an effective mental health system needs interest from both the provider and its users. A system is said to have failed if a depressed patient cannot access help services. Likewise, a system has also failed if services are freely available, yet a depressed patient refuses to access them in fear of stigma, discrimination and community backlash.

Combating the issue hence requires a dual approach that targets both these aspects. From a provider perspective, this involves working with governments to establish support systems, psychiatry training for doctors and anti-discrimination laws. The World Health Organisation has led the way with its Project Atlas, which has mapped all the mental health resources and policies of every country in the world, and the Mental Health Gap Action Programme, which is a knowledge resource to aid countries in developing their own mental health systems.

From a user perspective, stigma is solved by identifying the causes, such as the cultural factors listed above, and attempting to change the status quo through those who control it.[4] In many countries, this may mean working with doctors, politicians, elders and religious figures. Stigma must be combated as mental health discrimination will continue to occur for as long as it exists.

A Story of HopeWendy’s story is only one of millions that will continue to be told as many countries around the world take its first steps in perceiving mental health as a disease like any other. The introduction of effective mental health systems and the purge of discrimination is not an issue that can be easily resolved and will require a tremendous amount of effort, time and money.

The gears, however, have begun to turn. More and more countries are seeing the importance of mental health and progressively, stigma is starting to evaporate in many areas with the help of a more educated generation.

One can only hope that developing countries will soon embrace mental health and provide services that its citizens deserve as we enter the key years of the 21st century.

Physician Dispensing In ChinaBy Shuyu Wang

Many have attributed increasing antimicrobial resistance in China to the institution of physician dispensing as it encourages over-prescription of many drugs, including antimicrobials, due to the financial incentives behind each individual prescription. Antimicrobial resistance has long been threatening to sweep modern medicine back to the pre-antibiotic-dark-ages. Being the nation containing the world’s largest population, China has a major impact on antimicrobial resistance burden. A 2006 study showed China’s mean prevalence of resistance in hospital-acquired infections to be 41%, compared with 6% in the U.S.[1] Moreover, with increasing globalization, China’s infectious diseases trends will doubtless leave a global mark. In order to formulate strategies to combat the attack of drug-resistance microbes, it is essential to gain an understanding into the contributing factors of hastening antimicrobial resistance in China and background behind physician dispensing.

Many other parts of Asia (including Taiwan, Japan, and Korea) have separated drug prescribing and dispensing to negate the phenomenon of over prescribing. The aim of separating the two is to limit the financial incentive behind the prescriptions, for the hope that doctors will base their prescription decisions purely on clinical experience and good-will for the patients. In recent years, China has also embarked on a path of healthcare reform, where the legitimacy of physician dispensing will doubtlessly be critiqued. However, without considering the interactions of cultural, economical, social factors complicating the issue of physician dispensing, such reform is almost doomed to fail.

The manifestation of physician dispensing can be originated back to Traditional Chinese medicine. This practice involved doctors not only diagnosing and prescribing advice and medication, but also undertaking the role of pharmacists in preparing and ensuring the quality of that medication. Today, most of China’s hospitals have integrated prescription and dispensing into a single provider, which supplies a significant proportion (up to 50%) of the hospital’s income. The Chinese phrase “yi yao yang yi” (literally meaning medicinal drugs feeding medicine) is a highly notorious and truthful saying. The phrase is double-fold in society. Firstly, drug profits keep hospitals running due to low government funds.

Secondly, doctors receive a “kick-back” from selling medicine, which adds to their base-line wage (which can be less than 1/5th of their Australian counterparts). Perhaps it is not greed, but a matter of sustainability, for the medical profession who are facing difficulties with recruitment due to lack of financial incentive.

However, merely removing the financial incentive for hospitals and doctors to over prescribe will not resolve the rapid rise of antimicrobial resistance. Beyond the medical industry, patients and cultural expectations play an integral role in antimicrobial overuse. It is not only the hospitals and doctors who enjoy the “perks” of an integrated prescribing and dispensing system at the hospitals. Travel time to pharmacies is reduced for the patients and some may feel comforted by the quality assurance from their physicians as their reputation is at stake. Low public awareness regarding differentiating bacterial and viral infections and also their treatments result in patients requesting antibiotics for viral upper respiratory tract infections. Regardless of whether it is a matter of demanding patients or doctors exploiting civilians’ lack of medical knowledge, it is clear that public education (to address the expectation of medicinal remedy for every consultation) is integral in tackling antimicrobial over prescription.

Despite the inherent flaws of physician dispensing, it carries historical and cultural armor, complicating the institution’s dismantlement. Indeed, healthcare reform in China must consider the review of finances for hospitals and doctors’ wages and public awareness in order to combat antimicrobial resistance.

Refugees and asylum seekers: Why should we care? Ming Fan

The 1951 UNHCR Refugee Convention, of which Australia is a party, defines a refugee as: "A person who owing to a well-founded fear of being persecuted… is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who… is unwilling to return to it.” (1) Over 90% of all asylum seekers arriving in Australia later achieve refugee status or receive humanitarian visas. (2)

In recent memory, issues surrounding refugees and asylum seekers in Australia have received heavy coverage by the media, while national policies for the processing of humanitarian visa applications have become increasingly punitive. It’s unclear which of these outcomes precipitates the other, or if they fuel one another in a constant cycle. Regardless, what is clear is that both politicians and the wider public opinion are missing the central issue – the moral obligation of humanity to help those in need.

This is the precise reason for which health professionals and trainees should make and effort to be involved in these issues. The health issues related to their persecution notwithstanding, reliable evidence indicates that our nation’s policies have significant impact on the health of asylum seekers arriving in Australia.

Most asylum seekers arriving in Australia come from resource poor countries whose health services, in the setting of disasters and conflicts, collapse in the destruction infrastructure and overwhelming numbers needing care. In addition to inadequate water and food supply and loss of shelter, there is also an increased prevalence of violence due to lack of regulations and cramped conditions in refugee camps that are suitable for breeding infectious disease. (3,4) These conditions, in addition to trauma from persecution, cause a number of mental health issues, including Post Traumatic Stress Disorder and Major Depressive Disorder. (3,5)

Asylum seekers pass through countries who are not signatories to the Refugee Convention and who therefore do not have a legal obligation to provide refuge. (1) In Malaysia, refugees are considered illegal immigrants and can be subjected to harsh penalties. (6) For this reason, they disguise their identities by destroying documentation and travelling through people smugglers to reach Australia, a country where they hope to start a new life. (2)

However, arrival in Australia, the country in which they hope to receive refuge, the situation does not improve. Immigration detention is mandatory for offshore arrivals in Australia. Conditions in Australia’s detention centres have been denounced as inappropriate by official medical bodies, including the Royal Australian College of General Practitioners (RACGP), the Royal Australasian College of Physicians (RACP) and the Royal Australian and New Zealand College of Psychiatrists (RANZGP). (7–9) As a result of cramped and poorly furbished living conditions, physical illnesses are rife in detention centres (9). Of these, infectious diseases are most prominent, with the common being preventative conditions such as dermatophytosis, otitis externa and upper respiratory tract infections. (10)

More concerning is the prevalence of mental illness in asylum seekers on detention centres. The prevalence of PTSD in those held in immigration detention is estimated to be between 32-100%. (10,11) Self-harm in unauthorised boat arrivals (of which all are sent to offshore detention centres) accounts for 17.7% of all injuries, compared with 6.2% in the total asylum seeker population. (10) Reports show a high prevalence of PTSD in children in detention centres since the commencement of this practice in 2012, (12) and children on Christmas Island are limited to a maximum of two weeks education annually. (13) Significantly, mental health conditions are chronic conditions and have long-lasting effects on detained persons long after their release into the general Australian community. (14)

Similarly worrying are other changes resulting in increasingly punitive policies for asylum seekers arriving in Australia. Both the introduction of the “no advantage” rule and the reintroduction of Temporary Protection Visas and later Temporary Humanitarian Concern Visas presented asylum seekers with inherent uncertainty, leading to higher rates of mental illness compared with those with permanent visas. (15,16) Since 2013, unauthorised onshore arrivals are no longer resettled in Australia and are transferred directly to offshore detention centres, where their health is subject to the conditions mentioned above, while unauthorised boats detected by naval forces in Australian waters may be towed outside the borders under the implementation of Operation Sovereign Borders (17). The Australian government’s recent resettlement deal with Cambodia has been condemned by the internationally and locally, given Australia’s capability to take provide for refugees, whilst Cambodia has neither the resources nor the environment suitable to settle refugees; (18,19) on this issue, Ou Virak, chairman of Cambodian Centre for Human Rights, stated: “Cambodia couldn’t give humanitarian support even if we wanted to... Cambodia is poor as hell.” (20) In any and all of these cases mentioned, the health of asylum seekers are not positively impacted by, and indeed are negatively impacted by, Australian policy, despite our responsibility under the Refugee Convention. In 2012, 67% of Australians reportedly supported offshore processing in Nauru and Manus Island. (21) However, despite strong, widespread support for the Liberal party’s “Stop the boats” election campaign in 2013, changes are being made to alter public opinion on issues surrounding asylum seekers. The Australian Human Rights Commission has led a National Inquiry into Children in Immigration Detention (13); recent High Court ruling of case S4 more clearly restricted the definition of mandatory detention (22); and the public response to the recent deal for the resettlement of asylum seekers in Cambodia was primarily discomfort and disgust rather than support (18–20).

Ultimately, the rise of definitive leadership can refocus the issue of asylum seekers and refugees as a humanitarian one, rather than a political one, and in doing so, improve the health of refugees and asylum seekers. As we have been taught, the role of a doctor is two-fold: to not only treat patients with medical skill, but also to advocate for our patients and be aware of health of the community as a whole. In the area of refugees and asylum seekers, we need only look at the impact of our nation’s policies on the health of these persecuted groups to know the role that we should play in improving health, as is our duty. Regardless of any other factors including political stance, religious beliefs or personal views, looking after the health of refugees and asylum seekers in Australia is a moral obligation of Australian health practitioners and trainees. However, the health burden of these groups on Australia’s health system is a symptom of a greater disease – in order to improve health outcomes, we must look at truly instigating social change. By changing public perception, we can change the government’s response to both refugees and asylum seekers arriving on our shores and global conflicts and disasters through effective foreign aid. Only then will we “solve Australia’s refugee problem”.

Humanitarian Space and the Impact of Blurring Lines1. Humanitarian Space: A review of trends and issues. Collinson, Elhawary, Humanitarian Policy Group Report, April 20122. Humanitarian Space. United Nations Office for the Coordination of Humanitarian Affairs, available at www.ochaopt.org/content.aspx?id=10101433. Playing with principles in an era of securitized aid: negotiating humanitarian space in post 9/11 Afghanistan. Shannon, Progress in Development Studies, 20094. Whither Humanitarian Space? Canadian International Council, 20125. Aid Policy: The myth and mystique of humanitarian space. Irin Global, May 20126. Shrinking Humanitarian Space? Trends and prospects on security and access. Brassard-Boudreau, The Journal of Humanitarian Assistance, Nov 2010

The Global Movement for Family Planning1. World Health Organization. The right to health [Internet]. 2014 [2 July 2014]. Available from: 1. http://www.who.int/mediacentre/factsheets/fs323/en/2. Carr B, Gates M, Mitchell A, Shah R. Giving the world’s poorest women the power to plan their families. 2012;.3. London Summit on Family Planning [Internet]. 1st ed. 2012 [3 July 2014]. Available from: http://www.familyplanning2020.org/images/content/old_site_files/London-Summit-Family-PlanningOverview_V1-14June.pdf4. Who.int. WHO | MDG 5: improve maternal health [Internet]. 2014 [3 July 2014]. Available from: http://www.who.int/topics/millennium_development_goals/maternal_health/en/5. Horton R, Peterson H. The rebirth of family planning. Lancet. 2012;380(9837):77.6. Population Reference Bureau. The Family Planning Ripple Effect for Child Survival [Internet]. 2014 [4 July 2014]. Available from: http://www.prb.org/infographic_childsurvival/index.html#Infographic-info-027. Summaries of Commitments [Internet]. 1st ed. 2013 [4 July 2014]. Available from: http://www.familyplanning2020.org/images/content/documents/COMMITMENTS_090712.pdf

Cash Tramsfers and Charities1. Too many cooks? The Guardian [Internet]. 2000 Nov 8 [cited 2014 Jul 5]; Available from: http://www.theguardian.com/society/2000/nov/08/guardiansocietysupplement52. GiveDirectly [Internet]. GiveWell. [cited 2014 Jul 5]. Available from: http://www.givewell.org/international/top-charities/give-directly3. GiveDirectly: Financials [Internet]. [cited 2014 Jul 5]. Available from: http://www.givedirectly.org/financials.php4. Cutting the strings: Why some aid orgs want to give money away | Global Envision [Internet]. [cited 2014 Jul 5]. Available from: http://www.globalenvision.org/2013/09/05/cutting-strings-why-some-aid-orgs-want-give-money-away5. Goldstein J. Is It Nuts to Give to the Poor Without Strings Attached? The New York Times [Internet]. 2013 Aug 13 [cited 2014 Jul 5]; Available from: http://www.nytimes.com/2013/08/18/magazine/is-it-nuts-to-give-to-the-poor-without-strings-attached.html6. Levy S. Progress against poverty: sustaining Mexico’s Progresa-Oportunidades program. Washington, D.C: Brookings Institution Press; 2006. 166 p. 7. Generating Skilled Self-Employment in Developing Countries: Experimental Evidence from Uganda by Christopher Blattman, Nathan Fiala, Sebastian Martinez :: SSRN [Internet]. [cited 2014 Jul 5]. Available from: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=22685528. Pennies from heaven. The Economist [Internet]. 2013 Oct 26 [cited 2014 Jul 1]; Available from: http://www.economist.com/news/international/21588385-giving-money-directly-poor-people-works-surprisingly-well-it-cannot-deal

9. Johannes Haushofer [Internet]. [cited 2014 Jul 5]. Available from: http://www.princeton.edu/~joha/10. Cash transfers in the developing world | GiveWell [Internet]. [cited 2014 Jul 5]. Available from: http://www.givewell.org/international/technical/programs/cash-transfers11. Relative Effectiveness of Conditional and Unconditional Cash Transfers for Schooling Outcomes in Developing Countries: A Systematic Review - Campbell Library - The Campbell Collaboration [Internet]. [cited 2014 Jul 5]. Available from: http://www.campbellcollaboration.org/lib/project/218/12. GiveDirectly? Not So Fast. (SSIR) [Internet]. [cited 2014 Jul 1]. Available from: http://www.ssireview.org/blog/entry/givedirectly_not_so_fast13. Top charities [Internet]. GiveWell. [cited 2014 Jul 5]. Available from: http://www.givewell.org/charities/top-charities14. Are cash transfers overrated? - Chris Blattman [Internet]. [cited 2014 Jul 5]. Available from: http://chrisblattman.com/2014/03/14/are-cash-transfers-overrated/

Refugee Health: The Bigger Picture1. UNHCR. War’s human cost: UNHCR Global Trends 2013 2013.2. UNHCR. Displacement: The New 21st Century Challenge. UNCHR Global Trends 2012 [Internet]. 2012. Available from: http://unhcr.org/globaltrendsjune2013/UNHCR%20GLOBAL%20TRENDS%202012_V08_web.pdf.3. Toole MJ and Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu Rev Public Heallth. 1997;18:183-312.4. Médecins Sans Frontières. Dadaab. No way in: the biggest refugee camp in the world is full2011. Available from: http://www.msf.org.au/resources/special-features/dadaab-refugee-camp.html.5. UNHCR. Protecting Refugees & the role of UNHCR2012. Available from: http://unhcr.org.au/unhcr/images/protecting%20Refugees%20and%20the%20Role%20of%20UNHCR.pdf.6. Minimun standards in health action. The Sphere Project 2011.7. Médecins Sans Frontières. Refugee Health: An approach to emergency situations. Oxford: Macmillan Education; 2008.8. Australian Government. Refugee and Humanitarian Issues: Australia’s Response. In: Citizenship DoIa, editor. 2009.

Tobacco Control1. Department of Health [homepage on the Internet]. Canberra; [updated 2013 July 31; cited 2014 June 2]. Plain packaging of tobacco products. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/tobacco-plain 2. The Cancer Council [homepage on the Internet]. [cited 2014 June 2]. Prevalence of smoking – adults. Available from: http://www.tobaccoinaustralia.org.au/1-3-prevalence-of-smoking-adults 3. Tobacco Control Laws [homepage on the Internet]. Washington; [updated 2013 April 24; cited 2014 June 2]. Tobacco Control Laws - Country Details For Australia. Available from: http://www.tobaccocontrollaws.org/legislation/country/Australia/summary 4. Young J, Stacey I, Dobbins T, Dunlop S, Dessaix A, Currow D. Association between tobacco plain packaging and Quitline calls: a population-based, interrupted time-series analysis. Med J Aust. 2014;200(January):29–32.5. Department of Health and Ageing [homepage on the Internet]. Canberra; [updated 2012 Oct 4; cited 2014 June 2]. Health Warnings on Tobacco Product Packaging. Available from: http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/content/hwot#.UZn_KJxYR8d 6. World Health Organisation [homepage on the Internet]. Geneva; [updated 2014 March 27; cited 2014 June 2]. Parties to the WHO Framework Convention on Tobacco Control. Available from: http://www.who.int/fctc/signatories_parties/en/

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