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Australasian
Junior Doctor Journal
New Zealand and Australias Medical Ofcer Journal
ISSUE 2 | JULY 2012
AUSTRALIA
The Global Health Issue
17 Million
Classied overweight
or obese
AUSTRALIA
2.2
Physicians per
1,000 people
NEW ZEALAND
More than
1 in 7
adults are living
with HIV
ZAMBIA
11.3%
Chance of not living
beyond 40 years
BRAZIL
By 2030
80%
of all diabetics
worldwide will live in
India
INDIA
2 Trillion
Cigarettes smoked
per year
CHINA
Australasian Junior Doctor Journal
CONTENTS
Note from the editors
Our world is changing and it is getting smaller.
We are witnessing tremendous advances in
healthcare and, at the same time, living through
a period characterised by numerous complex
challenges in the health arena.
ln the frst ed|t|on of th|s journa|, we exp|ored the
|mportant |ssue of |eadersh|p |n hea|thcare. Th|s
ed|t|on |s ded|cated to the equa||y |mportant top|c of
global health.
ln th|s era of connectedness, soc|a| med|a and
unprecedented access to |nformat|on, cha||enges
such as |so|at|on, |nequa||ty and |ack of bas|c
sanitationpersist. Our ability to travel and connect has
not only made the world smaller, but has meant that
these issues now have a global audience.
G|oba| hea|th has rece|ved a great dea| of attent|on |n
recent years. Th|s focus has g|ven the g|oba| hea|th
agenda the attention it deserves; however, it has
also highlighted that this is a complex subject. In this
ed|t|on, we acknow|edge the breadth of op|n|on and
inherent complexity in this area by including articles
which communicate both complementary and
opposing views.
Our intent is to challenge, stimulate, provoke and
inspire critical thought. Our global health world
needs the ta|ent, |deas and efforts of many to meet
and overcome the cha||enges we face today and
tomorrow.
So we |ook to you for feedback, thoughts and
refect|ons to expand and share our stor|es |n th|s
increasingly connected world. Please continue to
prov|de your feedback and v|ews: email us at info@
juniordoctorjournal.com, visit us on facebook or at
our website: www.juniordoctorjournal.com.
THE EDITORIAL TEAM
To subscr|be to rece|ve an e-copy of th|s journa| and to |earn more about subm|tt|ng art|c|es, contact us at:
info@juniordoctorjournal.com
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We Listen to Our Members.
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We know that you value education, resources,
medico-legal advice and support.
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and medico-legal education.
The Perfect Fit for Doctors in Training.
MDA National
is th e perfect fit
on member ser vices
and benefits.
2 Co-development
or global health activism
10 The trouble with health
indicators: Why global health
data mislead us
6 Questioning the global health
doctor model
12 The challenges and learning
opportunities of a global
health placement
8 Youth are a fundamental force
for change in global health
16 The little country that could
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Australasian Junior Doctor Journal Australasian Junior Doctor Journal
lt was a voyage of d|scovery for me. l soon
realised that there was a great deal that we
could do, particularly in training and educating
health workers because there is a critical
shortage of hea|th workers |n most |ow and
middle income countries. We could help
by creating partnerships, supporting local
institutions and providing inputs in person or
over the |nternet or phone as we||, of course, as
by prov|d|ng fund|ng.
The rea| reve|at|on, however, was |n how much
we had to learn.
Throughout my trave|s |n Afr|ca and South
As|a l came across peop|e who, w|thout
our resources or our baggage and vested
interests, were innovating and creating new
ways of dea||ng w|th the prob|ems they
encountered. Some of these are serv|ce and
product |nnovat|ons: new ways of treat|ng and
d|agnos|ng Hlv/AlDS and TB are com|ng out of
Afr|ca, for examp|e, wh||st lnd|an organ|sat|ons
have created new |enses for cataract sufferers
and there are new eHealth and mHealth
applications being developed everywhere.
Not everyone |s ab|e to |nnovate, of course, and
the common exper|ence of hea|thcare |n most
|ow and m|dd|e |ncome countr|es |s of enormous
need, a |ack of resources and very poor access
for most of the popu|at|on to hea|thcare.
Poverty, ||tt|e educat|on, d|rty water, h|gh fert|||ty
and, a|| too often, corrupt|on and conf|ct make
the tasks of hea|th promot|on and hea|thcare
very d|ffcu|t. Our peers as hea|th workers |n
other countr|es have a far harder job to do than
we do.
Desp|te these d|ffcu|t|es there are many
innovations, with the most interesting being in
CO-DEVELOPMENT
OR GLOBAL HEALTH
ACTIVISM
Lord Nigel Crisp
I ran the largest health organisation in the
world the English NHS - for more than
5 years and experienced all the upsides
and downsides of delivering healthcare to
a nation of more than 50 million people.
When I retired in 2006 Prime Minister Blair
invited me to review how the UK could use
its experience and expertise in health to
promote and improve health in low and
middle income countries.
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talk or think about international development
w|th |ts top down connotat|ons but about co-
development and the recognition that everyone
has something to teach and everyone has
something to learn.
We need action as well as analysis. Continuing
as we are cou|d be d|sastrous. The hea|th
systems of r|cher countr|es need re-th|nk|ng and
re-deve|op|ng or they w||| s|mp|y become more
cost|y and |ess effect|ve. There |s a|so the r|sk
that other countries as they become richer will
adopt the old models we need to discard and
neg|ect the th|ngs they have deve|oped. None of
this will help those in the poorest countries or the
poorest people in our own.
It is important to spell out an alternative vision
and to develop and live it through our work. For
me th|s means 3 major act|ons:
help make visible what is already happening,
promote and protect the innovators and the
groups who are making change. We can all
learn and all teach
deve|op new ways of educat|ng and tra|n|ng
health workers so that they are equipped with
the mindset and skills needed in this new
future. Ohange w||| on|y happen at sca|e when
|t |s |nterna||sed |n the m|nds of hea|th workers
and in their actions
build a movement, create partnerships across
countries, experience exchanges, join up and
commun|cate; ce|ebrate the potent|a| of a
d|fferent future.
Lord Nigel Crisp is an independent member of the House of
Lords. He was Chief Executive of the English NHS the largest
health organisation in the world and Permanent Secretary of
the Department of Health from 2000 to 2006. He led major
reforms and improvements in the NHS. He now works mainly
in Africa and India on health issues and has written Turning
the World Upside Down the search for global health in the
21st century which describes what rich countries can learn
from poorer ones and 24 Hours to Save the NHS the Chief
Executives account of reform 2000 to 2006. More information
is at nigelcrisp.com.
how services are delivered and health systems
designed. I believe there is a new tradition
deve|op|ng based on 5 s|mp|e pr|nc|p|es:
fu|| engagement of commun|t|es, fam|||es and,
in particular, women
creative linkages between healthcare,
education, employment and other local
services
the promot|on of soc|a| bus|nesses and
activities by local entrepreneurs
the |ntegrat|on of c||n|ca| med|c|ne w|th pub||c
health and population health
and, most controvers|a||y, the tra|n|ng of peop|e
for the job needed and not just to become
mu|t|-competent profess|ona|s. Throughout
Afr|ca, for examp|e, so-ca||ed m|d-|eve| hea|th
workers are undertaking roles which we
norma||y reserve for doctors, from carry|ng
out caesarean sections to giving anaesthetics.
They can do them except|ona||y we|| under the
r|ght cond|t|ons of tra|n|ng and superv|s|on and
as part of a system - or very bad|y |f |so|ated
and |eft unsupported.
ln the h|gh |ncome countr|es of Austra|as|a,
Europe and Amer|ca we are exper|enc|ng
ep|dem|cs of obes|ty and non-commun|cab|e
diseases and our health systems are having to
dea| w|th |arge numbers of genera||y o|der peop|e
w|th mu|t|p|e |ong term cond|t|ons. As we know,
the hospital and physician based systems which
have served us so well over the last century are
no |onger equa||y adept at prov|d|ng for these
pat|ents. They need far more commun|ty based
serv|ces wh|ch engage the efforts of ne|ghbours
and vo|unteers as we|| as a p|ethora of h|gh|y
educated profess|ona|s and tra|ned ass|stants.
The mode|s of care needed |n the future are very
d|fferent and w||| re|y on us deve|op|ng just those
skills and attributes I have listed in the bullet
po|nts above - from commun|ty support to new
ways of tra|n|ng new groups of hea|th workers.
Co-development
My travels also made me understand better
someth|ng l was a|ready d|m|y aware of - that
a|| of us throughout the wor|d and our hea|th
and our health systems are interconnected
and interdependent. New diseases, perhaps
originating in a low income country with poor
health surveillance, can spread round the
wor|d |n days. O||mate change or the fa||-out
from |ndustr|a| processes or acc|dents trave|s
on the w|nd regard|ess of nat|ona| boundar|es
and we are all dependent on the same limited
supp||es of hea|th workers and the same drugs.
Moreover, as |ndustry and affuence becomes
more w|despread so does fast food and
unhealthy habits and behaviours. Freer trade
spreads some of the ev||s of affuence as we|| as
some of the benefts. These 5 pr|nc|p|es app|y
here as well.
Desp|te th|s |nterdependence, |t |s c|ear that
access to health, to health services and to
health resources is not equitable between or
w|th|n countr|es. Poorer parts of the wor|d
are worst h|t by m|grat|on of hea|th workers,
poor access to medicines and the likely
|mpacts of major c||mate change. Poorer
people everywhere have the worst health and
the worst health services and live in the least
healthy environments.
Nevertheless, we are all in this together. What
happens |n poorer countr|es affects r|cher ones,
we share many problems and, as I have argued
above, richer countries have much they can
|earn from poorer ones. As a resu|t, l no |onger
We are all in this together. What happens in poorer countries
affects richer ones, we share many problems and, as I have
argued above, richer countries have much they can learn
from poorer ones.
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Surgeons, hopp|ng on the bandwagon, often
sponsor m|ss|ons to operate on scores of
patients (many with ailments that are not directly
||fe-threaten|ng}. Th|s |ssue becomes even more
acuteleaving patients with unhealed wounds
makes them ||ab|e to |nfect|on and other potent|a||y
||fe-threaten|ng comp||cat|ons. And a|though they
may train local personnel to provide a minimal
|eve| of post-operat|ve care, pat|ents need|ng
reoperat|on or more comp|ex procedures are |eft
with little recourse.
ln the end med|ca| m|ss|ons often |ack the
|nfrastructure or fores|ght to prov|de adequate care.
They prov|de the|r target popu|at|ons w|th noth|ng
more than stopgap hea|thcare w|th ||tt|e fo||ow-up,
overs|ght, or cons|derat|on for the |ong-term.
And what about the structura| dynam|cs of th|s
model? Western doctoreducated, upper class,
usually Whitetravels to remote Eastern village
to care for uneducated, poor, dark-sk|nned
|nd|genous peop|es. The |mage re|nforces a
deep|y troub||ng h|erarchy of c|ass and race
whereby there |s an |mp||ed dependence of the
|atter on the former-'these peop|e can`t take care
of themse|ves." And rather than avo|d that rhetor|c,
many visiting physicians use it as a principal
just|fcat|on for the|r |nterference.
Lastly, a question about intentions. Economists
argue that people are rationalthey make
decisions about how they allocate their resources,
like time and money, in order to maximise their
ut|||ty. So, what do med|ca| v|s|tors get |n return for
the|r sacr|fces |n t|me and money? Ostens|b|y, |t`s
the sat|sfact|on of hav|ng he|ped those |n need.
But noth|ng |s ever that s|mp|e. lt`s a|so c|ear
that these physicians are rewarded with other
amenities upon their returns home. Labels like
'human|tar|an" and 'ph||anthrop|st" carry we|ght
in our societiesthey earn doctors prestige and
admiration. Whats more, these labels can propel
them, especially those in academic settings,
forward |n the|r careers.
Are med|ca| m|ss|ons categor|ca||y bad? No.
There are c|rcumstances where th|s type of
|ntervent|on |s just|fed-|nstances where there
really is no other recourse to healthcare and where
peop|e are suffer|ng. These are c|rcumstances
where the economic and sustainability issues are
less pressing than the immediate consequences
of |ack of care. Wh||e fortunate|y, these
c|rcumstances are re|at|ve|y few, they are not the
c|rcumstances |n wh|ch Western Doctors are
willing to venture given the very reasons that they
|ack access to a|most any hea|thcare: they are
usua||y ||fe-threaten|ng or they |ack even the most
bas|c |nfrastructure. Take, for examp|e, the war-
torn sett|ng of rura| Afghan|stan, wh|ch |acks even
the most bas|c hea|thcare resources but |s far too
dangerous for most Western phys|c|ans.
The rea| prob|em |s that most adventurous
'g|oba| hea|th doctors", want|ng the amen|t|es
that embarking on these missions may provide,
choose to go to contexts where th|s type of
intervention is not appropriatewhere care is
already available and the challenges discussed
above are imminent. In so doing, they outcompete
native physicians with substandard, unsustainable
care, and re|nforce h|erarch|es of race and c|ass-
|n fact, |t wou|d be better for them not to have
intervened at all.
Fortunate|y, G|oba| Hea|th |s far b|gger than
med|ca| m|ss|ons. lf they are w||||ng to forgo the
fa|se-hero|sm that m|ss|ons enta||, there are other
avenues where committed physicians really
can make a d|fference. These |nc|ude capac|ty-
building through training and consulting with
native doctors, working with aid and development
organ|sat|ons to better a||ocate resources |n |ow-
income settings, or working to better understand
the causes and consequences of poor hea|th |n
these settings via guided research.
Ultimately, righting the health inequity borne
of centur|es of s|phon|ng resources from the
Global South by the Global North is a serious
respons|b|||ty. lt`s cruc|a| that |n the|r efforts,
phys|c|ans are carefu| not to fa|| |nto the same
parad|gms of th|nk|ng that created th|s |nequa||ty
|n the frst p|ace.
QUESTIONING
THE GLOBAL
HEALTH DOCTOR
MODEL
Dr Abdul El Sayed
As he presented his experience treating the
indigent in a Sub-Saharan African country,
a PowerPoint slideshow documented, in
pictures, his time. Photo after photo featured
the young doctorone picture centered on a
hug shared with an elderly woman, another
with a gaggle of smiling children, and a third
with a pregnant woman conveniently garbed
in her native birthing dress.
The presentat|on had |ts |ntended effect. H|s
aud|ence of med|ca| students sat mesmer|sed as
he spoke of the tr|a|s and tr|bu|at|ons of h|s t|me
'on the Oont|nent". At |ts c||max, he pass|onate|y
|mp|ored them to take up the ca|| for 'G|oba|
Hea|th", ||ke he had.
'l assure you", he sa|d, 'that you too can make a
d|fference."
And, just ||ke that, the quest|on of the d|fference
he had made was sett|ed. After a||, he had spent a
week |n Afr|ca, us|ng h|s own hard-earned money
to treat peop|e he may never see aga|n. After the
talk, eager students swarmed to ask his advice
about how they, too, cou|d have such a fu|f|||ng
experience.
He is but one entrepreneur in a burgeoning
|ndustry of do-|t-yourse|f G|oba| Hea|th whereby
wea|thy doctors 'g|ve someth|ng back" by
embark|ng on one or two-week med|ca| m|ss|ons
|n remote sub-Saharan Afr|can, |at|n Amer|can, or
Southeast As|an v|||ages treat|ng a coup|e hundred
patients and returning home with pride in their
accomp||shments, p|ctures for Facebook, and
stor|es to te|| the|r fr|ends.
It is an industry that has capitalised on the
questionable premise that no matter what, no
matter where, providing healthcare is always good.
Th|s prem|se, though, embeds severa|
assumptions that must be articulated clearly and
exam|ned carefu||y. These |nc|ude the econom|c
|mp||cat|ons of |nterference, the capac|ty to
manage comp||cated |||nesses, the re|nforcement
of h|erarchy, and the pur|ty of |ntent|ons.
|et`s cons|der the frst: the econom|c |mp||cat|ons
of |nterference. Oons|der th|s-one of the most
press|ng |ssues |n hea|thcare on the Afr|can
cont|nent |s the 'bra|n dra|n" of the cont|nent`s
best doctors to higher income countries where
the fnanc|a| rewards are substant|a||y greater
for |ess d|ffcu|t work. Among the causes of th|s
phenomenon are the fa|se percept|on that Western
doctors are super|or and the free serv|ces they
offer: W|th sh|ny new equ|pment and starched,
crisp white coats, visiting doctors are better able
to attract pat|ents (desp|te the|r re|at|ve |ack of
exper|ence or understand|ng of hea|th or med|c|ne
|n th|s context} than the|r nat|ve counterparts. More
importantly, their services cost nothing.
Free care from Western doctors becomes
preferab|e to more expens|ve care from nat|ve
ones. In this way, despite their intentions to
provide the native population with healthcare,
v|s|t|ng phys|c|ans can actua||y rob them of qua||ty
hea|thcare |n the |ong-term by outcompet|ng
the few nat|ve doctors st||| work|ng |n the v|||age
and exacerbating the imbalanced incentives that
potent|ate the bra|n dra|n |n the frst p|ace.
Consider, also, the limited capacity to provide
h|gh-qua||ty care |n the span of a one or two-
week mission. What attracts medical visitors to
|ow-|ncome countr|es |s the perce|ved depth and
sever|ty of |||ness |n these contexts. lron|ca||y,
though, treating more severe illness takes more
time and oversight. Shouldnt it be less amenable
to one or two-week forays? Th|s |rony |eaves
patients with substandard care.
Take, for examp|e, a pat|ent w|th a comp||cated
|nfect|on-who`s go|ng to make sure that that
pat|ent fn|shes her course of ant|b|ot|cs? And
what happens |f, ||ke pat|ents the wor|d over, she
assumes that because her |nfect|on has c|eared,
that she doesn`t need to fn|sh her course of
treatment? Ant|b|ot|c res|stance can resu|t.
Dr Abdul El Sayed is a MD/PhD student at Columbia
University, where he is pursuing a PhD in Epidemiology
alongside a medical degree. His research interests include
Arab-American health; paediatric and peri-natal epidemiology;
obesity; complex systems approaches in epidemiology; and
the social determinants of health. As a Rhodes Scholar he
completed a DPhil in Public Health at the University of Oxford.
He is also a Fellow at Demos, a progressive policy think tank
and regularly contributes to the Guardian, Al Jazeera and the
|0//||o| |os|, w|e|e ||s comme||a|, e|aes ||e o0o||c
debate regarding Public Health; the US health system; racial,
ethnic and socioeconomic inequalities; and Islam in the West.
Australasian Junior Doctor Journal Australasian Junior Doctor Journal
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Australasian Junior Doctor Journal Australasian Junior Doctor Journal
g|oba| context of hea|thcare. ln the K, n|vers|ty
Oo||ege |ondon (O|} students approached the|r
Dean |n 1999, and s|nce O|`s |nterca|ated BSc
(|BSc} |n 2001
2
, similar advocacy by students
across the country has increased the number
of |BScs to 8. Students a|so p|ayed a key ro|e
|n ca|||ng for the |nc|us|on of a 'g|oba| hea|th
outcome" |nto the 2009 ed|t|on of Tomorrow`s
Doctors
3
and |n the pub||sh|ng of a proposed
global health curriculum
4
. Transform|ng med|ca|
training in this way will provide young doctors
w|th the sk|||s they need to face the cha||enges of
modern medical practice.
Youth are engaging political processes that shape
our world and planning interventions which make
a d|fference even at an |nternat|ona| |eve|, such
as a range of measures at OOP17 |n Durban and
campaigns such as Root Out, Reach Out at the
2011 Wor|d Oonference on Soc|a| Determ|nants of
Health
5
.And we can take act|on, on |oca|, nat|ona|
and international levels. Locally, young people
have often |ed the way |n vo|unteer|ng |n the|r |oca|
commun|ty w|th projects such as Oross|ng Borders;
a group wh|ch works w|th refugees to |mprove
the|r hea|thcare. Th|s |s a trend sen|or doctors
m|ght do we|| to fo||ow as an express|on of the|r
moral contract to society and a way to build public
trust and gain a better understanding vulnerable
members of the commun|ty
6
. lnternat|ona||y, lFMSA
fac|||tates both c||n|ca| and research-based student
exchanges, enabling students to learn about the
g|oba| context of hea|thcare.
l`ve just returned from two weeks |n Ghana at the
March Meet|ng of the lFMSA. Gather|ngs such as
these, wh|ch br|ng together up to 1,200 students
from 101 nat|ons, are a powerfu| rem|nder that
students everywhere are affected by these |ssues,
and that students everywhere are implementing
change. Each one of us |s young, re|at|ve|y
|nexper|enced, and |dea||st|c. But we use these
factors to dr|ve us. The peop|e who change th|s
wor|d are not those who |et the|r |mperfect|ons
and |nadequac|es get |n the way. They are not
those who wa|t. They are the peop|e who desp|te
the|r faws, desp|te the|r |ack of exper|ence and
despite their inadequacies are taking action, and
are taking it now.
Every young person can train themselves
and take act|on. Together, we can create a
movement strong enough to not only challenge
the bu||d|ng b|ocks of g|oba| |njust|ce, but to br|ng
them tumb||ng down. Together, we can be the
fundamenta| force for change |n g|oba| hea|th.
1. Novak S. Taking a More Holistic Approach to Global
Health Education. The New York Times [Internet]. 2012 Feb
19 [cited 2012 Mar 22]; Available from: http://www.nytimes.
com/2012/02/20/world/europe/20iht-educlede20.html
2. Yudkin JS, Bayley O, Elnour S, Willott C, Miranda JJ.
Introducing medical students to global health issues: a Bachelor
of Science degree in international health. The Lancet. 2003
Sep;362(9386):8224.
3. Tomorrows Doctors online (2009) [Internet]. [cited 2012
Mar 22]. Available from: http://www.gmc-uk.org/education/
undergraduate/tomorrows_doctors_2009.asp
4. Johnson O, Bailey SL, Willott C, Crocker-Buque T, Jessop
V, Birch M, et al. Global health learning outcomes for medical
students in the UK. The Lancet [Internet]. 2011 Oct [cited 2012
Mar 22]; Available from: http://www.thelancet.com/journals/
lancet/article/PIIS0140-6736(11)61582-1/fulltext
5. Guinto RLL, Yore D, Habibullah NK, de Leon AM, Tillman T,
Elliott-Green A, et al. Students perspective on rooting out causes
of health injustice. The Lancet. 2011 Dec;378(9808):e20e21.
6. Earnest MD, et. al. Physician Advocacy: What is It and How Do
We Do It? Academic Medicine. 2010 Jan; 85(1): 63-67.
Felicity Jones is the joint national coordinator of Medsin-UK
In our increasingly globalised world,
the local and national health challenges
which medical professionals tackle on a
daily basis cannot be disengaged from
their global context. Todays medical
professionals face: health threats which
transcend national borders; patients who
can, and do, travel the world overnight;
and diverse, multicultural societies - trends
which are only increasing.
lf doctors of the twenty-frst century want to care
effect|ve|y for the|r |nd|v|dua| pat|ents and |oca|
community, then they must study and impact upon
not only local and national health issues, but also
the broader determ|nants of we||-be|ng and the
g|oba| frameworks wh|ch shape the ||ves of each
and every one of us.
None of th|s w||| come as a surpr|se to you. Young
peop|e across the wor|d are as fam|||ar w|th the
concepts of g|oba||sat|on as they are w|th the
use of Facebook. We are the generat|on w|th the
Ooca-Oo|a |ogo |mpr|nted upon our bra|n. We are
the generation who, through television, buy into
a|| of Ho||ywood`s |dea|s. We are the generat|on
with technology that connects us with those on
the other s|de of the wor|d at a drop of a hat. A||
these factors have |mp||cat|ons for hea|thcare.
And th|s fact makes sense to us |n a way that
those who have grown up before g|oba||sat|on
often fa|| to grasp. Th|s understand|ng, our
passion, and our credibility as the generation
who w||| have to dea| w|th the outcomes of
current policy all place us in a unique position to
implement change in global health.
But how? As jo|nt pres|dent of Meds|n-K, the
K`s Student G|oba| Hea|th network, l have seen
hundreds - probab|y thousands - of students and
jun|or doctors fred up by the |njust|ces wh|ch face
our troub|ed wor|d. 'But l`m young, |nexper|enced,
and idealistic! they tell me, What can I do? Not
only can we do a lot, but we already are.
Young people across the world are educating
themse|ves about g|oba| |ssues us|ng extra-
curr|cu|ar means. The lnternat|ona| Federat|on
of Med|ca| Students Assoc|at|ons (lFMSA},
wh|ch represents 1.2 m||||on med|ca| students,
fac|||tates r|gorous |nternat|ona| tra|n|ng courses
and its member organisations run events such as
conferences, debates and journa| c|ubs
1
.
Young profess|ona|s are chang|ng ant|quated
medical curricula to incorporate teaching about the
YOUTH ARE A
FUNDAMENTAL
FORCE FOR
CHANGE IN
GLOBAL HEALTH
Felicity Jones
11 Register now at www.juniordoctorjournal.com July 2012 July 2012 Register now at www.juniordoctorjournal.com 10
Australasian Junior Doctor Journal Australasian Junior Doctor Journal
in low income countries, where there is no system
of overs|ght. l have v|s|ted hea|th fac|||t|es |n remote
areas wh|ch were comp|ete|y non-funct|ona| and
yet reported hav|ng seen thousands of cases |n the
past month. l have a|so seen government offc|a|s
|n severa| deve|op|ng countr|es pu|| stat|st|cs out of
th|n a|r for the|r month|y reports.
ln fa|rness, |t |s extreme|y d|ffcu|t to co||ect hea|th
data in the developing world. I carried out my
own surveys concurrently with the census data
collection in Nepal and I can attest that many
of the househo|ds |n hard-to-reach p|aces were
om|tted ent|re|y. So, |f you take an |nd|cator ||ke
MMR, which is dependent on knowing the number
of ||ve b|rths |n a country, and you factor |n that on|y
35% of b|rths |n Nepa| are reg|stered - poss|b|y
an |naccurate stat|st|c |tse|f - how do you rea||y
know that the situation is improving when the
statistics on which this assumption is based may
not be accurate? Accord|ng to Attaran (2005},
MMR is almost immeasurable because it uses an
assortment of |ncomp|ete surveys and reg|str|es to
essent|a||y guess at a po|nt est|mate and range for
a particular region
1
.
lt |s a|so easy enough to man|pu|ate fgures to
prove a point by throwing out outliers, trimming
data, or only using data that supports a given
hypothesis
6
. Moreover, we can manipulate
p-va|ues so that they make anyth|ng seem
s|gn|fcant
8
. We can even cherry pick data,
selectively collecting data which will only highlight
success. lndeed, l once worked for an NGO that
d|d prec|se|y that. When we cons|der that fund|ng
often |s cont|ngent upon demonstrated
progress, we can appreciate how practices that
enable indicators to be presented in an unnaturally
optimistic light may be promoted.
Finally, one can pool data in such a way that
camoufages poor |nd|cators. For examp|e, one
can aggregate stat|st|cs so that the r|ch offset the
poor. The aggregate-|eve| under-fve morta||ty rate
for Nepa| |s, accord|ng to the WHO, 48 per 1,000
She was sixteen, sitting upright in a
hay pile, breathing heavily. I had been
surveying a household down the hill when
an NGO worker asked if I could deliver
the womans baby since the villages
midwife was away. Ironically, this was in
a country which had recently received
a Millennium Development Goal award
for its outstanding national leadership,
commitment and progress towards MDG
Goal Five to improve maternal health.
Th|s was rura| Nepa| and, desp|te progress, there
|s a d|sconnect between the rea||t|es of |ts hea|th
s|tuat|on and |ts |dea|s. The seem|ng|y opt|m|st|c
p|cture pa|nted by the |nd|cators - the reduct|on of
Nepa|`s under-fve morta||ty rate and reduct|on of
MMR from 415 per 100,000 ||ve b|rths |n 2000 to
229 per 100,000 ||ve b|rths |n 2010 - often betrays
the underlying truths, that many children still die
from d|arrhoea| and resp|ratory d|seases and that
many women deliver children with no skilled birth
attendants ava||ab|e - 71.2% accord|ng to the
Government of Nepa|.
The fundamenta| prob|em |s that we need a
better way to quant|fy hea|th progress than those
traditional indicators.
Lets begin with data collection. Even in
r|gorous c|rcumstances, data can be and often
are fabr|cated. ln an |nternat|ona| survey of
b|ostat|st|c|ans, 51% of respondents knew of at
|east one fraudu|ent project |n the|r |nst|tut|on w|th|n
the prev|ous ten years, and most of those were
cases |n wh|ch data were b|atant|y fa|s|fed
2
. In a
North Amer|can study, 36% of post-doctora| or
doctoral candidates reported having been aware
of such m|sconduct. Yet 15% a|so adm|tted that
they themselves were willing to do whatever was
necessary to get a grant or publish a paper
4
.
A|though the mot|vat|ons may not be NlH grants
or journal publications, what is true in a lab setting
remains relevant when applied to public health data
THE TROUBLE WITH HEALTH
INDICATORS: WHY GLOBAL
HEALTH DATA MISLEAD US
Laurel S. Gabler
How do you really know that the
situation is improving when the
statistics on which this assumption is
based may not be accurate?
live births. However, when we look at the statistics
for rura| Nepa|, |t |s much h|gher: 84 per 1,000 ||ve
births
10
. In short, one should exercise skepticism
when exam|n|ng progress towards the MDGs or
any other health indicators. So, what do we do?
Some have argued that we shou|d v|ew the MDGs
not as realistically attainable targets, but rather
as constant rem|nders of the d|rect|on |n wh|ch
development should be heading
3
. Others have
advocated reworking the metrics so that we have
more realistic and measureable outcomes
1
.
But that just addresses MDGs. ln order |mprove
health data collection in general, we need data
co||ect|on agenc|es to be more se|f-cr|t|ca|;
we need a better system of accountab|||ty and
data-check|ng; we need to move away from the
compu|s|on to bend stat|st|cs to ft preconce|ved
hypotheses; and we need donors to stop dictating
the agenda so that organ|sat|ons m|ght fee| the
need to provide optimistic pictures. In short, we
need a real sea change in the way we collect and
th|nk about data so that an untra|ned Amer|can
PhD cand|date |s not requ|red to de||ver the frst
baby of a s|xteen-year-o|d Nepa|ese g|r|.
References:
1. Attaran, A 2005, An immeasurable crisis? A criticism of the MDGs
and why they cannot be measured, PloS Med, vol. 2, no. 10, pp.
0955-0961.
2. Buyse, M, George, SL, Evans, S, Geller, NL, Ranstam, J, Scherrer,
B 1999, The role of biostatisticians in the prevention, detection and
treatment of fraud in clinical trials, Stat Med., vol. 18, no. 24, pp.
3435-3451.
3. Clemens, MA, Kenny, CJ & Moss, TJ 2004, The trouble with the
MDGs: confronting expectations of aid and development success,
Center for Global Development, Washington DC.
4. Commission on Research Integrity 1996, Integrity and
misconduct in research, CHSS, Washington.
5. Government of Nepal 2010. Nepal Millenium Development Goals:
progress report 2010, National Planning Commission, Kathmandu.
6. Jaffer U & Cameron AEP 2006, Deceit and fraud in medical
research, International Journal of Surgery, vol. 4, no. 2, pp. 122-126.
7. Ranstam, J, Buyse, M, George, SL, Evans, S, Geller, NL, Scherrer,
B 2000, Fraud in medical research: an international survey of
biostatisticians, Controlled Clin Trials, vol. 21, no. 5, pp. 415-427.
8. Simmons, JP, Leif, DN, & Simonsohn, U 2011, False-positive
os,c|o|o,. 0|d|sc|osed /ex|o||||, || da|a co||ec||o| a|d a|a|,s|s
a||ows o|ese|||| a|,|||| as s|||/ca||', |s,c|o|o|ca| 5c|e|ce,
vol. 20, no. 10, pp. 1-8.
9. Ho||d |ea||| O|a||za||o| ^eoa| Co0|||, O//ce 2009, ^eoa|
|ea||| ||o/|e, Ho||d |ea||| O|a||za||o|, |a||ma|d0.
10. World Health Organization 2010, WHO Nepal Country Site,
Kathmandu, viewed 1 February 2012, <http://www.searo.who.int/
countries/npl/en>
Laurel Gabler |s a /|a| ,ea| doc|o|a| s|0de|| || |0o||c |ea||| a| ||e
University of Oxford. Laurel holds an MSc in Global Health and is a
Rhodes and Fulbright Scholar currently based in Nepal. Laurel is due
to commence her medical degree at Harvard later this year.
13 Register now at www.juniordoctorjournal.com July 2012 July 2012 Register now at www.juniordoctorjournal.com 12
Australasian Junior Doctor Journal Australasian Junior Doctor Journal
As awareness of global health increases,
medical students and professionals are
encouraged to work in a resource-poor
country to complement their clinical
studies at home. Firsthand experience in a
contrasting environment offers unparalleled
benefts and contributes to both personal
and professional development.
Many hospitals in developing countries are
short staffed and often have a h|gh pat|ent |oad,
so students may fnd themse|ves |mmed|ate|y
engaged w|th pat|ent care. nder-resourced
wards typ|ca||y mean a return to the bas|cs of your
hea|thcare educat|on; d|agnos|ng and form|ng
treatment plans with minimal access to the
laboratory or medical equipment that are available
as standard |n the Austra|as|an sett|ng. Re|y|ng on
judgement and medical knowledge also sharpens
clinical skills and acumen. For many it provokes
questions about the reliance on technology and
potent|a| 'sk|||s-fade` |n hea|thcare profess|ons.
'l was surpr|sed to see res|dents s|tt|ng w|th
pat|ents for ten m|nutes at a t|me w|th the|r fnger
t|ps on the pat|ent`s be||y, fee||ng and t|m|ng
contract|ons. They ||stened to the feta| heart rate
with a Pinard stethoscope, something I have
on|y seen |nc|uded |n obstetr|ca| textbooks for
h|stor|ca| |nterest. At home, we re|y on mach|nes
to measure contract|ons and feta| heart rate; |n
Mendoza, phys|c|ans re||ed on the|r sk|||s"
1
There is also opportunity to see
cases that are rarely, if ever, found
in Australasia. Signicant tropical
diseases such as malaria, leprosy
or dengue fever are common and
exposure to their management
allows students and practitioners to
broaden their clinical repertoire and
awareness of major global health
issues.
'l spent the frst week |n genera| paed|atr|cs, and
saw many cases of common ch||dhood |||nesses
|n Tanzan|a such as ma|ar|a, s|ck|e ce|| d|sease
and ma|nutr|t|on. Because these cond|t|ons are
not common I had only ever encountered them in
textbooks."
2
Students and practitioners can use the
opportun|ty of an e|ect|ve or overseas p|acement
to enhance d|sease-spec|fc know|edge.
Charlotte
3
had completed a rotation in oncology
and fe|t that a p|acement |n Afr|ca wou|d
provide a good opportunity to compare cancer
treatments between regions. Her time with
the so|e onco|og|st |n Northern Tanzan|a gave
her va|uab|e exper|ence of a country |n wh|ch
an est|mated 80% of a|| cancer pat|ents have
advanced disease at initial presentation, but only
5% have access to care.
'Work|ng |n Mwanza prov|ded enormous |ns|ght
|nto the d|ffcu|t|es of prov|d|ng an onco|ogy
serv|ce |n Tanzan|a. lt a|so gave me an opportun|ty
to observe an ent|re|y new range of cond|t|ons
and procedures. Until now I had only ever read
about Burk|tt`s |ymphoma, ret|nob|astoma and
Kapos|`s sarcoma |n textbooks. Here they are an
everyday occurrence."
3

nfortunate|y, cost, d|stance and a |ack of
educat|on and awareness |n resource-poor
countries results in a situation whereby delayed
presentation extends beyond cancer patients.
Commonly, individuals present with conditions
at a cr|t|ca| stage, wh|ch may fac|||tate |mproved
understand|ng of d|sease progress|on.
A further beneft of an overseas p|acement, and
someth|ng that may he|ghten apprec|at|on of
med|ca| care and systems |n Austra|as|a, |s
d|rect exper|ence of ut|||s|ng bas|c or dated
medical equipment.
THE CHALLENGES AND
LEARNING OPPORTUNITIES OF
A GLOBAL HEALTH PLACEMENT
Ruth Chapman
Australasian Junior Doctor Journal
14 July 2012 http://www.facebook.com/juniordoctorjournal
'Staff have to |mprov|se, and are w||||ng to teach
students how to de||ver the best standard of care
with the limited resources available. It sounds
small but I was shown how to use gauze as
the pr|mary dress|ng for a|| wounds, est|mat|ng
exact|y how much w||| be needed before cutt|ng
it to minimise wastage and how to use it to
effect|ve|y secure sk|n grafts |n ||eu of spec|a||sed
dressings such as Jelonet. While I have access
to a greater var|ety of dress|ng opt|ons |n the K,
l have a greater |eve| of confdence |n my ab|||ty
to |mprov|se and adapt my opt|ons for wound
dress|ngs |n emergency s|tuat|ons".
4
Whilst there are positive observations, there are
a|so frustrat|ons. Pract|t|oners and students a||ke
are cha||enged by the |ack of |nfect|on contro|,
in part because key practices such as hand
washing appear easy to implement. Education is
an ongo|ng cha||enge |n resource-poor countr|es,
which is why sharing knowledge and skills has
been h|gh||ghted as a key b||atera| beneft:
5

'A good part of the exper|ence was show|ng
the staff that the Western standard |s to c|ean
your hands regu|ar|y between each pat|ent. The
water in Nepal is highly polluted by domestic
and industrial waste so I used alcohol hand gel.
The staff |n the hosp|ta| seemed fasc|nated by
this strange solution that I kept applying to my
hands and |t was on|y after some t|me that l
noticed that they also had some alcohol gel on
the drug tro||ey."
6
A|though educat|on around the |mportance
of prevent|ng spread of |nfect|on and
contamination is achievable, there are situations
whereby solutions to seemingly basic issues
may appear elusive.
'From the t|me l arr|ved to the t|me l went home
on this particular day, there was no power or
water and therefore no ||ght|ng, no autoc|ave for
sterilising instruments, no oxygen concentrator
to administer oxygen to a newborn babe with
breath|ng d|ffcu|ty, no hot water for morn|ng cha|
(perhaps the most |mportant part of the morn|ng
for the m|dw|ves}, no effect|ve handwash|ng and
on and on |t goes."
7
An overseas p|acement can be a profound, eye-
open|ng exper|ence and offers the opportun|ty to
learn more about disease progression, advanced
pathologies, and tropical disease, as well as
broaden|ng your understand|ng of g|oba| hea|th
cha||enges. These p|acements may prov|de an
unparalleled learning opportunity, which can
a|d persona| and profess|ona| deve|opment and,
ultimately, help you on your journey to being a
better clinician.
CONTACT
Work the World on 1-800-601-365 or
email info@worktheworld.co.uk
for more information.
References
1. Shannon Saro, Work the World student http://www.
worktheworld.co.uk/case-studies/shannon-saro/
2. Hannah Townsend, Work the World student http://www.
worktheworld.co.uk/case-studies/hannah-townsend/
3. Charlotte Brown, interview Jun 28, 2010 http://www.
worktheworld.co.uk/case-studies/charlotte-brown
4. George Glass http://www.worktheworld.co.uk/blog/the-
oe|e/|s-o/-do||-,o0|-o|aceme||-o.e|seas_3090
5. A Guide to Working Abroad for Australian Medical Students
and Junior Doctors, The Medical Journal of Australia e
supplement. 2011;194: eS11.
6. Craig Hickson, Work the World student http://www.
worktheworld.co.uk/blog/infection-control-the-reality-of-
developing-country-hospitals_2938
7. Carlee Mark, Work the World student http://www.worktheworld.
co.uk/case-studies/carlee-mark/
Ruth Chapman is a consultant at Work the World.
These placements may provide an
unparalleled learning opportunity,
which can aid personal and
professional development and,
ultimately, help you on your journey
to being a better clinician.
Medical Indemnity Protection Society Ltd
po box 25 carlton south vic 3053 | info@mips.com.au | www.mips.com.au
member services | p. 1800 061 113 | f. 1800 061 116 | abn 64 007 067 281
Put yourself in safe hands. MIPS benets include MIPS Members
Medical Indemnity Insurance Policy, MIPS Protections for non medical
indemnity matters, medico-legal advice, Group Personal Accident
cover, risk management education sessions, special member benet
offers, e-publications and more! Apply online at www.mips.com.au
Medical Indemnity Protection Society Ltd (MIPS) is an Australian Financial Services Licensee (AFS Lic. 301912). MIPS Insurance Pty Ltd (MIPS Insurance) is a
wholly owned subsidiary of MIPS and holds an authority issued by APRA to conduct general insurance business and is an Australian Financial Services Licensee
(AFS Lic. 247301). Any nancial product advice is of a general nature and not personal or specic.
17 Register now at www.juniordoctorjournal.com July 2012 July 2012 Register now at www.juniordoctorjournal.com 16
Australasian Junior Doctor Journal Australasian Junior Doctor Journal
|ntent from students and profess|ona|s keen to
expand on current opportunities, New Zealand
has demonstrated relatively little active association
or engagement with global health education,
research, innovation or delivery.
At frst g|ance, |t |s easy to see why we have
adopted a conservative approach to our role in
g|oba| hea|th: var|ous Foundat|ons and Funds,
together w|th h|gh-prof|e campa|gns and
targeted media coverage, have done a stellar
job in creating and later perpetuating the image
that global health is synonymous with, and
essent|a||y ||m|ted to, spec|fc |nfect|ous d|seases,
malnutrition, and maternal and child health issues
in developing countries. When presented with this
narrow, na|ve and frank|y fa|se v|ew, and w|thout
|ndependent cr|t|ca| ana|ys|s, we can forg|ve those
who question the need to make global health a
pr|or|ty for New Zea|and. After a||, ma|ar|a makes
for a rare d|agnos|s down here. However, as |ord
N|ge| Or|sp w|se|y states, g|oba| hea|th |s 'that
wh|ch affects us a||." These are not other peop|e`s
prob|ems and these are not prob|ems from wh|ch
re|at|ve|y wea|thy countr|es are |mmune. ln fact,
when we acknow|edge a broader defn|t|on and
look beyond mere assumption, we see that many
key global health issues display direct alignment
with our current challenges.
We all know that New Zealand boasts a diverse,
mob||e popu|at|on. lt fo||ows that our c||n|c|ans
witness and manage a respectable range
of cond|t|ons. We may not see |t a||, but our
exposure is still broad and challenging. Certainly,
and often trag|ca||y, we see the b|g stuff. W|th
our trad|t|ons of trave| and m|grat|on, and a|so
as a consequence of our pred|ctab|e (yet awfu|
and ||ke|y worsen|ng} |nequa||ty, ||festy|e stresses
and excesses, we see what the rest of the wor|d
sees. Our d|sease burden |s skewed toward non-
communicable illness just as it is on the global
scene. We have a grow|ng recogn|t|on of the
ro|e and contr|but|on of the soc|a| determ|nants
of hea|th to annua| stat|st|cs - just ||ke everyone
e|se. Now, more than ever, the sh|ft from an
emphas|s on treatment to urgent pr|or|t|sat|on of a
preventative approach is understood as something
more than just a romantic notion. We struggle to
understand and appropriately address the role
of cu|ture |n hea|th; we have yet to effect|ve|y
|ntroduce much needed |nter-d|sc|p||nary
co||aborat|on; and our cont|nued hea|th workforce
issues, including physician migration, remain a
h|gh prof|e and somewhat raw prob|em.
We cannot escape global health when it is
already acutely relevant: our challenges are
the challenges.
We also cannot escape the simple truth that we
are a small country and, no matter where you
draw the line, these are big issues. Furthermore,
we recognise that our research and total
healthcare budgets cannot compare with those
generated by other key p|ayers. But, as w|th so
many th|ngs |n ||fe, |t |s about perspect|ve. By
considering an alternative view, we can instead
concentrate on NZ-spec|fc e|ements wh|ch
promote rather than hinder our capacity to be a
global health leader.
New Zea|and |s we||-known for |nnovat|on
and the ability to rapidly implement practical
solutions. In addition, our small population means
that we are ideally placed to develop and test
approaches, treatments and programmes in the
healthcare space. Furthermore, when compared
to other countr|es, there are perhaps fewer
bureaucratic and political barriers to change in
New Zea|and. At a pract|ca| |eve|, g|oba| hea|th
requires evidence to drive policy development
and |mp|ementat|on. Our hea|thcare |nformat|on
technology solutions are amongst the best in
the world and, as a consequence, New Zealand
has established systems to collect, analyse
and |nterpret data. Th|s capac|ty for rap|d and
accurate evaluation places New Zealand in
a un|que pos|t|on to |ead the deve|opment of
a robust ev|dence base to |nform po||cy and
programmes. When we comb|ne these factors
w|th our recogn|sed apt|tude for creat|on and
innovation, New Zealand is an excellent location
to pilot cutting edge advances in global health.
Whilst some would argue that our geographical
|ocat|on |nsu|ates and |so|ates New Zea|and from
certain global health challenges, this is a globalised
world and our relatively mobile and well travelled
workforce, and |ndeed broader popu|at|on,
fac|||tates tremendous opportun|t|es to create and
share solutions. New Zealand should be a hub
for the deve|opment, test|ng and |mp|ementat|on
of approaches, treatments and programmes that
have the potential to progressively advance and
transform g|oba| hea|th. We shou|d not on|y be
the |ncubator but a|so the major exporter for these
ideas and solutions.
F|na||y, peop|e rea||y do make the d|fference.
Though we p|ace great va|ue on hum|||ty, New
Zea|anders are capab|e of outstand|ng success.
Our passion, skill, originality, ability to execute,
and humour are almost unrivalled. Given that
we can, |t |s t|me for us to expand our amb|t|on,
realise our potential, and lead.
Dr Karina McHardy graduated from the University of
Aucklands School of Medicine in 2005. In 2008, she moved
to the UK to undertake an MSc in Global Health at the
University of Oxford. Karina is currently a Clarendon, Wolfson
and Department of Public Health Scholar and is completing a
doctorate through Oxfords Department of Public Health. She is
also an honourary clinical lecturer at Aucklands Department of
Medicine and works as a Global Health and Health Promotion
Tutor at Oxford.
Dr Lloyd McCann is currently the Medical Director for Harris
Healthcare Solutions for EMEA, a global communications,
information and technology company. He is also a consultant
for NHS Interim Management and Support. Lloyd has worked
clinically and managerially in the New Zealand and UK healthcare
systems. He holds an MSc in Health Services Management from
the University of Warwick.
THE
LITTLE
COUNTRY
THAT COULD
We are two Kiwis whose career and life
paths have unexpectedly taken us away
from New Zealands shores for a few years.
Our time away has afforded us a different
perspective on the organisation and
management of healthcare in New Zealand,
together with the opportunity to work in,
contribute to, and compare both established
and developing healthcare systems.
Furthermore, our recent choice to pursue
profess|ona| opt|ons outs|de the bounds of
c||n|ca| med|c|ne has fac|||tated a broader v|ew
on these systems and the diverse and complex
soc|et|es |n wh|ch they funct|on. We rema|n
passionate about and engaged with health and
healthcare in our home nation, despite our current
state of geograph|ca| remova|. Throughout our
experiences overseas, a clear message is that
New Zealand is ideally placed to be a leader
not on|y |n hea|th, but a|so |n g|oba| hea|th. Th|s
message emerges as a consequence of persona|
observations and experiences in various settings
and a|so through profess|ona| and |nforma|
commun|cat|on w|th K|w|s and others at home
and abroad in distinct roles.
However, up until this point, it seems that
New Zealand has used its position as a small,
somewhat remote, and developed nation to
excuse ourse|ves from accept|ng a prom|nent
ro|e |n th|s fe|d
1
. Indeed, despite communicated
Dr Karina McHardy
and Dr Lloyd McCann
1
This statement is intended to apply at the national level: we
recognise that many individual ex-pat Kiwis are already well
es|ao||s|ed a|d ||||, |esoec|ed || |||s /e|d.
July 2012 Register now at www.juniordoctorjournal.com
18
Australasian Junior Doctor Journal
Global health is a hot topic in healthcare and in many political circles.
We are keen to hear your views and thoughts on the issues that affect
us all in healthcare.
Here are some questions to get you and your colleagues thinking and talking.
Please feel free to write to us at info@juniordoctorjournal.com to share your opinions
or if youd like us to explore a specic question or issue.
What does global
health mean to you?
What is the role of
the media in global
health?
What is the
role of the media
in the global
health?
What role should
independent actors
(e.g. Gates Foundation)
play in setting the
priorities for global
health?
Should global
health form
a compulsory
element of medical
curricula?
Which
organisations
should lead the
global health
agenda?
How should
we train
global health
leaders?
How do we move
from an international
development model
to a co-development
global health
model?
What are the
main challenges
facing the
global health
community?
What role should
information and
technology play in
global health?