A Case of Oesophageal Candidiasis with Underlying HIV Infection

Issue 10 Volume 2
Case study
Peer reviewed article



This is a case of a 32-year old man with HIV infection and candida oesophagitis. Systemic candidiasis is one of the common presenting features in late stage HIV infection in Myanmar and is considered pathognomonic for AIDS in resource poor settings. Candida oesophagitis causes epigastric pain and tends to occur concomitantly with oropha- ryngeal candidiasis, yet epigastric pain is also a leading symptom of peptic ulcers, which are common in Myanmar. Therefore, it can easily mislead doctors to diagnose a peptic ulcer and treat accordingly. In Myanmar private health care physicians and traditional healers are initial points of contact for the majority of the population seeking health care. If private general practitioners misdiagnose, it will delay diagnosis of AIDS, resulting in further HIV transmission to others and subsequent complications for the presenting patient. This is pertinent as Myanmar has the second highest HIV prevalence in Southeast Asia, hence this case elucidates how important it is for a clinician to have a high index of suspicion for HIV infection in a patient who presents with epigastric pain, chronic fever, chronic diarrhea and weight loss.[1]

Case report

A 31-year-old man presented with a five week history of fever, four week history of epigastric pain, semi-solid bowel movements, dysphagia, weight loss and a two week history of mild headache. He described the character of his epigastric pain as burning, which was not exacerbated or alleviated by meals and did not radiate to the back. The site was constant, localized and he experienced insomnia due to continuous burning pain although the pain did not improve or worsen at any time during the day or night. During this time his initial point of contact with health services was a traditional healer who administered a remedy that did not relieve his symptoms. It was unknown by the patient what the contents of the remedy were. This patient had no history of regular medication before his current illness. He had sex with female sex workers, at times without condoms although his last contact was 5 years ago. This is because he developed purulent discharge with dysuria following his last contact, which was relieved by a general practitioner prescribing medication. The patient was unable to identify the medication or name his previous infection. He did not provide any previous history pertinent to peptic ulcer and gastro-oesophageal reflux disease.

Upon physical examination he appeared pale and emaciated. The body temperature was 37.8 degrees Celsius. His other vital signs such as blood pressure and respiratory rate were within normal range. His palate and pharynx showed white patches with erythema along the rims. Examination of heart and lungs revealed no abnormalities. There were no obvious signs of dehydration. The initial differential diagnosis list included opportunistic infection due to HIV, peptic ulcer in addition to HIV infection, malaria as he came from an endemic region and tuberculosis as this is the most common opportunistic infection in the population. Upon reflection it may have been prudent to include neoplasia in this list given the clinical signs and symptoms.


A complete blood count revealed a hemoglobin of 8.6 gm/dl, white blood cell count of 4,810/ mm3 with 79% neutrophils, 7.7% lymphocytes, 0.2% eosinophil, 0.06% basophils and 8.4% monocytes. He had a platelet count of 688,000/ mm3 and an ESR of 95 mm after the first hour. His blood glucose and electrolytes levels were within normal limits. Rapid diagnostic test for malaria was negative. Serological tests for hepatitis B and C were negative. However, his HIV rapid diagnostic test results were positive. The CD4 count was 66/mm3. The stools were examined for evidence of parasitic infection and were found to be negative.

He then underwent an upper gastrointestinal endoscopy which showed candidiasis at middle and lower end of the esophagus with no varicose vein or evidence of reflux. However, the stomach had mild mucosal congestion and edema at the pyloric antrum with no growth and ulceration. The diagnosis was acquired immunodeficiency syndrome (AIDS) with oesophageal candidiasis.


Oral fluconazole was initiated at the dose of 200mg daily for 14 days. Then for fever and diarrhea, he was given ciprofloxacin 500mg twice a day for 5 days and he also received co-trimoxazole as a primary prophylaxis of Pneumocystic jiroveci pneumonia (PCP) and toxoplasmosis and ranitidine 300mg daily for mild gastritis. He was also suggested to take a nutritious diet and vitamins. He showed significant improvement of his burning pain. In addition, loose motion and fever subsided within a week.

There were strong indications for antiretroviral therapy (ART) so other laboratory and radiological investigations were done as a part of preparation for ART. Sputum microscopy for acid fast bacilli (AFB) were negative and chest radiography revealed no abnormalities. Serological testing for syphilis was non-reactive. Serum alanine transaminase (ALT) was 22 U/L.

He started to take the first line regimen of ART after two weeks of the initial empirical antibiotic treatment with the patient’s improvement. The first line regimen includes stavudine (d4T), samivudine (3TC) and nevirapine (NVP). There was no skin rash or liver toxicity during the first two weeks of lead-in dose so the NVP dose was increased from 200mg once a day to 200mg twice a day.[2]

One week after starting full dose of the ART, he complained of high fever, abdominal pain and loose motion again. However, he had no jaundice or skin rash. There was a high index of suspicion of Mycobacterium Avian Complex (MAC) immune reconstitution disease, hence some indirect indicators for MAC infection were used. Direct MAC diagnostic facilities were not available. On stool analysis, AFB and pus cells were seen.

Serum alkaline phosphatase (ALP) was 544 units per liter. Ultrasound abdomen showed enlarged para-aortic lymph nodes and mild hepato-splenomegaly. Therefore, he was treated as MAC by giving Azithromycin and Ethambutol. The patient improved over a 12 day course.

He completed the course of MAC treatment and has continued to take the first line ART until now. His body weight increased from 50 kilogram to 65 kilograms and the CD4 count rose to 275/ mm3 over the three years. His counselor reported that he adhered to more than 95% of his ART doses. The CD4 count has not increased beyond 300/mm3 although his HIV plasma viral load became undetectable.


Odynophagia and dysphagia are common symptoms of oesophagitis. There are many conditions causing oesophagitis: oesophagitis due to gastric acid reflux, drug-induced oesophagitis and infections. If it is not treated, they may severely compromise nutritional status of the patients and may be responsible for life threatening complications.[3]

Oesophageal related symptoms occur in 40-50% of patients with AIDS at some point in the course of their disease.[4] These are mainly caused
by infections. There are a variety of pathogens which may cause oesophagitis, including fungi, bacteria, viruses and protozoa.[3] Among the causes, fungal agents especially Candida species are the most common etiology and other oesophageal disorders such as cytomegalovirus (CMV), herpes simplex virus (HSV) may coexist. [4] CMV infection has been reported in 10% to 28% of HIV infected patients complaining of oesophageal symptoms while HSV is diagnosed in approximately 10% of HIV infection.[3]

Candida species may survive in food, air, floor, other surfaces and hospital environment and therefore be transmitted. Candida albicans is the major isolate found in individuals with candidiasis. [5] Other Candida species that cause candidiasis include Candida glabrata and Candida krusei.[3] These Candida species are detected in 31% to 55% of healthy individuals.[5] This is just colonization, and does not indicate active disease.

In the immunocompromised, (such as those with poor nutritional status and diabetes mellitus) taking broad spectrum antibiotics, colonization may progress to infection and produce inflammatory responses. Oropharyngeal candidiasis commonly occurs in the above mentioned conditions while oesophageal candidiasis is common in advanced immune deficiency associated with HIV infection. Although oesophageal candidiasis may occur at any stage of HIV infection, it is usually seen in patients with CD4 count of less than 200/mm3. [5] According to the WHO clinical staging of HIV/ AIDS, oesophageal candidiasis can be diagnosed presumptively on the basis of clinical signs or simple investigation.[6]

Oesophageal related symptoms seen in candida oesophagitis are non-specific so it is difficult to diagnose candida as the definite cause. There is also the possibility of co-infection. Candida oesophagitis presents most commonly with dysphagia, odynophagia, and retrosternal pain but occasionally epigastric pain is the dominant symptom and fever occurs infrequently.[5] Dysphagia and odynophagia are common symptoms not only in oesophageal candidiasis but also in CMV and HSV oesophagitis.[4]

In this case report, the HIV infected patient presented with epigastric pain and fever. The pain is not a specific marker for oesophageal candidiasis and it can be caused by various gastrointestinal diseases such as peptic ulcer, gastroesophageal reflux and acute gastritis. As a result, it may be easy for physicians to overlook candida oesophagitis as a potential cause. However, the patient had oropharyngeal candidiasis, which should prompt the physician to consider oesophageal candidiaisis. It is also important to note that oesophageal candidiasis may be completely asymptomatic.[3]

The treatment regimen depends on the causative organism and the drugs used for candidiasis and other viral infections are also different. If there
is coexistence of CMV or HSV with candidiasis, a combination of different drug regimens is required. Therefore, detection of definite cause is important for proper management of candida oesophagitis.

For HIV/AIDS staging and management purpose, diagnostic accuracy is important. In earlier time, Barium esophagography was a main diagnostic tool. Double contrast barium esophagography has a high sensitivity (over 80%) in detecting oesophageal lesions but radiographic abnormalities are often non-specific and endoscopy with biopsy and/or brushing is necessary to make a definite diagnosis.[3] Endoscopy has its benefits of not only rapid and high sensitivity diagnosis but also reliable method of differentiating the various causes of oesophagitis.[5] In a study conducted by Connolly, Forbes & Gleeson, endoscopy (without pathological support) had a sensitivity of 97.5% and a specificity of 100% compared with the sensitivity and specificity of 25% and 100% respectively for barium studies.[7] Therefore, endoscopy has displaced radiography. In the resource limited situation, both esophagoradiography and endoscopy are not available. Therefore, clinicians in such a situation have to rely mainly on presumptive diagnosis.

Some studies have been conducted to analyse the reliability of clinical features for diagnosis. Oral thrush, either alone or in combination with oesophageal symptoms was a reliable marker of candida oesophagitis only in patients with a previous AIDS-defining event.[8] The same study concluded that a presumptive diagnosis of candida oesophagitis on the basis of the Centers for Disease Control and Prevention (CDC) clinical criteria is a valid diagnostic method only in HIV- 1 infected patients with a previous diagnosis of full-blown AIDS.[8] CDC clinical criteria for the diagnosis of oesophageal candidiasis are recent onset of retrosternal pain on swallowing and oral candidiasis diagnosed by the gross appearance of white patches or plaques on an erythematous base.[9] Therefore, oropharyngeal candidiasis and oesophageal symptoms are important markers for clinical diagnosis in a situation where there are no facilities for endoscopy. However, there might be an argument that clinical diagnosis cannot exclude infectious oesophagitis caused by CMV and HSV.

In HIV infection, candidiasis is the commonest cause of oesophagitis while CMV and HSV are generally less common and they rarely occur unless CD4 count is less than 100/mm3. This means that CMV and HSV are at risk in far advanced immune deficiency. Another point is that HSV oesophagitis is frequently associated with labial or oral cavity lesions.[10] Rationally, candidiasis should be considered as a cause of oesophagitis in HIV infected individuals with odynophagia unless it is in the state of very
low immune status. Thus, Belitsos described that if the CD4 count is appropriately low and other gastrointestinal conditions appear unlikely by history, the next diagnostic step in an HIV- infected person with odynophagia is usually an empirical trial of antifungal therapy and if it is not responsive, upper endoscopic evaluation should be done.[10]

Asymptomatic oesophageal candidiasis is usually seen in people with significant immune suppression. It is shown in a study conducted by Zaidi & Cervia, invasive candidiasis in esophagus can be seen in 90% of patients having CD4 count less than 100/ mm3.[4] So, severe immunocompromised HIV infected individuals are likely to get candida oesophagitis, though some will be asymptomatic.

Regarding the treatment, systemic antifungals are required for effective therapy and a 14-21 day course of either fluconazole (oral or IV) or oral itraconazole is highly effective.[9] Other antifungals which are effective in treating oesophageal candidiasis include IV caspofungin, IV voriconazole, micafungin and anidulafungin. Although these are effective, oral or IV fluconazole remains the preferred therapy.[9]

However, it should be noted that there is high risk of recurrence in HIV infected individuals. Fluconazole (or azole) resistance is predominantly the consequence of previous exposure to fluconazole (or azole) and it is followed by gradual emergence of non-albican Candida species, particularly Candida glabrata, as a cause of refractory mucosal candidiasis.[9] If an individual does not improve in their candidiasis related symptoms despite fluconazole therapy, initially, it is better to consider other causes rather than resistance. It may be co-existant CMV or HSV oesophagitis or other causes of oesophagitis or incompliance of the drug. In the resource limited countries, health care providers should also be careful not to use unqualified or counterfeit fluconazole drugs which do not improve the illness.

Fluconazole refractory disease frequently develops in HIV infected individuals with very low CD4 T cell count who are not treated with ART. Zingman has shown that refractory AIDS- related mucosal candidiasis can be resolved by initiating antiretroviral therapy.[11] ART improves immune function which fights effectively against the refractory candidiasis in synergistic action with fluconazole. Thus, ART should be initiated as quickly as possible in the case of candida oesophagitis with HIV infection. In some cases, mucosal candidiasis recurs repeatedly instead of being refractory to the treatment.

Despite the frequency of oesophageal candidiasis in HIV-infected patients, primary prophylaxis is not widely administered because the disease is not life threatening, and therapy is usually very effective. There is also some concern about drug resistance if primary prophylaxis was used extensively.[4] However, secondary prophylaxis (with fluconazole 100mg/day or 150mg once weekly) is commonly given for patients with multiple recurrences of oropharyngeal and oesophageal candidiasis until effective ART can be instituted.[4]


Oesophageal candidiasis is one of the common AIDS defining diseases and it can be diagnosed clinically if the patients are symptomatic and HIV has been diagnosed. It may be the first presenting symptom of AIDS in resource poor countries. Private health care providers should have a high index of suspicion and not miss the disease because it is an entry point for diagnosis of HIV infection in late stage which is necessary to initiate antiretroviral therapy as quickly as possible. Moreover, the treatment of candida oesophagitis is simple and even non-specialist medical providers can provide it at private clinics. Another important point is that if it is not relieved by fluconazole after a week, the patient should be referred to a higher level medical facility for assessment of other cause or co-existing viral oesophagitis or drug resistance. Furthermore, fluconazole is an effective drug for systemic candidiasis, there is a high risk of refractory to the drug unless ART is initiated.

In this case report, the patient was also co-infected with MAC because he was in very severe immune deficiency state (CD4 count 66/ mm3). Management of late stage of HIV infection is more difficult and complicated than that of early stage of infection. Therefore, early detection and management of HIV infection is desirable not only improves quality of life but also control to reduce complications.

Andrew Samaan & Min Zaw

Andrew Samaan obtained his Bachelor Medical Science (UNSW), ranked second in his
class and graduated with First Class Honours. He then joined the department of Anatomy
first working as a tutor then enjoying the lofty heights of associate lecturer. He was the
youngest lecturer in department history. He moved on to study medicine, a masters in tropical medicine and has been interning in his holidays at Oxford University Tropical Medicine Department since 2013.

Min Zaw is a consultant infectious diseases physician with over 30 years of clinical experience, ten of them obtained serving as an army doctor in Myanmar active war zones. He recently retired as head of infectious diseases depart- ment to become Chief Medical Officer of a 100 bed hospital in Dawei. He is looking forward to meeting and working with more Australian medical students looking for placements.


I would like to thank Dr Zaw for his time, input and guidance in the writing of this paper.

Conflict of interest

No known conflicts


1. National AIDS-STD control program DoH, Ministry of Health. Guidelines for the clinical management of HIV-AIDS in adults and adolescents. Yangon, Myanmar2004.

2. AIDSinfo Drug Database 2012 [cited 2015 Jan]. Available from: http://aidsinfo.nih. gov/drugs/116/nevirapine/0/professional – Section_5.4.

3. Parente F, Porro GB. Infectious Esophagitis: Etiology, Diagnosis, and Treatment. In: Bremner CG, DeMeester TR, Peracchia A, editors. Modern approach to benign esophageal disease. New York, USA: Quality Medical Publishing, Inc. ; 1995.

4. Zaidi SA, Cervia JS. Diagnosis and management of infectious esophagitis associated with human immunodeficiency virus infection.
J Int Assoc Physicians AIDS Care (Chic). 2002;1(2):53-62.

5. Vazquez JA, Sobel JD. Mucosal candidiasis. Infect Dis Clin North Am. 2002;16(4):793-820, v.
6. WHO. Interim WHO clinical staging of HIV/AIDS and HIV/AIDS case definitions for surveillance. Geneva, Switzerland: WHO, 2005. 7. Connolly GM, Forbes A, Gleeson

JA, Gazzard BG. Investigation of upper gastrointestinal symptoms in patients with AIDS. AIDS. 1989;3(7):453-6.
8. Antinori A, Antinori A, Ammassari A, Masetti R, De Luca A, Murri R, et al. Presumptive clinical criteria versus endoscopy in the diagnosis of Candida esophagitis at various HIV-1 disease stages. Endoscopy. 1995;27(5):371-6.

9. Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-infected Asults and Adolescents. (2009).

10. Belitsos PC. Management of HIV-associated esophageal disease. AIDS Clin Care. 1995;7(3): 19-22

11. Zingman BS. Resolution of refractory AIDS-related mucosal candidiasis after initiation of fifanosine plus saquinavir. The New England journal of medicine. 1996;334(25):1674-5

Drug Control in Australia: Where to Next?



Substance use and associated disorders are increasingly recognised as a global health issue. As attitudes towards drug use disorders evolve, varying drug control policies worldwide are called into question. Nations such as the United States of America utilise the criminal justice system to place sanctions on those contravening drug control policy, which often results in cycles of incarceration, further drug use, and poverty. In contrast, Portugal has revolutionised its approach to drug control since the turn of the century by decriminalising all drugs to great effect. In view of this wide spectrum of attitudes towards drug control, the future of Australia’s approach to drug control policy is examined. 



The International Classification of Diseases defines substance use disorders as “continuing drug consumption despite severe adverse consequences”.[1] A report by the office of National Drug Control Policy in 2010 outlined the detriments of substance use disorders using a biopsychosocial paradigm (Figure 1).[1, 2]

Figure 1: The biopsychosocial adverse outcomes related to substance use disorders [1, 2]
Substance use disorders are managed through three main drug policy approaches: decriminalisation, criminalisation, and harm minimisation. Decriminalisation involves prohibiting and regulating drugs but excluding sanctions from criminal law jurisdiction, whereas criminalisation is the attribution of criminal offences to drug-related activities.[3, 4] Harm minimisation strives to decrease adverse consequences without aiming to reduce consumption.[1] Substance use disorders are perpetuated by social stigma and thus the political context is a key determinant of long-term health outcomes.[3]

Benefits and detriments of different policy approaches

Criminalisation of drugs, and the subsequent incarceration of drug users, provides the immediate benefit of removing the individual from an environment that exacerbates their drug use, and prevents the community from being threatened by drug-affected behaviour. Additionally, incarceration allows the government to demonstrate the work being done to tackle drugs in a manner that is tangible and easily understood by the general public. However, punitive drug law enforcement alone may fail to address or even worsen health complications of drug use. It can marginalise populations at risk of poorer health and increase barriers to seeking health services, as illustrated by the growing epidemic of HIV/AIDS and hepatitis C amongst injecting drug users.[5] Moreover, drug law enforcement has minimal impact on the drug market itself, although there is some evidence that it may alleviate a degree of associated harm.[1, 6]

Advantages of the harm minimisation approach include curbing the progression of the HIV/AIDs epidemic through safe needle programs and deterring criminal behaviours.[1, 7] This is achieved through demand and supply reduction, prevention campaigns, and improved access to treatment and harm reduction.[8] Critiques of this approach include maintaining demand for the illicit drug market, and ineffectively addressing all biopsychosocial facets of substance use disorders.[8]

The main benefit of decriminalisation is that it reframes drug use as a public health problem, which allows for reallocation of funds from drug-related criminal justice proceedings and the prison system to rehabilitation services focusing on long-term health outcomes.[3] This, coupled with a shift in criminal justice focus to high-level drug offenders, ultimately results in less drug use and better long-term health outcomes.[3] Decriminalisation addresses substance use disorders in a biopsychosocial context and identifies it as a key public health issue, both key steps in arresting the perpetuation of stigma which only serves to isolate drug users from health services.[3] Criticisms of decriminalisation include potential for increased accessibility to drugs and a cheaper street value, which could result in increased uptake of drug use.[9]

In 2009, Antonio Costa, the executive director of the United Nations Office on Drugs and Crime, affirmed that “drug use should be treated as an illness in need of medical help”, and appealed for universal access to drug treatment.[2] In 2011, the Global Commission on Drug Policy emphasised that it was time to “end the criminalization, marginalization and stigmatization of people who use drugs but who do no harm to others”.[1] The World Health Organization and the United Nations echoed this view in their joint statement published in June 2017, stating that to ignore such a call to “[review] and [repeal] punitive laws….[including] drug use or possession of drugs for personal use” would be to “[violate] the most fundamental human rights protected in international treaties and in national laws and constitutions”.[10] This strong stance against discrimination in health care settings reflects the global shift in attitudes towards drug policy, from incarceration to rehabilitation of drug offenders. 

Drug control approaches worldwide

Criminalisation: the United States

The United States (US) has a strong stance of criminalisation towards illicit drugs and has a low threshold to prosecute drug offenders.[3] Its prison population has increased by almost 800% since 1980, in marked disproportion to its population growth, with 47% of all inmates imprisoned for drug-related crimes, and many with drug use disorders.[3] In 2010 alone, US $80 billion was spent on continuing incarceration of inmates.[3] Drug users, possessors and traffickers are treated equally in this criminal system, with mandatory minimum prison sentences.[3]

Without adequate rehabilitation services or emphasis on drug use and use disorders as a public health issue, the high rates of recidivism are unsurprising, often resulting in a cycle of criminality, incarceration and poverty, with subsequent economic burden on the community.[3] This is an issue fuelled by media sensationalism, portraying

Where drug courts – legal committees which redirect non-violent drug offenders from incarceration to treatment – have been trialled in the US, they have proven to decrease crime rates (7-14%) and recidivism (up to 35%), and improving rehabilitation uptake, treatment outcomes and stability of the family unit.[2] Such models are estimated to reduce health care costs related to substance use disorders by US $4 for every US $1 spent.[2]

While marijuana is considered illicit under US federal law, states are able to make independent laws, which are only disregarded in cases concerning juveniles, cross-border trafficking, or organised crime.[9, 11] Presently, over half of American states have legalised medicinal marijuana, and eight have further allowed recreational use.[9] Given the relatively recent legalisation of marijuana, data on its impact on usage patterns is currently conflicting, and more time is required for reliable assessment.[9] Studies have indicated that diversion of black market marijuana from legalised to criminalised states is likely to decrease marijuana prices, although the degree and impact of this is uncertain.[12, 13] Notably, there are significant economic benefits associated with the legalisation of marijuana.[9] In Colorado, where recreational marijuana use is legal, marijuana tax and licensing fees have been implemented, together generating over US $70 million in the first year alone.[9] This revenue was subsequently funnelled into school construction and youth and substance use programs).[9]

Criminalisation: Central Asia

Central Asian countries, such as Tajikistan, Kazakhstan, and Uzbekistan, have adopted an increasingly stringent approach to drugs.[14] In the year following the September 11 attacks, these countries received US $187.5 million from the US government to improve border control, counter-terrorism measures and counter-narcotics initiatives.[14] Between 2004 and 2007, a strong criminal justice-based approach was further reinforced in Central Asia with funding from international agencies, other foreign governments and national budgets directed to legal action against drug use.[14]

Further, national campaigns in Central Asia often label drug users as evil, increasing the stigma and discrimination which perpetuates cycles of drug use.[15] Little or no rehabilitation or treatment is available for substance users, with such countries preferring a model of criminalisation and incarceration.[14] For example, opioid substitution treatment is prohibited in Tajikistan and Turkmenistan, minimally available in Uzbekistan and Kyrgyzstan, and non-existent in Kazakhstan.[14] The lack of treatment for drug users and increasing accessibility of opiates has resulted in a growing HIV epidemic in Central Asian prison systems with poor long-term health outcomes.[14]

Decriminalisation: Portugal

Prior to 2001, drug use was criminalised in Portugal, yet rates of heroin use and drug trafficking continued to increase.[3] Consequently, the Portuguese government drafted a law decriminalising all drugs purchased, possessed or consumed for personal use. This law also had a public health focus towards rehabilitating those with substance use disorders, and a punitive focus towards high-level drug trafficking. This involves a committee of two medically-trained persons and one legally-trained person, deciding first whether an offence is protected by this law, and then whether the offender is suffering from a drug use disorder.[3] This law only aimed to decriminalise low-level drug offences; strict laws remain against high-level offenders and drug traffickers who propagate this vicious cycle and endanger the general community.[16]

After this law was passed, Portugal reduced its burden on the criminal-justice system, allowing more funding allocation towards public health endeavours, including prevention campaigns, treatment, and facilities.[17] Treatment uptake consequently increased, resulting in decreasing rates of drug-associated illnesses.[4, 18] During the four years following decriminalisation in 2000 to 2006, there was a significant decrease in the incidence of new cases of HIV/AIDS amongst drug users in Portugal, from almost 1400 to 400 persons.[18] Decreased rates of new hepatitis B and C infections have also been evident, attributed to the improved treatment and rehabilitation programs afforded by decriminalisation.[17, 18] Moreover, absolute numbers of drug-related deaths by each prohibited substance decreased; the total number of drug-related deaths decreased from 400 in 1999 to 290 in 2006.[18]

Importantly, while some speculated that decriminalisation would lead to lower prices of drugs and subsequent higher rates of usage, the cost of drugs did not decrease.[19] In fact, the rates of cannabis and cocaine use after decriminalisation have been three times lower than before.[18] Further, data extrapolations have predicted lower lifetime prevalence rates of drug use for almost all drug categories post-decriminalisation.[18]

Decriminalisation: West Africa

West African countries must contend with both international drug cartels and the growing transit of illicit substances to Europe and North America. Consequently, local consumption of illicit substances has increased, especially among younger persons, with significant economic, health and social consequences.[20] While data is scarce, in 2008 it was estimated there were 1.8 million intravenous drug users in Sub-Saharan Africa, of whom 12% were thought to be living with HIV.[20, 21]

In 2014, the West Africa Commission on Drugs published a declaration specifically stating that “criminalisation of drug use worsens health and social problems, puts huge pressures on the criminal justice system and incites corruption”, and that “drug use must be regarded primarily as a public health problem”, mirroring the movements of Portugal.[20] Despite these recommendations, there is currently no evidence that any West African countries have been successful in implementing drug decriminalisation policies.

Drug policy in Australia and the way forward

In 1985, the Australian Government adopted an official national drug policy of harm minimisation.[1] In the 2002-03 financial year, the Australian Government allocated $3.2 billion to managing illicit drugs, 75% of which was spent on drug law enforcement, aiming to decrease drug and drug-related crime, and improve public health and safety.[1, 16] Despite this investment, a staggering 400 Australians die yearly from heroin overdose, and most areas have a demand for substitution products far out-weighing the supply, notwithstanding the costly co-payment.[1] The methadone substitution program and syringe exchange services available in Australia have made an impact, yet with a growing affected population and the root cause unaddressed, the need is largely unmet.[1] Harm minimisation still perpetuates discrimination and marginalisation of drug users, instead, decriminalisation can reduce stigma and is essential to better health outcomes.[3]

The Australia21 report, published in 2012, was effective in initiating a debate on drug reform. The report not only illustrated the harmful effects of criminalising possession and personal use on drug-dependent individuals in an Australian context, but also highlighted the potential health benefits of some currently illicit drugs.[1, 8] This report left Australians to decide which legal system would allow for better biopsychosocial health and economic stability for the community with respect to those consuming drugs – rehabilitation or incarceration.

Australia should act to follow countries like Portugal that have prospered from revolutionising drug policy with respect to low-level offences and reform to decriminalise all drugs. As supported by the Global Commission on Drug Policy, a move towards decriminalisation of low-level drug offenses in Australia would allow for decreased economic burden on the criminal justice system, reallocation of funds to drug rehabilitation programs, and a sharpened focus on the illegality of high-level drug trafficking offenses.[3] Viewing drug use as a public health problem is the key first step to reducing stigma and consequently improving access to treatment and long-term health outcomes.


Criminalisation marginalises those afflicted with drug use disorders, who are already burdened with significant health, social and economic disadvantage. Where there is demand, there is supply, and tackling drug use disorders with criminal law is simply too late to create a meaningful impact on the individual or society at large. Poverty breeds poverty; while incarceration may remove the immediate threat from society, it does nothing to address the root cause.

Substance use disorders are a medical condition and public health problem, not a moral choice. Epitomised by Portugal, decriminalisation of drugs and rehabilitation fortifies a community, not just immediately, but with long-term positive effects in the workforce and crime rates, spanning generations. Substance use disorders, therefore, need to be reframed from a criminal, punitive problem, to one befitting the biopsychosocial model of health. Fortunately, throughout the world this is increasingly becoming the case.

Raquel Maggacis

Raquel Maggacis is a final year medical student at the University of Queensland. She has a keen passion for public health endeavours and hopes to one day intertwine this with a career as a medical physician.


Sophie Lim, Vector Associate Editor 

Conflict of Interest

None declared




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  19. Felix S, Portugal P. Drug decriminalization and the price of illicit drugs. Int J Drug Policy. 2017;39:121-9.
  20. Drugs WACo. Not Just in Transit: Drugs, the State and Society in West Africa. West Africa Commission on Drugs; 2014.
  21. Mathers BMD, Louisa; Phillips, Benjamin; Wiessing, Lucas; Hickman, Matthew; Strathdee, Steffanie A; Wodak, Alex; Panda, Samiran; Tyndall, Mark; Toufik, Abdalla; Mattick, Richard P. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet. 2008;372(9651):1733-45.


Non-Health for Non-Persons: Rohingya Muslims in Crisis


In a tightening spiral of human suffering that winds back five decades, the Rohingya have come to be mentioned as a customary precursor to the phrase “most persecuted minority in the world”. The long-disowned nationals of Myanmar are estimated at a population of 1.2 million,[1] stateless victims of humanitarian violations so comprehensive and extensive that the world’s empathy can only be directed towards a vague fog of injustice. However, as flagbearers of the right to health and human dignity, healthcare professionals must be able to shine a torch into the fog and discern the faces within.

Current Situation

While systematic persecution of the Rohingya Muslims has been noted since the stripping of voting rights and the military “purges” of the 1970s, events within the past year have seen violence escalate dramatically. A border attack by a group of radicalised Rohingya Muslims on Myanmar’s police last October resulted in an estimated 10 casualties. Extremist violence is unacceptable and unhelpful, though one can see the desperation, injustice and generations-worth of marginalisation from which this radicalisation was inevitably born. Since the attack, disproportionate and indiscriminate military retaliation has resulted in hundreds of deaths and torrents of Rohingya fleeing Myanmar’s northern Rakhine state, where the situation is worst. The United Nations (UN) reports that from the last week of October 2017 to the first week of September 2017 alone – just two weeks – 270,000 people fled to Bangladesh for safety.[2]

The humanitarian crisis in which the Rohingya find themselves is undeniable. Officially stateless, access to basics such as healthcare, education, employment, security and freedom is often impossible. Tragically, these deprivations are far less confronting than other reasons for which the Rohingya have been forced to flee. With UNHCR reports documenting common experiences of “mass gang-rape, killings, including of babies and young children, brutal beatings, disappearances and other serious human rights violations by the country’s security forces”, returning to Myanmar is not an option.[3]

UNHCR interviews with Rohingya refugees detail random shooting at crowds who were fleeing houses, schools, mosques and markets that had been set alight by Myanmar’s army, police and occasionally civilian mobs.[4] Destruction of food, livestock and food sources; cases where the army or Rakhine civilians have trapped an entire family, including the elderly and disabled, inside a house and set it on fire “killing them all”; mothers assaulted by “security” forces while being forced to watch their babies stabbed and killed – words cannot do it justice.[4]

Recent news reveals that Burmese officials have planted landmines along the Bangladesh border, posing a lethal threat to Rohingya peoples fleeing atrocities. Deemed unlawful for their inability to distinguish between civilians and militants, children and adults, landmines have been banned in many countries under the 1997 Mine Ban Treaty. Not a signatory to this, Myanmar officials continue to use them against Rohingya civilians, protected by the unsurprising denial by the Burmese government that such landmine plantings have taken place.

An assortment of condemnations have been offered by the UN; crimes against humanity,[3] genocide, ethnic cleansing. The UN High Commissioner for Human Rights Zeid Ra’ad Al Hussein, concludes his report on the Myanmar atrocities by despairing, “What kind of ‘clearance operation’ is this? What national security goals could possibly be served by this?”.[3] As Hussein seems painfully aware, these words fall on deaf ears.

Medical Crisis

Humanitarian agencies are floundering, desperately attempting to provide emergency care for the monsoonal influx of Rohingya refugees, most of whom have a variety of physical and psychological conditions. Studies of the health conditions within Bangladesh’s two main registered refugee camps present unsurprisingly dire findings.

One psychiatric study surveyed a group of registered Rohingya refugees and reported experiences of torture (39.9%), sexual abuse (12.8%), rape (8%), forced abortions (2.4%), PTSD (36%), depressive symptoms (89%), suicidal ideations (19%) and deaths of friends or family due to illness or starvation while fleeing (22.4%).[5] Hopelessness was the common theme, with one Rohingyan interviewee asking, “Our future has been spoiled, but what will happen to the future of our children?”

In 2015, another study investigated the general health conditions of Bangladesh’s largest Rohingya refugee camp, Nayapara.[1] With a population of 18,777, the camp was attended by only four trained doctors and six nurses. The infant mortality rate was 45.4 per 1000 livebirths and one quarter of the population was children, most of whom were born in a camp. Additionally, the study reported widespread stunting due to malnutrition (57%), anaemia (49%), and a high prevalence of respiratory (46.9%), endocrine (21.9%) and cardiovascular disorders (14.8%). Mental health conditions were ubiquitously poor; 18.7% of camp injuries were caused by self-harm, and in Bangladesh’s other major camp, 43.3% of Rohingya refugees were diagnosed with a psychotic disorder.

Importantly, health conditions in registered refugee camps far surpass those of the many unregistered camps in countries neighbouring Myanmar. These makeshift shelters, which house twice as many Rohingya as the registered camps, are conferred no security or support from the already-drowning NGOs servicing the area. This, however, is still favourable to staying in the northern Rakhine state of Myanmar where health conditions are so abysmal that, for example, mortality in children under 5 has reached 224 per 1000 livebirths.[6]

Role of Health Professionals in Social Justice

In situations where political and military injustice seem impenetrable, often the most basic human right affordable is emergency medical care, but is the assumption that medical aids are exempt from political and military violence still applicable today? As seen in reports of hospitals targeted in Syria by Western military, it seems that medical neutrality is no longer a guarantee. Combined with the Myanmar government’s notoriously uncooperative relationship with humanitarian organisations, one must ask what responsibility healthcare professionals are expected to bear in the realm of human rights.

In 2014, Médecins Sans Frontières was banned in Rakhine, and a month later, when humanitarian aid agencies were attacked by Buddhist anti-Rohingya radicals, Myanmar’s government only further restricted humanitarian aid.[6] This ban has since been lifted but access is now parlous again due to the Myanmar government’s “formulated and disseminated accusations against the UN and international NGOs, denial of required travel and activity authorisations, and threatening statements and actions by hardline groups”.[7] Also recently, the UNHCR High Commissioner Hussein has struggled with repeated government restrictions on humanitarian access to the worst affected regions of Rakhine, and bans on UN investigative officials entering Rohingyan regions of Myanmar. Forced to work within the law, the UN can only deploy officers to the Bangladeshi border.[2]

These tensions between humanitarian aid and the state beg the question: in health emergencies and human rights violations as staggering as those experienced by the Rohingya Muslims, should human rights and healthcare organisations bend to the will of unjust – even criminal – governments? It is a problem the UN and its subcommittee, the World Health Organization, still grapple with. Do they obey their mandate to respect the sovereignty of their member states? Or do they perform their constitutional role of helping member states “respond to…emergencies with public health consequences”?[8] How can they, when the member state itself is perpetuating the emergency? Additionally, the aforementioned lack of confidence in medical neutrality makes it unsafe for health workers to stand against government and military opposition.

The only solution where a full response to this humanitarian crisis can be appropriated lies in either cooperation with Myanmar’s government – which seems unlikely – or direct actions against the government by UN member states. Ideally, the Burmese government would grant the Rohingya some form of internationally recognised citizenship, allowing for better organisation of refugee status and resettlement programs for the Rohingya in neighbouring countries. Sanctions intended to force the Burmese government’s hand have failed in the past,[6] but if the global community can unite with harsher repercussions for the continued persecution of Rohingya Muslims, surely the situation can only improve.


The Rohingya peoples are born into a cycle of poor health outcomes that begin with low birthweight and continue with dismal access to healthcare. Timid international responses to the systematic abuse, torture and dehumanisation of this minority have allowed for the continuation of historical persecution. The 2015 election of Nobel Prize laurate Aung San Suu Kyi as Myanmar’s Prime Minister presented an opportunity for a Myanmar government to end their denial and dismissal of decades of Rohingyan suffering. However, as stated by her aide, it seems she has “other priorities”,[6] which probably includes avoiding conflict with her majority-Buddhist supporters and the hugely politically influential Burmese military. For now, Rohingya Muslims will have to continue to relying on NGOs who are drowning under resource insufficiencies and legal restrictions, attempting to deal with the desperate masses in any way possible.

History paints a picture of peaceful generations of Rohingya living in Myanmar. Their future seems increasingly uncertain, although ideally it involves them returning safely home. One and a half million people await a saving grace, security for their children, medicine, clean water. If international global health organisations cannot work within Myanmar’s policies, then they must find a conclusive alternative. It is unacceptable that there is still not a light at the end of this half-a-century long tunnel.

Jumaana Abdu

Jumaana is currently finishing her first year of medicine at the University of New South Wales. She aims to find a career path which combines her passion for medicine and human rights. She also hopes her future involves as a side-profession of writing, fiction or otherwise.

Photo credit

EU/ECHO/Pierre Prakash

Accessed from https://www.flickr.com/photos/eu_echo/17337141093/in/photostream/

Conflicts of interest

None declared




1. Milton, A. H., Rahman, M., Hussain, S., Jindal, C., Choudhury, S., Akter, S., … & Efird, J. T. (2017). Trapped in Statelessness: Rohingya Refugees in Bangladesh. International Journal of Environmental Research and Public Health, 14(8).

2. United Nations (2017). UN scales up response as 270,000 flee Myanmar into Bangladesh in two weeks. Retrieved from http://www.un.org/apps/news/story.asp?NewsID=57480#.WbZ6eK2B3Vo

3. United Nations (2017). UN report details ëdevastating crueltyí against Rohingya population in Myanmarís Rakhine province. Retrieved from http://www.un.org/apps/news/story.asp?NewsID=56103#.WbZ4w62B3Vp

4. OHCHR Zeid Raíad Al Hussein (2017). Interviews with Rohingyas fleeing from Myanmar since 9 October 2016. Retrieved from http://www.ohchr.org/Documents/Countries/MM/FlashReport3Feb2017.pdf

5. Riley, A., Varner, A., Ventevogel, P., Taimur Hasan, M. M., & Welton-Mitchell, C. (2017). Daily stressors, trauma exposure, and mental health among stateless Rohingya refugees in Bangladesh. Transcultural Psychiatry, 54(3), 304-331.

6. Mahmood, S. S., Wroe, E., Fuller, A., & Leaning, J. (2017). The Rohingya people of Myanmar: health, human rights, and identity. The Lancet, 389(10081), 1841-1850.

7. Médecins Sans Frontières (2017). Myanmar: International humanitarian access to Rakhine State must urgently be permitted. Retrieved from http://www.msf.org/en/article/myanmar-international-humanitarian-access-rakhine-state-must-urgently-be-permitted

8. Kennedy, J., & McCoy, D. (2017). WHO and the health crisis among the Rohingya people of Myanmar. The Lancet, 389(10071), 802-803.

LGBTIQ peoples’ experiences of and barriers to healthcare



Increasing data on sexual orientation and gender identities in large scale social studies has revealed that significant portions of the Australian community are sexuality and/or gender diverse. In the 2014 ABS General Social Survey, 3% of the Australian population identified as not heterosexual,[1] and whilst Australian data is unavailable, a study of 8500 New Zealand secondary school students revealed that 1.2% identified as transgender.[2]

LGBTQIA+ refers to lesbian, gay, bisexual, transgender, queer and questioning, intersex, asexual and aromantic individuals, with the “+” connoting other diverse sexualities, sexes and genders. LGBTQIA+ Australians continue to face significant barriers to care which in turn impact individuals’ help seeking behaviours.[3, 4]

Until 1973, homosexuality was considered a mental disorder. Similarly, transgender and gender diverse (TGD) identities were classified as “gender identity disorder” until the 2013 edition of the Diagnostic & Statistical Manual (DSM-5) [4] and continues to be listed as such by the World Health Organizationís  International Statistical Classification of Diseases and Related Health Problems (ICD-10).[5] Furthermore, access to hormonal and/or surgical intervention largely remains tied to gatekeeper models requiring TGD individuals to be “diagnosed”.[6, 7]

Despite having been widely condemned as ineffective and causing significant psychological harm,[8, 9] pseudoscientific “gay conversion therapy” continues to persist. Most recently, a New South Wales GP appearing in a “Vote No” television campaign against same-sex marriage was identified as a founder of a “family values” group advocating this practice. Many intersex individuals have also been subjected to risky, non-consensual genital mutilation surgery as infants in a bid to “normalise” them.[10] Furthermore, some clinicians expressly feel awkward treating LGBTQIA+ individuals.[11] Hence, to effectively advocate for greater inclusivity and equity, it is paramount that health professionals understand both current and historical healthcare barriers as well as the specific health concerns of LGBTQIA+ communities

As such, this article will outline:

1) Effects of individual, interpersonal and structural social determinants of health on healthcare access for LGBTQIA+ individuals;

2) Key health issues affecting LGBTQIA+ individuals; and

3) Recommendations for improving access.

Social determinants of healthcare access for LGBTQIA+ individuals

Despite the acronym LGBTQIA+ construing homogeneity, LGBTQIA+ communities are distinctly heterogeneous. Individuals may have different experiences of their identity and come from different social contexts such as ethnic background or socioeconomic class.[12] However, they do share a continued exposure to societal stigma associated with their diverse identities. This stigma plays into all levels of the social determinants of health which in turn impact both individuals’ health and healthcare access. These include individual internalised shame, interpersonal discrimination and ignorance and structural legal, administrative and systemic challenges. These determinants limit LGBTQIA+ Australians’ confidence in our healthcare system.

Individual and interpersonal

While accessing healthcare, LGBTQIA+ individuals face interpersonal barriers in the form of clinicians’ lack of knowledge and discrimination as well as their own individual internalised homophobia.

Many practitioners have limited training and awareness around the importance of comprehensive, non-judgmental sexual history taking. Clinicians’ unconscious biases often result in LGBTQIA+ clients being forced to “out” themselves in response to questions that assume heterosexuality and do not recognise gender diverse or intersex experiences (e.g. asking a trans woman about birth control). This exacerbates existing awkwardness around sexual and mental health and is associated with significant discomfort, which may contribute to patients’ decisions not to disclose their sexuality or gender identity.[13] Additionally, some GPs did not understand different sexual practices and felt uncomfortable broaching the topic.[14] One third of LGBTQ* Australians still hide their sexuality or gender identity when accessing healthcare.[15] In youths, half did not disclose.[16] This not only impacts individuals’ ability to build trust with healthcare providers but also undermines the provision of targeted health services such as human immunodeficiency virus (HIV) testing in men who have sex with men (MSM).

Healthcare providers’ lack of knowledge regarding TGD identities and unique health needs is a common theme.[17-20] Having to educate healthcare providers was found to be a key contributor to negative GP encounters in Australia.[17] A lack of sensitivity [19, 20] with practitioners asking invasive or offensive questions [17] and misgendering clients through the use of incorrect pronouns or old names [15, 21] contributes to these barriers. Clinicians not working in TGD-specific fields often have little knowledge on the issue, resulting in these clients’ exclusion from mainstream health services.[2, 15, 21] Even clinicians regularly engaged with TGD clients enlist gatekeeping behaviours which restricts access to hormonal and surgical intervention.[17, 22] This discourages TGD individuals from raising mental health concerns and many find this process of “assessment” to be degrading and pathologising.[21] Moreover, rigid, binary views of gender results in non-binary individuals feeling invisible and unwelcome to services.[23]

Additionally, the view of LGBTQIA+ identities as inherently pathological by some providers is discriminatory.[13, 21, 24] TGD individuals may face clinician discomfort, disgust, ridicule, contempt and even refusal of treatment.[19, 21-23] One participant of the Australian and New Zealand TranZnation report was told by their doctor that she was “the filthiest, most perverted thing on earth” while another was informed they “needed to find god not hormones”.[21] Asexuality is also pathologised. While DSM-5 now allows for self-identification as asexual as an alternative to diagnosis with “hypoactive sexual desire disorder” or “female sexual arousal/interest disorder” [25], historically, a lack of interest in sex has been pathologised by Western medicine.[26]

Internalised homophobia may manifest as a further barrier to seeking healthcare services. Consequently, during periods of illness, individuals turn to pharmacies and only seek health services when self-medication has been unsuccessful.[27]


LGBTQIA+ communities also face a myriad of structural barriers to quality healthcare.

Australia is currently the only Western country which requires TGD adolescents to gain Family Court ëapprovalí to access hormones. Despite the time-sensitive nature of hormone therapy, the legal process can take up to 10 months, and cost tens of thousands of dollars.[28] However, this is currently under review by the Family Court.[29]

TGD communities, especially non-binary individuals, also face inaccurate medical record keeping that do not reflect individual’s chosen names, genders and/or pronouns and a lack of gender-neutral bathroom access.[18, 23] Moreover, TGD individuals experience discomfort in gendered spaces such as gynaecologists’ clinics [23] and heightened discomfort surrounding pap smears and breast checks.[18, 22] The relegation of TGD services to the realm of expensive private healthcare[15] is at heads with their increased risk of poverty, underemployment and housing instability.[18, 19, 23]

Furthermore, unconscious bias can also manifest in the distribution of research funding and practitioner training. Compared to the relative visibility of gay menís health around the HIV/AIDS epidemic, TGD health as well as queer womenís health have largely been ignored.[13]

Key LGBTQIA+ health issues 

Besides issues of access, LGBTQIA+ individuals have specific healthcare risks, needs and concerns. Pertinently, LGBTQIA+ individuals have significantly poorer mental and sexual health. They also have higher incidence of certain chronic diseases such as cardiovascular disease, asthma and diabetes.[30]

Mental health

Poorer mental health is one of the ways that stigma affects LGBTQIA+ individuals’ wellbeing. Compared to the general population, LGBTI  people in Australia are five times more likely to attempt suicide in their lifetimes and more specifically, TGD-identifying individuals are eleven times more likely.[31] LGBT people are also twice as likely to be diagnosed and treated for mental health disorders, and 24.4% of LGBT people aged 16 and over currently meet the full criteria for a major depressive episode.[31]

Reasons for poorer mental health are also based in internalised, inter-personal, organisational and structural stigma and discrimination.[31] These include: bullying at schools, lack of bullying laws, ostracism from families and faith communities, fear of employment and economic stability, and inner conflict and internalised phobia about their respective identities. LGBTQIA+ individuals also have higher risk for poor coping mechanisms and substance abuse.[32]

Sexual health

LGBTQIA+ individuals may also experience poorer sexual health. There is evidence to suggest that women who have sex with women (WSW) are at higher risk for cervical cancer.[32] Both patients and clinicians lack awareness around sexually transmitted infection (STI), specifically human papilloma virus (HPV), transmission during cisgender woman to woman sexual contact. Consequently, WSW are less likely to have Pap or other cervical smears.[33]

In addition, MSM have greater incidence of HIV. In Australia, HIV transmission occurs primarily through male-to-male sex with 68% of new HIV diagnoses in 2015 having been attributed to male-to-male sex.[34] Besides the greater susceptibility of anal mucosa, this increased incidence arises from the concentration of HIV within MSM sexual networks in Western nations.[35] Receptive anal intercourse in male-to-male sex may also increase risk of hepatitis B, HPV and herpes.[32] In NSW, MSM are also more likely to report ever having had an STI, particularly chlamydia, pubic lice, genital herpes, syphilis, anal warts and gonorrhoea.[36] As some of these STIs are risk factors for anal cancer, MSM are also at greater risk for anal cancer.[32] However, MSM are also more likely than any non-MSM to be tested for STIs.[36]

Furthermore, poor data collection means that the sexual health of TGD populations in Australia remain poorly understood. The tendency to collapse TGD experiences into a single “third gender” category ignores the vast differences in risk associated with different gender identities, sexual orientations and partners.  For example, the Kirby Institutes’ 2016 annual report on STIs recorded sex as “male”, “female” and “transgender/missing”.[37] This is particularly disappointing in the context of trans women in particular being significantly overrepresented in global HIV prevalence.[38]


Owing to Australiaís aging population, the issue of older LGBTQIA+ individuals is topical. LGBTQIA+ individuals in aged care have specific care needs such as ongoing HIV/AIDS treatment and hormone therapy. Having lived through the criminalisation of homosexuality, many may be impacted by an internalised need to go ëback into the closetí for fear of discrimination.[39]

Improving access

To reduce the aforementioned barriers and risks, various areas can be improved. Institutionally, education around LGBTQIA+ issues of sexuality, gender diversity, access and risk should be integrated into the medical curriculum. Trainees should be taught to adopt non-judgmental approaches to history taking and communication.[16, 40] Whilst questions such as “do you have a boyfriend/girlfriend?” seem innocent, they carry value judgements on what is considered “normal”. Instead, more inclusive terminology should be encouraged to enable clinicians to invite discussion around sexual health without assuming heterosexuality or gender binaries. Encouragingly, previous efforts in introducing LGBTQIA+ content through lectures and clinical simulations have been effective in decreasing at least clinician discomfort in providing LGBTQIA+ related care.[41-44]

Clinicians should also create environments of inclusiveness. This includes respecting patientsí chosen pronouns and names, and keeping open minds about their relationships. This is imperative to building trust. Introducing intake forms that include diverse gender identities and LGBTQIA+ specific signage or educational brochures also increase patient comfort.[40] Additionally, revision of current data collection systems would enable more targeted healthcare delivery for TGD populations. This could be aided through mandatory recording of both sex assigned at birth and current gender identity which would enable the disaggregation of different TGD experiences.[45]


LGBTQIA+ people face on-going barriers to healthcare on individual, interpersonal and structural levels and have an increased risk of mental, sexual and chronic illnesses. Thus, in order to improve health outcomes, barriers to access should be targeted on both interpersonal and structural levels. Ultimately, treating LGBTQIA+ people with individual respect and a willingness to learn will go a long way in in reducing these inequities.

Salwa Barmaky and Alexander Lee

Salwa is a fourth year medical student at the University of New South Wales. and a public health enthusiast, especially interested in health disparities and programme interventions.

Alexander is an undergraduate medical student currently studying at the University of New South Wales. His interests include improving healthcare access for marginalised populations including gender and sexuality diverse groups and reproductive health.


The authors acknowledge and thank Gale Chan for their contributions to the drafting and revising of this article.

Photo credit

©2008 laverrue, accessed from https://www.flickr.com/photos/23912576@N05/2942525739

Ryan melaugh, accessed from https://www.flickr.com/photos/120632374@N07/13974181800

Conflicts of interest

None declared





1. Australian Bureau of Statistics. General Social Survey: Summary Results, Australia, 2014 2014 [cited 2017 September 9]. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4159.0.

2. Clark TC, Lucassen MFG, Bullen P, Denny SJ, Fleming TM, Robinson EM, et al. The health and well-being of transgender high school students: Results from the New Zealand Adolescent Health Survey. Journal of Adolescent Health. 2014;55:93-9.

3. Mulé NJ, Ross LE, Deeprose B, Jackson BE, Daley A, Travers A, et al. Promoting LGBT health and wellbeing through inclusive policy development. International Journal for Equity in Health. 2009;8(18).

4. Potter J, Goldhammer H, Makadon M. Clinicians and the care of sexual minorities Potter J, Goldhammer H, Makadon M, Mayer K, editors. Philadelphia: American College of Physicians; 2008.

5. World Health Organisation. International Statistical Classification of Diseases and Related Health Problems 10th Revision 1992 [updated 2016. 10:[Available from: http://apps.who.int/classifications/icd10/browse/2016/en#/F60-F69.

6. Australian and New Zealand Professional Association for Transgender Health. Standards of Care  [Available from: http://www.anzpath.org/about/standards-of-care/.

7. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender and gender nonconforming people 2011 [Available from: http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351&pk_association_webpage=3926.

8. Mayers L, Chow K. Same-sex marriage survey: Petition to deregister Pansy Lai, doctor in No campaign ad, taken down. ABC News. 2017.

9. Daniel H, Butkus R. Lesbian, Gay, Bisexual, and Transgender Health Disparities: Executive Summary of a Policy Position Paper From the American College of Physicians. Annals of Internal Medicine. 215(163):135 ó 7.

10. Minto CL, Liao L-M, Creighton SM, Woodhouse CRJ, Ransley PG. The effect of clitoral surgery on sexual outcome in individuals who have intersex conditions with ambiguous genitalia: A cross-sectional study. Lancet. 2003;361(9365):1252 ó 7.

11. Smith D, Mattews W. Physiciansí attitudes toward homosexuality and HIV: a survey of a California medical Societyal of Homosexuality. Journal of Homosexuality. 2007;52(3/4):1 ó 9

12. Ard KL, Makadon HJ. Improving the health care of lesbian, gay, bisexual an transgender people: understanding and eliminating health disparities. Boston, Massachusetts: The Fenway Institutee; 2012.

13. Australian Human Rights Commission. Resilient Individuals: Sexual Orientation, Gender Identity & Intersex Rights 2015.

14. Hinchliff S, Gott M, Galena E. ëI daresay I might find it embarrassingí: general practitionersí perspectives on discussing sexual health issues with lesbian and gay patients. Health & Social Care in the Community. 2005;13(4):345.

15. Leonard W, Pitts M, Mitchell A, Lyons A, Smith A, Patel S, et al. Private Lives 2: The second national survey of the health and wellbeing of gay, lesbian, bisexual and transgender (GLBT) Australians. Melbourne: The Australian Research Centre in Sex, Health & Society, La Trobe University; 2012.

16. Robinson KH, Bansel P, Denson N, Ovenden G, Davies C. Growing Up Queer: Issues Facing Young Australians Who Are Gender Variant and Sexuality Diverse. Melbourne Young and Well, Cooperative Research Centre 2014.

17. Riggs DW, Coleman K, Due C. Healthcare experiences of gender diverse Australians: a mixed-methods, self-report survey. BMC Public Health. 2014;14(1):230.

18. Roberts TK, Fantz CR. Barriers to quality health care for the transgender population. Clinical biochemistry. 2014;47(10-11):983-7.

19. Safer JD, Coleman E, Feldman J, Garofalo R, Hembree W, Radix A, et al. Barriers to healthcare for transgender individuals. Current opinion in endocrinology, diabetes, and obesity. 2016;23(2):168-71.

20. Snelgrove JW, Jasudavisius AM, Rowe BW, Head EM, Bauer GR. ìCompletely out-at-seaî with ìtwo-gender medicineî: A qualitative analysis of physician-side barriers to providing healthcare for transgender patients. BMC Health Services Research. 2012;12(1):110.

21. Couch M, Pitts M, Mulcare H, Croy S, Mitchell A, Patel S. TranZnation: A report on the health and wellbeing of transgendered people in Australia and New Zealand Melbourne Australain Research Centre in Sex, Health & Society, La Trobe University  2007.

22. Pitts M, Couch M, Croy S, Mitchell A, Hunter M. Health service use and experiences of transgender people: Australian and New Zealand Perspectives Gay & Lesbian Issues and Psychology. 2009;5(3):167-76.

23. Mogul-Adlin H. Unanticipated: Healthcare Experiences of Gender Nonbinary Patients and Suggestions for Inclusive Care. United States, Connecticu: Yale University; 2015.

24. Transgender and Gender Diverse Health and Wellbeing: Background paper. Victoria Gay, Lesbian, Bisexual, Transgender and Intersex Health and Wellbeing Ministerial Advisory Committee, ; 2014.

25. Bogaert A. Asexuality: What It Is and Why It Matters. The Journal of Sex Research. 2015;52(4):362-79.

26. Gupta K. ìAnd Now Iím Just Different, but Thereís Nothing Actually Wrong With Meî: Asexual Marginalization and Resistance. Journal of Homosexuality. 2017;64(8):991-1013.

27. Alencar Albuquerque G, De Lima Garcia C, Da Silva Quirino G, Alves MJH, Belém JM, Dos Santos Figueiredo FW, et al. Access to health services by lesbian, gay, bisexual, and transgender persons: systematic literature review. BMC international health and human rights. 2016;16(2):22.

28. Taylor J. Chief Justice vows change to ëtraumaticí court process for transgender children. ABC News. 2016.

29. Ryan E. Access to justice for young transgender Australians: Laywers Weekly 2017 [Available from: https://www.lawyersweekly.com.au/opinion/21101-access-to-justice-for-young-transgender-australians.

30. Bolderston A, Ralph S. Improving the health care experiences of lesbian, gay, bisexual and transgender patients. Radiography. 2016;22:207 ó 11.

31. Alliance NLH. Snapshot of mental health and suicide prevention statistics for LGBTI people. National LGBTI Health Alliance; 2016.

32. Lee R. Health care problems of lesbian, gay, bisexual, and transgender patients. The Western Journal of Medicine. 2000;172(6):403 ó 8.

33. Curmi C, Peters K, Salamonson Y. Lesbiansí attitudes and practices of cervical cancer screening: a qualitative study. BMC Womenís Health. 2014;14(153).

34. The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia. The Kirby Institute; 2016.

35. Amirkhanian YA. Social Networks, Sexual Networks and HIV Risk in Men Who Have Sex with Men. Current HIV/AIDS reports. 2014;11(1):81-92.

36. Richters J, Zou H, Yeung A, Caruana T, O de Visser R, Rissel C, et al. Sexual health and behaviour of men in New South Wales 2013ñ2014. School of Public Health and Community medicine 2015.

37. The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2016. Sydney, Sydney NSW 2052: The Kirby Institute

38. Groves A. Transgender women and HIV: A footnote to the epidemic. HIV Australia. 2012;9(4):30-2.

39. Australian Department of Health and Aging. National Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI): Ageing and Aged Care Strategy. 2012.

40. Ard KL, Makadon HJ. Improving the Health Care of Lesbian, Gay, Bisexual and Transgender People: Understanding and Eliminating Health Disparities Boston, MA: The National LGBT Health Education Center; 2012.

41. Arora M, Walker K, Duvivier RJ, Wynne K. Transgender health delivery and education in the Hunter New England local health district.  ANZPATH 2017 Biennial Conference; Sydney, Australia2017.

42. Canty J, Gray L. The last taboo? Teaching skills for clinical consultations with sex/gender diverse people in medical education. .  ANZPATH 2017 Biennial Conference; Sydney, Australia2017.

43. Grosz AM, Gutierrez D, Lui AA, Chang JJ, Cole-Kelly K, Ng H. A Student-Led Introduction to Lesbian, Gay, Bisexual, and Transgender Health for First-Year Medical Students. Family Medicine. 2017;49(1):52-6.

44. Safer JD, Pearce E. A simple curriculum content change increased medical student comfort with transgender medicine. Endocrine Practice. 2013;19(4):633-7.

45. Sizemore LA, Rebeiro PF, Mcgoy SL. Improving HIV Surveillance Among Transgender Populations in Tennessee. LGBT Health. 2016;3(3):208-13.

Commercial Surrogacy in Australia: the Benefits of Harm Minimisation Through Legalisation


Surrogate /sʌrəɡət/

A substitute, or someone or something that represents another person or thing in their stead.[1]

The status quo

There is much controversy around surrogacy in Australia. We have what is known as ‘altruistic surrogacy,’ whereby a woman cannot be compensated beyond reasonable expenses for gestating a baby intended for someone else. Even the name puts our moral intuitions at ease. Altruistic. Contrast this with the term ‘commercial surrogacy’, which makes many of us instinctively recoil. So what is it about commercial surrogacy, where a woman is paid to gestate a baby, that we take issue with?

The most common type of surrogacy is gestational surrogacy, wherein the commissioning parent(s) uses IVF to create an embryo from their own or donor gametes and transfer it into the uterus of the gestational surrogate. With this method, the surrogate mother does not provide any genetic material. People that seek out surrogacy commonly include infertile heterosexual couples and homosexual couples desiring children of their own. The demand for surrogacy has heightened in recent years following changes to child protection policy, which lead to drastic falls in the number of children for adoption and stricter criteria implemented by overseas countries regarding the age and family types who can adopt. For example, none of Australia’s current international adoption agreements allow same-sex couples to adopt.[2] The status quo in Australia (except the Northern Territory) only allows altruistic surrogacy, where one must not compensate the surrogate mother beyond out-of-pocket expenses like medical cost, travel, and time off work. The options are further limited by the fact that surrogacy is illegal for single people and same-sex couples in certain states like Western Australia and South Australia. The increasing number of roadblocks to accessing surrogacy has left many desperate couples resorting to offshore commercial surrogacy. But even this option is becoming more restricted now that Thailand, Cambodia, India, and Nepal have banned foreigners from commercial surrogacy following the notorious “Gammy scandal” in 2014.[3]

Objections to commercial surrogacy

Commercial surrogacy commonly encounters several types of objections. Some think it is inescapably a form of exploitation of women, reducing the surrogate to her base reproductive capability, and effectively turning her into a walking incubator. Certainly, the idea of a class of ‘breeders’ is eerily reminiscent of Margaret Atwood’s classic novel The Handmaid’s Tale, which could be interpreted as a cautionary tale warning against the harms of surrogacy. In a similar vein, some argue that pregnancy belongs in a special moral realm, and that by bringing market forces into the arena we degrade the intrinsic value of creating life. Maybe there are some things in life which simply should not come with a price tag.

Commercial surrogacy also raises objections that intersect with other ethical and societal issues. Some assume that a child is best raised with both a father and a mother figure, and therefore believe that enabling same-sex couples to access surrogacy would be harmful for children. However, existing Australian law allows same-sex couples to adopt, and it is difficult to see why, on the grounds of concern for the child, surrogacy would be different. Furthermore, the assumption that same-sex parenting is harmful to children is not borne-out in the evidence,[4] and so we do not see this as a relevant argument against commercial surrogacy.

Another objection to commercial surrogacy is that it would change the nature of the family unit by involving the surrogate as a third parent figure. But these changes to the more ‘traditional’ family unit are already common in society. Take for example adoption, where both biological and adoptive parents may be involved in the child’s life. It is also possible for women to become single parents through the help of donor sperm and IVF. In neither case has disruption of the ‘traditional’ family unit been viewed as reason for prohibition, and it would be inconsistent ban commercial surrogacy on these grounds.

These ethical objections may be why Australia has made commercial surrogacy illegal. But given that no one has ever been prosecuted on these grounds,[5] the legal threat is a poor deterrence.[6] For people desperate to have a baby of their own, but who are otherwise unable to, the risks of commissioning illegal surrogacy can pale in comparison to the intoxicating notion of holding a flesh-and-blood child.

Undesirable consequences

The supply of altruistic surrogates in Australia falls well short of demand, driving Australian couples to search for surrogates overseas. Most are travelling to countries like India or Thailand where the process was until recently legal, cheaper, and poorly regulated. It is this scene that has become inextricably associated with commercial surrogacy. The transnational surrogacy market operating out of developing countries has been widely criticised in popular media,[7,8] and rightly so. Women who become surrogates in these countries tend to be poorly educated, have low incomes, and may even be coerced into surrogacy by family members or intermediaries seeking to turn a profit.[9] Often, very little of the money actually reaches the surrogate herself. There are some surrogacy agencies which effectively imprison surrogates, controlling their diet, sleep, sexual activity, and contact with the outside world. All this is done under the guise of antenatal care, which is in truth scant and inadequate.[9] It is difficult to see how informed consent could truly be said to exist in this environment.[10]

Even if the surrogacy results in a liveborn child, the challenges do not necessarily resolve. The lack of enforceable contracts between commissioning parents and surrogates, combined with issues of legal citizenship and parentage, can create a veritable labyrinth if conflict arises or if commissioning parents change their minds and no longer want the child. Case examples of transnational surrogacy debacles abound in the media. For example, commissioning parents have divorced before the surrogacy was complete, leaving the child with an uncertain future.[11] Another case saw a baby left stranded with no identity or legal papers for as long as two years.[11] Fortunately, Australian laws allow a child born from an international surrogacy arrangement to be given Australian citizenship, provided that at least one parent is an Australia citizen and a parent-child relationship is proven with DNA testing, although other measures of ‘parent’ can be used. If ineligible, commissioning parents may be required to apply for a permanent visa or an adoption visa. Despite being lengthy and difficult for parents to navigate, these processes and laws minimise the risk of children born internationally via surrogacy being left stateless.[12,13]

Australia’s current approach is to prohibit commercial surrogacy because it is regarded as immoral, but is this policy helping the situation or making it worse? At present, Australians for whom altruistic surrogacy is simply not feasible appear to be turning to transnational surrogacy. In 2011, only 21 births by altruistic surgery were recorded in Australia.[14] In the same year, it is estimated over 270 babies were born via transnational commercial surrogacy arrangements.[6] Banning commercial surrogacy domestically has created a transnational black market of commercial surrogacy that does not protect the best interests of the surrogate, the child, or the intended parents; the process is expensive, risky, poorly regulated, and is largely a profit-making exercise for overseas surrogacy agencies. Despite being designed to prevent exploitation, our current system might in fact ironically be encouraging it.

Harm minimisation

Simply prohibiting a behaviour on the basis of its supposed immorality is not necessarily an effective strategy. Data shows that in Australia and overseas, drug use and morbidity increased under policies of prohibition, and decreased with decriminalization and regulation.[15] Harm minimisation is a principle we see being used more often in Australia’s approach to illicit drug use and prostitution. It recognises that prohibition can be counterproductive in achieving its overarching goal of improving the lives of Australian citizens. Instead, our laws regulate the potentially damaging behaviour or substance in a way that realistically protects the people involved. So why not apply a similar harm-minimization approach to surrogacy? Given that our prohibitive model is failing to protect Australian couples seeking surrogacy, and instead funnelling business into exploitative transnational surrogacy agencies, we should instead look to harm minimisation to guide how we approach the issue at hand. This could be best accomplished through the decriminalisation of commercial surrogacy in Australia. Decriminalisation and the establishment of a strictly regulated system would better enable us to protect the interests and rights of the intending parents, surrogates, and children. But what should these regulations actually look like?

A suggested solution

Ideally, a reformed system in Australia would be carried out by a centralised institution that could oversee the entire process, from psychological screening and matching, to counselling, and support services. This centralised institution could be national, state-run or not-for-profit. Strict criteria of eligibility could then more easily be applied, screening out individuals who are unsuitable for surrogacy arrangements due to medical, social, or psychological reasons. This assessment could draw on existing assessment processes for adoption.[16]

The relationship between the surrogate and intending couple appears to be the most crucial factor affecting satisfaction with the experience and the likelihood of conflict regarding parentage of the baby.[17] In fact, some studies suggest the most common reason for a surrogate to want to keep the baby is being unsure of the commissioning couples ability to provide adequate care.[17] With this in mind, matching surrogates and intended parents with similar values and desired levels of contact, as well as facilitating educated discussion about the possibilities of chromosomal abnormalities or multifetal gestation, would also mitigate conflict.  Antenatal and postnatal support, including mental health checks, could also be provided through this system.

The exclusion of profiting intermediaries increases the likelihood that the interests of all parties would be equally considered, rather than sacrificing the surrogate’s health and experience in favour of maximising profits. Moreover, any surrogacy arrangements would still be constrained by Australia’s existing common law and family law. This ensures that the surrogate maintains all the decision-making powers throughout the pregnancy, including her rights to access termination of pregnancy and to bodily autonomy.

In terms of the appropriate compensation, it seems prudent to set both a minimum and a maximum limit. Pregnancy is unavoidably risky for a woman, and gestating a growing fetus is no easy task. Why should it not, like many other jobs, receive recompense proportionate to the task? Moreover, pregnancy is intrinsically care-based ‘women’s work’, which is still insidiously undervalued even in modern times. Conversely, to titrate the price of surrogacy to the intensity of a commissioning couple’s desire for a child is hardly ethical. The US can shed light on what prices may look like in an uncapped surrogacy market; the estimated reimbursement for surrogates advertised by leading US agency Circle Surrogacy, not including medical or otherwise associated expenses, is US$30,000.[18] Most couples experiencing infertility would struggle to pay this price, which does not include medical and legal costs. The aim of setting both minimum and maximum limits on a surrogate’s compensation is to strike a balance between the interests of the surrogate and the commissioning parents – or more simply put, ensuring fair pay for fair work.

Furthermore, a centralised agency would also offer benefits for children born from surrogacy arrangements. There would exist a database through which children could later in life track down their surrogates should they choose to, just as adopted children can request information regarding their birth origins after turning 18.

The laws regarding surrogacy should be standardised across all Australian states and territories. At present, the laws are fractured and discordant, diverging on points including whether same-sex couples should be eligible to be intended parents, the legality of advertisement for surrogacy, as well as that of seeking overseas surrogates. The murky legalities of surrogacy make it confusing for surrogates without deterring commissioning parents; if they are willing to pay tens of thousands of dollars for surrogacy, they would probably be happy to travel to states with more favourable laws.[6]

Challenges of decriminalisation of commercial surrogacy

One might argue that by decriminalising commercial surrogacy in Australia, we simply shift the burden of exploitation from overseas to our own shores. The concern is that commercial surrogates will be uneducated and disempowered, and have little informed choice in the matter. If we assume that the demographic of paid surrogates in Australia would resemble that of the US, then this concern does not appear to be relevant.[17, 19] Small studies of commercial surrogates in the US have suggested the while surrogates do tend to have lower incomes and less education than commissioning parents, they are generally not of a vulnerable population. In one study, most had gone to college, or at least finished high school, were from middle income earning families, and were in long-term relationships.[17,20] Furthermore, their primary motivation was not the money, but rather to help a couple start their families. While self-report studies do have limitations, perhaps we are too quick to assign altruistic and commercial surrogates into two camps: those who are doing it purely for selfless reasons and those who are doing it for money.

The move may also be politically unpopular, with possible public resistance making the implementation slow and difficult. Moreover, creating a system which successfully protects commissioning parents, surrogates, and children born from surrogate arrangements would be a time-consuming and expensive exercise, fraught with pitfalls. Unless it is well-designed, decriminalising commercial surrogacy could perpetuate the very consequences it was designed to mitigate.


Our approach is not to judge the morality of surrogacy, neither promoting or undermining its value as a reproductive option relative to other methods such as adoption. The problem is a thorny and possibly intractable one, and requires careful consideration of racial politics, gender and income inequality, and human rights. Even in a moral grey zone, however, there are things which are arguably more morally reprehensible than others. Australian couples are resorting to the unregulated and deeply unethical commercial surrogacy market in developing countries, as a result of the failure of our current system. Working towards a safer, more regulated model of surrogacy should be on the Australian and international agenda.

Emily Feng-Gu and Keyur Doolabh

Emily is an enthusiastic fourth year medical student at Monash University. She is completing a Diploma of Liberal Arts (Philosophy), and hopes to complete a Bachelor of Medical Science next year in her area of interest: bioethics. In her spare moments, she can be found with a coffee in one hand and a book in the other.

Keyur is a medical student with an interest in philosophy. He enjoys writing, and is particularly interested in poverty, climate change and animal welfare.


The authors would like to acknowledge the contribution of ideas and research from their fellow medical students, Su Ern Poh and Eli Ivey.

Photo credit




Conflicts of interest:

None declared




1.Company H. The American Heritage Dictionary entry: surrogate [Internet]. Ahdictionary.com. 2017. Available from: https://www.ahdictionary.com/word/search.html?q=surrogate

2. Australian Institute of Health and Welfare. Adoptions Australia 2011-12. Canberra: AIHW; 2012. Contract No.: CWS 42.

3. Baby Gammy case reveals murky side of commercial surrogacy [Internet]. The Conversation. 2014 [cited 1 October 2017]. Available from: https://theconversation.com/baby-gammy-case-reveals-murky-side-of-commercial-surrogacy-30081

4. Crouch S, Waters E, McNair R, Power J, Davis E. Parent-reported measures of child health and wellbeing in same-sex parent families: a cross-sectional survey. BMC Public Health. 2014;14(1).

5. Stuhmcke A. The regulation of commercial surrogacy: The wrong answers to the wrong questions. Journal of Law and Medicine. 2015;23:333.

6. Everingham SG, Stafford-Bell MA, Hammarberg K. Australians’ use of surrogacy. The Medical Journal of Australia. 2014;201(5):270-3.

7. Alford P. Surrogacy Scandal Widens with Southeast Asia Infant Trafficking Operation Exposed. The Australian. 2014 9 August 2014.

8. Murdoch L. Australian couples’ baby plans in limbo as Cambodia bans commercial surrogacy. The Sydney Morning Herald. 2016 4 November 2016.

9. Saxena P, Mishra A, Malik S. Surrogacy: ethical and legal issues. Indian Journal of Community Medicine. 2012;37(4):211.

10. Deonandan R, Green S, van Beinum A. Ethical concerns for maternal surrogacy and reproductive tourism. Journal of Medical Ethics. 2012;38(12):742-5.

11. Trimmings K, Beaumont P. International surrogacy arrangements: legal regulation at the international level: Bloomsbury Publishing; 2013.

12. Fact sheet – International surrogacy arrangements [Internet]. Border.gov.au. [cited 1 October 2017]. Available from: http://www.border.gov.au/about/corporate/information/fact-sheets/36a-surrogacy#offshore

13. Birth, adoption and surrogacy [Internet]. Smartraveller.gov.au. [cited 1 October 2017]. Available from: http://smartraveller.gov.au/guide/all-travellers/birth-death-marriage/pages/birth-adoption-and-surrogacy.aspx

14. Macaldowie A, Wang YA, Chambers GM, Sullivan EA. Assisted reproductive technology in Australia and New Zealand 2010: AIHW; 2012.

15. Wodak A. The failure of drug prohibition and the future of drug law reform in Australia. Australian Prescriber. 2015;38(5):148-9.

16. Review of the Adoption Act 1984. Melbourne: Victorian Law Reform Commission; 2015.

17. Busby K, Vun D. Revisiting The Handmaid’s Tale: Feminist theory meets empirical research on surrogate mothers. Can J Fam L. 2010;26:13.

18. Circle Surrogacy. Anticipated Costs for Gestational Surrogacy [Available from: http://www.circlesurrogacy.com/costs.

19. Jadva V, Murray C, Lycett E, MacCallum F, Golombok S. Surrogacy: the experiences of surrogate mothers. Human Reproduction. 2003;18(10):2196-204.

20. Ciccarelli J, Beckman L. Navigating Rough Waters: An Overview of Psychological Aspects of Surrogacy. Journal of Social Issues. 2005;61(21):21-43.



Polio vs Politics: The Case of Pakistan


Polio is a highly infectious disease caused by poliovirus which predominantly infects young children by invading the nervous system and can result in paralysis.[1] Polio reached epidemic proportions in the early 1900s but was brought under control after the introduction of effective vaccines in the 1950s and 1960s.[1] Despite the progress that has been made, as long as a single child remains infected with poliovirus, children in all countries are at risk of contracting the disease.[2] This is because poliovirus can easily be imported into polio-free countries and subsequently spread, potentially resulting in as many as 200,000 new cases every year. There is no cure for polio, it can only be prevented by the polio vaccine which, if administered correctly, can protect a child for life.[2] As such, vaccination programs are key to achieving global polio eradication.

War and civil unrest have a destructive effect on population health. In particular, conflict increases the prevalence of vaccine preventable diseases and decreases the success of vaccination programs.[3] For instance, Pakistan is one of the few countries in the world where polio is still endemic [1, 4, 5] and this is largely due to its geopolitical and socioeconomic challenges.[6] In 2006, Taliban insurgency intensified in Pakistan and the resulting political insecurity has been directly associated with the rise in polio transmission.[7] Failure to achieve polio eradication in Pakistan demonstrates the importance of non-health sector issues, such as barriers to access in war and conflict zones [6].

Conflict and insecurity in Pakistan is clustered in Khyber Pakhtunkhwa (KP) and Federally Administered Tribal Areas (FATA) which are home base to the Taliban and al-Qaeda.[5, 7, 8] The conflict and insecurity in KP and FATA has led to a dramatic rise of reported paralytic polio cases in Pakistan with more than 85% of the global polio cases coming from these regions.[7, 9] The establishment of KP and FATA as major polio reservoirs is undeniably linked to active conflict and insecurity in these regions.[7-10]

Polio eradication in Pakistan jeopardises worldwide efforts aimed at eradicating polio.[6] In 2013, polio strains originating in Pakistan were detected in sewage samples in Egypt, Israel, the West Bank, the Gaza Strip, Syria, and Iraq.[1, 7] The first subsequent polio case occurred in Syria in October 2013, resulting in 35 children being paralysed by November.[1] The first Iraqi polio case was confirmed in March 2014.[1] Polio has spread from Pakistan in South Asia to countries in the Middle East that have been polio-free for decades, unraveling progress that has been made on a global scale [1, 7] and confirming that polio eradication is no longer solely Pakistan’s problem, but a global one.

Fueling this problem is the United States’ involvement in Pakistan. In 2011, the CIA attempted to obtain DNA samples from the children in KP as part of the search for Osama bin Laden. In order to do this, the CIA conducted a fake vaccination program against hepatitis B, leading to an erosion of public trust in immunisation.[1, 7-9] The use of aid workers for intelligence purposes and the use of health initiatives to advance security and foreign policy motives has undermined global healthcare initiatives aimed at polio eradication, jeopardising long-term global health goals.[7]

Recent fatal attacks on polio vaccination workers in politically fragile parts of Pakistan pose a further threat to the global eradication of polio.[11] It is believed that the international attention paid to polio eradication may have led terrorist groups to believe that they can achieve some of their aims by interfering with its eradication.[11] As such, the Pakistani Taliban announced in June 2012 that it would place a ban on all vaccinations until the United States ended drone strikes.[9] Since then, the Taliban have orchestrated targeted attacks on immunisation teams that have tragically killed over 40 vaccinators.[1, 7] This includes the killing of Abdul Ghani (who was the head of the government’s vaccination campaign) by a road-side bomb after upon his return from a meeting with tribal elders to dispel rumours that vaccination is a U.S. conspiracy to sterilize their children.[5] To this day, vaccination program staff remain under threat of kidnappings, beatings, harassment, and even assassinations in conflict zones.[9]

It is believed that the actions against polio workers may be driven by two objectives; to terrorise local populations and government workers, or to stop the house-to-house movement of polio workers who some terrorist groups suspect of carrying out US surveillance activity (brought about by the fake hepatitis B campaign).[11] Regardless of the reason, it is clear that polio eradication has evolved into a war tactic resulting in an environment of fear and anarchy.

Global health initiatives are becoming increasingly intertwined with diplomatic, foreign policy, and security interests.[7] This is not limited to Pakistan: earlier this year, six Red Cross Aid workers were killed in Afghanistan [12], and healthcare in Syria has been transformed into a target of war.[13] It is clear that global health programs can no longer isolate themselves from economic, security, and political interests.[7] The recent portrayal of polio as the new battleground between Western forces and terrorist groups illustrates the importance of efforts to depoliticise polio activities.[11] We can no longer allow security or foreign policy motives to undermine polio eradication and thus compromise the wellbeing of the 7.5 billion people living on earth.

Key Messages

  • The persistence of polio in Pakistan jeopardises worldwide efforts aimed at eradicating the disease.
  • Global health initiatives are becoming increasingly intertwined with the diplomatic, foreign policy, and security interests
  • With the portrayal of polio as a battleground between Western forces and terrorist groups, greater effort should be made to depoliticise polio activities

Jeanine Hourani

Jeanine has just completed her first year of the Master of Public Health at the University of Melbourne, having come from an Immunology & Microbiology background. She is particularly interested in refugee and migrant health as well as the effect of warfare on Public Health. Her previous work includes ‘As Syria Bleeds’ which explores the effect of the Syrian Crisis on the health system.

Photo credit

Sanofi Pasteur / Almeena Ahmed / Sanaullah Afridi, accessed from https://www.flickr.com/photos/sanofi-pasteur/29837040256/in/album-72157673062558422/

Conflicts of interest

None declared




1. Akil L, Ahmad HA. The recent outbreaks and reemergence of poliovirus in war and conflict-affected areas. Int J Infect Dis. 2016;49:40-6.

2. WHO. Does polio still exist? Is it curable? 2017 [Available from: http://www.who.int/features/qa/07/en/.

3. Glatman-Freedman A, Nichols K. The effect of social determinants on immunization programs. Hum Vaccin Immunother. 2012;8(3):293-301.

4. Afzal O, Rai MA. Battling polio in Pakistan: breaking new ground. Vaccine. 2009;27(40):5431.

5. Ahmad K. Pakistan struggles to eradicate polio. The Lancet Infectious Diseases. 2007;7(4):247.

6. Nishtar S. Pakistan, politics and polio. Bull World Health Organ. 2010;88(2):159-60.

7. Hussain SF, Boyle P, Patel P, Sullivan R. Eradicating polio in Pakistan: an analysis of the challenges and solutions to this security and health issue. Global Health. 2016;12(1):63.

8. Roberts L. Fighting Polio in Pakistan. Science. 2012;337.

9. Chang A, Chavez E, Hameed S, Lamb RD, Mixon K. Eradicating Polio in Afghanistan and Pakistan. A Report of the CSIS Global Health Policy Center. 2012.

10. Shah M, Khan MK, Shakeel S, Mahmood F, Sher Z, Sarwar MB, et al. Resistance of polio to its eradication in Pakistan. Virol J. 2011;8:457.

11. Abimbola S, Malik AU, Mansoor GF. The Final Push for Polio Eradication: Addressing the Challenge of Violence in Afghanistan, Pakistan, and Nigeria. PloS Med. 2013;10(10):1-4.

12. SBS. Opinion: Aid workers are not a target, and never should be 2017 [Available from: http://www.sbs.com.au/news/article/2017/02/17/opinion-aid-workers-are-not-target-and-never-should-be.

13. The Guardian. Syria ëthe most dangerous place on earth for healthcare providersí 2017 [Available from: https://www.theguardian.com/world/2017/mar/15/syria-conflict-study-condemns-weaponisation-of-healthcare.

Turning up the Heat


American environmentalist and journalist, Bill McKibben, offers a simple yet revolutionary proposition in the climate debate: “Leave oil in the soil, coal in the hole and gas under the grass”.

The birth of an idea

Divestment is a very simple idea. You just remove your money from companies that are involved in extracting fossil fuels. It’s a novel movement in the climate debate that is different from your traditional change-your-lightbulb kind of ideas.

Its underlying basis is that to avoid catastrophic global warming, we will need to reduce our carbon dioxide emissions. There are three key numbers that explain this. First, 2˚C is the maximum global temperature rise this century that is aspired to in the Paris Agreement.[1] Secondly, we have a ‘carbon budget’ of 565 gigatons which is essentially the amount of carbon dioxide that can safely be released into the atmosphere while still complying to our 2˚C rule.[2] Most importantly, the third number to know is 2795 gigatons. This is the amount of carbon dioxide that will be released if all of the documented fossil fuel reserves were burned.[2]

Addressing a sixfold rise in energy demand in the last 50 years, fossil fuels provide roughly 80% of the energy we need through coal, gas and oil.[3] Yet, the money-making industry releases greenhouse gases into the atmosphere and thickens Earth’s blanket of air pollution which led to 3.7 million deaths in 2012 due to pneumonia, asthma, heart disease, stroke and cancer.[3] Needless to say, carbon dioxide is a tiny molecule with a big bite.

So, while as individuals we could make some adjustments such as changing our lightbulbs and switching from car use to public transport, if companies continue to dig up and burn their reserves, these measures will prove This is where divestment comes in – a movement about shifting your money away from the problem and towards the solution.

Turning back time

In history, divestment has been shown to be a powerful political tool in several major movements. ­­­

In the latter half of the 20th century, a time when South Africa’s Apartheid was our world’s largest moral issue, two prominent figures created massive change. Nelson Mandela and Desmond Tutu suggested a revolutionary tactic to help counter institutionalised racial segregation and white supremacy, imploring Western institutions to cut their economic ties with companies backing the Apartheid regime. Experts often deem this as the model of symbolic pressure as it raised awareness and embarrassed many American businesses.[4]

Then, through the 1990s, a movement against the tobacco industry took place to shun the industry’s negative impacts on health. Along with regulation and taxation, tobacco divestment had a sizeable impact on society, shrinking the industry and smoking rates.[4]

Most recently, divestment has had a role in the Darfur genocide – the first genocide of the 21st century. Darfur divestment involves removing money away from companies with ties to the Sudanese government. Some Western institutions including Brown University divested; however, other investors interested in the nation’s valuable resources simply filled their place. Drawing from this rather unsuccessful campaign, fossil free activists are encouraged to consider how their actions could lead to the success or failure of the divestment movement. More specifically, it is important to weigh the impact of divesting from a company relative to giving up your voice as a shareholder.

Fuelling a movement 

Nevertheless, the balance scales show that divestment is well worth the bet. Major goals of the fossil fuel divestment campaign can be captured in the following:[4]

  1. leverage the power of investors and institutions to make strong political statements and influence policy change
  2. raise awareness of the impact of the fossil fuel industry in our society
  3. lead the market to consider the effects of climate change when evaluating any investments
  4. drive capital investment into clean energy and other climate mitigation strategies

Above all else, divestment stigmatises the fossil fuel industry, eroding its social license to operate and posing the largest threat to these companies.

And, if you have not figured it out yet, the fossil fuel divestment campaign is not a normal movement. There are no great leaders. There is no Gandhi or Martin Luther King Jr. of the climate movement. But, establishing firm roots in society, the fossil fuel movement is set to be colossal with or without a figurehead.

Blossoming ideas

Since its initial conception in 2010, the idea of fossil fuel divestment has been spreading like wildfire. The campaign celebrated its first major victory in mid-2014 when Stanford University committed to divesting its US$18.7 billion endowment from the industry.[5] Later that year, the campaign inspired the People’s Climate March where a 400,000-strong crowd flooded Manhattan’s streets, demanding U.N. action on global warming.[4] By 2015, around 2500 investors representing US$2.6 trillion in assets had divested, including major organisations such as the Rockefeller Brothers Fund and the Canadian Medical Association.[6]

Back home, Australian universities are making bold statements with the help of several fossil free organisations on campus. La Trobe University, Swinburne University and the Queensland University of Technology pledged to divest their A$40 million, A$150 million and A$300 million portfolios from fossil fuels respectively.[7] Recently, both Monash University and the Australian National University have partially divested.[8] But sadly, Westpac, ANZ, NAB and the Commonwealth Bank – which make up the ‘big four’ banks of Australia — have failed to divest, instead funding the industry to the tune of A$5.5 billion in 2015.[7]

Figure 1: global health groups are leading the fossil fuel divestment game with eight societies having divested; while, only three medical societies have divested so far.

Pop goes the bubble

From an economic point of view, fossil fuel divestment is falsely thought to come with financial uncertainty and major repercussions. Addressing this, a key argument in the fossil fuel divestment campaign is that returns will, in fact, improve once investors have divested – an argument based on a concept called the ‘carbon bubble’ – named by the Carbon Tracker Initiative. Much like the US housing bubble of 2009, the ‘carbon bubble’ has its underlying roots in the fact that our financial markets The problem here is that all reserves simply cannot be burned if we intend to comply with the ‘carbon budget’, or else, there’s no doubt that we will find ourselves amidst catastrophic climate change.

More importantly, with increasing pressure from pollution regulations, competition from renewables and one of history’s fastest growing stigmatisation campaigns, the value of fossil fuels is already diminishing.[4,8] Last year, energy use emissions grew less than 1% for the third consecutive year.[9] Oxford University researchers and commercial analysts are predicting that fossil fuels are likely to become ‘stranded assets’ which cannot be used, rendering them worthless to investors.[8, 9] It follows that investors should prepare for such a scenario by selling their assets now rather than after the ‘carbon bubble’ bursts when investors are likely to lose money.

Preparing accordingly, investors in Wall Street banks, such as HSBC and Chase, have demanded that fossil fuel companies discuss the risks of the bubble; while, oil companies, including Shell, are now committed to disclosing their asset portfolios and discussing the bubble.[4] Similarly, with major financial news venues such as Bloomberg and the Financial Times now backing the movement, we are beginning to achieve one of our primary aims: influencing the economy’s thinking on climate change.[4] In fact, as of September 2017, US$5.53 trillion has been divested by almost 800 institutions.[7]

Renewable energy: a brave new world of investment

So, you move your money away from the fossil fuel industry and then what? Many experts have shown that investing in ethical funds such as the renewable energy industry will have financial returns similar to, if not better than, the fossil fuel industry.[10]

Renewable energy has made ambitious headlines around the world. For instance, China recently became home to the world’s largest solar farm at 27-square-kilometres which can produce 850 mega-watts of power – enough to supply around 200,000 households.[11] However, even though renewable technology needs to be used by all, it’s only accessible to those who can afford it. Addressing this gap, many grassroots movements are committed to providing renewable energy to developing nations. For instance, one such foundation, Liter of Light, teaches communities to recycle plastic bottles and use locally sourced materials with the aim of illuminating their homes – a strategy which has received much recognition and is often adopted for use in UNHCR camps.[12]

The power of smaller players  

Speaking of smaller players making big waves, medical societies and faculties, are major targets of the fossil fuel divestment campaign. As highly regarded entities within universities, they are large enough to matter but small enough to have an influence on. Now, more than ever, we are seeing Australian medical university groups divesting (Figure 1). Most recently, the University of Newcastle’s global health group, Wake Up!, switched from the Commonwealth Bank to Newcastle Permanent – a major win in our medical scene (Figure 2). Although divestment will not cripple the fossil fuel industry overnight, this strategy can still operate effectively, conveying a loud and clear message of disapproval – an objective we are closer to achieving thanks to societies like Wake Up!

One of divestment’s main jobs is to draw attention and challenge the status quo – a powerful opportunity to be noticed, and be remembered, in times of tragedy and turbulence. It’s a movement that inspires students, banks and universities alike to make ethical commitments and invest in a sustainable future. With global warming looming large, now is the time to blaze trails and boldly transform the climate debate.

Figure 2: the committee of the University of Newcastle’s global health group, Wake Up!, proudly put their W’s up to celebrate their divestment win. Congrats Wake Up!

Key messages

  • Fossil fuel divestment is a very simple idea: a global movement focussed on shifting money away from a problem and towards a solution.
  • Divestment has been shown to be historically successful
  • Establishing firm and expansive roots in our society, divestment now sets out to radically influence the world’s thinking on climate change

Tara Kannan

Tara Kannan is a first-year MD student at the University of Newcastle. Passionate about global health, she represents AMSA’s 2017 Code Green portfolio within her university’s global heath group. She believes that a major way forward in advancing medicine on the world stage is through nursing our environment back to good health. Aside from that, when she’s not busy dissecting Guyton’s diagrams, she enjoys perusing news articles online and loves her Cadbury.

Conflicts of interest

None declared




1. United Nations Framework Convention on Climate Change: Adoption of the Paris Agreement. 21st Conference of the Parties, 2015: Paris, France: United Nations.

2. 350.org. Do the Math [Internet]. Math.350.org. 2017 [cited 15 September 2017]. Available from: http://math.350.org/

3. Perera F. Multiple Threats to Child Health from Fossil Fuel Combustion: Impacts of Air Pollution and Climate Change. Environmental Health Perspectives. 2017; 125: 141-8. Doi:10.1289/EHP299

4. Apfel DC. Exploring Divestment as a Strategy for Change: An Evaluation of the History, Success, and Challenges of Fossil Fuel Divestment. New School for Social Research. 2015; 82:913-37.

5. Carroll R. Major University Divests $18 Billion Endowment From Coal Companies [Internet]. HuffPost. 2017 [cited 15 September 2017]. Available from: http://www.huffingtonpost.com/2014/05/07/stanford-university-divesting_n_5276899.html

6. Rowe JK, Dempsey J, Gibbs P. The Power of Fossil Fuel Divestment (And its Secret). The University of California eScholarship. 2016.

7. Go Fossil Free. Divestment Commitment [Internet]. Go Fossil Free. 2017 [cited 15 September 2017]. Available from: http://gofossilfree.org/commitments

8. Ansar A, Caldecott B, Tilbury J. Stranded assets and the fossil fuel divestment campaign: what does divestment mean for the valuation of fossil fuel assets?. Smith School of Enterprise and the Environment. 2013.

9. Brahic C. Living with climate change: Have we reached peak emissions? New Scientist. 2017; 234: 32-4.

10. De George R. Ethics, corruption, and doing business in Asia. Asia Pacific Journal of Economics and Business. 1997; 1: 39ñ52.

11. Phillips T. China builds worldís biggest solar farm in journey to become green superpower #GlobalWarning [Internet]. The Guardian. 2017 [cited 15 September 2017]. Available from: https://www.theguardian.com/environment/2017/jan/19/china-builds-worlds-biggest-solar-farm-in-journey-to-become-green-superpower

12. Liter of Light. Liter of Light – About Us [Internet]. Liter of Light. 2017 [cited 15 September 2017]. Available from: http://literoflight.org/about-us/

Coal Mining, Climate Change and the Global Impacts on Health: Examining Adani’s Proposed Carmichael Coal Mine



The proposed Adani-owned Carmichael coal mine in central Queensland is currently in the final stages of planning with the support of both the Queensland and Australian governments. It is in the interest of human health, locally and abroad, for the medical profession to advocate on behalf of the community and lobby our legislators to reject this project.

The Carmichael site will be the world’s largest export coal venture and the biggest mining site in Australia, consisting of six open cut pits and five underground mines. Mined in the Galilee Basin, 160km north-west of Clermont, coal will then be transported on a new railway network before connecting to shipping terminals bound for India via the Great Barrier Reef Marine Park.[1] Adani has stated that it plans to mine 60 million tonnes of coal every year over the expected 60 year lifespan of the Carmichael mine site.[2] The estimated annual average emissions of the proposed Adani coal mine are equivalent to the annual emissions of Malaysia, Vietnam or Sri Lanka.[3]

The Carmichael mine is a highly politicised topic with widespread implications. This article considers some of the impacts on Australia’s economy, our natural environment (and that of our regional neighbours), and crucially; the seriousness of the Carmichael mine’s contribution to climate change and its effect on human health.

Health Implications on a Global Scale

The World Health Organization (WHO) has said that climate change is the greatest threat to human health this century.[4] This gigantic coal mine is set to contribute significantly to climate change. It will adversely affect population health through greenhouse gas emissions, waterway damage and land clearing. A report recently published in The Lancet has condemned the planned Adani Carmichael project as a “public health disaster”, arguing that the health impacts and environmental damage will be significant for Australia and its regional neighbours.[5]

The net effect of obtaining and using coal from the Carmichael site is estimated to release 4.7 billion tonnes of greenhouse gas emissions,[6] which will contribute to climate change. This will result in increased human exposure to pollen, moulds and air pollution, reducing air quality and increase the incidence of respiratory diseases.[7] Ambient pollution in Australia is primarily derived from fossil fuel powered electricity generation, heavy industry and wood or coal based home heating.[8] Annually, 3000 Australians die due to urban air pollution, more than the national road toll.[9] In its current state, the air pollution problem is already being insufficiently addressed. Additionally, exposure to ozone is linked with increased hospital admissions for respiratory diseases amongst both children and the elderly.[10] Our legislators must act decisively and commit meaningful action to reduce the impact of climate change as it will affect the health of future generations and our present vulnerable elderly population.

Currently, 5% of the population will experience an allergic respiratory response to airborne moulds during their lifetime.[11] Changes in global precipitation are likely to increase the prevalence of airborne moulds.[7] Additionally, ambient air pollutants and allergens are most likely to exacerbate respiratory disease in individuals with pre-existing respiratory conditions.[12] Climate change associated air pollution will undoubtedly worsen the quality of life of patients living with chronic airway diseases.

Coal combustion affects the water as well as the air. Rising water temperatures linked to climate change will cause further aerosolisation of marine toxins, thereby increasing respiratory disease prevalence globally.[7] Asthmatics exposed to the harmful algal bloom Karenia brevis’ marine aerosols on the south east coast of the United States of America (USA) experienced respiratory symptoms after just one hour of exposure. Inland residents experienced an average of 3.49 symptoms, more than coastal residents, who experienced an average of 2.24 symptoms.[13] This suggests that aerosolisation of marine toxins will increase respiratory morbidity as climate change related aerosols proliferate and distribute further afield.

The cardiovascular burden of disease will worsen in the future if action is not taken now to reduce the impacts of climate change.[7] Airborne particulate matter is associated with compromised heart function, atherosclerotic disease, deep vein thrombosis,[14] and pulmonary embolism.[15] The particulates contributing to air pollution include black carbon, sulphates, nitrates, a complex mixture of metals and other by-products from the incomplete combustion of fossil fuels.[16] In areas with long term exposure to high levels of particulate matter air pollution, it was found that an increase of just 10 ug/m3 is associated with a 70% increase in DVT risk.[15] Ozone is another key pollutant – exposure to a 10g/m3 increment has demonstrated an increase in the risk of cardiopulmonary mortality by 1.014 times.[14] Both particulate matter and ozone type air pollution cause adverse cardiovascular outcomes.

Increased global temperatures will exacerbate heat related deaths due to an increased frequency of heat stress events.[7] Untreated heat exhaustion can progress to heat stroke,[17] of which 15% of cases are fatal.[18] Heat related health events typically occur on the same day as initial exposure.[19] Emergency departments (ED) in Brisbane have demonstrated that during days ≥35°C, elderly patients were 1.9 times as likely to present to the ED and 3.75 times as likely to present due to heat-related complications specifically.[20] Based on current modelling of Brisbane’s population growth, ED presentations on days ≥35°C and the projected climate change related temperature increases, it is predicted to cause a 125-2065% increase in excess visits by 2060.[20] Consequently, political inaction now will continue to worsen the burden on public ED services.

The psychological impacts of climate change are generally indirect and have only recently been considered as part of the widespread impacts of climate change on health. Extreme weather events can lead to mental health disorders associated with loss, displacement and social disruption. This can increase anxiety about the future, with already-disadvantaged communities most likely to suffer the most severe consequences.[21] Two hundred million people will be displaced by climate change by 2050.[22] This emerging group of environmentally displaced people will need support to cope.[23] Climate change has the potential to create disasters beyond the capacity of developing nations’ public health systems.[24] Action must be taken to reduce the impact of climate change for the sake of public health. The global community is interconnected and each nation has the responsibility to reduce its contributions to climate change. Consequently, the impact of the planned Carmichael mine site and its extensive environmental damage will have substantial impact on human health into the future.

Locally, coal worker’s pneumoconiosis has re-emerged in Queensland with at least 20 cases recently diagnosed, highlighting the lack of appropriate health protection within the Queensland coal industry.[25] If the Queensland and Australian governments can’t manage these Occupational Health and Safety issues at home, how can they contribute to the ‘safe’ delivery and burning of this coal in Adani’s power stations in India – a country where air pollution already kills an estimated 1.1 million people annually.[26] If the mine proceeds, the flow on effects of poor governing locally will have detrimental health impacts on a global scale.

Environmental Implications

The establishment of the proposed Carmichael coal mine and its shipping impact will damage vital ecosystems and reshape the lives and health of the people reliant on waterways and reefs. More than 500 million people around the planet rely on coral reefs for food, income and storm protection.[29] Climate related changes in waves, ocean circulation, cyclone frequency, temperature and precipitation will impact fisheries in tropical Queensland and further north.[30] Additionally, fisheries in our region may be contaminated by chemicals released into seawater by the mine and from increased shipping traffic. This will have economic, social and health implications and affect the productivity of the seafood industry in Australia and surrounding nations, especially those that rely on it as a major industry and cultural cornerstone.[30] Climate change associated contamination of food staples is also likely to impact on nutrition and human development.[7] In parallel, the social aspects of recreational fishing are also highly sensitive to climate change.[30] Thus, along with the state of the environment, multiple social determinants of health are at risk of declining for our coastal communities.

Implications for Australia

In Central Queensland, the proposed Adani mine will see more than 10,000 hectares of native bushland cleared from around the Galilee Basin. Combined with the Carmichael mine’s generous water licence enabling unlimited groundwater use from the Great Artesian Basin,[31] this has huge potential for irreversible environmental damage.

The Great Artesian Basin is a drought-prone area that is critically responsible for supplying an estimated 200 towns and settlements with irrigation and drinking water.[31] The construction of the world’s largest coal mine at this site could risk the livelihoods and lives of Australian primary producers in this region. The importance of water security in drought-prone areas is tantamount and supporting this mine renders these remote Australians even more vulnerable. Australians living in rural and remote settings already have a lower standard of health service provision and are more likely to suffer worse health outcomes as a consequence of their social determinants.[32] The health impacts from the proposed mine are likely to impact rural Australians to an even greater magnitude.

Massive quantities of coal will be shipped overseas through the Great Barrier Reef.[3] It is feared that this will exacerbate the already extensive coral bleaching. This will impact Australian coastal communities as the Great Barrier Reef and other coral reefs provide protection from wave and storm damage.[33]

Implications for Australia’s regional neighbours

Climate change is projected to slow economic growth, erode food security and hinder poverty reduction. The negative effects will be most felt by those who are already disadvantaged.[34] This is especially pertinent for our regional neighbours, predominately developing countries.

Many of our regional neighbours are already suffering from the effects of climate change. Bangladesh has experienced increased temperatures, swollen rivers and sea level rises; all which threaten infrastructure, livelihoods and homes and undermining the region’s development.[35] Climate change is now making cyclones on many of our neighbouring Pacific Islands even more powerful and destructive. In 2016, Tropical Cyclone Winston hit Fiji, affecting more than half a million people and decreasing its national GDP by one-fifth.[36] As a developed nation, our government has a responsibility to contribute to the prosperity, safety and health of our region by supporting these developing nations. This begins with reducing our carbon footprint by stopping the expansion of our fossil fuel industry, including the proposed Carmichael coal mine.

The climate impacts of the proposed Carmichael coal mine go against Australia’s international commitment to promote a sustainable future by limiting increases in global temperatures. The United Nations Framework Convention on Climate Change (UNFCCC) promotes the work of the Paris Agreement to limit a global temperature rise this century to below 2°C above pre-industrial levels.[27] Many of our regional neighbours do not believe this goes far enough. The “1point5toStayAlive” movement by the Caribbean and their partner states is fighting to prevent the temperature associated rises in sea levels in order to prevent their nations going underwater. A 2°C goal requires a 40-70% reduction in greenhouse gas emissions compared with 2010 levels, whereas a 1.5°C increase will require a 70-95% reduction.[28] As one of the most influential developed countries in our region, Australia has a responsibility to support the continuing development of our regional peers. This begins with supporting their call for action to reduce the global temperature rise to 1.5°C. There is simply no room for the proposed Carmichael coal mine and its extensive pollution in a sustainable future – a future that needs action now.

Economic and Political implications

The proposed Carmichael mine project has struggled to achieve financing. Nineteen banks (including Australia’s ‘Big Four’) have refused to fund the venture due to ethical concerns, environmental policies, or the likelihood that renewable energy will outprice fossil fuels over the proposed life of the mine. The use of Australian mined coal in Indian power plants will also inevitably become economically foolhardy.[37] Both the Australian and Queensland governments should not continue to support this proposal as it will create few lasting jobs and crucially it will increase the loss of human life and burden of disease locally and abroad.

The continued approval of Adani’s Carmichael mine by the Australian and Queensland governments is unwise as the economic return on taxpayer investment is questionable. The Northern Australia Infrastructure Facility (NAIF) has proposed a $1 billion AUD loan to Adani for the North Galilee Basin Rail Project – a 310km rail link from the mine site to the Abbot Point export terminal. Despite widespread coverage, little information was publicly available at the time of writing; only four documents were published on NAIF’s website, with none focussing explicitly on coal mining in the Galilee Basin.[38-41] Both Adani and the former Minister for Resources and Northern Development have suggested that the loan is “not critical” and consequently the mine should be ineligible for NAIF funding.[42] Other requirements for NAIF funding include public benefit and commercial viability, both of which are questionable.[42]

Adani continues to claim that the Carmichael mine will create 10,000 direct and indirect jobs. However, reef industries threatened by the mine provide approximately 69,000 jobs.[43] The proposed “10,000 jobs” is even more questionable because Adani has, under oath, stated only 1,464 jobs will be created.[42] A loan of this magnitude seems wasteful for taxpayers. In September 2016, the Minister for Resources and Northern Australia Matthew Canavan stated that opening the Galilee Basin for coal mining would “not damage the environment”.[38] The political mismanagement and fabrications surrounding the Carmichael mine site are a disservice to Australian taxpayers.

The lifespan of the proposed Carmichael coal mine is 60 years.[2] Australian coal is expected to be burnt in India, a country where the Power Minister plans to ban coal imports. India’s draft National Electricity plan states that until 2022, India will not require an increase of coal from its current rate of supply.[44] India is also a signatory to the Paris Agreement and has declared commitment to utilising emerging “cleaner sources of energy” as they become feasible.[45] The long term profitability of Adani’s Carmichael coal mine is even more questionable as there is growing public discontent in India with coal-based power sources and its resulting air pollution. Whilst there was an absolute increase in the use of coal in India, renewable generation grew at over six times the rate of conventional sources. Between April-October 2016, 28% of Indian energy production came from renewable resources.[44] This demonstrates that the global trend towards increasing utilisation of renewable energy sources is extending to India and the coal industry is declining.

The United Nations (UN) recognises that climate change is a threat to human health and rights.[4] In 2016, Australia ratified the Paris Agreement with a declaration to work towards combatting climate change. Yet due to the export nature of the proposed Adani Carmichael coal mine, these Australian sourced emissions will not count as part of our Intended Nationally Determined Contributions. The UN’s Committee on Economic, Social and Cultural Rights (CESCR) stated that Australia’s increasing carbon footprint is “at risk of worsening in the coming years”[46] which would undermine the vision of the Paris Agreement and its predecessor, the Kyoto Protocol, both of which we are signatories to. The CESCR’s panel of international human rights experts has recommended Australian politicians “review (their) position in support of coal mines and coal export”.[46] In light of the USA’s recent withdrawal from the Paris Agreement, it is of increased importance for Australia and other developed countries to consider the impact of our carbon footprint beyond our national border. 


The real cost of Australia enabling the continuing burning of coal will be measured in health impacts, hunger and humanitarian disasters. Therefore, the Australian and Queensland governments must act now to preserve the health of Australian and global citizens into the future. The medical profession has a long and proud history of protecting public health. We must add our voices to the wave of protest to stop the construction of the world’s largest coal mine, and for the sake of our patients’ health, to make coal history.

John E Morgan

John Evan Morgan is a fourth year medical student at James Cook University. He is passionate about advocacy, climate change and issues facing the developing countries within our region. He is a member of Doctors for the Environment and AMSA’s Mental Health Campaign. Based in Cairns, he loves bushwalking and camping (and so far hasn’t had any crocodiles up close).


Doctors for the Environment Australia

Conflict of Interest

None declared




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  2. Australian Government. Carmichael coal and rail infrastructure factsheet [Internet]. Canberra ACT: Minister for the Environment’s office; 2014 [cited 2017 Aug 28]. Available from: https://www.environment.gov.au/minister/hunt/2014/pubs/mr20140728-factsheet.pdf
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  42. Swann, T. Don’t be so naif; Adani and Governance of the Northern Australia Infrastructure Facility (NAIF) [Internet]. Canberra ACT: The Australia Institute; Mar 2017 [cited 2017 Oct 15]. Available from: http://www.tai.org.au/sites/defualt/files/P318%20Dont%20be%20so%20naif%20FINAL.pdf
  43. Deloitte Access Economics. Economic Contribution of the Great Barrier Reef [Internet]. Townsville Qld: Great Barrier Reef Marine Park Authority; Mar 2013 [cited 2017 Oct 15]. 52p. Available from: http://www.environment.gov.au/system/files/resources/a3ef2e3f-37fc-4c6f-ab1b-3b54ffc3f449/files/gbr-economic-contribution.pdf
  44. Burton B, Fernandes A. Is the Indian coal domino about to fall? [Internet]. Australia: Renew Economy; Dec 2016 [cited 2017 Oct 15]. Available from: http://reneweconomy.com.au/indian-coal-domino-fall-91973/
  45. United Nations Framework Convention on Climate Change. Paris Agreement – Status of Ratification [Internet]. New York USA: United Nations; Dec 2015 [updated Apr 2017; cited 2017 Oct 15]. Available from: http://unfccc.int/paris_agreement/items/9444.php
  46. United Nations Committee on Economic, Social and Cultural Rights. Concluding observations on the fifth periodic report of Australia [Internet]. Geneva Switzerland: United Nations Office of the High Commissioner; 2017 July 11 [cited 2017 Aug 28]. Available from: http://tbinternet.ohchr.org/_layouts/treatybodyexternal/Download.aspx?symbolno=E%2fC.12%2fAUS%2fCO%2f5&Lang=en

Paddling Upstream: Experiences from a Medical Placement in Rural Papua New Guinea


I sit in an office on my GP rotation. My insides burn, courtesy of my morning doxycycline. The patient, who has come in with fever and a sore throat, coughs. I flinch. My eyes fly across the room, searching for a face mask. Then I remember I am back in Toowoomba, and not every fever is likely due to an unpronounceable parasitic infection. This is perhaps a slight dramatisation of my GP block, however, I cannot help but cast my mind back to when a cough could signal something far more sinister than an URTI.

I was recently given the opportunity to spend six weeks at the Kiunga District Hospital in rural Papua New Guinea (PNG) as part of the Griffith Rural Medical Education program. Every rotation block, four students are given the opportunity to spend six weeks in Kiunga hospital. For those as unfamiliar with Papua New Guinean geography as me prior to my visit, Kiunga is a town in the western province of PNG, on the banks of the Fly River. The hospital serves a town of approximately 13000 people, in addition to being a referral centre for the region, with approximately 45 beds spread over numerous wards (medical, surgical, women’s), as well as a pathology lab and an emergency department/outpatient department (OPD). The wards are managed by a physician and a surgical/obstetrics and gynaecology doctor, health extension officers, community health workers and nurses. As medical students we were well accustomed to being at the bottom of this hierarchy; however, in PNG we were given far greater responsibility.

General Ward

Common things occur commonly. This phrase had been thrown at me all throughout my clinical years. Most coughs are probably not cancer, most sore throats are not the harbinger of quinsy. However, the medical ward showed us just how context-specific this phrase is, with the words ‘common things occur commonly, therefore, this is probably tuberculosis or malaria’ heard at least once per ward round. Ascites was probably due to abdominal seeding of tuberculosis, a headache was probably due to cerebral malaria. We quickly learned to appease the ward doctor by suggesting tuberculosis as the cause for nearly every presenting complaint. The range of tropical diseases surpassed my expectations, from tuberculosis, malaria and malnutrition, to less common cases of severe AIDS and Buruli ulcers. I was even exposed to diseases I had not even fathomed I might see, such as toxic epidermal necrolysis as a result of leprosy medications.

Our time in the general ward consisted of a morning ward round followed by jobs, and it was eye-opening to see how health care could be limited by a lack of resources. Intramuscular antimalarials often ran out, meaning that oral antimalarials had to be followed by an ondansetron chaser. There was no adrenaline in the emergency room, meaning it was necessary to trawl the hospital to find some before it was needed. A lack of funds for staff meant the occupants of the tuberculosis ward were at the far end of the general ward, placing the rest of the patients at risk of nosocomial infection. Consequently, we soon learned that ward rounds began by applying appropriate PPE as soon as we entered the building (Figure 1).

One patient made a particular impression on me. M was a 7-month old female admitted due to malnutrition. Throughout the week, she slowly gained weight and started to take an interest in the strange pale humans trying to make her smile with a toy koala, and was eventually discharged. The next week she returned with a cough, initially thought to be viral in origin. However, common things occur commonly, and imaging suggested M had tuberculosis. While unable to pinpoint the exact cause, it was possible that her long stay on the ward could have been the source. It was incredibly frustrating knowing that if the hospital had funding, these incidents could be prevented. Nonetheless, the case of M is not an isolated one, and the lack of resources was evident in all the areas of the hospital during our stay.

Figure 1. Students in PPE

Surgical Ward

Having heard of other elective experiences, I expected that surgery in a developing country would be exceptionally hands-on, however, this was not what I experienced. The reasons for this were unique. A number of issues, such as the surgeon having malaria, or the building having no functioning water with which to sterilize equipment, resulted in my group having relatively few surgeries to attend. Something I was exposed to, however, was overcoming challenges in a resource-poor setting. In the absence of K-wire cutters, garden pliers were sterilised with alcohol wipes; on another occasion, an abdominal drain was secured in place with a tongue depressor snapped and taped together. The persistence shown by the staff to make the most of what was available was inspiring, especially given they face these challenges continually.

Women’s Ward

In my third year, I was placed in a rural hospital in Australia which did not see a huge amount of obstetrics. You could say I was unprepared for obstetrics in Kiunga. Caesarian sections were an uncommon event, meaning that we witnessed births which probably would not have happened in Australia. Examples of this include a mother with malaria struggling to give birth due to severe lethargy, or the two breech births occurring during my six weeks.

In an Australian setting, we are used to working under the guidance of a senior team member, especially in a high-intensity situation. However, in PNG we were expected to step up and start to manage situations ourselves. In the maternity suite births were usually facilitated by one midwife, and if something went wrong, the focus was on looking after the mother. This meant that care of the neonate typically came after the mother’s situation was controlled.

Therefore, on a number of occasions, a routine birth would end with the midwife handing a limp neonate to two medical students. Prior to coming to PNG, I was aware of the debate regarding medical students overstepping their boundaries while on elective. However, in that moment we had to make a choice to either stand by and watch the neonate die due to a lack of resources and staff, or give it the best chance it could have in the circumstances by applying pre-departure training in neonatal resuscitation. It is hard to imagine the situation where there are no medical students to assist, but sadly due to lack of staffing that is the situation this hospital faces every day. We were involved in three such scenarios during my time in PNG, and I am thankful for the training we received on resuscitation prior to departure. In saying that, the unsuccessful resuscitations were amongst the most confronting moments in medical school, but I am glad we were present to intervene when no one else was available.


Not all births were intense, and even in uncomplicated births we were routinely supported by the midwives to assist the mother in delivering the child. The midwives in PNG are incredible, managing most births without intervention of a doctor, and even performing procedural skills such as perineal repair and vacuum-assisted delivery.

Emergency and Outpatient Department

Although other areas of the hospital were perhaps more confronting, I felt most out of my depth in the OPD. We were expected to independently see patients and prescribe medications, with no guidance offered unless required. While the OPD allowed us to practice our Pidgin, the language barrier remained a significant issue. Personally, I felt very uncomfortable prescribing anti-malarials according to a guideline I did not know well, to a 4-year-old whose parents I could not explain anything to, a situation I found myself in on our first day in the hospital. The staff were probably annoyed by my constant questions, however, I was worried about overstepping my boundaries as a student and potentially causing significant harm. In saying that, the range of presentations was diverse (although malaria was exceptionally common), and the chance to practice our newly-acquired language skills was excellent.

Similar to the obstetric department, we were forewarned that if resuscitation needed to be performed, we would potentially be in charge. Even with this in mind, I certainly did not expect to be performing compressions one Sunday afternoon while wearing thongs and board shorts. Due to a lack of staff on this particular weekend, three medical students who had been playing soccer with the local kids were now attempting to resuscitate a man who had been in the ED since the morning. Eventually the doctor arrived to take control, but it is hard to imagine students in Australia ever being in such a situation.


Aside from the clinical experience, one of the highlights of the placement was the chance to become involved in the local community. We stayed in a house a close walk away from the hospital, meaning that we often had spare time in the afternoons/weekends. Most afternoons we played sport with the local kids, and every Sunday we played a movie for them at the hospital. Not all of the children were so keen, however, as one particular girl started crying as soon as she saw us, a sobering reminder that foreign faces are still uncommon in such parts of the world.

One of the most surreal experiences was going to a local club and listening to Justin Bieber while meeting locals over Papua New Guinean beer. A local gentleman was adamant Justin was in fact a Papua New Guinean artist, but in his defence the local brew was quite potent. At the end of the night we were even offered a lift home by the police chief, provided we let him finish his drink first. Another highlight was being shown wild birds of paradise by a guide who had taken David Attenborough to see them years ago. The people were exceptionally welcoming, often stopping on the street or in the markets to talk to us and see how we were finding the experience.


There were a few main lessons I took away from this experience in regards to students experiencing a global health elective. The most striking point was the issue regarding medical students on electives in resource-poor settings. This issue deserves a review unto itself, but suffice to say it became very apparent to me how easy it could be for an overconfident medical student to abuse the level of trust placed in them by the local population. Particularly, in a poorly-resourced setting with a lack of supervision, students may be placed in situations that are beyond their level of knowledge. However, in certain circumstances, capable students, and especially those in their final year, may be able to have a positive impact on their chosen placement. Such an experience highlighted how aware students must be before embarking upon such an elective, and to have these issues in their minds while on the placement to avoid overstepping their scope of practice.

Such difficulty is exacerbated by the challenges of healthcare provision in resource-poor settings, and this placement was invaluable in showing me how it differs compared to  Australia. The shortage of staff, medications and equipment was evident throughout the hospital, and it was clear that the entire health system could be improved by further funding. It was confronting seeing individuals suffer because the medication they needed was not available, however, it was inspiring to see the ways staff attempted to overcome these barriers. Additionally, the attitude of the staff continually stayed positive, even in the face of these challenges.

Finally, it was evident to me throughout the placement that global health challenges in developing nations are changing. While infectious and tropical diseases were rife, the impact of chronic conditions such as cardiovascular disease, hypertension and diabetes was evident during my time in Kiunga. These conditions were often poorly managed due to lack of proper medications and monitoring. Their increasing prevalence coupled with the lack of resources to manage these conditions mean students doing a similar placement in the future will face a host of different conditions.

In summary, this elective was an excellent experience. Not only for the clinical exposure, but also for the chance to see how healthcare functions in a resource-poor setting. At times it seemed like the health care workers were battling their way upriver against a tide of financial constraints and poor government support, however, the enthusiasm and dedication shown towards the people of Kiunga was inspiring. Additionally, the chance to experience life in a rural town in PNG was a highlight in itself. This placement has, undoubtedly, been one of the most motivating placements of medical school, and I strongly urge anyone considering something similar to take the opportunity.

Nicholas Snels

Nick is a final year medical student from Griffith University. Throughout his degree he has been interested in gaining clinical exposure in a variety of settings, ranging from a rural experience in Warwick to furthering an interest in global health in Papua New Guinea and India.


QRME and Graeme Hill for continual support of this program; Aisha, Ryan and Emily for sharing the experience and for support throughout difficult times.

Conflicts of interest

None declared



Sugar tax – A Sweet Solution for Obesity?




The rising prevalence of obesity and obesity-related illnesses parallels the increase in sugar consumption across the globe. To limit consumption of sugar and tackle obesity, the World Health Organization has recommended that member states implement a tax on sugar. Such a tax is envisioned to reduce sugar consumption at a societal level, generate stable revenue for governments, and drive product reformulation. However, at present there is insufficient evidence to suggest any beneficial effect of a sugar tax on the incidence and prevalence of obesity.


This review examines the effectiveness of a sugar tax as an obesity prevention strategy.


A qualitative review of modelling and observational studies investigating the link between sugar tax and obesity, and conducted over the past ten years, was carried out. 


Modelling studies suggest that a tax on high-sugar foods and beverages is likely to have beneficial effects on obesity as increased price of taxed items leads to reduced consumption. However, observational studies suggest little benefit of a sugar tax on actual obesity rates in a population. Taxes in combination with other policy and regulatory approaches, for example health food subsidies and education campaigns, might be more effective than a tax on its own.


A tax on sugar is likely to be a step in the right direction as it would raise public awareness of the negative health effects of excess sugar and de-normalise consumption of excess sugar.



The obesity epidemic

Over the past few decades, overweight and obesity have risen to epidemic proportions all over the globe. In 2014, more than 1.9 billion adults were overweight and 600 million were obese.[1] In 2013, 42 million children under the age of five were either overweight or obese, and this is predicted to increase to 70 million by 2025.[2] The growing prevalence of childhood obesity is particularly alarming given that it is a predisposing factor for lifelong obesity.[3] Obesity, defined as having a body mass index (BMI) greater than or equal to 30, is a major risk factor for non-communicable diseases such as cardiovascular disease, diabetes, cancer, and mental illness.[4] Since non-communicable diseases were responsible for 68% of all deaths in 2012, [5] it is apparent that the health burden of obesity is high.

Obesity is a complex heterogenous disease that arises from an interplay between our genes and the environment we live in. Highly energy-dense diets combined with a lack of adequate physical activity leads to a positive caloric balance and hence weight gain in genetically susceptible individuals. Our diet and physical activity are increasingly shaped and driven by broader social, cultural, economic, and political landscapes that are often beyond individual control and awareness.[6] The modern obesogenic environment, which provides easy access to calorie-rich processed food and encourages sedentary lifestyle, is mismatched to human physiology that evolved to survive in an environment of food scarcity.[7] At a population level, obesity can be viewed as a manifestation of a global economic system that currently prioritises wealth creation over health creation.[8]

Obesity’s sweet tooth

In recent decades, the rising prevalence of obesity has closely paralleled the burgeoning consumption of sugar all over the world.[9] Sugar is recognised as one of the biggest risk factors for obesity,[10-15] and the leading source of sugar in the diet is sugar sweetened beverages (SSBs).[15] Therefore, the current review will focus on SSBs as a proxy for sugar and the discussion about policies aimed at limiting sugar intake (i.e. sugar taxes), will predominantly revolve around SSBs.

SSBs are non-alcoholic beverages with added sugar and include soft drinks, fruit drinks, sports drinks, energy drinks, iced tea and coffee, and lemonade. SSBs are becoming increasingly popular in low- and middle-income countries, with Latin America and Asia leading the world in consumption.[16] The worldwide impact of SSBs on the burden of adiposity-related cardiovascular disease, cancer, and diabetes is estimated at a total of 8.5 million (95% CI: 2.8 – 19.2) disability-adjusted life years (DALYs) [17].

Limiting the intake of free sugars to less than 10% of total daily energy consumption is strongly recommended by the World Health Organisation and the US Dietary Guidelines Advisory Committee.[18, 19] For every additional serving of SSB per day, the likelihood of a child becoming obese increases by 60% over the course of two years.[20] The energy obtained from SSBs is added to an individual’s total energy intake rather than displacing other sources of calories due to the poor satiating properties of sugar in liquid form.[21] The net increase in calorie consumption is likely to contribute to an increase in body mass. Given the high burden of obesity-related illnesses on healthcare systems [17] and the strong evidence linking excess consumption of SSBs to obesity in children and adults,[15, 22] a reduction in SSB consumption is warranted. A decrease in consumption is especially pertinent as the major SSB consumers are children, adolescents and poorly educated individuals from lower socio-economic strata of society who may be less aware of the harmful effects of added sugar.[10]

Sugar tax as an obesity prevention strategy?

Population health interventions aimed at curbing the consumption of excess sugar are pertinent to curtail the obesity epidemic. Price is one of the key factors influencing food purchasing behaviour. People tend to reduce consumption of unhealthy foods in response to increased prices of such products.[23] To discourage purchase of SSBs and address the growing burden of obesity, countries such as France, Mexico, the UK, and Hungary, and several jurisdictions in the USA, have implemented a tax on sugar.[10] Following implementation of a €0.11 per 1.5 L excise tax on SSBs, which translated to a 6% price increase, France saw a 6.7% decline in demand for cola in the first two years.[24] SSBs are a sensible target for a sugar tax as they have a high calorie density with no additional nutritional value [10, 25] and can be clearly defined for policy implementation.[2]

A number of assumptions underscore the success of an SSB tax [26]: first, the tax must be passed onto consumers, leading to an increase in cost; second, SSBs follow the law of demand; and finally, the tax leads to a significant net reduction in energy intake despite substitution by consumers, for example by increasing consumption of fruit juices with comparable caloric content.[27] While a tax on sugary drinks may not be the silver bullet for obesity on its own, it has the potential to slow the epidemic. For this reason, recommendations to implement diet-related taxes should be taken seriously.[28, 29]

The success of an SSB tax as an obesity prevention strategy remains controversial. The plethora of studies investigating the link between sugar taxation and obesity prevention demonstrate conflicting results. There is currently no consensus regarding the best approach to implement a sugar tax. Furthermore, existing meta-analyses on the topic show inconsistent findings and are unable to include many primary studies in their analysis owing to methodological inconsistencies.


Electronic databases (PubMed and Web of Science) were searched for relevant journal articles between 1 January 2007 and 1 July 2017. The year 2007 was chosen to ensure included studies were relevant to modern dietary habits and practices.

The following search strategy was used: (tax* OR price* OR economic* OR financial*) AND (sugar OR sweetened OR beverage* OR drink*) AND (intake OR consumption OR demand OR sale* OR diet OR weight OR overweight OR obes* OR body mass index OR BMI).

Searches were limited to articles published in English. Relevant articles were also identified by searching the reference lists of included studies. Abstracts were assessed for suitability of inclusion. Studies that were found to be suitable were read in full and their salient features reported here.

Economic feasibility of a sugar tax

Consumers do not bear the full costs of their decisions when it comes to high-calorie foods and beverages.[30] It is estimated that an individual with a BMI between 30 and 35 will accumulate 30% higher medical costs than a normal weight individual;[31] this increases to 50% in individuals with a BMI greater than 35.[32] In Canada, obesity-related healthcare costs are close to $6 billion [33] whereas in Australia this figure is close to $10.7 billion.[34] In addition to direct healthcare costs, there are indirect costs to the community associated with absenteeism and obesity-related premature death.[35]

A number of modelling studies have reported substantial healthcare cost savings and stable revenue streams from a tax on sugar.[14, 36-38] For example, annual healthcare cost savings of $23.6 billion (95% CI: 9.33 – 54.9) and annual revenue of $12.5 billion (95% CI: 8.92 – 14.1) have been predicted for a tax of $0.01 per ounce of sugar in the United States (US).[39] Importantly, a sugar tax combined with a fruit and vegetable subsidy is deemed to be poverty neutral,[37] an important consideration given the significantly higher relative cost of fresh produce,[40] especially in rural and remote communities. The revenue generated from an SSB tax can be used to cover the healthcare costs of obesity, support subsidies on healthy food options, and fund public and school education campaigns promoting childhood nutrition and obesity prevention.

Effectiveness of a sugar tax for preventing obesity

Of various taxes on “unhealthy” foods, a tax on sugar was modelled to have the biggest health gain in the Australian population, equating to 270,000 DALYs (95% CI: 250,000 – 290,000) averted.[37] The effect of a sugar tax on BMI was found to be modest, equating to a BMI reduction of 0.1 in males and 0.06 in females, and a decline in obesity prevalence of 2.7% in males and 1.2% in females [36]. In a study modelling the German population, a 20% SSB tax was shown to reduce the prevalence of obesity by 4% in males aged 20 to 29.[41] Similarly, a modelling study by Cancer Research UK estimated that a 20% tax on SSBs could prevent 3.7 million people from becoming obese by 2025. Significant, albeit small, inverse associations between SSB taxes and weight gain have been reported by other modelling studies.[15] These could represent important changes over time and alter the prevalence of obesity at a population level.[42] Importantly, reductions in energy consumption were more pronounced in low- and middle-income groups.[38, 41, 43]

One of the biggest limitations of these studies is that they are population models.[37] They rely on national data which may be outdated and assume a linear relationship between weight changes and energy consumption without accounting for substitution behaviour by consumers and often relies on self-reported data.[41] The substitution effect is an obvious confounder in studies that do not classify fruit juices as SSBs, despite juices often containing more sugar than soft drinks.[14] Another limitation of modelling studies is the lack of information on long-term SSB price elasticity that is specific to geographic and economic subgroups.[14]

Six months after implementation of an SSB excise tax ($0.01 per ounce), consumption of SSBs decreased in Berkeley, California (–21%) and increased in comparable neighbouring cities that did not levy a sugar tax (+4%). Of the 124 people who reported changing drinking habits as a result of the tax, 82% reported drinking SSBs less frequently and 40% reported drinking smaller sizes because of the tax.[44] Similarly, following introduction of an SSB tax (1 peso/litre) by the Mexican government, the purchase of SSBs declined by an average of 6% during the first year of the tax and this decline was greater in low income groups.[45] The average Mexican purchased 4.2 litres less taxed beverages than expected during the first year, however, purchase of untaxed beverages increased by 13 litres on average.[45] Whether the increased consumption of untaxed beverages compensated for the reduced caloric intake due to the decline in taxed beverages was unable to be determined, so the effect of the sugar tax on net caloric intake remains to be seen. Given their short time frame, these observational studies provide no indication of the effect of a sugar tax on actual obesity rates in a population.

Similarly, surveys investigating consumers’ purchasing behaviour may not necessarily predict their actual purchasing habits.[46] This is critical in light of the fact that a 20% tax on SSBs did not result in an appreciable reduction in consumers’ likelihood to buy SSBs, despite their perception that they were more expensive.[46] Notwithstanding these pitfalls, a review of cross-sectional and longitudinal studies investigating the impact of sugar taxes on weight gain found several studies that demonstrated an inverse association between price increase of SSBs and point prevalence of overweight and obesity.[13] However, the magnitude of change reported in these studies was small.[13]


Reduced consumption of sugar by virtue of an SSB tax may not necessarily translate to decreased body weight, particularly if unhealthy alternatives still exist. A tax on SSBs will only be effective in reducing obesity when there is no substitution with another untaxed high-calorie food or beverage.[47] A tax on sugar-rich foods (e.g. confectionary) in conjunction with a tax on SSBs would reduce the likelihood of substitution and therefore increase the effectiveness of the public health intervention. Taxes on high-fat foods will need to be considered in the future as adjuncts to the sugar tax. Given the complexity of taxing foods high in sugar and fat, and limited research on their effectiveness, this requires further study.

In addition to reducing calorie intake through a sugar tax, other aspects of the obesogenic environment that require monitoring and regulation include food labelling, food portions, food advertisements, and plain packaging. A sugar tax on its own is unlikely to be the panacea for obesity prevention. It is widely accepted that taxes have the potential to reduce sugar consumption, drive production reformulation, and generate substantial revenue for governments.[16] While it appears plausible that reduced sugar consumption and product reformulation would be beneficial to tackle obesity, whether this is actually the case remains to be seen. To address the obesity epidemic, a number of other population level policy measures, including advertising restriction, reformulation targets, health star rating systems, promotion of healthy transport choices, and sustained high-impact education campaigns are warranted.[48]

While the effect of sugar taxes on SSB consumption and obesity have been carried out in some low- and middle-income groups,[38, 41, 43] there is a paucity of literature from developing nations on the impact of decreasing SSB consumption on obesity rates. This is pertinent given that low- and middle-income nations are disproportionately impacted by obesity and related non-communicable diseases.


Obesity and obesity-related diseases are a significant burden on healthcare systems around the world. The global prevalence of obesity has increased and excess consumption of sugar, in particular SSBs, is one of the strongest drivers of that increase. To curb the obesity epidemic, a number of countries have adopted various forms of sugar taxes. While theoretically and economically sound, a sugar tax on its own might be insufficient to curb the obesity epidemic. However, a tax on sugar is likely to be a step in the right direction as it would raise public awareness of the adverse health effects of excess sugar and de-normalise excess consumption. A tax on SSBs can also encourage industry to reformulate its products with lower sugar levels. Taxes in combination with other policy and regulatory approaches, for example subsidies to healthy foods, graphic warning labels, and awareness campaigns, might be more effective to curb the obesity epidemic than a tax on its own. A sustained, focussed, and multi-pronged public health intervention worked in the past against Big Tobacco. There is no reason to believe that similar perseverance will not work against Big Sugar.

Saiuj Bhat

Saiuj is a first year medical student at the University of Western Australia with a passion for understanding the social and commercial determinants of health. He also has an interest in tissue engineering, in particular organoid technology, and the promising that holds for many aspects of medicine in the future. He graduated last year with Honours in pharmacology.

Conflicts of interest

None declared




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