Interview with Professor Barry Marshall


Zoe Wood

Professor Barry Marshall is an Australian Nobel Prize Laureate in the field of gastroenterology and microbiology. Early in his career, Professor Marshall went into internal medicine with a gastrointestinal emphasis, working with Dr J. Robin Warren to demonstrate that Helicobacter pylori is the cause of most peptic ulcers. In this conversation, Professor Marshall describes drinking a dose of the bacteria himself in order to prove causation amongst risk taking in medicine as well as future directions in his field.

I’d like to talk about the very famous story of how you drank a Petri dish containing cultured Helicobacter pylori to make the causal connection of the bacteria with peptic ulcers. Considering the resistance your findings faced by the medical and scientific community, what do you think the reasons were that people were unwilling to consider the connection? For example, do you think there was an economic motive?

What triggered me to do that experiment was a grand round that I did at Fremantle hospital, when I was a medical registrar there. I was in the senior registrar job in internal medicine, so I did a grand round about this bacterium. It became evident that normal non-specialists were just so entrenched with this stress idea – the brain/gut axis. I don’t believe in any of that. They were so entrenched; it was exactly like a religion at that point. You couldn’t move stuff that people knew. Even if you had facts, they just didn’t feel it was right. So the fallback position for everybody was ‘there’s only one person, there must be something he’s doing wrong, otherwise how come it’s not been discovered before?’. So there was that attitude, then the pathologist got up and said ‘well these changes in gastritis are extremely subtle, how can you really measure them objectively? Obviously people with ulcers have got a hole in their stomach and other bacteria can come and live in the ulcer, it’s probably just commensals, you’ve got a long way to go, where’s your animal model?’

At that point, I had been trying to infect rats and mice, guinea pigs and piglets for about six months and getting nowhere. It was kind of frustrating – I had no answer for that. I could not really do the next step. However, I did submit an MD thesis proposal and in that I said that if the animal work fails, then we would try to get a human volunteer experiment. So I had decided that I needed to go to that step. Looking back on it, it was riskier than I originally thought it was because I was pretty certain that I could eradicate it with antibiotics, but the ones I chose in fact probably wouldn’t have worked. I had an endoscopy to make sure I didn’t already have H. pylori. So I drank the bug thinking that I would just be asymptomatic. Most people I knew with H. pylori were infected blood donors. I found 40% of blood donors at Fremantle were infected and didn’t even know they had it. So obviously, it wasn’t killing them and no one could remember where they caught it from. There was no history involved with the infection so it was a bit of a puzzle.

Even Dr. Warren and a couple of other people thought it might have been sexually transmitted, close contact with somebody, because ladies who attended the STD clinic were more likely to be infected than everybody else. There were a whole slough of crazy little pilot studies trying to sort the epidemiology out, it was very confusing. However, I drank the bug and I did become unwell with a vomiting illness and there was no acid in the vomit. That triggered something that I had read in an old medical textbook, The Principles and Practices of Medicine by Sir William Osler in 1910. They described exactly the acute illness that I had. I suddenly realized that these old descriptions of vomiting without any acid in the vomit were probably H. pylori and it became less common and people forgot about it.

Putting it all together at that point, the endoscopy showed a very heavy infection with H. pylori, so it was lucky that I had chosen that strain because I could have chosen one that didn’t infect very well. However, I didn’t get an ulcer and the illness got better after two weeks – it was all over. Discussing it with a few colleagues enabled me to do this hypothesis article for the Medical Journal of Australia. I believe it is either the second or third most cited article in MJA with thousands of citations.

What changes occurred in your life after receiving the Nobel Prize?

I believe Nobel laureates develop a bit of an inferiority complex and maybe some paranoia. One of the things is that I’m always talking about things I know, I’m the font of knowledge for Helicobacter and I keep up in that field, but there are so many other topics that I don’t keep up with. If I pick up the Medical Journal of Australia, I’ll look at the headlines and think that I don’t have time to read certain articles. Similarly, I’m not going to have time to be able to read the journals that I used to read, so I get a bit paranoid about not keeping up.

The other thing is that you’re worried that you don’t have peer review as a Nobel laureate. If you say something, someone is happy to print it or put it up on the web. If I twitter about something and say “this is a load of rubbish” about the microbiome of the stomach, nobody else is saying that. So I think, am I nuts? I’m just looking for a little niche where I can fight the consensus. Anybody who says something is a consensus, I am immediately totally suspicious of it.

Moving on to some of your current research, increasing antibiotic resistance accounts for 15% of patients who are not cured of their H. pylori infections. When these patients are referred to you, you isolate their strain, they receive a ‘tailor-made’ combination of antibiotics. I was hoping you could discuss how much of a threat you believe antibiotic resistance is with respect to H. pylori?

It’s a moderate threat, once you know how to get around it. You learn these principles of microbial therapy in medical school and it’s not going to change. Always, if you find the resistance pattern of the organism, you navigate around it with your antibiotics. The tricky part is that many of the antibiotics I like to use are active in the stomach and are often old. The best example is tetracycline. Everyone says “don’t use that, it’s not very well absorbed, it stays there in the lumen of the gut, it passes out in the stool.” Hang on a minute – that’s great for H. pylori.

There is need for further studies to work out the pharmacology of antibiotics in the gastric mucosa because when amoxicillin fails, we have no idea why it fails. All Helicobacter are always sensitive to amoxicillin. So you should be able to just give people amoxicillin and a PPI (proton pump inhibitor), and expect a cure. We’re not seeing that. So you have to add the third drug, there are different ones.

So I’m not too worried about it with Helicobacter, it’s a bit like a Streptococcus. It’s got a limited repertoire. However, it mutates extremely fast. It’s almost like a virus. According to a paper we did, its right on the top of the list for mutation. The reason is because it doesn’t have to protect its genome. There’s nothing else floating around much except other Helicobacters. So they’re all moving genes around, sucking them in and out as they divide. It doesn’t check the accuracy of its copying. So it’s continuously disabling its ribosomes or changing its ribosomes, so it very easily becomes resistant to macrolides or metronidazole. So it becomes interesting; there’s so many Helicobacter in your stomach – 1010 organisms. So for the stomach, it doesn’t matter that its doing bad copies of itself because it will just continue to have an evolution in the gastric mucosa. That’s why it becomes resistant to these things that require some interaction between an antibiotic and a functional protein, because they disable the protein in some way and then it’s resistant. So I think in the future, we need to do more studies on the pharmacology of the gastric mucosa and immunology. I’m optimistic that we’ll figure it out eventually. But, at the moment we haven’t made much progress in the last 10 years. That said, we still kill 99% of H. pylori that is referred to us.

The Marshall Centre for Infectious Diseases Research and Training has a principle goal in facilitating the development of new vaccines for H. pylori. Given that the bacterium is part of the normal flora as you mentioned before, for approximately 50% of people, do you believe that non-pathogenic H. pylori should be eradicated?

This is the question that I had trouble with. So, statistically it is normal because half the people in the world have it, so they’re not at the two standard deviations from the mean to have H. pylori. However, it is a pathogen even in the normal flora. It’s been normal in stone age Man, ever since humans left Africa 70,000 years ago they’ve been carrying H. pylori – maybe even hundreds of thousands of years before that. So in that respect, you could say it is normal flora and it may have had a beneficial effect. The ones that get the press are due to the fact that it downregulates the immune system a little. The beauty of this might be that if you had H. pylori you were less allergic and everybody’s a little bit allergic so that’s okay. But there are these kids that are outliers in their allergy response who are way up high in their responsiveness. They’re the ones that get anaphylaxis. So maybe if you had H. pylori, you would be less likely to be up in that group, you’d be more down in the middle of the range. As humans migrated out of Africa and visited all these other continents, with different plants and animals, it’s possible that having H. pylori was a bit beneficial. You’re hiding in the bushes from a lion, all of a sudden you start sneezing, that would not be good. Being less allergic might have helped human migrations.

Nowadays, Helicobacter has been disappearing by about 50% every generation in the last 50 years. So since about 1960, in Western countries it’s just been declining. It’s not antibiotics. It’s better hygiene, smaller families and it’s not terribly infectious. If you have both parents infected, each child has about a 50% chance of picking it up from an Australian parent. It’s in the next generation, but not a lot. So you can’t blame me if Helicobacter disappears. I’m killing it, I’m doing my best, but in fact 90% of the work is just done by modern living in 21st century life.

Are there any other medical issues that you would like to see gaining the same attention as the microbiome?

I think the immune system of the gut is important. We can put things into the stomach and into the colon, but the small intestine we can’t really investigate. As far as I’m concerned, there’s only two causes of anything: genetic and environmental, in particular all the viruses that you catch in the first few years of life. I think we’ve got a long way to go but we are on the threshold of cheap sequencing. So what we’re going to see is a lot of cheap sequencing during the lifetimes of lots of people. Then maybe 10 years from now, we will have computers big enough to figure out what it all means. We will probably be able to see that a lot of it is viral triggers – who knows.






Photo credits

Image 1: SHKP and CUHK Present Distinguished Lecture by Nobel Laureate in Physiology or Medicine [Barry Marshall]. Communications and Public Relations Office. 2013 [cited 30 May 2018]. Available from:

Image 2: public domain, accessed from

Conflicts of interest

None declared


Low-wage migrant workers in Singapore

Six weeks at HealthServe

Elective Report

Sarah Tan Yingli & Kai Yuan Tey


B was leaving Singapore that weekend, heading home to Bangladesh. His workplace injury compensation case had finally been resolved. We asked if he was excited for the reunion with his family after so many years abroad, and the subdued acceptance in his sad smile—“[I’m a] little bit happy”—was striking. B had fallen from scaffolding and severely injured his back, leaving him unfit for further work. Under the orders of his employer he spent months bouncing between various hospitals and clinics, looking for the “cheapest rates”. His eventual injury compensation fell far short ofhis entitlement. Ongoing disputes with his employer about his injury compensation culminated with a heated argument during which B was struck in the face. His search for help had brought him to HealthServe, and it was there he was generous enough to share his story.

It is a story that would resonate with the experiences of many low-wage migrant workers in Singapore. A review conducted by the Ministry of Manpower (MOM) in June 2017 found migrant workers account for a 37.9% of the Singaporean labour force.[1] More than half are employed as low-wage labour or in service industries.[1] Despite serving as the cornerstone for Singapore’s booming economic and architectural development, B and his fellow low-wage migrant workers constitute an especially vulnerable population,[2,3] subject to exploitation and often left shouldering significant burdens of illness and injury.

HealthServe is a not-for-profit, non-government organisation that reaches out to a community whom its small staff and indispensable volunteers pointedly refer to as their “migrant brothers and sisters”. Dr Goh Wei-Leong founded HealthServe in 2006, offering migrant workers medical care, social assistance, casework, personal development classes, and a hub for communal recreation. The 2017 Singaporean of the Year title awarded to Dr Goh (and the HealthServe organisation as a whole) has fuelled the long waiting list of medical students keen to assist with its operations.[4] We were fortunate to complete our 6-week internship at HealthServe over the recent summer university vacation.

Working at the clinic

HealthServe began as a clinic in Singapore’s Geylang district providing general practice (GP) and dental services two evenings a week and Saturday afternoons. It has since expanded to include regular specialist dermatology and orthopaedic consulting and two additional worker-dormitory-based clinics offering similar healthcare services.

As interns, clinic days meant arriving 3 hours ahead of advertised opening times to prepare for the imminent rush. Migrant brothers and sisters would come in throngs—busy days, with more than 50 patients waiting before even the first had been seen, necessitated the emotionally draining process of turning some away. HealthServe saw patients from a range of occupational backgrounds. Although most of the patients were men, staff also assisted the occasional female domestic worker referred from the Humanitarian Organisation for Migration Economics (HOME).

The clinics themselves were unlike anything we had experienced. Every role relied on volunteers, from doctors to receptionists. The clinic manager helped interns fill staffing gaps as needed, becoming temporary dental assistants, receptionists, triage ‘nurses’ and medication packers. We soon learnt that even the seemingly menial jobs played pivotal roles in the clinic’s operations, underlining the importance of an effective multidisciplinary team in delivering quality patient care.

Resources were scarce. It was eye-opening to witness how the clinic’s financial dependence on grants and donations impacted healthcare. Proton pump inhibitors were often replaced with H2 antagonists. Measuring tapes substituted for height charts. ECG machines left over from the 1990s tested our abilities to adapt and make do. We embraced the challenge.

We were soon eagerly conversing with the migrant brothers as we triaged the waiting patients, finding joy in the supposedly mundane vitals measurements. They had many stories to tell—of Bangladesh’s six seasons in a year, of the food back home in China, or of their dreams and aspirations. Triaging was an opportunity to exercise our clinical judgment supported by the safety net of the clinical manager’s review. The conversations that unfolded while doing so were potent reminders of the individuals behind the pathological processes it was so easy to become absorbed in. As Sir William Osler once said, “The good physician treats the disease; the great physician treats the patient who has the disease.”[5]

Chronic conditions like diabetes and hypertension were rife, exacerbated by poor diets and a reluctance to seek medical attention understandable when a standard consultation could cost the equivalent of 3 days’ wages. A large proportion of our patients presented suffering from muscle strains, ligament sprains, back and soft-tissue injuries, and chronic pain—the inevitable results of gruelling 12-hour shifts 6 or 7 days a week. Patients with injuries severe enough to stop them working were stuck in a jobless and incomeless limbo between the termination of their work permits and the payment of their workplace injury compensation.[6] Our hearts went out to those who described their predicament—the perpetual uncertainty of the process, the months or even years waiting for resolution, the scheming employers intent on cutting costs, and the meagre compensation eventually received.

Beyond the clinic

The inherent precarity of migrant worker life discourages outspoken resistance against exploitation for fear of pay cuts and retrenchments. Movement restrictions, squalid housing conditions, and passport confiscations are alarmingly common practices.[7,8] In 2014, one manager was jailed after pleading guilty to breaching employment regulations and underpaying wages.[9] But the enforcement of accountability is rare. Many workers arrive already in debt from the 6000 to 15,000 Singaporean dollar employment agency fees paid to secure positions before departing their home countries, leaving some convinced “it’s better to be underpaid than not paid at all.”[10]

Dr Goh, a strong proponent of learning through immersion, would encourage interns to explore migrant worker haunts, travel to dormitories, and encounter the plight of the migrant workers firsthand. We visited some of HealthServe’s dormitory-based clinics and were taken aback. The fencing erected following the 2013 ‘Little India’ riot was reminiscent of a penal institution. A dormitory floor housed 20 rooms, each shared by 8 to 10 migrant brothers. Washing machines and refrigerators were bought by the workers themselves and every floor contained one communal bathroom. The migrant brothers’ days were strictly regimented— waking up at 5:00 AM, taking the shuttle bus to work, and then returning to the dormitories to cook, bathe and sleep.


On days when the clinic did not open, our intern responsibilities included everything from sorting medications and autoclaving dental instruments to organising the specialist referrals some migrant brother patients required. These pro bono specialist consultations relied on the goodwill and altruism of Dr Goh’s friends and colleagues who share his outlook on migrant worker health. We would accompany the migrant brothers during these appointments to alleviate their anxiety and offer emotional support. Cases we witnessed ranged from foreign body removal to the diagnosis of kidney stones secondary to horseshoe kidneys (ren arcuatus or renal fusion). Diagnostic reasoning and management plans were tailored to a population so different from the Australian and primarily Caucasian patients we had dealt with in medical school. The social determinants of a patient’s health were a factor in every decision about appropriate treatment options. No matter the outcome, the migrant workers showed gratitude towards their treating doctors and were generous in expressing appreciation towards us for accompanying them to the clinics.

Behind closed doors

Every Thursday afternoon, the staff gather for a lunch meeting at the heart of Little India. As food and laughter are shared, ideas on improving the services supporting the low-wage migrant worker community are exchanged with equal passion. The English lessons and computer classes now run by HealthServe volunteers are just two of the fruits of these weekly meetings. Dr Goh was always open to informal meetings with staff and interns to reflect and recalibrate.

Our experience at HealthServe was enriching to say the least. While there is much more to be done to help the migrant brothers and sisters driving Singapore’s economic progress, it is heart-warming to witness the ever-increasing awareness and support for migrant worker advocacy. Organisations such as Transient Workers Count Too (TWC2) and Migrant Workers’ Centre (MWC) are contributing to one day achieving what Dr Goh sees as his advocacy’s ultimate aim: “Our job in HealthServe is to make sure that we are out of job.”

We appreciate the time taken to read this article. Var Lock Tergo (“God bless” in Bengali).


The authors would like to thank HealthServe for providing the consent for writing this report on their experiences. The authors would also like to express their gratitude to HealthServe for the opportunities and experiences provided, and extend the same to everyone they met during their internship who together made the experience so enriching.

Photo credits

Images 1–4: With permission from Xi Zhe Sim, fellow HealthServe intern.

Conflicts of interest

None declared



1. Summary Table: Labour Force [Internet]. Singapore (SG): Ministry of Manpower; 2018 Jan 26 [cited 2018 Mar 25]. Available from:

2. Harrigan NM, Koh CY. Vital Yet Vulnerable [Internet]. Singapore (SG): Singapore Management University; 2015 Nov 4 [cited 2018 May 22]. Available from:

3. Lyon E. Wage challenges faced by migrant workers in Singapore [Internet]. Singapore (SG): CSR Asia; 2017 Mar 29 [cited 2018 May 22]. Available from:

4. Toh WL. GP Goh Wei Leong and healthcare charity he co-founded named The Straits Times Singaporean of the Year 2017 [Internet]. Singapore (SG): The Straits Times; 2018 Feb 6 [cited 2018 Mar 30]. Available from:

5. Centor RM. To be a great physician, you must understand the whole story [Internet]. Medscape General Medicine Vol. 9 Issue. 1; 2007 Mar 26 [cited 2018 Mar 30]. Available from:

6. WICA versus common law [Internet]. Singapore (SG): Ministry of Manpower; 2017 Jun 28 [cited 2018 Mar 26]. Available from:

7. Singapore: Events of 2016 [Internet]. New York (US): Human Rights Watch; 2017 [cited 2018 Mar 26]. Available from:

8. Rajah M. What plagues the migrant worker? [Internet]. Singapore (SG): Transient Workers Count Too (TWC2); 2014 Nov [cited 2018 May 22]. Available from:

9. Chelvan, VP. Manager jailed 34 weeks for exploiting more than 100 foreign workers. Channel News Asia (International Ed.). 2017 Feb 24 [cited 2018 Mar 26]. Available from:

10. Han, K. Singapore’s migrant workers struggle to get paid. CNN (International Ed.). 2018 Feb 25 [Cited 2018 Mar 26]. Available from:


Are active citizens healthy citizens? Evaluating the health effects of community engagement and global citizenship

Original research

Nic Mattock


Global citizenship is a relatively new concept that broadly includes facets of social awareness, activism, and engagement. As a framework, global citizenship is designed to build capacity in individuals and produce social change within their local and global communities.[1] Mansouri et al. define global citizenship as a state uniquely defined by traditional concepts of nation-state citizenship in the context of progressive globalisation.[2] That is, global citizenship is an ethical framework rather than a legal construct; it recognises the limitations of traditional citizenship in a world characterised by globalisation, and instead seeks to provide a globally inclusive political and cultural environment that empowers individuals, rather than nation-states. In the context of growing social and economic inequalities as well as persisting global issues, including those specific to global health, empowering individuals is necessary to nurture change.

The Matariki Network is a group of seven international universities that are committed to supporting and developing this concept of global citizenship.[3] Ustinov College— a postgraduate college at Durham University, a member of the Matariki Network, administers a specific global citizenship program whereby a governing student body is established and tasked with the maintenance of various academic and social outreach initiatives. In 2017, a bilateral student exchange program was established between members of the Matariki Network, the McCusker Centre at the University of Western Australia and Ustinov College at Durham University; its aim to build international relationships, explore the concept of global citizenship and evaluate aspects of global citizenship as a tool for both social and personal change. Quantifying aspects of the global citizenship framework is necessary as a means of developing a more rigorous case for the implementation of similar programs beyond the network and defining the utility of this approach for broader evaluation.

Mental health is of particular concern in modern education systems, such as those detailed in this study, given well-characterised associations with academic and occupational achievement.[4,5] Evidence remains mixed with respect to the prevalence of mental health disorders in students, and the interaction between mental health and academic involvement.[6,7] It is likely that significant geographical and social variation exists; however, mental health complaints in college-aged individuals remain uniformly high.[4,7] Access to mental health services at a tertiary level, whilst improving, remains limited and typically has poor uptake.[8] Interventions designed to prevent or address mental health issues in students are necessary to ensure ongoing maintenance of an effective and capable workforce, and to mitigate the economic and social strain of mental disease in our community.[8] Indeed, recent work suggests that implementation of mental health interventions for students has benefits that persist beyond tertiary education.[9]

Volunteering is well-established as a positive determinant of health and health-related behaviours among individuals of varied demographics.[10] In particular, volunteering appears to improve mental health and, to a lesser degree, reduces all-cause mortality.[11,12] However, such findings have not been confirmed in clinical trials. Interestingly, a number of studies have found that volunteering was not related to positive mental health outcomes in those of early- to mid-adulthood.[13,14] Elias et al. suggest that volunteers experience improvements in wellbeing and mental health proportional to the duration of volunteering.[15] Other studies have noted that sustained volunteering, as opposed to intermittent volunteering, has a greater impact on health.[16,17] It is unknown whether the global citizenship framework, which includes aspects of social engagement such as volunteering, would confer similar positive health outcomes for the individual. Determining whether such benefits exist, if any, would have implications for the delivery of similar programs in education settings as a way of both addressing student wellbeing and social engagement.

The impact of activities of global citizenship, such as social activism and volunteering, are directly quantifiable at a community or global level. For example, in 2010, the economic value of volunteering in Australia was estimated to be worth $25.4 billion to the Australian economy.[18] Global citizenship is multifaceted and dynamic, but the social issues it addresses are relatively more static in category: political, economic, social and health, among others.[2] Activities of global citizenship can have a measurable impact on all such domains.[18] However, it is less clear whether a reciprocal impact exists for the individual; that is, to what degree do activities of global citizenship produce change in the individual? This evaluation postulated that individuals whom are active global citizens are, in turn, healthier global citizens in that their engagement with global issues has a positive effect on personal well-being. Such effects may be related to direct improvements in mental or physical wellbeing and/or improvement in perceptions of wellbeing. This study aimed to develop and validate a tool to investigate the effect of activities of global citizenship on individual self-perceptions of health.


This evaluation was performed in conjunction with the Ustinov College (Durham University, Durham, UK) student representative team. The aim of the survey was to assess an individual’s self-perceptions of general, physical and mental health according to their participation in activities of global citizenship. Demographic characteristics were also collected.

The survey was delivered to all residents of Ustinov College at Durham University via an online web form in January, 2018. Promotion of the survey was performed by the Ustinov College student representative board via social media platforms; the survey remained open for completion for two weeks. Ustinov College has a mixed population of live-in and live-out students,

Global citizenship is an ethical framework rather than a legal construct; it recognises the limitations of traditional citizenship in a world characterized by globalisation, and instead seeks to provide a globally inclusive political and cultural environment that empowers individuals, rather than nation-states. 35

all of whom are postgraduate students, with a considerable international contingent. There were no exclusion criteria.

For the purpose of this brief evaluation, global citizenship was defined as having three primary domains, as below. These domains were chosen in consultation with academics from both the University of Western Australia and Durham University, and are designed to parallel the structure provided by the Matariki Network for delivery of global citizenship education,[3] in a way that is measurable according to involvement in specific activities:

1) Awareness: The cornerstone of global citizenship is an awareness of the challenges faced at a global level. Global citizenship, therefore, is inclusive of activities that build this awareness (for example, lectures, seminars, etc.);

2) Engagement: Practical experience addressing the aforementioned challenges, whether in the local community or further afield (for example, volunteering); and

3) Activism: Activism is variably expressed amongst individuals. For some, this may be considered synonymous with engagement, whereas others would consider activism to have specific connotations (for example, advocacy activities, blogging, etc.).

All survey questions were structured around these core themes. Involvement in each of these domains was assessed using pre-defined activities and frequencies. The survey questions can be found in the appendix below (Online Supplement 1). Students were permitted to provide free-form answers, which were subsequently assessed for relevance to the abovementioned domains. Self-reported perceptions of health were evaluated according to 3 domains: general, physical, and mental health. Scores were recorded on visual analogue scales (range 1 – 10). Further, students who regularly participated in any of the activities were asked whether such activities improved, worsened, or were unrelated to their perceptions of wellbeing. Given the limited sample size and tendency towards capture of students involved with activities of global citizenship, a descriptive analysis was performed. Results are reported as frequencies with percentages, unless otherwise stated. Consent to publish anonymised results was obtained from participants.


Sixteen postgraduate students from Ustinov College at Durham University responded to the survey. The demographics of this population are given in Table 1. Of note, from the 16 students participating in the survey, 10 different nationalities were reported; furthermore, most of these students were involved in, or aware of, the Ustinov Global Citizenship program. The sample included a relatively wide range of ages and areas of study, given the limited number of participants. Self-reported perceptions of general, physical, and mental health were largely positive. The median scores for physical and mental health were 7 (range: 6 – 10) and 7 (range: 1 – 10) (see Table 2).

Surveyed students were typically active in extracurricular academics. This survey evaluated extracurricular activities both explicitly related and unrelated to global issues, provided that the latter was external to an individual’s area of study. Eleven of the 16 students (68.8%) attended extracurricular lectures or seminars at least once per semester, with many reporting higher rates of engagement. Similarly, 12 (75%) students reported volunteering at least a few times per year, with 4 (25%) volunteering at least monthly.

As noted previously, given the limited sample size and skewed distribution towards participation in global citizenship activities, no evaluation of the differences in self-reported perceptions of health could be performed. Despite this, however, 11 of 13 eligible respondents (85%; 3 excluded due to ‘not applicable’ response) agreed that participation in activities of global citizenship improved their perception of wellbeing. The reasons given for such improvements were varied, but largely focused on the core themes of community participation and belonging, and perspective or context building from experiencing the problems of others.


The effects of global citizenship on communities and global issues can be easily quantified; however, the reciprocal effects on the individual, in particular with respect to personal capacity-building and health outcomes, are less clear. This study found that students who engage with activities of global citizenship report improved perceptions of wellbeing and identify such activities as fundamental to these improvements.

Contrary to expectations, research suggests that current involvement in tertiary-level education may be associated with lower rates of mental health diagnoses when compared to age- and sex-matched non-students.[4] Such a finding could suggest that academic involvement, at a general level, has a positive effect on mental health. Indeed, this evaluation of Ustinov College students noted that involvement in extra-curricular activities, in particular academic pursuits unrelated to the individual’s core area of study, may be associated with wellbeing. This is consistent with the concept that wellbeing is positively affected by academic involvement; however, it is unknown whether such improvements are the product of consequent social inclusion, academic involvement, or a combination thereof. Alternatively, it is possible that such a finding reflects underlying characteristics of the population, rather than the effect of academic involvement specifically. In particular, it is likely that healthier students are more able to participate in such activities, potentially confounding the relationship between global citizenship and wellbeing. Nonetheless, extra-curricular academic pursuits, particularly those in the domain of global citizenship, appear to be related to self-perceptions of health.

Of note, the proportion of individuals involved in volunteering activities of any regularity in this study was greater than that reported in national data.[19] This reflects the aforementioned reporting bias towards those involved in the Global Citizenship Program at Ustinov College and, more generally, in activities of global citizenship. While no quantitative association between volunteering and perceptions of wellbeing could be performed in this study, all respondents felt that volunteering had a positive effect on their perception of wellbeing. Indeed, such a lack of quantitative association derives not from an insufficient relationship, but instead from the overwhelming percentage of respondents involved in volunteering of any regularity (75%), making it impractical to assess the association between volunteering and health in an isolated manner. This is considerably higher than that noted in other studies,[11] but likely reflects a reporting bias towards survey completion in those with positive responses, which is true of any self-directed evaluation. Of note, the extremely limited sample size prevented statistical analysis.

This evaluation has a number of limitations. First, the concept of global citizenship is flexible and broad, and may differ by institution and individual. Indeed, such breadth makes it difficult to identify whether specific domains are responsible for the improvements in wellbeing noted, or whether such improvements are the product of activities of global citizenship as a complete framework. Unfortunately, the sample size in this study precludes evaluation of specific activities or domains. Second, this study evaluated students from only 1 university, and from a solely postgraduate population; therefore, the small sample size and relatively narrow socioeconomic context make the findings difficult to generalize. Nonetheless, it should be noted that among the 16 respondents, 10 different nationalities were registered. Finally, given practical considerations regarding the collection of specific health information, this evaluation chose to focus on self-reported wellbeing, which fails to provide any clarity regarding the mechanisms involved in participant wellbeing.

Activities of global citizenship may be related to the self-reported wellbeing of postgraduate students. Such a framework has positive implications for local and global communities, but also for the individual, and should, therefore, be considered as a more general component of tertiary education. Questions remain regarding the mechanisms underpinning these effects, the magnitude of these effects, and the degree to which such findings can be generalized to other populations, in particular undergraduate students and those not currently engaged with such activities of global citizenship. Further research should seek to assess direct health outcomes, rather than self-reported perceptions of health in a larger population, permitting quantitative analysis of the effects of activities of global citizenship.




This piece was written and researched in with Ustinov College at Durham University and the McCusker Centre for Citizenship at the University of Western Australia. The author would like to thank the individuals in particular who participated in, and enabled, the evaluation.

Conflicts of interest

The author is currently involved in the review of manuscripts for Vector Journal. No other conflicts of interest are reported relevant to the study content.



1. Oxfam UK. What is global citizenship? [Internet]. Oxfam UK, available from: [cited 2018 May 21].

2. Mansouri F, Johns A, Marotta V. Critical global citizenship: contextualising citizenship and globalisation. J Citizensh Global Stud. 2017;1(1):1.

3. Matariki Network. About the Matariki Global Citizenship Program [Internet]. 2017: Matariki Network, available from: [cited 2018 Jan 20].

4. Auerbach RP, Alonso J, Axinn WG, Cuijpers P, Ebert DD, Green JG, et al. Mental disorders among college students in the WHO World Mental Health Surveys. Psychol Med. 2016;46(14):2955-70.

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6. Cvetkovski S, Reavley NJ, Jorm AF. The prevalence and correlates of psychological distress in Australian tertiary students compared to their community peers. Aust N Z J Psychiatry. 2012;46(5):457-67.

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Online Supplement 1- Link to Survey Questions: https://


Guidelines for low birth weight: a literature review comparing national guidelines in Vietnam with WHO guidelines

Review article

Line M Pederson



This study was prompted by the persisting high prevalence of low birth weight (LBW) in Vietnam. LBW, defined as an infant weighing less than 2500g, is a leading cause of perinatal (22 weeks of gestation to 7 days postpartum) and neonatal (within 28 days postpartum) deaths globally. It contributes indirectly, through maternal factors, and directly, through postpartum factors, to 40-60% of newborn mortality.[1] LBW is the most important criteria for determining both immediate and long-term outcomes of neonates and infants. This includes chance of survival, healthy growth and freedom from morbidities.[2]

Vietnam is part of the WHO Western Pacific Region (WPR). Neonatal deaths in the WPR region contribute to the highest proportion (56%) of the under-five mortality compared to other WHO regions.[3] In Vietnam specifically, neonatal deaths account for 55% of the under-five mortality.[4]

Nutrition has a major impact on LBW and associated infant morbidity and mortality.[5-7] Nutritional factors are related to the biological processes that affect the fetus in utero and the mother’s physiology.[8, 9] The most important maternal risk factors[10] increasing risk of LBW are: body mass index (BMI) at conception[7, 8, 11-16], stature[17, 18], nutrition (including suboptimal gestational weight gain[10, 11, 19]), intake of micronutrients (iron[20, 21] and iodine deficiency[22]), maternal age (age <18[23-27], age >35[28, 29]) and cultural food habits and behaviours.[30, 31]

Maternal pre-partum health status, immediate care of the LBW infant and exclusive breastfeeding (EBF) for 6 months are crucial to reducing the burden of LBW.[32] Guidelines are important as they act as a tool for quality assurance, facilitating improved quality of care provided by informed healthcare workers.[33]


A Quick Scoping Review was performed to evaluate existing knowledge of LBW. This involved a rapid review of literature on LBW risk factors. Guidelines were obtained from the WHO website, Vietnamese government website, online and through formal email correspondence with the WHO WPR Reproductive, Maternal, Newborn, Child and Adolescent Health team to ensure the most recent guidelines were included.

An extensive literature search was then conducted to identify barriers to proper implementation of LBW guidelines in Vietnam. Bibliographic databases (Pubmed, ProQuest, Cochrane Library, Google Scholar, WHO and UNICEF) were searched using combinations of keywords including low birth weight, guidelines, barriers, attitude, beliefs, maternal health/nutrition, health services utilisation, satisfaction and quality of care. Additional articles were identified and retrieved by reviewing the reference list of relevant articles, while further reports and materials from organisations and governments were identified manually and found online.

Only English language papers published between 2000 and 2016 were included. Articles pertaining to women with co-morbidities were excluded, as separate sets of guidelines often exist for these women. Besides the WHO guidelines, only studies relating to Vietnam were included. Furthermore, only studies related to antenatal care (ANC), perinatal care, postnatal care (PNC) and breastfeeding practices were included, with a focus on LBW. The critical evaluation of studies included looking at the study methodology, perceived objectivity, study provenance, research evidence, and the contribution of the study to the literature.

The review was conducted by the author from February to June 2016 as part of a master’s thesis. Subsequently, the Ministry of Health (MoH) Vietnam has launched The National Guideline on nutrition for pregnant women and lactating mothers, acting as a practical step for effective implementation of the National Nutrition strategy 2011-2020 with a vision toward 2030. The WHO has since updated their recommendations on newborn health, but no significant changes occurred with regards to the included guidelines.


Variance between WHO guidelines and national guidelines in Vietnam

Differences between the WHO’s guidelines and national guidelines in Vietnam were analysed to identify whether Vietnam follows the evidence-based guidelines proposed by the WHO, and to determine whether both sets of guidelines are appropriate considering the national context. As shown in Table 1 below, national guidelines in Vietnam are largely in agreement with WHO guidelines. However, significant disagreements exist, and are highlighted in the table.

Barriers to guideline implementation in Vietnam

1. Health sector

Structural components, including health facilities,[43] staff[44, 45] and basic equipment for reproductive health care,[46] are lacking mostly in rural areas. The Joint Annual Health Review 2015 conducted by the MoH Vietnam and Health Partnership Group suggested that restricted health financing may impede improvement.[47] Health funds are allocated via input indicators (number of beds and staff). Thus, rural areas are faced with smaller hospitals and fewer staff. At a commune and district level, less funding is relatively available, and investments are rather made in high-tech equipment such as ultrasound.[47]

A study by Eriksson et al. involving 412 primary health care practitioners found availability of national guidelines for reproductive health care similar across hospitals (67%) and community health centres (70%) in northern Vietnam.[48] However, in a study by Trevisanuto et al. conducted in South/South Central Vietnam, only half of clinical practitioners from provincial level hospitals deemed written guidelines ‘very important’.[49] Despite a limited sample size (n=54) including a mix of professional backgrounds (nurses, midwives, doctors), the majority of the sample were considered local experts in neonatal infections. Though content of national guidelines was considered relevant by such professionals, they were rarely used.[50] Furthermore, Eriksson et al found no association between level of knowledge of neonatal care and access to guidelines.[48] This suggests limited knowledge and utilisation of guidelines despite availability.[48] Thus, a need for stronger implementation strategies and/or more context appropriate guidelines is necessary.

In-service and competency-based training as well as the quality of health workers’ performance is also unequally distributed between urban and rural areas[46-48, 51-57], particularly for infant feeding practices.[57-61] This is primarily due to working conditions and the lack of compensation for time spent on training, in addition to a paucity of career development opportunities.[46, 50, 52] In contrast, one study by Eriksson et al., found relatively high knowledge scores on LBW care and early breastfeeding among health workers[48] which could contribute to reducing LBW morbidity and mortality.

Structural components, including health facilities [43], staff[44, 45] and basic equipment for reproductive health care[46], are lacking mostly in rural areas. The Joint Annual Health Review 2015 conducted by MoH Vietnam and Health Partnership Group suggested that impedance to improvement stems from restricted health financing.[47] Health funds are allocated via input indicators (number of beds and staff). Thus, rural areas are faced with smaller hospitals and fewer staff. At a commune and district level, less funding is relatively available, and investments are rather made in high-tech equipment such as ultrasound.[47]

2. Mothers and cultural factors

Another cultural factor often overlooked is the occurrence of home births, particularly in rural areas.[40, 43] Homebirths are preferred by patients given lower costs and travel. However, they are also related to a higher prevalence of LBW and neonatal mortality.[67, 68] Such births are often chosen to avoid embarrassment and stigmatisation in cases of non-marital status or lack of knowledge. Furthermore, the convenience of local family support[69] or adherence to cultural traditions favour home births in rural areas.[55, 69] In contrast, urban mothers tend to over-use technology, with a strong preference for birth via caesarean section (CS)[53, 67, 68]. CS has been associated with poorer rates[55, 70, 71] and durations of EBF,[68, 72] thus having negative consequences for breastfeeding practices.

EBF and lactation mechanisms are often poorly understood and under-appreciated amongst mothers, relatives and lay persons.[59, 70, 71, 73-76] An example is the low value placed on colostrum – a vital dietary component for the LBW infant.[59, 71, 72, 77-80] Whilst women traditionally follow postpartum rituals passed on from grandmothers and other surrounding mothers[57, 58, 73], these breastfeeding practices may be dangerous and suboptimal due to feeding of water [71, 78] and the perception that breastmilk is insufficient in quantity and quality.[59, 71, 77, 78] Such practices may increase the risk of poor postnatal outcomes,[57-60, 73, 80] as the LBW infant does not receive vital nutrients from colostrum that stimulate the development of the infant’s digestive system, antibodies and white blood cells.[71]

Two different scenarios were found for breastfeeding in Vietnam. For rural areas, women with high education tend to breastfeed longer than women with lower education. On the contrary, highly educated women in urban areas tend to breastfeed for a shorter duration and non-exclusively.[68, 72, 76] Thus, higher educational level improves breastfeeding practices in rural areas, but presents as a barrier in urban areas. This may be due to exposure to mass media and infant formula advertisements, amongst other reasons yet to be explored.[71, 81, 82]

Despite guideline discouragement,[40] pre-lacteal feeds[57, 59, 71, 73-75] and complementary feeding[83, 84] are often given before the 6 months of exclusive breastfeeding ends. Interestingly, the cultural preference for sons has caused a disparity between breastfeeding practices in male and female infants. Due to the belief that breastfeeding is inferior to formula milk, males are breastfed less often.[68, 85] This is often a belief carried by the whole family and undermines the importance of EBF, meaning that emphasis must be placed on familial involvement and education to encourage breastfeeding practices and prevent morbidity and mortality due to LBW.[79, 80, 86]

3. Inconsistent and confounding policies for LBW prevention and care

The International Code of Marketing of Breastmilk Substitutes is enacted in Vietnam.[87] However, implementation has been challenging,[88-90] and the International Baby Food Action Network along with the WHO and UNICEF have identified common violations, such as biased/inaccurate advertisements, improper labelling and promotion of complementary infant foods.[91, 92] Health workers are often approached by formula companies to promote complementary foods from which they receive commission.[55, 58, 71, 93] Such practices have adverse consequences on promotion of healthy infant feeding practices[58, 60, 71, 76, 93, 94], thus hindering breastfeeding practices and the health and survival of LBW infants.

Confounding policies regarding maternity leave are also contributing to suboptimal LBW prevention and care. Since 2012, maternity leave has been 4-6 months, which is longer than the recommended 14 weeks proposed by the International Labor Organisation.[95] However, the unpaid nature of maternity leave has been found to be a barrier to EBF. [84, 93] Casual or temporary workers find it necessary to return to work given financial responsibilities, thus necessitating complementary infant foods.[59, 71, 73, 74, 77, 79]


As evident from this study, developing coherent guidelines and aligning strategies preventing LBW is difficult at national and international levels. Even more challenging is implementation of such guidelines in countries with high prevalence of LBW and neonatal morbidity and mortality. Appropriate evidence-based guidelines have the potential to promote beneficial interventions and discourage ineffective medical practice.[96] Their appropriateness for prevention and management of LBW infants in Vietnam will therefore be discussed.

Appropriate cut-off for referral of LBW

Different cut-offs for referral of LBW infants were found in two current WHO WPR documents: a 2000g cut-off and a 1500g cut-off in the WHO WPR Action Plan 2014-2020[37] and the WHO WPR EENC guide (2014),[97, 98] respectively. This demonstrates intra-organisation disparity. The 2000g cut-off in Vietnam seems to be more appropriate, due to the seemingly lower risk of mortality associated with the 2000g threshold when compared to 1500g. On the other hand, a 1500g cut-off may be more easily adaptable to the context given high ANC coverage in Vietnam. However, high coverage does not always mean high quality of care.[98] Thus, rather than debating between cut-off values, focus should remain on intensifying quality care for LBW infants whilst reducing unnecessary CS as recommended by the WHO WPR Action Plan.[37]

Qualifying as an LBW infant might not necessarily increase risk of mortality – a phenomenon known as the LBW paradox.[99, 100] In Vietnam, factors such as high altitude may be a risk factor for LBW, but not necessarily for mortality.[99, 100] Knowledge of the predominant distribution (weight distribution of term births) and the residual distribution (percentage of small and preterm births) is essential in gaining insight into the gestational-age characteristics. Epidemiological data is needed to provide a better basis to judge the appropriateness of cut-off values.

Appropriate number and timing of ANC visits

Despite the WHO recommending 4 ANC visits,[35] the exact timing of ANC visits has been debated.[101] Current recommendations are based on a large WHO ANC randomized trial comparing the standard model of ANC (12 visits) with the new ANC model (4 visits). No differences in maternal and perinatal outcomes were found between the two models.[102] A systematic review of studies from developed and developing countries provided similar findings

where good perinatal outcomes persisted despite reduced ANC visits.[103] However, it proposed that in a setting of low ANC coverage, visits should not be reduced without close monitoring of foetal and neonatal outcomes.[103]

There is no current documentation of 3 visits being equal to or better than 4. One argument for increasing the number of ANC visits from 3 to 4 would be the relatively high contribution of neonatal mortality to under-5 mortality in Vietnam. One-third of neonatal deaths are estimated to be caused by prematurity,[104] including a proportion of LBW infants, for which higher frequency of ANC visits could be beneficial. Further supporting arguments include the relatively high maternal malnutrition rates that could be potentially addressed through increased counselling by clinicians. Increasing visitation might facilitate breastfeeding education and allow healthcare providers to detect and counsel women at risk of prematurity and LBW. However, this requires further investigation.

Nevertheless, recommending 4 ANC visits comes with increased societal costs as well as costs to the mother via transportation and loss of working hours for mothers without access to free reproductive health services. This potentially increases disparities between urban and rural areas where socioeconomic standing differs. Therefore, changes in policy and practice should be closely monitored. Outcomes including monitoring of customer (mother) and provider (healthcare worker) satisfaction should be monitored alongside trends in peri- and post-partum morbidity and mortality.

Appropriate number and timing of PNC visits

A Cochrane review conducted by Yonemoto et al. found no strong evidence on the association between number and timing of home-visits and improvements in neonatal and maternal mortality.[105] However, the review found 4 studies with evidence suggesting that home visits may encourage women to participate in EBF. An association between home visits and increased maternal satisfaction with postnatal care was also described, which suggests that PNC is beneficial in alleviating the burden of LBW. Unlike the WHO, the MoH in Vietnam does not recommend a PNC visit at 7-14 days. Considering the high neonatal mortality within the first week of life,[106, 107] the low rate of EBF, the importance of managing potential infections and educating mothers in nutrition/feeding practices for LBW infants, recommending a PNC visit at 7-14 days could be appropriate. This should be considered only after evaluating the availability of resources and assessing morbidity and mortality risk within the first week of life. To date, it remains unknown if a PNC visit at 7-14 days is appropriate in Vietnam. Furthermore, the current Vietnamese PNC schedule articulates well with the Expanded Programme on Immunisation.[108] Similar to ANC, the focus should be on content and quality of care to facilitate optimal breastfeeding practices as opposed to increasing PNC visits, which may incur economic and consumer costs.

Discussion of strengths and limitations

While based on secondary data and guidelines supplied by key stakeholders, it is assumed that the retrieved guidelines represent the current state of guidelines for LBW and associated barriers and implementation. However, a literature review is dependent on the current state of research. The reviewed research into LBW is limited, especially with regards to guidelines in Vietnam, which sometimes display contradiction. Small sample sizes in the individual studies reviewed may have further limited the validity, reliability and generalisability of this study. Larger and prospective studies of current practice and potential improvements are recommended, but with a focus on the actual users of current guidelines, such as first-line healthcare workers and the women, before, during and after birth. Persistently high rates of neonatal morbidity and mortality in Vietnam call for future studies to address relatively simple questions, including the discrepancy between available guidelines regarding ANC frequency and the threshold of referral.


Guidelines on ANC, perinatal care, PNC and breastfeeding for LBW infants weighing between 1500-2500g were available and accessible in Vietnam. Structural factors, including culture, infrastructure and economy, appeared to be major barriers to implementation and acceptance of guidelines.

The appropriateness of LBW guidelines requires

further research. In the context of relatively high neonatal mortality, four ANC visits in Vietnam might be more appropriate than three. In line with recommendations by the WHO, breastfeeding and skin-to-skin contact were found appropriate for Vietnam given their potential to reduce the burden of LBW morbidity and mortality in low-resource settings. The internal institutional alignment and coherence of guidelines, particularly the cut-off for referral of LBW infants, should also be monitored to ensure healthcare workers are appropriately informed of practices and the complications of nonadherence. Further studies comparing divergent WHO guidelines, local guidelines and local cultural norms and traditions are recommended.




The author would like to thank her supervisor Professor Ib Bygbjerg, Priya Mannava, and Dr. Ashraful (Neeloy) Alam for their guidance, advice and support.


The materials used and analysed during the current study are available from the author upon reasonable request.

Conflicts of interest

None declared



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Mental illness in refugees fleeing conflict and persecution: what can be done?

Review article

John Koh



The United Nations Refugee Agency estimates that there are currently 22.5 million refugees worldwide, most of whom are fleeing conflict and persecution in their homeland. A further 28,300 more are displaced from their homes every day.[1] There is a large body of evidence that suggests a correlation between psychopathology and exposure to armed conflict and targeted persecution. While needs such as physical health, safety, food and shelter often take precedence over psychological concerns, the sheer scarcity of mental health services means that most refugees who develop mental illness will never receive appropriate care.[2] This adversely affects overall psychosocial wellbeing and has demonstrable long-term implications on refugee mental health.[3] This paper seeks to examine the factors that contribute to mental illness in refugees fleeing conflict and persecution, identify refugee subpopulations at high risk of long-term mental health issues, and provide evidence-based recommendations by reviewing the literature on interventions.

Common mental illnessess among refugees exposed to conflict and persecution

Psychological disturbance is a common consequence of exposure to traumatic events. However, a disturbance may only be classified as a ‘mental disorder’ if it continues to inflict psychological distress over an extended period of time and causes dysfunction in daily life. The degree of the disorder will vary according to the level of exposure to potentially traumatic events (PTEs) and other ongoing stressors.[4]

The most common mental illness among refugees exposed to violence and persecution is Post-Traumatic Stress Disorder (PTSD), where sufferers experience flashbacks of traumatic experiences, as well as heightened levels of anxiety and reactivity to sensory stimuli. The rate of PTSD in refugees can be up to ten times more than the general population.[5] Refugees exposed to PTEs also had an overall rate of 30.8% for depression, with some populations reporting rates as high as 85.5%.[6] Furthermore, a survey of over 16,000 war-affected refugees found prevalence rates of unspecified anxiety disorders between 20 and 88%.[3]

Other mental conditions include psychosis (9-16%) and somatization disorders, which often manifest as chronic pain or other medically unexplained somatic complaints. Most refugees have several co-morbidities in addition to their primary psychopathology. For example, a Danish study showed that virtually all war-refugees who sought psychiatric treatment at the Competence Center for Transcultural Psychiatry in Copenhagen had depression, pain and somatic complaints in addition to PTSD.[7]

In the absence of proper health services, many refugees afflicted by mental illness turn to substance and alcohol abuse, in turn, creating an addiction problem.[8] Research involving 64 refugees with PTSD showed that most had suicidal ideations and half had a history of suicide attempts.[9]

The diagnosis of mental disorders among refugees is often impeded by language barriers and cultural variance in its manifestations and conceptualisation. In some cultures, mental illness is stigmatised, leading to the suppression of verbal and emotional expressions of distress.[10] For example, among Rohingya refugees, psychological distress is expressed idiomatically and often attributed to spirit possession.[11] Somali refugees conceptualize mental illness as Murug, Waali and Gini – sadness, craziness due to spirits and craziness due to trauma. These terms did not exist in pre-war Somalia, however have come to fruition in recent years.[12] Understanding these cultural differences, in contrast to Western conceptualizations of mental disorders, and having a degree of cultural competence can prove helpful to clinicians working with traumatized refugees and in devising appropriate interventions.[3]

Factors associated with mental illness

1. Direct exposure to violence

Refugees exposed directly to violence are predisposed to mental illness. This violence can come in the form of witnessing shooting and bombardment, the destruction of their homes and significant loss of life such as the injury or death of friends and family.[13] Violence can also be targeted directly at individuals. Persecution for racial, religious or other reasons are prime examples. Being subject to torture as a means of persecution is one of the strongest contributing factors to the development of PTSD in refugees.[6] Often times, the victimised individuals find the sheer atrocity of the actions inflicted on them to be incomprehensible, and may assign supernatural or religious meaning to their experiences or mental illness. In other cases, they are unable to conceptualise their experience within their traditional framework for handling crises, leading to distress, depression, anxiety, guilt or shame.[14] In understanding the impact of PTEs and targeted violence on refugee mental health, it is important to take into account the traditional interpretive frameworks used to comprehend trauma and mental illnesses.

2. Gender and sexual orientation

Female refugees are known to have higher rates of both depression and PTSD than their male counterparts, as well as a greater propensity to rely on psychotropic drugs post-migration.[15] Women are particularly vulnerable due to pre-migration trauma such as sexual or gender-based violence during war as well as ongoing stressors.[16] Post-migration stressors include safety concerns in refugee camps as well as discrimination following resettlement in a different country.[5] Cultural differences in internalised gender roles may also explain why male and female refugees are affected differently by post-migration stress. Blight and colleagues found that while job occupancy was important to the mental health of male refugees in Sweden, job occupancy and living in an urban environment appeared to adversely affect the mental health of female refugees.[17] However, research on this topic is limited.[15]

Refugees who are lesbian, gay, bisexual, transgender or intersex also have higher rates of mental illness.[16] Although acts of violence towards LGBTI individuals may increase during times of conflict, many LGBTI refugees have endured years of persecution at the hands of their families or communities. This abuse includes beatings, corrective rape and honour killings.[18] War can exacerbate pre-existing mental illnesses and prompt many LGBTI refugees to flee from their communities.

3. Socioeconomic background and educational status

Refugees from relatively higher socioeconomic and educational statuses in their countries of origin had poorer mental health outcomes.[2] Researchers had previously assumed that these factors would act as a buffer against mental illness, but found that greater social and intellectual status prior to displacement resulted in greater distress and depression when those statuses were reduced to nought.[19] Previously affluent refugees often lose their possessions and homes as a result of persecution and war, while the well-educated found that their degrees and prior work experience were not recognised in the countries they resettled in.

Long-term mental health issues in refugee sub-populations

Even many years after traumatic events and resettlement, mental illness may continue to persist in refugee populations.[3] Vietnamese refugees exposed to 3 or more traumatic events continued to have a 12% risk of mental illness 10 years after resettlement.[20] Furthermore, refugees resettled in western countries continued to exhibit rates of PTSD that are ten times higher than the general population(s).[21] These are consequences of long-term non-treatment,[21] pre-migration trauma and unresolved post-migration stressors.

Refugees who are subject to protracted periods of detention represent a sub-population that is particularly prone to long-term mental health issues. Living conditions and further exposure to violence and PTEs while in detention often re-traumatise refugees.[22, 23] Following detention, adults experience a threefold increase in mental illness, while a tenfold increase was observed in children.[23] The deprivation of freedom of movement and independence following escape from collective violence and persecution is known to be a major post-migration stressor for refugees.[11] Even several years after resettlement and release from detention, refugees continued to experience high levels of PTSD, anxiety and depression, which they associated with feelings of insecurity and injustice resulting from their experiences in detention.[24] Longer periods of detention were associated with greater degrees of long-term psychological disturbance following follow-up with refugee children in Sweden indicated a gradual improvement in mental illness over time, children who had been exposed to violence and conflict displayed persisting psychological disturbances. This was similarly observed in Cambodian refugees over a 12-year period, with specific regard to PTSD.[27] The most common types of PTEs experienced by children during times of conflict include funerals, witnessing armed conflict and seeing injured or dead strangers and family members.[28] Adult refugees who experienced PTEs as children had worse long-term mental health. Indeed, the extent of childhood PTEs was found to be more strongly related to mental illness than the degree of exposure to more recent violence and human rights violations.[29] This suggests that child refugees fleeing conflict have a high risk of long-term mental illness, which may persist even into adulthood.

Recommended interventions

There remains a pressing need for diagnostic tools to conduct large-scale screening for mental illness in refugees. This is essential for early intervention, to prevent deterioration of mental health and to halt the progression to long-term mental illness. The Kessler Psychological Distress Scale (K10) has shown potential as a screening instrument for mental illness, particularly PTSD.[30] However, it may have limited effectiveness in culturally diverse populations,[31] likely due to interpretative complications. Nevertheless, until further research into transcultural diagnostic tools, K10, used in conjunction with other conventional instruments such as PTSD-8, has utility in initial screening for mental illness.[30] The effective translation of these diagnostic tools into the primary languages used by large and potentially diverse refugee populations, while taking into consideration cultural and linguistic nuances, is an intervention that must be explored. Collaboration between healthcare professionals, interpreters and ‘culture brokers’ is crucial for this intervention to be successful and for the subsequent treatment of diagnosed mental illnesses.[5]

Where there is access to psychiatric services, Narrative Exposure Therapy (NET), which helps individuals contextualise their experiences of persecution and violence, has been shown to alleviate mental illness in refugees from a diverse range of backgrounds and with varying traumatic experiences.[32, 33] Psychopharmacological treatments involving antidepressants and antipsychotics are also known to be effective.[34] However, due to a lack of data, no specific pharmacological regimens can be recommended at this juncture.[35] Nevertheless, if available and deemed appropriate by a clinician, pharmacological interventions should be used in conjunction with psychotherapy. For instance, Sertraline used with Trauma-Focused Cognitive Behavioural Therapy (TFCBT) is known to be efficacious in the treatment of PTSD.[7] In addition, clinicians should take into account cultural variations in the conceptualisation and expression of psychological distress when conducting conventional psychotherapy.

Although more research needs to be done to develop precise, culturally-adapted therapeutic interventions, the Delphi Method has been proven to be useful in creating mental health interventions for culturally diverse groups and Iraqi refugees in Australia.[10] It is a type of consensus method which allows a panel of mental health experts to devise comprehensive mental health interventions through multiple rounds of anonymous input and feedback. This method should be adopted and tested with other refugee populations and may prove successful in creating refined interventions.

In low-resource settings, mental health interventions may need to be community-based, delivering mental health support within schools, peer-systems and families, rather than between individuals and mental health professionals.[36] This is especially important for refugee children exposed to violence and traumatic events. One of the primary protective factors against long-term mental illness in trauma-exposed refugee children is stable social support in schools.[37] With a shortage of mental health professionals equipped to deal with this specific type of trauma, community-based aid workers can successfully be trained in mental health first aid and provide initial assistance to refugees.[38] The World Health Organisation’s scalable psychological interventions, such as Problem Management Plus (PM+), can be delivered face-to-face, in a group sessions, or with a smartphone by non-professionals.[39] Healthcare institutions may serve as training-providers for government or non-government organisations (NGOs) which are providing the community-based care.

Electronic-mental health interventions are another promising way of reaching refugees who do not have access to mental health professionals or are afraid of stigmatisation. Although there is limited research in low-resource settings, internet-delivered Cognitive Behavioural Therapy was found to significantly improve PTSD in war-traumatised Arab individuals.[39] The internet and development of new technology can allow clinicians to administer psychotherapy without being there in-person, such as via video-call.

It is essential that these psychological interventions take place as soon as mental illness is diagnosed or an individual is determined to be at risk. Untreated mental illness can lead to long-term issues following resettlement or further deterioration of mental health following repatriation, whether voluntary or involuntary.[40] Mental illness may persist for many years, and successful resettlement may not necessarily lead to the resolution of pre-existing mental disorders. There is therefore a need for longitudinal interventions to help refugees through the stages of resettlement and acculturation.[41] This involves making mental healthcare accessible and affordable locally in the countries they are resettled in, so that continued care in the form of psychotherapy and/or medication is readily available. Discharge from care or a decreased frequency of checkups can be considered once a pre-existing mental illness is resolved and deemed unlikely to recur.

Social interventions are necessary to address ongoing stressors, particularly for refugees in the process of resettlement or confined in closed camps for extended periods. Social interventions must address socioeconomic concerns which are commonly associated with long-term depression, such as the lack of gainful employment.[3] The present nature of detention, including its re-traumatising effects, level of safety, extent of restriction of movement and overall duration needs to be addressed as well. Social interventions for refugee mental illness falls in grey area between healthcare and politics, therefore requiring significant dialogue between both healthcare professionals and policymakers. Potential interventions would include job opportunities, recognition of academic accreditations, social support for resettlement and legislation pertaining to the harmful duration and conditions of detention.



Refugees fleeing conflict and persecution are prone to developing mental illness, which if left untreated can have long-term implications on psychosocial wellbeing. There is presently a major lack of resources being allocated to refugee mental health. Research pertaining to culturally-adapted diagnostic tools and transcultural psychotherapy is only just beginning to emerge. This paper examined the factors associated with mental illness in refugees exposed to PTEs, as well as identified refugee subpopulations at a high risk of long-term mental health problems. The literature regarding psychiatric interventions was then reviewed and recommendations were made based on the evidence gathered. Areas where further research is required, or where current research is limited, were noted. Social interventions were addressed as well but may be potentially limited by non-medical factors (e.g. political and economic concerns). Assessing the practicality of social or socioeconomic interventions would likely fall outside the purview of medical literature and was therefore not attempted. Further research into methods for alleviating mental illness in traumatised refugees is still desperately needed.




Photo credit

Image 1: public domain, accessed from

Conflicts of interest

None declared



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Poor mental health: the relationship between poverty and mental health in low and middle income countries

Review article

Salwa Sayeed & Damindri Fernando



The World Health Organization (WHO) defines mental health as a state of well-being which allows an individual to work and contribute meaningfully to their community whilst coping with the normal stresses of life.[1] Mental illness, on the other hand, is defined as disorders characterised by combinations of abnormal behaviour, thoughts, emotions and interpersonal relationships.[2] Mental illness currently carries an immense global burden of disease, estimated to contribute 32.4% of years lived with disability (YLD) and 13.0% of disability-adjusted life-years (DALYs). This places mental illness as an indisputable, global first by years of life lost (YLL) and on par with cardiovascular disease burden by DALYs.[3]

Notably, in low to middle-income countries (LMIC) with a gross national income (GNI) per capita of <$12,236 ,[4] the WHO estimates depressive disorders to be the second leading cause of years lived with disability.[5] Schizophrenia, bipolar disorder, alcohol use disorder and anxiety disorders are also in the top 10 causes of disability due to health-related conditions in LMIC.[6] Strikingly, 80% of sufferers of mental illness reside in LMIC.[7]

Whilst the relationship between poverty and mental illness in industrialised nations has been well-established, the same correlation in LMIC is yet to be established by the literature. This is due to the following reasons: 1. The impact of third factor variables interacting with poverty and mental health, including barriers to mental health services,[8] 2. The way poverty and mental health cyclically cause and impact one-another, 3. Controversy surrounding the best instrument to measure poverty,[9] 4. Lack of research in the area.[10]

Nonetheless, an understanding of poverty as a mental health determinant in these regions is valuable for its ability to inform and direct global mental health policies and interventions. If a causal link between poverty and mental health is established, then there would be health benefits in reducing income inequality. However if such a relationship is disproved, resources could be re-directed into changing health knowledge, preferences and behaviour.[11] This review aims to summarise the literature on whether a causal link between poverty and mental illness can be drawn and thus provide direction for future areas of research in this field.

As the literature on poverty and mental illnesses is primarily on common mental disorders, this review focuses on the same. Regarding definitions of poverty, there are various parameters that can be used including: consumption poverty, highest level of education attained, yearly income, food insecurity and financial stress.[12] As each study cited uses its own measurements, this review does not provide an overarching definition of poverty.


In the interface between poverty and mental health, two main theories have been proposed. Firstly, the ‘social causation theory’ highlights that poverty is a risk factor for mental illness through various mechanisms of social exclusion, stress, deprivation, malnutrition, increased obstetrics risk, violence and trauma.[13] On the other hand, the ‘social drift (or social selection) theory’ suggests vice versa, that mental illness can cause impoverished conditions through low employment, low productivity and stigma. Nevertheless, it is likely that both pathways are at play in mental illness.[14]

Poverty and mental illness

A 2003 article by Patel and Kleinman et al. reviewed the association between poverty and common mental health disorders in six LMIC through English-language journals and global mental health reports published since 1990.[10] Most studies showed a robust association between poverty and common mental disorders, particularly asserting that they interact in a vicious cycle. The most strongly associated measure of poverty was low levels of education. The contribution of low level education to increasing hopelessness, insecurity, rapid social change and limited opportunities ultimately increases mental illness development risk. Contrastingly, actual income was less implicated as a risk. However, the article did not find causal associations between poverty measurements. That is, most LMIC populations living in poverty do not develop mental illness. These findings called for further longitudinal research.[10]

Another study done by Das et al. (2007) revisited the relationship using survey data from five LMIC: Bosnia and Herzegovina, Indonesia, Mexico, India and Tonga.[15] Contrasting the findings of Patel & Kleinman et al. (2003), the study found that the relationship between consumption poverty and mental illness was poor while the strongest factors were widow-hood and poor physical health. It was hypothesised that the differences in the poverty-mental health relationship between developing and developed LMIC could be attributed to two causes. The first being the flexibility of work hours and attendance in LMIC in the informal sector (primary industries, self-employment), allowing individuals with mental illness opportunity to maintain employment. The second, larger village and family support systems lowering the risk of developing mental illness and insuring against poverty development.[15]

Other additional findings of the report were that life changes – either positive or negative – had bigger, long-term impacts on mental health. Thus, Das et al. (2007) argued that public mental health interventions in LMIC should focus on individuals experiencing upheaval and adverse life changes.[15]

However, a critique of Das et al. (2007) by Corrigall et al. (2008) expanded on certain limitations of the study.[16] Firstly, it argued that the effect of downstream variables, such as age and poor health, is statistically larger than upstream variables, such as poverty. This is primarily because upstream variables exert their effect through downstream factors, resulting in poverty being less associated with mental illness. Secondly, the use of household expenditure (i.e. consumption poverty) as the measure of poverty could be misguided as the measure can be confounded with household debt. This itself has been found to be independently associated with poverty.[17] Thirdly, their study contradicts the vast majority of community-based epidemiological studies that had been conducted in low, middle and high-income countries. Lastly, it was not clear whether a multivariate regression was performed.[16]

In order to combat these issues, Lund et al. (2010) conducted a systematic review of the epidemiological literature in LMIC, using a variety of poverty measures.[8] 79% of the 115 studies reviewed showed positive associations between different poverty measures and common mental disorders. However, there were differences in impact depending on the measure studied. Income, unemployment and consumption were less associated with CMD, whilst education, socio-economic status, food insecurity, housing, social class, financial stress were strongly and consistently associated. Lund et al. (2010) mentioned that such differences could account for the weak association between poverty and mental illness in LMIC as suggested by previous studies.[8]

Lund et al. (2010) also noted that most of the 115 studies used in the reviews were cross-sectional. Thus, conclusions about the original cause in the interface between mental illness and poverty could not be drawn. It did, nevertheless, confirm that poverty and mental health most likely interact in a vicious cycle, as originally hypothesised.[8] Individuals living in poverty are at risk of mental illness through high stressors, social exclusion, reduced social capital, malnutrition, increased risk for violence and trauma, and obstetrics risk. Concurrently, individuals with mental illness are inclined to be in poverty due to stigma surrounding mental illness, lost employment, school dropout and reduced social support.[8]

In summary, the relationship between poverty and mental illness is complex and varied. Whilst a strong correlation between poverty and mental illness exists, there is also evidence to suggest the vice-versa – mental illness resulting in poverty. Hence, both social drift and social causation pathways are relevant in understanding poverty and mental health in LMIC.


Limitations and further areas of research

The limitations within the current body of literature indicates a wide scope for further research and improvement.

One of the most significant limitations of the literature thus far is accepting and validating definitions of poverty. The definition of ‘poverty’ has historically been controversial as it is imbued with socio-political ideological baggage. The lack of rigorous reporting of poverty indicators, and lack of consequent justification of the measures utilized based on current theoretical understanding in the field is concerning in this context. It impairs critical assessment and comparison across studies and consequently, future studies should focus on clearly defining variables with validated measures to be used.[9]

In addition to more stringent quality of reporting, qualitative studies that reflect lived experiences would be a helpful contribution to this field as it may better capture the contextual differences across different developing countries as well as contribute to development of theoretical causality.[8]

Given the complex interplay of factors that inform mental health outcomes in the context of multiple deprivation, further research is required to ascertain the strength of association amongst these factors. The ultimate goal is to identify those that may be protective in nature. Longitudinal epidemiological studies are required to establish direction of causality.[8] Despite schizophrenia and bipolar disorders belonging to the top causes of disability in LIMC, there has been little effort to evaluate how these conditions uniquely interact with various determinants of poverty across an individual’s lifespan.[6, 18]

Further research is also required in evaluating the interventions targeting poverty and mental health in LMIC. Despite a clear positive trend between mental health interventions and improved economic outcomes in LMIC, the feasibility and efficacy in scaling up these interventions is unclear with macroeconomic costs involved in implementation and subsequent impact to be determined.[14]



In reviewing the literature, it becomes clear that both the social drift and social causation theories are central to our understanding of the dynamic relationship between mental illness and poverty in LMIC. Of the measures examined, poverty, education, socio-economic status, food insecurity, housing, social class, financial stress were the most strongly associated with CMD, whilst income, employment and consumption did not having as significant an impact.[8] Whilst correlations between poverty factors and mental illness have been established, causation has not. In this regard, longitudinal studies are important in establishing causality, with focus on the recognition of protective factors and time points for intervention in resource poor settings.[13] As the degree of impact on mental illness is influenced by which poverty indicator is used, rigorous reporting of studies is critical to establish the framework which future studies will utilise to ultimately influence the development of effective policy.




Conflicts of interest

None declared



1. World Health Organisation. Mental health: state of well-being 2014 [updated 2014; cited 2018. Available from:

2. World Health Organisation. Mental Disorders 2017 [Available from:

3. Vigo D, Thronicraft G, Atun R. Estimating the true global burden of mental illness. Lancet Psychiatry. 2016 3(2):171-8.

4. World Bank Development Team. 2017. [cited 2018]. Available from:

5. World Health Organisation. Global Health Estimates 2015: Disease burden by Cause, Age, Sex, by Country and by Region, 2000-2015. Geneva: World Health Organisation; 2016.

6. Rathod S, Pinniti N, Irfan M, Gorczynski P, Rathod P, Gega L, et al. Mental Health Service Provision in Low-and Middle-Income Countries. Health Services Insights. 2017;10.

7. World Health Organisation. Disease and Injury Regional Estimates for 2004. Geneva, Switzerland: World Health Organisation 2008.

8. Lund C, Breen A, Fisher A, Kakuma R, Corrigall J, Joska J, et al. Poverty and common mental disorders in low and middle income countries: A systematic review. Social Science & Medicine. 2010;71:517-28.

9. Cooper S, Lund C, Kaukma R. The measurement of poverty in psychiatric epidemiology in LMICs: critical review and recommendations. Social Psychiatry and Psychiatric Epidemiology. 2012;47.

10. Patel V, Kleinman A. Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization. 2003;81:609-15.

11. Hanandita W, Tampubolon W. Does poverty reduce mental health? An instrumental variable analysis. Social Science & Medicine. 2014;113:59-67.

12. Howe L, Galobardes B, Matijasevich A, Gordon D, Johnston D, Onwujekwe O, et al. Measuring socio-economic position for epidemiological studies in low- and middle-income countries: a methods of measurement in epidemiology paper. International Journal of Epidemiology. 2012;41(3):871-86.

13. Li C, Jiang S, Yin X. Understanding the Relationship between Poverty and Children’s Mental Health in Poverty-Stricken Area of China: Social Causation or Social Selection? Journal of Child and Family Studies. 2017;27:1186-92.

14. Lund C, De Silva M, Plagerson S, Cooper S, Chisholm D, Das J, et al. Poverty and mental disorders: breaking the cycle in low-income and middle-income countries. The Lancet. 2011;378:1502-14.

15. Das J, Do Q, Friedman J, McKenzie D, Scott K. Mental health and poverty in developing countries: Revisiting the relationship. Social Science & Medicine. 2007;65(3):467-80.

16. Corrigall J, Lund C, Patel V, Plagerson S, Funk MK. Poverty and mental illness: Fact or fiction? A commentary on Das, Do, Friedman, McKenzie & Scott. Social Science & Medicine. 2008;66:2061-3.

17. Araya R, Lewis G, Rojas G, Fritsch R. Education and income: which is more important for mental health? Journal of Epidemiology and Community health. 2003;57:501-5.

18. Lund C. Poverty and mental health: Towards a research agenda for low and middle-income countries. Commentary on Tampubolon and. Social Science & Medicine. 2014;111:134e6


State of emergency: a call to action on environmental issues

Feature article

Ike Schwartz

Modifiable environmental factors account for almost a quarter of global deaths.[1] Climate change and associated environmental issues such as air pollution severely impact on the health of communities around the globe, and today’s medical students have a unique choice between leading forward-thinking preventative action or managing the future health consequences of inaction. Given this stark choice, why aren’t globally minded medical students more interested in advocating for what the WHO director-general has called the ‘defining global health issue of our time’ ?[2]

A cause that affects us all

The effects of environmental degradation on human health are wide and deleterious. Many of the most pressing global health issues of our time, ranging from food availability to water quality, malaria prevalence to cardiovascular and respiratory disease rates, are being increasingly exacerbated by the global effects of anthropogenic climate change,[3] and dealing with this problem is a matter of urgency.

Individual organisations dealing with such problems receive funding, publicity and support from medical students and their organisations around the world. While these efforts are nevertheless worthwhile, greater consideration must be given to the climatic and environmental causes that intensify these issues.

Climate change is an existential threat to humanity, but its causes are the result of profound injustices mimicking global patterns of inequality such as health resource disparity and the burden of communicable disease; whilst wealthy nations account for the vast majority of global consumption and emissions, climatic consequences impact most heavily on impoverished populations least equipped to deal with such issues.[4] Far from guiltless, Australia has the highest per capita material footprint of any country in the world on consumption-based measures of resource use.[5] In comparison, though each of Bangladesh’s citizens consumes only half the resources of the global average, it will see a loss of 17 percent of its land mass by 2050 on current estimates of sea level rise, creating approximately 20 million climate refugees.[6] Such stark inequity should evoke an immediate response from global health groups, especially in Australia, but currently seems to generate far less discussion than comparative global health issues.

In addition to such massive inequities, environmental issues exist that can be felt concretely throughout the developed world, albeit to a lesser extent. For example, one of the environmental issues most directly affecting human health is air pollution, an issue intrinsically linked with climate change in many ways. Greenhouse gases including carbon dioxide and air pollutants such as particulate matter, sulphur and nitrogen oxides, largely all stem from fossil fuel combustion. Particulates aggravate climatic effects by absorbing sunlight and altering precipitation patterns, and changes to the climate in turn prolong air circulation of pollutants through alteration of natural removal processes.[7] The atmosphere over inhabited locations commonly contains tens of thousands of particles per millilitre, capable of penetrating deep into the lungs and inducing alveolar inflammation, which can exacerbate lung disease and lead to increased blood coagulability, cardiovascular disease and ischaemic stroke.[8] Evidence also suggests such air pollution can impact on perinatal outcomes such as birth weight.[9] Current guidelines rely, often unsuccessfully, on keeping pollution below ‘safe thresholds’, when evidence suggests there may in fact be no lower limit under which no health effects are observed.[10]

Such devastating environmental issues require attention from populations around the world, and communities of medical students are well placed to lead immediate and necessary action on their health implications.

Ineffective Leadership

Historically, governments and other institutions above the level of the community have been heavily relied upon to take leadership on environmental issues. However, current systems for environmental protection are failing to meet the needs of the present and future global population.

Air pollution management is one such example. On the 30th October, 2018, the World Health Organisation will hold its first Global Conference on Air Pollution and Health, featuring a “call for urgent action” aimed at encouraging policymakers to produce more progressive solutions to a growing crisis of air quality.[11] While undoubtedly a worthy effort, this action comes too late for the estimated 103.1 million disability-adjusted life years accounted for by outdoor ambient air pollution in 2015 – a measure of years of healthy life lost. Within that figure is 4.2 million premature deaths and similar numbers of people likely died as a result of air pollution in 2016 and 2017.[12]

History would have us believe that international collaborative efforts are doomed to a large extent to be reactive, rather than preventative, on environmental issues. While global cooperation has had moments of marked success, such as the 1989 Montreal protocol which was able to successfully phase out use of ozone depleting chlorofluorocarbons,[13] international law pertaining to issues such as water use, chemicals, and the climate is often incomplete and ineffective.[14] A contemporary example of this is the 2015 Paris Agreement. While this agreement marks a significant achievement in international environmental collaboration, its aims of “keeping a global temperature rise this century well below 2 degrees Celsius… and pursuing efforts to limit further to 1.5 degrees” appear to be ambitious yet completely unachievable based on current action. [15] Present voluntary national contributions imply warming will in fact reach 2.6-3.1 degrees Celsius this century, and commitments would have to be substantially strengthened for prevention of disastrous interference with the global climate.[16]

While governments and international organisations may play an important role in environmental protection, these structures cannot be solely relied on to instigate prompt and effective change on this time-sensitive issue. Medical students and doctors must recognise this fact, and commit to educating themselves and creating action in absence of support from these institutions.

Community level organisation, and hope for a healthier future

Medical students and doctors occupy a unique space in the public eye, and must utilise this privilege to advocate for those who do not. Climate change, and all its ugly associated symptoms, is a health issue, a humanitarian issue and a moral issue. It is imperative that we, as members of the medical community, take a stand now and fight for the health of our communities and planet, or we risk vast and irreparable damage.

Action on such issues not only prevents climatic and environmental disaster, but has a range of co-benefits. For example, creating sustainable cities through urban management strategies reduces greenhouse gas emissions, but also provides health benefits to residents through improved cooling and reduced air pollution.[17] Research even suggests that the co-benefits of many climate mitigation policies provide enough cost reduction for them to have a net economic benefit, as well as the obvious climate and health advantages.[18]

Though truly lasting environmental sustainability may only be achievable through a systemic shift in the way we value natural resources and the environment, individuals and groups can create essential change that impacts on broader society.

Environmental advocacy groups, for example, have been historically effective in creating change on a range of issues. Massive community response was instrumental in preventing the development of the Jabiluka uranium mine in 1998, when up to 14000 young people, including tertiary students organised by the National Union of Students, joined with Aboriginal action groups to run one of the most successful environmental campaigns in Australia’s history.[19] In 2017, the ongoing national campaign against the proposed Adani Carmichael coal mine, which would be the largest coal mine in Australia and was called a “public health disaster” by The Lancet saw two health professionals arrested for protesting out of concern for the health impacts of the mine.[20-22]

A variety of strategies exist for medical students to become active in this space. Medical students are perfectly capable of lobbying elected representatives, organising or participating in public forums that discuss the interaction between environmental and health issues, or joining action groups. Becoming educated on these topics and spreading information empowers individuals to agitate for larger change. Using existing student groups such as medical societies to hold corporations to account for the environmental consequences of their production through boycotts and promotion can be an incredibly effective way to make change at a local level, and ensuring that student groups themselves are aware of their own carbon and waste footprint is a method of creating awareness and encouraging personal investment in the environment. Getting involved in local environmental groups can be as simple as searching for the environmental issues most relevant in your area and sending someone an email or attending a community meeting. Even individual actions such as turning off the lights or opting for the bike can be empowering and contribute to the efforts of millions of others attempting to reduce their carbon footprint.

Medical student organisations should be actively seeking collaboration with other community groups that lead change in this area. For instance, collaboration with First Nations peoples is an essential and oft-neglected component of any successful environmental strategy, and it is imperative that well-meaning groups provide a platform for Indigenous voices and knowledge to be included in any discussion involving the natural environment. In Australia, Aboriginal and Torres Strait Islander peoples successfully and sustainably thrived in a diverse range of ecosystems for tens of thousands of years, and Western ignorance of the strategies that facilitated these populations is a tragedy whose effects are perennially experienced in today’s bushfires, soil degradation crises, and ecological extinctions.[23] Medical students should take responsibility for building relationships with First Nations Peoples, for health and social reasons as much as environmental. Indigenous community leaders are often the most passionate advocates for environmental protection, and open discussion and collaboration provides unique opportunities for community driven change as well as opening channels for discussion of other complex Indigenous health issues.

Strong, inclusive, community action creates change, and climate change is a truly global issue providing an opportunity for the medical profession to collaborate with and inspire other groups with leadership and initiative. Environmental health groups already operate in Australia and worldwide, and they need the support and initiative that the next generation of doctors and medical students can provide. Students and doctors have a responsibility to fulfil the expectations of social conscience the community has of us. If we don’t take urgent action, we can’t expect that anyone else will.



The author would like to thank Georgia Behrens for her help in making important revisions to the first draft.

Photo credits

Image 1: public domain, accessed from

Image 2: Frontline Action on Coal. Medical doctors and health professionals arrested whilst highlighting devastating health risks of Adani’s mega coal mine [Internet]. 2017 [cited 20 May 2018]. Available from:

Conflicts of interest

None declared



1. WHO. Preventing Disease Through Healthy Environments [Internet]. Geneva: World Health Organisation; 2016 [cited 2018 May 27]. Available from:

2. Chan M. WHO Director-General addresses Human Rights Council on climate change [Internet]. Geneva: World Health Organisation; 2016 [updated 2018; cited 2018 Mar 29].

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3. Grasso M, Manera M, Chiabai A, Markandya A. The Health Effects of Climate Change: A Survey of Recent Quantitative Research. International Journal of Environmental Research and Public Health. 2012;9(5):1523-47.

4. Campbell-Lendrum D, Corvalán C. Climate Change and Developing-Country Cities: Implications For Environmental Health and Equity. Journal of Urban Health. 2007;84(1):109-17.

5. Wiedmann TO, Schandl H, Lenzen M, Moran D, Suh S, West J, et al. The material footprint of nations. Proceedings of the National Academy of Sciences. 2015;112(20):6271.

6. Bayes A. Who takes responsibility for the climate refugees? International Journal of Climate Change Strategies and Management. 2017;10(1):5-26.

7. Fiore AM, Naik V, Leibensperger EM. Air quality and climate connections. Journal of the Air & Waste Management Association (1995). 2015;65(6):645-85.

8. Seaton A, Godden D, MacNee W, Donaldson K. Particulate air pollution and acute health effects. The Lancet. 1995;345(8943):176-8.

9. Fleischer NL, Merialdi M, van Donkelaar A, Vadillo-Ortega F, Martin RV, Betran AP, et al. Outdoor Air Pollution, Preterm Birth, and Low Birth Weight: Analysis of the World Health Organization Global Survey on Maternal and Perinatal Health. Environmental Health Perspectives. 2014;122(4):425-30.

10. Chow JC. Health Effects of Fine Particulate Air Pollution: Lines that Connect. Journal of the Air & Waste Management Association. 2006;56(6):707-8.

11. WHO. WHO’s First Global Conference on Air Pollution and Health, 30 October – 1 November 2018 [Internet]. Geneva: World Health Organisation; 2017 [updated 2018; cited 2018 Mar 27]. Available from:

12. Cohen AJ, Brauer M, Burnett R, Anderson HR, Frostad J, Estep K, et al. Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015. The Lancet. 2017;389(10082):1907-18.

13. Spurgeon D. ‘Surprising success’ of the Montreal Protocol. Nature. 1997;389:219.

14. Conca K. An unfinished foundation : the United Nations and global environmental governance: New York : Oxford University Press; 2015.

15. UNFCCC. The Paris Agreement [Internet]. Bonn: United Nations Framework Convention on Climate Change; 2014 [updated 2018; cited 2018 26 Nov]. Available from:

16. Rogelj J, den Elzen M, Höhne N, Fransen T, Fekete H, Winkler H, et al. Paris Agreement climate proposals need a boost to keep warming well below 2 °C. Nature. 2016;534:631.

17. Harlan SL, Ruddell DM. Climate change and health in cities: impacts of heat and air pollution and potential co-benefits from mitigation and adaptation. Current Opinion in Environmental Sustainability. 2011;3(3):126-34.

18. Bollen J, Guay B, Jamet S, Corfee-Morlot J. Co-benefits of climate change mitigation policies: literature review and new results. OECD Publishing; 2009.

19. Branagan M. The Australian movement against uranium mining: Its rationale and evolution. International Journal of Rural Law and Policy. 2014(1):1-12.

20. Osborne R. Adani’s Carmichael Coal Mine and Health: Fact Sheet [Internet]. Adelaide: Doctros for the Environment Australia; 2017 [Available from:

21. McCall C. Australia’s new coal mine plan: a “public health disaster”. The Lancet. 2017;389(10069):588.

22. Cooke S, Selvey L. Professionals ready to stand up for health of Australians [Internet]. Pyrmont: Fairfax Media; 2018 [cited 2018 May 28]. Available from:

23. Pascoe B. Dark Emu: Black Seeds : Agriculture Or Accident? Broome: Magabala Books; 2014.


The Gaza Healthcare System

Feature Article

Qazi Sarem Shabab



The land of Palestine has long been subject to conflict between the Palestinian Arabs and Israeli Jews. This conflict, which began before the mid-twentieth century, has displaced millions, many of whom continue to live as refugees. Frequent conflict escalation leads to considerable morbidity, mortality and, increasingly, strain on the Gazan health system.

This paper aims to critically evaluate the current health crisis in Gaza, both in terms of loss of life and damage to infrastructure. The impact of the conflict on the Gazan health system and the role of the international community in supporting and promoting health justice on the Gaza strip are also explored.

Overview of the health system in Gaza

The Gazan health system is vulnerable to conflict by virtue of the complexities introduced by a combination of public, military, non-government and private health agencies. The healthcare system in Gaza comprises the Ministry of Health, United Nations Relief and Works Agency for Palestinian Refugees (UNRWA), non-government organisations (NGOs), military medical services and multiple private healthcare providers. Thirty-two hospitals provide secondary and tertiary services to a population of 1.82 million. During times of conflict, the Ministry of Health becomes the only emergency care provider. The Gazan health system is overstretched, lacks adequate physical infrastructure, supplies and standard training opportunities. The Israeli blockade and fiscal crisis have exacerbated these insufficiencies.[1]

Power crisis and drug shortage

As the Palestinian inhabitants of Gaza continue to suffer from persecution at the hands of Israel, the end of 2017 has seen a growing medical crisis. The primary reason for this is the worsening shortage of drug supplies in Gaza’s major hospitals and clinics, and a power shortage that has had a catastrophic impact on the health facilities.

Health facilities in Gaza have been crippled by worsening power shortages related to conflict in the area. This power crisis has been ongoing since June 2006, following an Israeli military strike on a power plant in Gaza, and has significantly impacted healthcare delivery. Hospitals in Gaza use approximately 500,000 litres of fuel monthly to operate emergency generators for the provision of life-saving services.[2] Power shortages severely restrict access to medical services, such as diagnostics and sterilisation, and the resulting delay in necessary surgical interventions is regularly life-threatening. The waiting time for elective surgery is now 48 weeks, as compared to the Gaza Ministry of Health threshold of 24 weeks.[2]

The power supply, on average, lasts for 3-4 hours. Power fluctuations frequently result in damage to essential life-saving equipment. Additionally, over 150 essential machines are currently out of service or unavailable, including defibrillators, anaesthetic machines and items such as surgical drains, epidural catheters and surgical sutures.[2] Functioning and well-maintained medical equipment are seen as a “luxury” by the critically ill. The head of the neonatal department at al-Naser hospital in Gaza recounts a horrific experience in the face of a power cut: “One of the most devastating times ever, we were rushing between the babies and alternating manual ventilation to take over the ventilating equipment for about 8 minutes. We were afraid to lose them.”[2]

Regular power cuts lasting 18-20 hours lead to generators being overused, which then require either repair or replacement. However, such maintenance is practically impossible, as spare parts are on the “dual-use list”: a list of items which Israel suspects might be used for both civilian and military purposes. Currently, an additional $800,000 USD funding is required to repair generators.[2]

Power shortages impair the collection, storage and transport of blood products. Storage of high quantities of donated blood at acceptable standards is currently a particularly concerning issue. An adequate supply of blood is a pre-requisite for emergency surgeries, managing blood loss after childbirth and for ongoing treatment of blood disorders. Gaza requires 35-40,000 units of blood annually, which increases by around 20% during periods of active conflict.[2]

In November 2017, 43% of all drugs on the essential drugs list were completely exhausted, with particular shortages in cancer, psychiatric and ophthalmological drugs. A wide range of essential medical disposables, including syringes, line tubes, filters for dialysis and dressing materials were also in short supply. As of October 2017, 30% of the items on the essential disposables list were reported to be at zero stock levels.2[]

A financial crisis causing a clinical crisis

Plunging cash flow has led to multiple problems. Short supply of critical necessities, including life-saving drugs, IV fluids and surgical instruments, threatens patient safety and treatment capacity. During the 2014 Gaza War, Gaza’s largest hospital, Al-Shifa, ceased all planned surgeries, instead performing only life-saving emergency surgery. Even today in the Gazan health system, 30% of the medications required in intensive care are unavailable. In the southern district, oncological treatments have ceased due to the shortage of medicines. A lack of laboratory supplies has rendered haematological and microbiological tests completely unavailable in outpatient clinics, and accessible only to severely ill hospitalised patients. Sterilizing agents are in short supply, thus increasing the risk of contracting deadly infections.[3] Similarly, the radiological department in Al-Shifa hospital has been made almost redundant due to malfunctioning CT and MRI scanners. The decommissioning of these machines is a result of budget limitations and spare parts supply. The latter has been severely restricted by the problems associated with obtaining Israeli permission to deliver spare parts.[3]

Salary payments to staff have remained an issue throughout the conflict. Over the past 12 months, doctors who receive their salary from the Palestinian Authority in Ramallah have only received a quarter or half of their pay.[3] Some staff members have been pushed to the point of sharing wages. However, despite a lack of adequate infrastructure, essential equipment and drugs, the staff at Al-Shifa continue to deliver the best possible patient care. The situation is particularly critical during Israeli military offensives when huge numbers of emergency cases push the hospital’s operational capacity to the brink of collapse.[4]

Insufficient access to treatment and the dilemma of referrals

With a chronically overburdened health system that is confronted by conflict and financial misfortune, the struggle to manage an enormous volume of patients is inevitable. Such incapacity regularly necessitates referral to facilities outside the Gaza Strip. However, an increasing number of patients are finding that their referrals are delayed or rejected. Typically, access to hospitals in Israel or the West Bank is requested for patients requiring specific treatments not available within the Gaza system, or in cases where services, supplies or personnel are lacking. Patients who have their applications approved are subject to stringent Israeli security interrogation. In addition, 60% of patient companions have their permits either delayed or denied.[5] Only 1 first degree relative is allowed to accompany the patient. From 2012 onwards, the approval rate for patient companions has steadily declined.[5] Restricted access to Egypt due to the closure of the Rafah border terminal has further exacerbated these problems. No medical aid or personnel are allowed to access Gaza via Rafah during times of closure, typically extending for up to 3 months. Multiple families have suffered through mourning the death of their loved ones due to these travel restrictions. For example, in one such case, a 45-year-old lady, who was the mother of 9 children, died of breast cancer after her requests for a permit to seek treatment in a hospital in Jerusalem were rejected twice. Similarly, a 2-year-old patient with renal failure died while waiting for financial approval to be referred out of Gaza. To make things worse, securing a permit does not guarantee permission to cross the border, since the Israeli military at the border may deny access.[5] Even if the referral is approved, the patient co-payment, accommodation for the accompanying relative, transport and incidental medical costs represent significant financial burdens for a population in which the unemployment rate stood at 41.7% in 2017.[6]

Water supply and food shortage

Population growth, the conflict and the Gaza blockade all contribute to the exacerbation of water and food shortages. Currently, Gaza draws the majority of its water from a coastal aquifer shared with Israel. The rate of extraction exceeds that of regeneration, which has led to increasing salinization of the water, rendering 95-97% of the tap water unsuitable for human consumption. Indeed, all groundwater wells in Gaza fail at least 1 WHO standard for water quality.[7] Conflict escalations often result in damage to the water supply. Repairing such damage is difficult, due to the blockade on construction materials, as well as a lack of funds. Power shortages have resulted in non-functional wastewater treatment facilities, with untreated sewage leading to increased pollution of the sea along Gaza’s coast. Without an adequate electricity supply to operate the 72 water wells and 10 waste pump stations in Gaza, drainage of untreated sewage and maintenance of an uninterrupted safe drinking water supply is a major cause of concern. Tap water is only accessible for up to 5 hours a day, and 300,000 cubic metres of poorly treated sewage is discharged daily into the sea, thus increasing the risk of water-borne diseases. Such water is unfit for consumption, meaning that the Gazan population must rely on water purchased from private vendors for drinking and food processing, further burdening a poor community. Pollution has already had medical consequences, with an increase in the number of diarrheal cases during the months of June and July last year among children under the age of 3.[2]

With respect to food security, strict restrictions on food exports to Gaza have made 77% of the Palestinian population dependent on food distribution by World Food Program (WFP) and UNRWA. A declining economy and a decrease in per capita income have resulted in a vicious circle of poverty, food and health insecurity.[3]

Mental health in Gaza

Epidemiological surveys have shown an average prevalence of 15.4% and 17.3% for PTSD and depression respectively among Gazans. Children inhabiting war zones are at a higher risk of developing PTSD and other emotional problems. Exposure to bombardment is the strongest predictor of developing post-traumatic stress reactions.[6] The recommendations for improving mental healthcare in Gaza include specific training courses for psychotherapeutic interventions, maintaining a constant supply of psychotropic drugs and establishing well-equipped mental health units.[8]

The role of the international community and health professionals

With the assistance of financial aid from organizations like the World Bank and countries around the world, organizations such as the UNRWA are playing a vital role in meeting the basic needs of Palestinians. UNRWA coordinates free food distribution, provision of shelter through refugee homes and construction of basic health infrastructure. Indeed, 70% of the population of refugees in Gaza are dependent on the UNRWA to meet their basic needs.[8] The Palestinian community requires the assistance of global organisations, both in terms of finance and technical training, to become self-sufficient in the provision of healthcare. Increased funding to procure essential health supplies, including medicines and disposables, would facilitate improvements in healthcare provision, avoidance of referrals and prevention of delays. Funding should also go towards capacity building, in maintaining a reliable supply of essential equipment and training of health professionals.

As the crisis in Gaza continues to mount, assistance is required in all forms for Palestinians. As medical students, we might not qualify as members of an Emergency Response team, but there remain opportunities to engage with, and advocate for, the Gazan population, particularly with respect to healthcare. Foremost, raising awareness of the humanitarian crisis in Gaza should remain a priority. Volunteering opportunities for doctors are also available through organisations such as the Palestinian Medical Relief Society or Volunteer Palestine.



The Gazan health system is under an enormous strain due to decades of conflict. It is vital that humanitarian organisations and governments continue to advocate for increased funding and develop strategies for efficient implementation of health resources. Moreover, further peace talks are essential to improve Gazan health outcomes by facilitating improved cross-border transfer of patients and essential supplies.




Photo credit

Image 1: public domain, accessed from

Conflicts of interest

None declared



1. Health Cluster; Occupied Palestinian Territory. Gaza Strip Joint Health Sector Assessment Report [Internet]. WHO [cited 2018 March 31]; 2014. Available from:

2. WHO Special Situation Report Gaza, Occupied Palestinian Territory [Internet]. WHO [cited 2018 March 31]; 2017. Available from:

3. Efrat M, Liftawi HI, Majadle G, Yahya SH. Overview of The Gaza Health System: Despite the Reconciliation, the Situation Keeps Deteriorating [Internet]. Physicians for Human Rights, Israel [cited 2018 March 31]; 2018. Available from:

4. Gilbert M. Brief Report to UNRWA: The Gaza Health Sector as of June 2014 [Internet]. UNRWA [cited 2018 March 31]; 2014. Available from:

5. Health Access for Referral Patients from the Gaza Strip [Internet]. WHO [cited 2018 March 31]; 2017. Available from:

6. Thabet A, Abed Y, Vostanis P. Emotional problems in Palestinian children living in a war zone: a cross-sectional study. Lancet. 2002;359(9320):1801-4.

7. Shomar B, Abu Fakher S, Yayha A. Assessment of Groundwater Quality in the Gaza Strip, Palestine Using GIS Mapping. J Water Res Protect 2010;10.4236/jwarp.2010.22011

8. Amid Despair: Hope for Palestine Refugees in Gaza | UNRWA [Internet]. UNRWA [cited 2018 March 31]; 2018. Available from:



This is just how it is when they’re old: obstacles to care of the elderly in rural Philippines

Feature Article

Marisse Sonido


Before I saw my grandma, my lola, again this year, I knew she would not be in good health. When we visited in 2015, she had gone from being active around the house to only standing when she was changing chairs. She was perpetually going to the bathroom at night, ate little, and tired easily. Her mental state had declined too. Instead of the lengthy, enthralling Skype conversations to which I had grown accustomed, our last call consisted of short replies from her after considerable prompting.

When I asked her what the doctor had said about the incontinence, or the poor appetite, or the forgetfulness, I was told that her doctor had said nothing because she had not seen her doctor.

‘Why not?’ I asked incredulously. I knew she lived about an hour’s drive away from the nearest hospital. It would be difficult, but not impossible to transport her.

My dad replied, with sad resignation, ‘Well, she’s grown old. They say that’s just how it is.’

Healthy ageing

Let us consider what ageing is ‘supposed’ to be from an evidenced-based perspective.

According to the World Health Organisation, healthy aging is ‘the process of developing and maintaining the functional ability that enables wellbeing in older age’.[1] This entails the individual’s ability to meet basic needs; to learn, grow and make decisions; to be mobile; to build and maintain relationships; and to contribute to society. When I last visited lola in December 2017, this is where things stood:

• She needed a full-time carer to assist her with all tasks. She could barely sit upright, much less walk.

• She would say short phrases to indicate when she was hungry, feeling too warm, or in pain. Beyond this, she made no other decisions and could not execute any of them independently.

• She failed to recognise many members of her own family without repeated reminders. Even her children. During my week-long visit, she was only able to acknowledge me lucidly for five seconds. After my aunt reminded her who I was, she said one short but heart-warming sentence: ‘It’s good you could come home.’ Despite repeated efforts, I could not start a conversation with her again.

Regardless of how devastating it was for me to witness my lola in this state, I believe it is worrying that this condition was to be ‘expected’ for anyone. She had lost all functional ability and was seemingly receiving no active medical intervention for a variety of chronic issues, including dementia.

During my visit, I realised that my grandmother’s case was not a single incident of an elderly woman receiving poor medical care. One of my lola’s carers, Lyn told me that she had cared for two of her own elderly relatives in the same way until they passed. She provided the same full-time assistance and described similar declines in their health as we were seeing in my grandmother. However, she did not share my disbelief and outrage at the way things had turned out with her relatives. To me—with my perspective heavily based on the Australian model of geriatric care— these stories represented a missed opportunity for timely, much-needed and pre-emptive medical intervention. To Lyn and many who lived in my lola’s rural town, they represented an inevitable progression. There was a commonplace acceptance that a state of being like my lola’s was to be anticipated.


Barriers to care

A question I found myself wondering a lot during and since that visit is why this resignation has become commonplace in my lola’s town and, possibly, in other rural towns in the Philippines. Peters et al.[2] comprehensively outlined these reasons in their model on the obstacles to care in developing countries: (1) geographic accessibility, (2) availability, (3) financial accessibility and (4) acceptability. According to Jacobs et al.,[3] considering supply and demand for each dimension is critical to appropriately addressing the issues at hand.

Geographic accessibility

Given where she lived, accessing healthcare was clearly not something that was in my lola’s favour. Based on my nephew’s stories, the two nearest health centres in neighbouring towns had closed since a change in political administration. This led to healthcare funds being redirected to other budget priorities. While seemingly unbelievable at the time, I later learned that public healthcare is the responsibility of local government. As such, local authorities have considerable autonomy in interpreting and executing central health policies.[4]

The best mode of transport to the nearest city available to my lola was a borrowed van. Would she be able to survive a 2–4 hour round trip in a shaking van over dirt roads? It was easy to say that the risk was worth taking but none of her family, including myself, felt comfortable insisting on it. Many other Filipino families have undoubtedly also faced distance as an obstacle to health, given that the average travel time to a hospital is around 39 minutes. In some remote areas, this can average up to 90 minutes,[5] which is not conducive in urgent situations and transporting patients with unstable health.


If the issue of distance could be miraculously resolved, then came the question of whether treatment was available once she arrived at the city hospital. In the Philippines, supply of available health practitioners fails to meet population needs, even with numerous vacant positions in rural areas, exacerbated by emigration in recent decades.[6] Based on the latest available statistics, the Philippines has 1.11 doctors, versus the 3.496 doctors in Australia, for every 1000 individuals.[7] While measures are being taken to improve the number of rural doctors (e.g., increased salaries) and doctors in general (e.g., reducing the length of medical education), it will be several years before these shortages are fully addressed.[8]

Because of this, the waiting time for a doctor in the Philippines could take hours in non-urgent situations. Considering that my lola had multiple comorbidities in the context of a resource-stretched healthcare system, I am not confident that her local public hospital would be able to provide the coordinated long-term care she would require. When she had been more able, she would make a biannual 13-hour road trip to Manila’s more equipped and better-staffed hospitals, where there are approximately 17 beds per 10,000 persons versus the 4 beds per 10,000 persons for the rest of the country.[9] This was no longer a viable option given her health.

On the demand side, availability is limited by the general population’s incomplete understanding of chronic diseases and awareness of where and when to seek medical assistance. Of the existing centralised health promotions run by the Department of Health, very few focus on the elderly and chronic diseases.[10] According to a statement by Dr Anthony Leachon, former president of the Philippine College of Physicians, patients often come to doctors when symptoms are already severe. He blames lack of health literacy.[11] This is could be true in the case of my lola, as the question of seeking professional care did not truly arise until her symptoms had interfered with her day-to-day life and, by then, it became too difficult to arrange.

However, one study demonstrated that late health seeking is not a hard and fast rule and that elderly Filipinos do seek care, if possible, when symptoms of concern appear.[10] Interestingly, the study also found that elderly Filipinos ranked ‘where to get care’ as the least important aspect of their health-seeking preferences. This indicated that, provided their symptoms were addressed, care was acceptable from other sources besides conventional medicine, such as self-care and family advice. According to my family who lived there, a local herbolaryo (folk healer) was sometimes called upon when people in my lola’s village were ill, to offer healing that was a mixture of religious, spiritual and herbal—a reflection of the Philippine’s current religious landscape, and roots in animistic and superstitious beliefs relating to natural health remedies.


Affordability is considered the main reason why Filipinos, elderly or otherwise, delay health seeking behaviours or resort to alternative, cheaper sources of healthcare. According to data from the WHO in 2007,[6] 54.3% of total health expenditure in the Philippines were out-of-pocket expenses. While senior citizens in the Philippines have extra discounts via the public health insurance scheme, Philhealth, the annual health expenditure per capita was still US$68 or approximately PHP 3500.[6] According to a study by de Guzman et al. of 304 elderly Filipinos, approximately 75% of elderly Filipinos earn PHP 10,000 or less yearly—making healthcare a considerable expense.[6] My lola’s main source of income had been a military pension for my grandfather’s service and some of the earnings from the corner store she used to run that was now under my uncle’s care, certainly not enough to afford continuous private care.


A prevailing health-seeking attitude in the Philippines is that, if it can be avoided (i.e., the symptoms eventually subside or are manageable through self-care), then one should refrain from going to a doctor. Besides the expense and inconvenience involved in health seeking, I believe that cultural factors contribute. The dislike of relying on ‘unnatural’ methods of symptom management and cultural stoicism are some of many beliefs at play. Ignoring medical symptoms to maintain daily routines is the norm for many Filipinos, for whom a missed workday could mean financial needs for their families. However, in the elderly, this is coupled with the stigma of losing independence and previous functionality.[12] I know that, until she was no longer able, my lola made it a point to do her regular chores around the house and run her store, even if several members of my family were happy to take over. To her, and perhaps others in her situation, admitting that she needed more medical care was to admit defeat to old age.

When I saw my lola again last year, I quickly realised that the care she received at home was not sufficiently improving her condition. I also knew that the idea of a nursing home or residential care would be disagreeable and unlikely to be accepted by most Filipino families like mine, a stark contrast to the attitude in Australia. As a natural extension of the Filipino family-centric culture, wherein all members remain heavily involved in each other’s lives throughout all stages of life, it would be a source of great guilt for a family to surrender the care of another family member to strangers, and would cause a sense of abandonment in the elderly individual.[11] Perhaps this, coupled with a lack of understanding of healthy ageing, is why those who watched my lola grow weaker were not as alarmed as I had been—this was a progression they had seen in the other elderly individuals who they had known, loved and taken care of all their lives.

Final thoughts

During the time I was writing this article, my lola passed away on the morning of April 1, 2018. While it is pointless to consider how much longer she could have lived with better care, I find myself doing so anyway. My lola is one of many who was failed by the current state of healthcare and health education in the Philippines which, while continuously developing, still has great strides to make in becoming accessible to all Filipinos. By acknowledging the obstacles to health in my lola’s story, perhaps a greater understanding can be gained of the issues faced in the Philippines and other developing countries regarding elderly care, particularly given the fast-growing ageing population in Asia.[13] And perhaps, it can also show how valuable it is to the elderly, and to their families, that they be given the care they need to live their final years to the fullest.



The author would like to thank Mark June and Alice Sonido for their support. A big thank you must also go to Memia Capili Sonido, who was the driving force and inspiration of this article. Rest in pease, lola.

Photo credit

Sonido family

Conflicts of interest

None declared



1. World Health Organization. World report on ageing and health [Internet]. Geneva: World Health Organization; 2015 [cited 2018 April 9]. Available from:

2. Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Rahman MH. Poverty and Access to Health Care in Developing Countries. Annals of the New York Academy of Sciences. 2008;1136(1):161-71.

3. Jacobs B, Ir P, Bigdeli M, Annear PL, Van Damme W. Addressing access barriers to health services: an analytical framework for selecting appropriate interventions in low-income Asian countries. Health Policy and Planning. 2012;27(4):288-300.

4. Oxford Business Group. Philippines government expands health care coverage 2017 [Internet]. Oxford Business Group; date unknown [cited 2018 April 24]. Available from:

5. Department of Health. National Objectives for Health Philippines, 2011-2016. In: Health Do, editor. Manila, Philippines: Health Policy Development and Planning Bureau Department of Health; 2012.

6. World Health Organization. Health service delivery profile Philippines [Internet]. Geneva: World Health Organization; 2012 [cited 2018 April 9]. Available from:

7. World Health Organization. Density of physicians (total number per 1000 population, latest available year) [Internet]. Geneva: World Health Organization; 2018 [cited 24 April 2018]. Available from

8. Cabato R. DOH Secretary: Philippines lacks 15,000 doctors CNN Philippines. 2016.

9. Barcia R. PH needs 45,000 hospital beds [Internet]. The Manila Times; 2017 [cited 2018 April 24]. Available from

10. de Guzman AB, Lores KVA, Lozano MCR, Lozano MC, Lu DM, Ma CEDV, et al. Health-Seeking Preferences of Elderly Filipinos in the Community via Conjoint Analysis. Educational Gerontology. 2014;40(11):801-15.

11. Gloor R. Health literacy: Department of Science and Technology Philippines; 2014 [cited 2018 April 9]. Available from:

12. South Eastern Region Migrant Resource Centre. Filipino Cultural Profile- older people. 2010 May [cited 2018 April 9]. Available from:

13. Dominguez J, de Guzman F, Reandelar Jr M, Thi Phung TK. Prevalence of Dementia and Associated Risk Factors: A Population-Based Study in the Philippines. Journal of Alzheimer’s Disease. 2018 Apr 25(Preprint):1-9.



Cancer Drugs: The Controversial Cost


Tessa Tan



Cancer, with its many permutations, carries the greatest burden of disease in Australia at one-fifth the total disease burden.[1] The cancer burden is also growing globally; at 8.7 million deaths worldwide, it is now the second leading cause of mortality after cardiovascular disease.[2]

In the past decade, the rise of novel cancer drugs has revolutionised treatment for cancers with historically poor prognoses. Cancer drugs rank first in terms of global spending by therapeutic class.[3] The market for cancer drugs, valued at over $110 billion in 2015, is forecast to escalate to $147 billion by 2021.[4] Consequently, potential profit in this market has drawn big pharmaceutical players to the arena. However, we need to consider if these drugs are cost effective and affordable. Where does the burden of cost fall? What is access to cancer treatments like for vulnerable populations?


A question of value

The price of new cancer drugs increased more than five-fold from 2006 to 2015, a substantial amount even after adjusting for inflation.[5] Exorbitant drug prices are often justified on the grounds of recouping research and development costs, but Imatinib, a drug used for chronic myeloid leukaemia has quadrupled in price since its launch despite the availability of generics. Novartis tried to justify this price rise by describing its recently approved new indication, however research costs for the new indication had already been included in its original price.[6] In the scientific community, mechanisms behind drug pricing are aptly termed a “black box”.

The most expensive of these new drugs are biologics – a class of cancer medication not synthesised chemically, instead utilising whole cells, antibodies, enzymes and other cellular components to target molecular processes.[7] Some of these drugs exemplify the zenith of biotechnological innovation, but with prices like $630,000 AUD per patient for Novartis’ latest approved drug, they have the potential to eviscerate government health budgets. Biologics are expensive due to the inherent difficulty in replicating complex molecular structures. Once they are off patent, biosimilars can be produced, yet they only reduce prices by 10 to 30%, requiring further trials prior to approval because they are similar but not identical to their competition. The necessary expenses involved in the process form a barrier to entry, fuelling a drug development model prone to increasing market exclusivity and pricing power concentrated in the hands of a few pharmaceutical giants.

While we do want more efficacious drugs to be available to patients as soon as possible, the value that some of these drugs add at current prices is questionable. Most new cancer drug approvals are used to extend the lives of patients with terminally advanced cancers, as opposed to offering a cure. When researchers looked at cancer drugs approved in the United States and Europe between 2003 and 2013, they found the average extension of survival a only 3.5 months.[8] How much should those 3.5 months cost? WHO guidelines recommend $72,620 – $217,900 AUD per quality-adjusted life year (QALY), and suggest countries should aim to spend between 1 and 3 times their average GDP per capita per QALY gained from treatment.[9] But there are still examples of blatant price-gouging: gemcitabine-erlotinib, a treatment for metastatic pancreatic cancer, provides a survival gain of 10 days at $510,000/QALY.[10] This can happen because first approvals for most cancer drugs occur in the United States, where legislation (Medicare Reform Act 2003) prohibits Medicare from negotiating drug prices with manufacturers, effectively setting a global benchmark for prices with little consideration of value.

In the pursuit of value-based cancer care, it is prudent to consider that treatment-related side effects may decrease quality of life while only marginally extending quantity of life. For example, advanced lung cancer patients with early palliative care intervention alongside standard therapy were found to have better survival and quality of life than those treated with more aggressive treatments.[11] Additionally, costs of novel oncology drugs have increased disproportionately to clinical benefit, as measured by the ASCO Value Framework and European Society of Medical Oncology (ESMO) Magnitude of Clinical Benefit scale.[12] This was demonstrated in a 2018 study where less than one third of randomised clinical trials for approved cancer drugs met thresholds for producing meaningful clinical benefit.[13]

Some of these drugs are being granted market entry presumptively. Courtney et al’s review on cancer drugs approved by European Medicines Agency found no evidence of a survival gain in 90% of indications at the time of market approval – highlighting a need for modelling greater market uncertainty at the time of authorisation.[8] A case in point is bevacizumab, which was granted accelerated approval for metastatic breast cancer, but subsequently had its market authorisation removed when later findings revealed no improvement in overall survival.[14]

On that note, government approvals for cancer drugs need to be informed by rigorous, objective criteria; less easily swayed by pro-innovation bias and industry-funded studies using surrogate end-points, in order to eliminate perverse incentives for drugs that provide marginal benefit.


Access in low-middle income countries (LMIC)

An understated 70% of cancer mortality occurs in low to middle income countries, which may be attributed to social determinants of health and a lack of screening and resources, leading to late-stage cancer at the time of diagnosis.[15,16] Barriers to accessing cancer treatment exist in these countries, including access to therapeutic drugs.

According to an analysis of national formularies in LMICs, it was found that over 80% of them listed less than half of the cancer medications considered by the WHO to be essential, and a majority of LMICs did not have monoclonal antibodies, protein kinase inhibitors or alpha-interferon on their national essential medicines lists (NEML).[17] Medicines on NEMLs form the basis for public reimbursement and have a definite impact on access to cancer treatments.[17] These results indicate that access is suboptimal, though direct measurement of availability and affordability of oncology medicines in LMICs is an area that requires further research.

There is also a lack of access to clinical trials in LMICs, with only 2.7% of global cancer research investment directed to these areas.[18] Necessary policies, guidelines and regulatory requirements governing LMICs can complicate the conduct of collaborative trials. Additionally, cultural disparities, language barriers and differences in healthcare systems make conducting clinical trials in LMICs less appealing to industry giants, limiting access to novel cancer therapies. A scarcity of health infrastructure, expertise, patient support and trained human resources compound the effect.[19] For example, In sub-Saharan Africa, there is less than 1 pathologist per 500,000 persons, compared to 1 pathologist per 15,000 in the United States.[20] Cancer registries in LMICs are also conspicuously absent, making it tricky to accurately collect data on the burden of specific cancers to inform health policy and planning.

On the bright side, there have been progressive changes toward improving access in recent years. Notably, GlaxoSmithKline ceased filing for patents in low income countries in 2016, allowing cheaper generics to proliferate unhindered. Historically, the prohibitively high cost of anti-retrovirals put them beyond the reach of millions of HIV-positive South Africans for years, before generics were finally allowed to be imported.[21] More action by pharmaceutical companies to give up rights to exclusivity in LMICs should be encouraged.



Redressing the issue of overpriced cancer drugs will take the collective effort of policy makers, healthcare providers and patient advocates alike. We need to work to ensure that the benefits of these biotechnological breakthroughs reach all sectors of society, including low to middle income countries. A value-based model for drug pricing is crucial to achieving this goal. Furthermore, increased pharmaceutical pricing transparency, strong regulatory incentives for pharmaceutical companies to produce drugs with clinically meaningful benefits and policies encouraging cross-border importation of generics and biosimilars should also be implemented.





Photo credit

Image 1: public domain, accessed from

Conflicts of interest

None declared



1. Australian Institute of Health and Welfare. Burden of Cancer in Australia: Australian Burden of Disease Study 2011. [Internet]. Canberra (AU): AIHW; 2017 [cited 2018 April 4]. Cat. no. BOD 13/ Available from:

2. Global Burden of Disease Cancer Collaboration. Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study. JAMA Oncol. 2017;3(4):524–548. doi:10.1001/jamaoncol.2016.5688

3. IMS Institute for Healthcare Informatics. Innovation in cancer care and implications for health systems: global oncology trend report [Internet]. 2014: IMS Health, available from /site/imshealth/menuitem.762a961826aad98f53c 753c71ad8c22a/?vgnextoid=f8d4df7a5e8b5410Vg nVCM10000076192ca2RCRD [cited 2018 May 31].

4. Aitken M, Kumar S, Kleinrock M. Quintiles IMS global oncology trends 2017: advances, complexity and cost. 2017: IQVIA, available from [cited 2018 April 20].

5. Gordon N, Stemmer SM, Greenberg D, Goldstein DA. Trajectories of injectable cancer drug costs after launch in the United States. Journal of Clinical Oncology 2018 36:4, 319-325.

6. Chen C, Kesselhem A. Journey of Generic Imatinib: A case study in oncology. Journal of Oncology Practice 13, no. 6 (June 1 2017) 352-355.

7. Morrow T, Felcone JH. Defining the difference: what makes biologics unique. Biotechnology Healthcare. 2004;1(4):24-29.

8. Davis C, Naci H, Gurpinar E, Poplavska E, Pinto A, Aggarwal A, et al. Availability of evidence of benefits on overall survival and quality of life of cancer drugs approved by European Medicines Agency: retrospective cohort study of drug approvals 2009-13 BMJ 2017; 359 :j4530

9. World Health Organisation. The world health report 2002: reducing risks, promoting health life [Internet]. Geneva, SUI: World Health Organisation; 2002 [cited 2018 May 31].

10. Grubbs SS, Grusenmeyer PA, Petrelli NJ, Gralla RJ. Is it cost-effective to add erlotinib to gemcitabine in advanced pancreatic cancer? Journal of Clinical Oncology 2006; 24 (18suppl.): 6048-6048.

11. Temel J, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363(8): 733-42.

12. Becker DJ, Lin D, Lee S, Levy BP, Makarov DV, Gold HT. Exploration of the ASCO and ESMO value frameworks for antineoplastic drugs. Journal of Oncology Practice 2017; 13(7): e653-e665.

13. Saluja R, Arciero VS, Cheng S, McDonald E, Wong WWL, Cheung MC, et al. Examining trends in cost and clinical benefit of novel anticancer drugs over time. Journal of Oncology Practice 2018; 14(5): e280-e294.

14. Kim C, Prasad V. Cancer drugs approved on the basis of a surrogate end point and subsequent overall survival: an analysis of 5 Years of US Food and Drug Administration Approvals. JAMA Intern Med 2015;175(12):1992–1994.

15. World Health Organization. Cancer factsheet [Internet]. 2013: World Health Organization, available from [cited 2018 May 31].

16. Clegg LX, Reichman ME, Miller BA, Hankey BF, Singh GK, Lin YD, et al. Impact of socioeconomic status on cancer incidence and stage at diagnosis: selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study. Cancer Causes Control 2009; 20(4): 417-435.

17. Bazargani YT, de Boer A, Schellens JHM, Leufkens HGM, Mantel-Teeuwisse AK. Selection of oncology medicines in low- and middle-income countries. Annals of Oncology 2014; 25(1): 270-276.

18. Sullivan R, Purushotham A. Avoiding the zero sum game in global cancer policy: beyond 2011 UN high level summit. Eur J Cancer 2011; 47(16):2375-2380.

19. Marmot M. Achieving health equity: from root causes to fair outcomes. Lancet. 2007; 370(9593): 1153-1163.

20. Adesina A, Chumba D, Nelson AM, Orem J, Roberts DJ, Wabinga H, et al. Improvement of pathology in sub-Saharan Africa. Lancet Oncol. 2013; 14 (Apr):e152-e157

21. Sidley P. Drug companies withdraw law suit against South Africa. BMJ 2001; 322: 1011