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.

5. Mojtabai R. Long-Term Effects of mental disorders on employment In the National Comorbidity Survey Ten-Year Follow-up. Soc Psychiatry Psychiatr Epidemiol 2015;50(11):1657-68.

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.

7. Blanco C, Okuda M, Wright C, Hasin DS, Grant BF, Liu S, et al. Mental health of college students and their non-college-attending peers: Results from the National Epidemiologic Study on Alcohol and Related Conditions. Arch Gen Psych. 2008;65(12):1429-1437.

8. Macaskill A. The mental health of university students in the United Kingdom. Brit J Guid Counsell. 2012;41(4):426-441. .

9. Winzer R, Lindberg L, Guldbrandsson K, Sidorchuk A. Effects of mental health interventions for students in higher education are sustainable over time: a systematic review and meta-analysis of randomized controlled trials. PeerJ. 2018;6:e4598.

10. Detollenaere J, Willems S, Baert S. Volunteering, income and health. PLoS One. 2017;12(3).

11. Jenkinson CE, Dickens AP, Jones K, Thompson-Coon J, Taylor RS, Rogers M, et al. Is volunteering a public health intervention? A systematic review and meta-analysis of the health and survival of volunteers. BMC Public Health. 2013;13:773.

12. Yeung JWK, Zhang Z, Kim TY. Volunteering and health benefits in general adults: cumulative effects and forms. BMC Public Health. 2018;18.

13. Tabassum F, Mohan J, Smith P. Association of volunteering with mental well-being: a lifecourse analysis of a national population-based longitudinal study in the UK. BMJ Open. 2016;6(8).

14. Van Willigen M. Differential benefits of volunteering across the life course. J Gerontol B Psychol Sci Soc Sci. 2000;55(5):S308-18.

15. Elias JK, Sudhir P, Mehrotra S. Long-Term Engagement in Formal Volunteering and Well-Being: An Exploratory Indian Study. Behav Sci (Basel). 2016;6(4):20.

16. Piliavin JA. Feeling good by doing good: health consequences of social service. In: Processes of community change and social action [Internet]. Mahwah, New Jersey, USA: Lawrence Erlbaum Associates Publishers; 2005 [cited 2018 Apr 17].

17. Nazroo J, Matthews K. The impact of volunteering on well-being in later life. A report to WRVS [Internet]. Cardiff, UK: WRVS; 2012 [cited 2018 Apr 17].

18. Volunteering Australia. Key facts and statistics about volunteering in Australia [Internet]. Victoria, Australia: Volunteering Australia; 2015 [cited 2018 May 21].

19. Department for Digital, Culture, Media, & Sport. Community Life Survey 2016-2017, Statistics. London: UK; 2017


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



1. United Nations Children’s Fund [Internet]. The state of the world’s children 2009: Maternal and Newborn Health. 2008. UNICEF [cited 2016 Feb 4]. Available from:

2. Edmond K, Bahl R [Internet]. Optimal feeding of low-birth-weight infants: technical review. 2006. WHO [cited 2016 Feb 2]. Available from:

3. Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: When? Where? Why? Lancet 2005;365(9462):891.

4. WHO/UNICEF [Internet]. Vietnam: Countdown Country Profile. 2013. WHO/UNICEF [cited 2018 Mar 18]. Available from:

5. Edmond KM, Kirkwood BR, Amenga-Etego S, Owusu-Agyei S, Hurt LS. Effect of early infant feeding practices on infection-specific neonatal mortality: an investigation of the causal links with observational data from rural Ghana. AM J Clin Nutr. 2007;86(4):1126-31.

6. Debes AK, Kohli A, Walker N, Edmond K, Mullany LC. Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health. 2013;13(Suppl 3):S19-S.

7. Ahmed T, Hossain M, Sanin KI. Global Burden of Maternal and Child Undernutrition and Micronutrient Deficiencies. Ann Nutr Metab. 2012;61(Suppl. 1):8-17.

8. Kramer MS. Determinants of low birth weight: methodological assessment and meta-analysis. Bull World Health Organ. 1987;65(5):663-737.

9. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet 2013;382(9890):427.

10. United Nations Children’s Fund [Internet]. Low Birthweight: Country, regional and global estimates. 2004. UNICEF [cited 2016 Feb 2]. Available from:

11. Ota E, Haruna M, Suzuki M, Anh DD, Tho le H, Tam NT, et al. Maternal body mass index and gestational weight gain and their association with perinatal outcomes in Viet Nam. Bull World Health Organ. 2011;89(2):127-36.

12. Han Z, Mulla S, Beyene J, Liao G, McDonald SD. Maternal underweight and the risk of preterm birth and low birth weight: a systematic review and meta-analyses. Int J Epidemiol. 2011;40(1):65-101.

13. Nestel P, Rutstein S. Defining nutritional status of women in developing countries. Public Health Nutr. 2002;5(01):17-27.

14. Kelly A, Kevany J, de Onis M, Shah PMAA. A WHO collaborative study of maternal anthropometry and pregnancy outcomes. Int J Gynecol Obstet. 1997;57(1):1-15.

15. Mavalankar DV, Gray RH, Trivedi CR. Risk factors for preterm and term low birthweight in Ahmedabad, India. Int J Epidemiol. 1992;21(2):263-72.

16. Dinh PH, To TH, Vuong TH, Hojer B, Persson LA. Maternal factors influencing the occurrence of low birthweight in northern Vietnam. Ann Trop Paediatr. 1996;16(4):327-33.

17. Siega-Riz AM, Adair LS. Biological determinants of pregnancy weight gain in a Filipino population. Am J Clin Nutr. 1993;57(3):365.

18. Fikree FF, Berendes HW. Risk factors for term intrauterine growth retardation: a community-based study in Karachi. Bulletin of the World Health Organization. 1994;72(4):581-7.

19. Han Z, Lutsiv O, Mulla S, Rosen A, Beyene J, McDonald SD. Low gestational weight gain and the risk of preterm birth and low birthweight: a systematic review and meta-analyses. Acta Obstet Gynecol Scand. 2011;90(9):935-54.

20. Allen LH. Anemia and iron deficiency: effects on pregnancy outcome. Am J Clin Nutr. 2000;71(5 Suppl):1280S.

21. Lassi ZS, Majeed A, Rashid S, Yakoob MY, Bhutta ZA. The interconnections between maternal and newborn health – evidence and implications for policy. J Matern Fetal Neonatal Med. 2013;26 Suppl 1:3-53.

22. Black R, Allen LH, Bhutta Z, Caulfield L, de Onis M, Ezzati M, et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008;371:243-60.

23. Qadir M, Bhutta Z. Low Birth Weight in Developing Countries. Pediatr Adolesc Med 2009;13:148-62.

24. Kushwaha KP, Rai AK, Rathi AK, Singh YD, Sirohi R. Pregnancies in adolescents: fetal, neonatal and maternal outcome. Indian Pediatr. 1993;30(4):501-5.

25. Khan A, Nasrullah FD, Jaleel R. Frequency and risk factors of low birth weight in term pregnancy. Pak J Med Sci. 2016;32(1):138-42.

26. Rah JH, Christian P, Shamim AA, Arju UT, Labrique AB, Rashid M. Pregnancy and lactation hinder growth and nutritional status of adolescent girls in rural Bangladesh. J Nutr. 2008;138(8):1505-11.

27. Viengsakhone L, Yoshida Y, Harun-Or-Rashid MD, Sakamoto J. Factors affecting low birth weight at four central hospitals in vientiane, Lao PDR. Nagoya J Med Sci. 2010;72(1-2):51.

28. Nair NS, Rao RS, Chandrashekar S, Acharya D, Bhat HV. Socio-demographic and maternal determinants of low birth weight: a multivariate approach. Indian J Pediatr. 2000;67(1):9-14.

29. Rizvi SA, Hatcher J, Jehan I, Qureshi R. Maternal risk factors associated with low birth weight in Karachi: a case-control study. East Mediterr Health J. 2007;13(6):1343.

30. Manderson L, Mathews M. Vietnamese attitudes towards maternal and infant health. Med J Aust. 1981;1(2).

31. Klainin P, Arthur DG. Postpartum depression in Asian cultures: a literature review. Int J Nurs Stud. 2009;46(10):1355-73.

32. Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, et al. Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost? Lancet. 2013;382(9890):452-77.

33. Scott GW. Guidelines are essential for quality assurance in practice. Can Med Assoc J. 1990;143(6):473-4.

34. Villar J, Bjergsjø P. WHO Antenatal Care Randomized Trial: Manual for the Implementation of the New Model. World Health Organ, Department of Reproductive Health and Research. 2002.

35. World Health Organization [Internet]. Standards for Maternal and Neonatal Care. 2007. WHO [cited 2016 Feb 12]. Available from:

36. World Health Organization [Internet]. WHO recommendations on newborn health: guidelines approved by the WHO Guidelines Review Committee. 2017. WHO [cited 2017 Mar 16]. Available from:


37. World Health Organization Western Pacific Region [Internet]. Action plan for healthy newborn infants in the Western Pacific Region (2014–2020). 2014. WHO [cited 2016 Feb 4]. Available from:

38. World Health Organization [Internet]. Guidelines on optimal feeding of low birth-weight infants in low- and middle-income countries. 2011. WHO [cited 2016 Feb 2]. Available from:

39. World Health Organization [Internet]. WHO recommendations on postnatal care of the mother and newborn. 2013. WHO [cited 2016 Feb 2]. Available from:

40. Ministry of Health Vietnam. National Guidelines for Reproductive Health care Services. Hanoi, Viet Nam: Ministry of Health. 2009.

41. Ministry of Health Vietnam [Internet]. National Nutrition Strategy for 2011-2020 with a vision toward 2030. 2012. Hanoi: Medical Publishing House [cited 2016 Mar 9]. Available from:

42. Ministry of Health Vietnam. WHO Western Pacific Region [Internet]. National Plan of Action for Child Survival 2009-2015. 2009. WHO [cited 2016 Mar 9]. Available from:

43. General Statistics Office (GSO) and UNICEF [Internet]. Viet Nam Multiple Indicator Cluster Survey (MICS) 2013-2014, Final report. 2014. [cited 2016 Mar 2]. Available from:

44. Malqvist M, Lincetto O, Du NH, Burgess C, Hoa DTP. Maternal health care utilization in Viet Nam: increasing ethnic inequity. Bull World Health Organ 2013;91(4):254.

45. United Nations Population Fund [Internet]. The State of the World’s Midwifery 2011. 2011. UNFPA [cited 2016 Apr 2]. Available from:

46. Ngo AD, Hill PS. The use of reproductive healthcare at commune health stations in a changing health system in Vietnam. BMC Health Serv Res. 2011;11:237-.

47. Ministry of Health Vietnam, Health Partnership Group [Internet]. Joint Annual Health Review 2015: Strengthening primary health care at the grassroots towards universal health coverage. 2016. Hanoi: Medical Publishing House [cited 2016 Apr 18]. Available from:

48. Eriksson L, Nga NT, Målqvist M, Persson L-Å, Ewald U, Wallin L. Evidence-based practice in neonatal health: knowledge among primary health care staff in northern Viet Nam. Hum Resour Health. 2009;7:36.

49. Trevisanuto D, Arnolda G, Chien TD, Xuan NM, Thu LTA, Kumara D, et al. Reducing neonatal infections in south and south central Vietnam: the views of healthcare providers. BMC Pediatr. 2013;13:51.

50. Eriksson L, Nga NT, Hoa DP, Persson L-Å, Ewald U, Wallin L. Newborn care and knowledge translation – perceptions among primary healthcare staff in northern Vietnam. Implement Sci. 2011;6:29.

51. Trinh LT, Dibley MJ, Byles J. Antenatal care procedures and information reported by women in three rural areas of Vietnam. Southeast Asian J Trop Med Public Health. 2007;38(5):927-35.

52. Graner S, Ingrid M, Duong LQ, Gunilla K, Klingberg-Allvin M. Maternal health care professionals perspective on the provision and use of antenatal and delivery care: a qualitative descriptive study in rural Vietnam. BMC Public Health. 2010;10.

53. Tran TK, Gottvall K, Nguyen HD, Ascher H, Petzold M. Factors associated with antenatal care adequacy in rural and urban contexts-results from two health and demographic surveillance sites in Vietnam. BMC Health Serv Res. 2012;12:40-.

54. Kruse AY, Phuong CN, Ho BT, Stensballe LG, Pedersen FK, Greisen G. Identification of important and potentially avoidable risk factors in a prospective audit study of neonatal deaths in a paediatric hospital in Vietnam. Acta Paediatr. 2014;103(2):139-44.

55. Tran TK, Petzold M, Eriksson B, Gottvall K, Nguyen CTK, Pham Nhat DPHHA, et al. Antenatal and delivery care utilization in urban and rural contexts in Vietnam: a study in two health and demographic surveillance sites [Doctoral Thesis]: Göteborg, Sweden: Nordic School of Public Health NHV; 2012.

56. Gottvall K, Bondjers G, Eriksson B, Nguyen Hinh D, Nguyen Chuc T, Tran Toan K, et al. Urban – rural disparities in antenatal care utilization: a study of two cohorts of pregnant women in Vietnam. BMC Health Serv Res. 2011;11(1):120.

57. Duong DV, Lee AH, Binns CW. Determinants of breast-feeding within the first 6 months post-partum in rural Vietnam. J Paediatr Child Health. 2005;41(7):338-43.

58. Nguyen PH, Menon P, Ruel M, Hajeebhoy N. A situational review of infant and young child feeding practices and interventions in Viet Nam. Asia Pac J Clin Nutr. 2011;20(3):359-74.

59. Almroth S, Arts M, Quang ND, Hoa PT, Williams C. Exclusive breastfeeding in Vietnam: an attainable goal. Acta Paediatr. 2008;97(8):1066-9.

60. Tuan NT, Nguyen PH, Hajeebhoy N, Frongillo EA. Gaps between Breastfeeding Awareness and Practices in Vietnamese Mothers Result from Inadequate Support in Health Facilities and Social Norms. J Nutr. 2014;144(11):1811-7.

61. Hillström T. Socio-economic determinants of postnatal care in Vietnam [Dissertation]: Uppsala University Department of Women’s and Children’s Health; 2013.

62. General Statistics Office (GSO) [Internet]. Viet Nam Multiple Indicator Cluster Survey (MICS) 2010-2011 Final Report. 2011. [cited 2016 Feb 22]. Available from:

63. Trinh LTT, Dibley MJ, Byles J. Determinants of Antenatal Care Utilization in Three Rural Areas of Vietnam. Public Health Nursing. 2007;24(4):300-10.

64. Tran TK, Nguyen CT, Nguyen HD, Eriksson B, Bondjers G, Gottvall K, et al. Urban – rural disparities in antenatal care utilization: a study of two cohorts of pregnant women in Vietnam. BMC Health Serv Res. 2011;11.

65. Ha B, Tac P, Duc DM, Duong D, Thi L. Factors associated with four or more antenatal care services among pregnant women: a cross-sectional survey in eight South Central Coast provinces of Vietnam. International Journal of Women’s Health. 2015;7:699-706.

66. Edvardsson K, Graner S, Thi LP, Åhman A, Small R, Lalos A, et al. ‘Women think pregnancy management means obstetric ultrasound’: Vietnamese obstetricians’ views on the use of ultrasound during pregnancy. Glob Health Action. 2015;8.

67. Nguyen HT, Eriksson B, Tran TK, Nguyen CTK, Ascher H. Birth weight and delivery practice in a Vietnamese rural district during 12 year of rapid economic development. BMC Pregnancy Childbirth. 2013;13:41-.

68. Nguyen HT, Ascher H, Eriksson B, Petzold M, Nguyen Thi Kim C, Nguyen LT, et al. Birth weight and growth during the first two years of life: a study in urban and rural Vietnam [Doctoral thesis]: Göteborg, Sweden: Nordic School of Public Health NHV; 2014.

69. Duong DV, Binns CW, Lee AH. Utilization of delivery services at the primary health care level in rural Vietnam. Soc Sci Med. 2004;59(12):2585-95.

70. Bui QT, Lee HY, Le AT, Van Dung D, Vu LT. Trends and determinants for early initiation of and exclusive breastfeeding under six months in Vietnam: results from the Multiple Indicator Cluster Surveys, 2000-2011. Glob Health Action. 2016;9:29433.

71. Alive & Thrive [Internet]. Formative research on infant and young child feeding in Viet Nam: Phase 1 summary report. 2012. Hanoi: Alive & Thrive [cited 2016 Mar 29]. Available from:

72. Duong DV, Binns CW, Lee AH. Breast-feeding initiation and exclusive breast-feeding in rural Vietnam. Public Health Nutr. 2004;7(6):795-9.

73. Lundberg PC, Thu TTN. Breast-feeding attitudes and practices among Vietnamese Mothers in Ho Chi Minh City. Midwifery. 2012;28.

74. Babington L, Patel B. Understanding Child Feeding Practices of Vietnamese Mothers. Am J Matern Child Nurs 2008;33(6):376-81.

75. Nguyen PH, Keithly SC, Nguyen NT, Nguyen TT, Tran LM, Hajeebhoy N. Prelacteal feeding practices in Vietnam: challenges and associated factors. BMC Public Health. 2013;13:932.

76. Duong DV, Lee AH, Binns CW. Determinants of breast-feeding within the first 6 months post-partum in rural Vietnam. J Paediatr Child Health. 2005;41.

77. Dearden KA, Quan le N, Do M, Marsh DR, Pachon H, Schroeder DG, et al. Work outside the home is the primary barrier to exclusive breastfeeding in rural Viet Nam: insights from mothers who exclusively breastfed and worked. Food Nutr Bull. 2002;23(4 Suppl):101-8.

78. Sanghvi T, Jimerson A, Hajeebhoy N, Zewale M, Nguyen GH. And young child feeding practices in different country settings. Food Nutr Bull. 2013;34(3 Suppl):S169-80.

79. Bui QT, Le Linh C, Rahman Z. Child health status and maternal and child care in Quangtri Province, Vietnam. Asia Pac J Public Health. 2008;20 Suppl:228-35.

80. Lundberg PC, Trieu TN. Vietnamese women’s cultural beliefs and practices related to the postpartum period. Midwifery. 2011;27(5):731-6.

81. The World Bank [Internet]. Vietnam country gender asssessment. 2011. World Bank [cited 2016 Apr 3]. Available from:

82. Klingberg-Allvin M, Berggren V, Binh NT, Bijay B, Johansson A. Married men’s first time experiences of early childbearing and their role in sexual and reproductive decision making: a qualitative study from rural Vietnam. Cult Health Sex. 2012;14(4):449-61.

83. World Health Organization [Internet]. Complementary Feeding of Young Children in Developing Countries: A Review of Current Scientific Knowledge 1998. WHO [cited 2016 Feb 20]. Available from:

84. International Baby Food Action Network (IBFAN): The Committee on Economic, Social and Cultural Rights [Internet]. Report on the situation of infant and young child feeding in Vietnam. 2014. IBFAN [cited 2016 Feb 20]. Available from:

85. Thu HN, Eriksson B, Khanh TT, Petzold M, Bondjers G, Kim CNT, et al. Breastfeeding practices in urban and rural Vietnam. BMC Public Health. 2012;12:964-.

86. Mistry Y, Freedman M, Sweeney K, Hollenbeck C. Infant-feeding practices of low-income Vietnamese American women. J Hum Lact. 2008;24(4):406-14.

87. United Nations Children’s Fund [Internet]. National Implementation of the International Code of Marketing of Breastmilk Substitutes. 2011. UNICEF [cited 2016 Mar 2]. Available from:

88. Alive & Thrive [Internet]. A Review of the Status of Implementation of Decree 21 and the International Code of Marketing of Breastmilk Substitutes in Vietnam. 2011. Hanoi: Alive & Thrive [cited 2016 Mar 10]. Available from:

89. Hajeebhoy N, Rigsby A, McColl A, Sanghvi T, Abrha TH, Godana A, et al. Change strategies to protect, promote, and support infant and young child feeding. Food Nutr Bull. 2013;34(3 Suppl):S181.

90. Harris J, Frongillo EA, Nguyen PH, Kim SS, Menon P. Changes in the policy environment for infant and young child feeding in Vietnam, Bangladesh, and Ethiopia, and the role of targeted advocacy. BMC Public Health. 2017;17(2):492.

91. International Baby Food Action Network (IBFAN) [Internet]. Report on the situation of infant and young child feeding in Viet Nam. 2012. IBFAN [cited 2016 Feb 20]. Available from:

92. WHO, UNICEF, IBFAN, [Internet]. Marketing of Breast-milk Substitutes: National Implementation of the International Code. Status Report 2016. 2016. Geneva: WHO [cited 2016 Mar 10]. Available from:

93. Ministry of Health Vietnam: National Insitute of Nutrition [Internet]. Plan of action for infant and young child feeding period 2006-2010. 2006. [cited 2016 Feb 12]. Available from:

94. Barennes H, Slesak G, Goyet S, Aaron P, Srour LM. Enforcing the International Code of Marketing of Breast-milk Substitutes for Better Promotion of Exclusive Breastfeeding: Can Lessons Be Learned? J Hum Lact. 2016;32(1):20-7.

95. International Labour Organization [Internet]. Maternity and paternity at work: Law and practice across the world. 2014. Geneva: ILO [cited 2016 Apr 20]. Available from:–en/index.htm.

96. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993;342(8883):1317-22.

97. World Health Organization Western Pacific Region [Internet]. Early Essential Newborn Care: Clinical Practice Pocket Guide. 2014. WHO [cited 2016 Feb 15]. Available from:

98. Obara H, Sobel H. Quality maternal and newborn care to ensure a healthy start for every newborn in the World Health Organization Western Pacific Region. BJOG. 2014;121 Suppl 4:154-9.

99. Wilcox AJ. On the importance—and the unimportance— of birthweight. Int J Epidemiol. 2001;30(6):1233-41.

100. Cogswell ME, Yip R. The influence of fetal and maternal factors on the distribution of birthweight. Semin Perinatol. 1995;19(3):222-40.

101. Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gülmezoglu M, Mugford M, et al. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet. 2001;357(9268):1565-70.

102. Villar J, Ba’aqeel H, Piaggio G, Lumbiganon P, Belizán JM, Farnot U, et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet. 2001;357(9268):1551-64.

103. Villar J, Carroli G, Khan-Neelofur D, Piaggio G, Gulmezoglu M. Patterns of routine antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2001(4).

104. World Health Organization, WHO Western Pacific Region [Internet]. Neonatal and child health country profile: Viet Nam. 2012. WHO. Available from:

105. Yonemoto N, Dowswell T, Nagai S, Mori R. Schedules for home visits in the early postpartum period. Cochrane Database Syst Rev 2013.

106. World Health Organization [Internet]. Newborns: reducing mortality. 2017. WHO [cited 2017 Jan 18]. Available from:

107. Jehan I, Harris H, Salat S, Zeb A, Mobeen N, Pasha O, et al. Neonatal mortality, risk factors and causes: a prospective population-based cohort study in urban Pakistan. Bull World Health Organ. 2009;87(2):130-8.

108. World Health Organization [Internet]. Immunization, Vaccines and Biologicals: Table 2 – Recommended Routine Immunizations for Children. WHO [cited 2016 Apr 26]. Available from:


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



1. The United Nations Refugee Agency. Figures at a Glance [Internet]. 2017 [cited 2018 March 24]. Available from:

2. Silove D, Ventevogel P, Rees S. The contemporary refugee crisis: an overview of mental health challenges. World Psychiatry. 2017;16(2):130-9.

3. Bogic M, Njoku A, Priebe S. Long-term mental health of war-refugees: a systematic literature review. BMC International Health and Human Rights. 2015;15.

4. Tay AK, Rees S, Chen J, Kareth M, Lahe S, Kitau R, et al. Associations of Conflict-Related Trauma and Ongoing Stressors with the Mental Health and Functioning of West Papuan Refugees in Port Moresby, Papua New Guinea (PNG). PLoS ONE. 2015;10(4).

5. Kirmayer LJ, Narasiah L, Munoz M, Rashid M, Ryder AG, Guzder J, et al. Common mental health problems in immigrants and refugees: general approach in primary care. Canadian Medical Association Journal. 2011;183(12):E959-67.

6. Steel Z, Chey T, Silove D, Marnane C, Bryant RA, van Ommeren M. Association of torture and other potentially traumatic events with mental health outcomes among populations exposed to mass conflict and displacement: a systematic review and meta-analysis. Jama. 2009;302(5):537-49.

7. Buhmann CB. Traumatized refugees: morbidity, treatment and predictors of outcome. Danish Medical Journal. 2014;61(8):B4871.

8. Kane JC, Ventevogel P, Spiegel P, Bass JK, van Ommeren M, Tol WA. Mental, neurological, and substance use problems among refugees in primary health care: analysis of the Health Information System in 90 refugee camps. BMC Medicine. 2014;12.

9. Ferrada-Noli M, Sundbom E. Cultural bias in suicidal behaviour among refugees with post-traumatic stress disorder. Nordic Journal of Psychiatry. 1996;50(3):185-91.

10. Uribe Guajardo MG, Slewa-Younan S, Santalucia Y, Jorm AF. Important considerations when providing mental health first aid to Iraqi refugees in Australia: a Delphi study. International Journal of Mental Health Systems. 2016;10(1).

11. Riley A, Varner A, Ventevogel P, Taimur Hasan MM, Welton-Mitchell C. Daily stressors, trauma exposure, and mental health among stateless Rohingya refugees in Bangladesh. Transcultural Psychiatry. 2017;54(3):304-31.

12. Carroll JK. Murug, Waali, and Gini: Expressions of Distress in Refugees From Somalia. Primary Care Companion to The Journal of Clinical Psychiatry. 2004;6(3):119-25.

13. Lindert J, Carta MG, Schäfer I, Mollica RF. Refugees mental health—A public mental health challenge. European Journal of Public Health. 2016;26(3):374-5.

14. Mann C, Fazil Q. Mental illness in asylum seekers and refugees. Primary Care Mental Health. 2006;4:57-66.

15. Hollander AC, Bruce D, Burstrom B, Ekblad S. Gender-related mental health differences between refugees and non-refugee immigrants–a cross-sectional register-based study. BMC Public Health. 2011;11:180.

16. Hassan G, Ventevogel P, Jefee-Bahloul H, Barkil-Oteo A, Kirmayer LJ. Mental health and psychosocial wellbeing of Syrians affected by armed conflict. Epidemiology and Psychiatric Sciences. 2016;25(2):129-41.

17. Blight KJ, Ekblad S, Persson JO, Ekberg J. Mental health, employment and gender. Cross-sectional evidence in a sample of refugees from Bosnia-Herzegovina living in two Swedish regions. Social Science & Medicine (1982). 2006;62(7):1697-709.

18. Messih M. Mental Health in LGBT Refugee Populations. American Journal of Psychiatry Residents’ Journal. 2016;11(7):5-7.

19. Porter M, Haslam N. Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons: a meta-analysis. Jama. 2005;294(5):602-12.

20. Steel Z, Silove D, Phan T, Bauman A. Long-term effect of psychological trauma on the mental health of Vietnamese refugees resettled in Australia: a population-based study. Lancet (London, England). 2002;360(9339):1056-62.

21. Fazel M, Wheeler J, Danesh J. Prevalence of serious mental disorder in 7000 refugees resettled in western countries: a systematic review. Lancet (London, England). 2005;365(9467):1309-14.

22. Steel Z, Silove DM. The mental health implications of detaining asylum seekers. The Medical Journal of Australia. 2001;175(11-12):596-9.

23. Steel Z, Momartin S, Bateman C, Hafshejani A, Silove DM, Everson N, et al. Psychiatric status of asylum seeker families held for a protracted period in a remote detention centre in Australia. Australian and New Zealand Journal of Public Health. 2004;28(6):527-36.

24. Coffey GJ, Kaplan I, Sampson RC, Tucci MM. The meaning and mental health consequences of long-term immigration detention for people seeking asylum. Social Science & Medicine (1982). 2010;70(12):2070-9.

25. Steel Z, Silove D, Brooks R, Momartin S, Alzuhairi B, Susljik I. Impact of immigration detention and temporary protection on the mental health of refugees. The British Journal of Psychiatry: The Journal of Mental Science. 2006;188:58-64.

26. Bronstein I, Montgomery P. Psychological distress in refugee children: a systematic review. Clinical Child and Family Psychology Review. 2011;14(1):44-56.

27. Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors. Lancet (London, England). 2012;379(9812):266-82.

28. Murthy RS, Lakshminarayana R. Mental health consequences :a brief review of research. World Psychiatry. 2006;5(1):25-

29. Opaas M, Varvin S. Relationships of Childhood Adverse Experiences With Mental Health and Quality of Life at Treatment Start for Adult Refugees Traumatized by Pre-Flight Experiences of War and Human Rights Violations. The Journal of Nervous and Mental Disease. 2015;203(9):684-95.

30. Shawyer F, Enticott JC, Block AA, Cheng IH, Meadows GN. The mental health status of refugees and asylum seekers attending a refugee health clinic including comparisons with a matched sample of Australian-born residents. BMC Psychiatry. 2017;17.

31. Stolk Y, Kaplan I, Szwarc J. Clinical use of the Kessler psychological distress scales with culturally diverse groups. International Journal of Methods in Psychiatric Research. 2014;23(2):161-83.

32. Tribe RH, Sendt KV, Tracy DK. A systematic review of psychosocial interventions for adult refugees and asylum seekers. Journal of Mental Health (Abingdon, England). 2017:1-15.

33. Slobodin O, de Jong JT. Mental health interventions for traumatized asylum seekers and refugees: What do we know about their efficacy? The International Journal of Social Psychiatry. 2015;61(1):17-26.

34. Brune M, Haasen C, Krausz M, Yagdiran O, Bustos E, Eisenman D. Belief systems as coping factors for traumatized refugees: a pilot study. European Psychiatry: The Journal of the Association of European Psychiatrists. 2002;17(8):451-8.

35. Sonne C, Carlsson J, Bech P, Mortensen EL. Pharmacological treatment of refugees with trauma-related disorders: What do we know today? Transcultural Psychiatry. 2017;54(2):260-80.

36. Betancourt TS, Newnham EA, Layne CM, Kim S, Steinberg AM, Ellis H, et al. Trauma history and psychopathology in war-affected refugee children referred for trauma-related mental health services in the United States. Journal of Traumatic Stress. 2012;25(6):682-90.

37. Fazel M, Stein A. The mental health of refugee children. Archives of Disease in Childhood. 2002;87(5):366-70.

38. Uribe Guajardo MG, Slewa-Younan S, Kitchener BA, Mannan H, Mohammad Y, Jorm AF. Improving the capacity of community-based workers in Australia to provide initial assistance to Iraqi refugees with mental health problems: an uncontrolled evaluation of a Mental Health Literacy Course. International Journal of Mental Health Systems. 2018;12.

39. Sijbrandij M, Acarturk C, Bird M, Bryant RA, Burchert S, Carswell K, et al. Strengthening mental health care systems for Syrian refugees in Europe and the Middle East: integrating scalable psychological interventions in eight countries. European Journal of Psychotraumatology. 2017;8(sup2):1388102.

40. von Lersner U, Elbert T, Neuner F. Mental health of refugees following state-sponsored repatriation from Germany. BMC Psychiatry. 2008;8:88.

41. Murray KE, Davidson GR, Schweitzer RD. Review of Refugee Mental Health Interventions Following Resettlement: Best Practices and Recommendations. The American Journal of Orthopsychiatry. 2010;80(4):576-85.


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].

Available from:

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

A Case of Oesophageal Candidiasis with Underlying HIV Infection

Issue 10 Volume 2
Case study
Peer reviewed article



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

Case report

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

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


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

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


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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

Andrew Samaan & Min Zaw

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

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


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

Conflict of interest

No known conflicts


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

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

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

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

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

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

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

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

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

Drug Control in Australia: Where to Next?



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



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

Figure 1: The biopsychosocial adverse outcomes related to substance use disorders [1, 2]

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

Benefits and detriments of different policy approaches

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

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

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

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

Drug control approaches worldwide

Criminalisation: the United States

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

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

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

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

Criminalisation: Central Asia

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

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

Decriminalisation: Portugal

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

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

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

Decriminalisation: West Africa

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

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

Drug policy in Australia and the way forward

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

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

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


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

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

Raquel Maggacis

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


Sophie Lim, Vector Associate Editor 

Conflict of Interest

None declared



  1. Wodak AD. The need and direction for drug law reform in Australia. The Medical Journal of Australia. 2012;197(6):312-3.
  2. Madras BK. Office of National Drug Control Policy: a scientist in drug policy in Washington, DC. Ann N Y Acad Sci. 2010;1187:370-402.
  3. Sapp CE. Rehabilitate or incarcerate? A comparative analysis of the United States’ sentencing laws on low-level drug offenders and Portugal’s decriminalization of low-level drug offenses. Cardozo Journal of International & Comparative Law. 2014;23(1):63-97.
  4. Félix S, Portugal P, Tavares A. Going after the Addiction, Not the Addicted: The Impact of Drug Decriminalization in Portugal. IDEAS Working Paper Series from RePEc. 2017.
  5. Elliott R, Csete J, Palepu A, Kerr T. Reason and rights in global drug control policy. CMAJ. 2005;172(5):655-6.
  6. Mazerolle L, Soole DW, Rombouts S. Street-level drug law enforcement: A meta-analytical review⋆. Journal of Experimental Criminology. 2006;2(4):409-35.
  7. Webster IW. Managing legal and medical complexities in caring for people with drug and alcohol problems: a call for change. Med J Aust. 2016;204(4):141-2.
  8. The prohibition of illicit drugs is killing and criminalising our children and we are all letting it happen. [press release]. Canberra2012.
  9. Homel PB, Rick. Marijuana legalisation in the United States: An Australian perspective. Canberra: Australian Institute of Criminology; 2017 June 2017.
  10. Joint United Nations statement on ending discrimination in health care settings [press release]. World Health Organisation2017.
  11. Adler J. Symposium Marijuana, Federal Power, and the States: Introduction. Case Western Reserve Law Review. 2015;65(3):505-12.
  12. Caulkins JP, Bond BM. Marijuana Price Gradients. Journal of Drug Issues. 2012;42(1):28-45.
  13. Hall W, Weier M. Assessing the public health impacts of legalizing recreational cannabis use in the USA. Clin Pharmacol Ther. 2015;97(6):607-15.
  14. Latypov A. Understanding post 9/11 drug control policy and politics in Central Asia. Int J Drug Policy. 2009;20(5):387-91.
  15. Wolfe D. Paradoxes in antiretroviral treatment for injecting drug users: access, adherence and structural barriers in Asia and the former Soviet Union. Int J Drug Policy. 2007;18(4):246-54.
  16. Willis K. Measuring the effectiveness of drug law enforcement. Trends and Issues in Crime and Criminal Justice. 2011;406(1):1-7.
  17. Hughes CE, Stevens A. What Can We Learn From The Portuguese Decriminalization of Illicit Drugs? British Journal of Criminology. 2010;50(6):999-1022.
  18. Greenwald G. Drug Decriminalization in Portugal: Lessons for Creating Fair and Successful Drug Policies. Washington, DC: Cato Institute; 2009.
  19. Felix S, Portugal P. Drug decriminalization and the price of illicit drugs. Int J Drug Policy. 2017;39:121-9.
  20. Drugs WACo. Not Just in Transit: Drugs, the State and Society in West Africa. West Africa Commission on Drugs; 2014.
  21. Mathers BMD, Louisa; Phillips, Benjamin; Wiessing, Lucas; Hickman, Matthew; Strathdee, Steffanie A; Wodak, Alex; Panda, Samiran; Tyndall, Mark; Toufik, Abdalla; Mattick, Richard P. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. The Lancet. 2008;372(9651):1733-45.