Changing Climate, Changing Perspectives: iDEA Conference Report

Issue 11 Volume 1
Conference Report

The iDEA conference is an annual national conference of Doctors for the Environment Australia (DEA). Run over two days with over 35 world-renowned speakers; engaging breakout workshops; and entertaining social nights with gourmet, ethically-sourced food; iDEA is the centrepiece of environmental health education and inspiration. iDEA unites medical professionals and students from around Australia “with one common goal – to address the human health impacts of the environment and climate change”,[1] with a 2017 theme of “Global Problems, Local Solutions”.

Global Problems

Throughout the weekend, I was reminded of why our changing climate is indeed “the biggest global health threat of the 21st century”,[2] affecting health both directly and indirectly.

The widely cited 2009 paper “A Commission on Climate Change” in The Lancet outlines the direct effects of climate change to be, namely; increased heat stress, floods, drought and increased frequency of intense storms.[2] In a panel of College Presidents at iDEA17, Dr Bastian Seidel, President of the Royal Australian College of General Practitioners, outlined the direct impacts of climate change on human health through referencing his everyday experiences as a general practitioner; “General Practitioners (GPs) are true climate change witnesses. As a GP in Southern Tasmania, there is not a single day that patients don’t come in and tell me about the effects of climate change; droughts, bushfires, allergies, asthma”. Similarly, Dr Simon Judkins, President-Elect of the Australian College of Emergency Medicine, asserted that “climate change means that we are seeing bigger and more frequent large scale disasters, and emergency physicians are front and centre when it comes to responding to those events”.

L to R: Dr Scot Ma (ANZCA), Prof John Middleton (UK FPH), Dr Simon Judkins (ACEM), Dr Bastian Seidel (RACGP), Dr Kym Jenkins (RANZCP)

In addition to the direct impacts of climate change on human health, there are also subtler, insidious, indirect effects. Some of these include air pollution, the spread of vector-borne diseases, food insecurity and under-nutrition, displacement and an increase in mental illness.[2] Dr Helen Szoke, CEO of Oxfam, directed our attention to the recent WHO report on pollution and child health, a landmark study which found that more than 1 in 4 deaths of children under 5 years of age are attributed to unhealthy environments. Additionally, climate change could drive 122 million more people into extreme poverty by 2030 through its impact on increasing vector-borne diseases, food insecurity, increasing the number of climate refugees and respiratory disease through air pollution.[3]

Dr Alessandro Demaio, Medical Doctor for the World Health Organization (WHO) and co-founder of NCD-Free, addressed the connection between obesity and climate change. This is a potentially hidden link, but one not to be ignored: if food waste were a country, it would be the third largest CO2 emitter.[4] He emphasised the importance of collaboration on global issues such as obesity and climate change, “when it comes to NCDs and climate change, opportunities for co-mitigation are profound and unprecedented. Inaction cannot be an option.” He urged us to think laterally on the topic – both issues have similar causes and solutions, so how can we address them together through lobbying, policy change and targeted public health strategies?

Local Solutions

In the face of impending “climate chaos”, as it was colloquially referred to throughout the conference, it is easy to feel overwhelmed by the reality of climate change. Despite this, the speakers provided messages of hope and inspired action and empowerment through local solutions.

Coming from a refreshingly non-medical perspective, Tim Buckley, one of Australia’s top financial energy analysts, provided an overview of the progress our neighbours in India and China are making in the renewable energy market [5]. He outlined the importance of knowing your audience – the motivation behind these nations’ transition to renewables wasn’t for health reasons, but economic reasons in India (considering renewables cost 80% of what it costs to import fuel) and population-driven air quality concerns in China. Buckley highlighted the financial stability and success these nations have had since leading the way in renewables and why it makes economic sense for Australia to follow suit.[6] Focusing the light on Australian shores, Dr Roger Dargaville from the Melbourne Energy Institute outlined the need for robust policy and strategic direction for the Australian energy market, if we are to move towards renewables and avoid further energy demand issues like the recent South Australian energy crises.

iDEA17 delegates

Changing Perspectives and Summary

I took away a bigger picture of how we conceptualise climate change, and left thinking that we need to change our perspective to achieve true change. What makes climate change so difficult to comprehend is the lack of a clear, single perpetrator; it doesn’t have a face. Without oversimplifying complex issues, it is clear that, for example, when we want to blame someone for the obesity epidemic we think of big corporate companies like Coco Cola or McDonalds. When we want to blame someone for displaced people and mass migrations, we think of war and governments.

With climate change, it isn’t as easy to play the blame game. We can’t easily point the finger at someone or something and say “this is the reason why; this is the cause”. Because we can’t readily shift the blame onto something easily identifiable, it makes the issue less tangible and more challenging to connect with. There is nowhere to direct the anger and frustration at the catastrophic changes we are seeing around us, the natural response is to either disconnect with the issue, or to feel overwhelmed with despair and subsequently be driven to inaction.

In truth, we should be pointing the finger at is ourselves. As was made abundantly clear at the conference and in countless articles and reviews presented by the wider scientific community, the evidence overwhelmingly indicates that climate change is largely human driven, and thus we must take responsibility.[7]

Yes, we are a large part of the cause. But if I learned anything over the weekend, it is that we can also drive the solution. In the words of Dr Helen Szoke, “the mission that you sign up to when you become a doctor means that you have a responsibility to assist humanity…climate change is a big part of that.” There needs to be a shift of focus from the negative outcomes of climate change, towards the positive ways we can address it. We need to stop seeing it as an issue and start seeing it as a potential for change and act in the infinite ways the speakers outlined at iDEA. While it is the biggest threat to our species and planet, climate change could also be “the greatest global health opportunity of the 21st century”.[8]

The evening before the conference commenced, I was honored to hear from human rights lawyer Julian Burnside AO QC, who eloquently stated; “to remain silent is as much a political act as to speak out”. This simple idea is as applicable to climate change and human health as ever; the health impacts of climate change are direct and indirect, immediate and long term, both overt and subtle. We must have a global perspective on the issue, but also the willingness to act locally to create sustainable and tangible change to protect the health of our planet and our people. It is our responsibility as informed, ethically-minded health professionals to act now. In the words of Dr Stephen Parnis, ex-AMA Vice President “prevention and mitigation is always better than reaction and recovery – as doctors, we have an obligation to talk and act on climate change”.

Isobelle Woodruff

Isobelle is a third year Doctor of Medicine student at UNDS, currently completing her clinical years in Melbourne. She is also the AMSA Code Green Co-National Project Manager and is passionate about empowering people to mitigate the health effects of climate change. Her other areas of interest include mental health and wellbeing, nutrition and behavioural change strategies.

Photo credit

Mack Lee

Acknowledgements

None

Conflict of Interest

None declared

Correspondence

isobelle.woodruff@amsa.org.au

References

  1. Doctors for the Environment Australia. iDEA17 Conference DEA2017 [Available from: https://www.dea.org.au/idea2017/.
  2. The Lancet. A Commission on climate change. The Lancet. 2009;373(9676):1659.
  3. Inheriting a sustainable world? Atlas on children’s health and the environment. Geneva: World Health Organisation, 2017.
  4. Food and Agriculture Organization of the United Nations. Food wastage footprint; impacts on natural resources (summary report). Natural Resources Management and Environment Department, United Nations, 2013.
  5. Buckley T. IEEFA Update: China Is Now Three Years Past Coal. IEEFA, 2017 Feburary 28, 2017. Report No.
  6. Tan JAMH. Economics: Manufacture renewables to build energy security. Nature. 2014;513(7517).
  7. McMichael AJ. Globalization, Climate Change, and Human Health. The New England Journal of Medicine. 2013;386:1335-43.
  8. Nick Watts et al. Health and climate change: policy responses to protect public health. The Lancet. 2015;386(10006):1861 – 914.

When Health is the Last Priority

Issue 10 Volume 2
Review
Peer Reviewed article

 

Abstract

On any given night, 1 in 200 Australians are homeless. Evidence shows that being homeless is associated
with an increased risk of poor health, yet for many people without adequate housing, healthcare is but a luxury. What can we as advocates for health do when for some, health is the last priority? In an attempt to address this question, this article first provides an overview of the homelessness issue in Australia and explores some of the current strategies for addressing homelessness. An evaluation of the effectiveness of these strategies reveals that while current response-based housing efforts yield positive results, an all-encompassing approach, consisting of response-based and prevention strategies, is needed for more meaningful and effective services in the prevention and management of homelessness. The knowledge gained from evaluating current strategies is useful in direct- ing future homeless policy, specifically, an increased focus on preventative strategies that identify risk factors, prevent homelessness at its source and support families and individuals to maintain tenancy. The final section of this article provides evidence-based recommendations for medical practitioners and other health care workers in the identification, prevention and management of homelessness. These recommendations include recognising patients at risk of homelessness and taking preventative action to ensure they remain safely housed, obtaining a comprehensive social history, understanding the specific needs of homeless people and the barriers they face to healthcare, making timely and appropriate referrals, and practising compassionate care.

Introduction

“Everyone has the right to a standard of living adequate for the health and well-being of themselves and their family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond their control.” Universal Declaration of Human Rights [1]

It is a rainy day in Melbourne city and I am on a street corner, pressing a few coins into the hand of a middle-aged man named George . I wonder aloud what kind of healthcare he has access to, if he ever needs to see a doctor. “Miss,” he replies, “I’m not really worried about healthcare right now. I just need to start eating properly. I’m wasting away.” I look at the greying clothes hanging off his body and I know he is right.

On a separate afternoon in the city, I’m sitting near a busy intersection with a young woman who introduces herself as Myra. She has three copies of The Big Issue held up with one arm and a sleeping corgi with a pink collar – Bailey- cradled in the other.

The magazines sell for $6 each, $3 of which is kept by the vendor. “Kept by Bailey,” she corrects me. “She was kicked in the ribs a few days ago and
is running out of painkillers. Once she gets those, I might look into accommodation for the night. Then I’ll think about food.” She lists her priorities in order of importance. “Dog, accommodation, me.” Healthcare is not even on the radar.

In the medical profession we are often concerned with the latest advancements, the newest drugs on the market or the efficacy of one procedure over another – and we should be. But when confronted with people at the very edges of society like George and Myra, all of that seems superfluous. What can we as advocates for health do when for some, health is the last priority?

In an attempt to address this question, this article will provide an overview of the homelessness issue in Australia and explore some of the current strategies for addressing homelessness and evaluate their effectiveness. This will lead to further discussion on future directions in homelessness policy. Finally, the article will discuss the role of the health system and medical practitioner and provide some recommendations for medical practitioners to adopt in their practice in order to help prevent and manage homelessness for patients.

The homelessness issue

Homelessness is defined by the Australian Bureau of Statistics[2] as a current living arrangement that:

  • is in a dwelling that is inadequate; or
  • has no tenure, or if their initial tenure is short and not extendable; or
  • does not allow them to have control of, and access to space for social relations.

By this definition, homelessness cannot be considered as merely the absence of a ‘roof’. It encompasses persons living in improvised, temporary, severely crowded or otherwise inadequate dwellings, and therefore not all who
are homeless can be seen out in public spaces. In the 2011 Census [3] just over 105,000 people in Australia were estimated to be homeless. This equates to approximately 1 in 200 Australians. Contrary to the belief that homelessness primarily affects older men, 60% of the homeless were aged under 35 years and nearly half were women.

Homelessness is a manifestation of a myriad of social issues, including domestic violence, a shortage of affordable housing, unemployment, mental illness, family breakdown and drug and alcohol abuse.[4] The most common reason for people to seek support from homelessness agencies is financial difficulty, followed by domestic and family violence.[5]

Homelessness is associated with poor health for a number of reasons. Health issues can be both a cause and a consequence of homelessness,
and homelessness may exacerbate illnesses that are pre-existing. Being homeless is associated with increased risk of depression and suicide,[6] poor dental health, eye problems, podiatry issues, infectious diseases, sexually transmitted disease, pneumonia, lack of preventive and routine health care and inappropriate use of medication.[4] When health is the last priority, or when services are not readily accessible, many who are homeless have no choice but to allow illnesses and injuries to progress until they are severe. Consequently, people who are homeless use hospital emergency services at higher rates than the general population, and to be treated for conditions and injuries that are worsened by being homeless.[7]

From an economic perspective, the Commonwealth Government spends annually $30,000 more on people experiencing homelessness for the same services than those who are stably housed. The potential savings, if homelessness and therefore its associated costs were addressed, total up to $1 million per person over an average lifetime.[8]

Decreasing rates of homelessness will allow those who are disadvantaged by their circumstances to rebuild their lives, improve their health, increase their participation in the community and contribute to the Australian economy.[4] In addition, addressing homelessness is a step towards ensuring all people enjoy the fundamental human right of having a place to call home.

Current strategies

In 2008, the first White Paper on homelessness (National Affordable Housing Agreement)[4] was released. The agreement set the ambitious target of halving homelessness by 2020, with plans to increase current investment in homeless services by 55% implement additional housing for homeless people and supporting victims of domestic violence to stay in their homes safely. The paper reported that current efforts to reduce homelessness in Australia were inadequate, and if no additional action was taken, it predicted that rates of homelessness would rise.[9]

As an extension of efforts in 2008, three National Partnership Agreements were made between all Australian States and Territories in 2009 in response to the National Affordable Housing Agreement.

  1. The National Partnership Agreement on Homelessness[10] committed $1.1 billion of funding over 5 years for the construction of 600 new homes for homeless families and individuals as well as provision of homeless support services.
  2. The National Partnership Agreement on Social Housing[11] committed $400 million of funding over 5 years for the construction of new, affordable, social housing dwellings targeted towards people who were homeless or at risk of homelessness.
  3. The National Partnership Agreement on Remote Indigenous Housing[12] committed $5.5 billion of funding over 10 years for the reduction of overcrowding, homelessness and poor housing conditions in remote Indigenous communities.

It is evident from the distribution of funding above that significantly more funding is directed towards building homes and managing homelessness
than on preventing homelessness in those who are at risk. Undoubtedly, both response and prevention-based strategies play crucial roles in the reduction of homelessness in Australia. However, it is important to examine the benefits delivered by each type of service in order to evaluate their cost- effectiveness and direct future funding.

Response-based strategies consistently yield significant positive outcomes for clients. In an evaluation of 14 homelessness programs in Western Australia aimed at moving clients into long- term accommodation most programs exceeded their target number of clients assisted and were able to obtain and maintain accommodation for these clients.[13] Being accommodated
led to improved health, return to work or study, maintenance of sobriety for sufferers of addiction, and restoration of dignity, self-respect, confidence and independence. Similarly, the Accommodation Options for Families (AOF) initiative in Victoria was able to achieve long-term housing for 74 previously homeless families.[14] Clients reported less stress and anxiety, improvements in their children’s health and improved ability to meet their children’s needs in terms of meals, access to healthcare and educational support.

However, the positive immediate and long-term benefits of response-based housing initiatives demonstrated by programs like the AOF are not extrapolated to all programs in Australia. Evaluation of Sydney’s Way2Home service 2012[15] part of Street to Home initiative, which involved assertive street outreach, immediate access to secure housing and ongoing ‘wrap around’ support, revealed that 90% of clients sustained housing over a 12 month period. Clients reported reduced psychological distress and improvements in nearly all measures of quality of life and satisfaction. However, there were no improvements in the low rates of employment, education, training and job-seeking behaviours among clients after the
12 month period of accommodation compared to baseline.[15] A similar limitation is seen with the Housing First approach, which is based on the concept that a homeless individual or household’s first and primary need is to obtain stable, permanent housing, after which more enduring issues can be appropriately addressed.[16] While the retention rate of this approach has been quoted in one randomised control study as 66%,[17] there is no strong evidence to suggest that the Housing First model affects rates of substance abuse, social isolation or loneliness.[18]

The literature makes it clear that simply providing a homeless person with a house is not always enough to facilitate their integration into society, as the underlying social determinants of homelessness such as employment and education are not addressed. In many cases, accommodated clients who receive no additional support will therefore continue to be at risk of social disadvantage or return to homelessness.

Another limitation is that as long as the causes of homelessness are not addressed through prevention strategies, people will continue to become homeless and place overwhelming burden on housing and support services. In
the Queensland Government’s Responding to Homelessness strategy in 2005,[19] $235.5 million of funding was spent on building new homes and providing support services over a period of four years. Initiatives were able to increase the quantity of accommodation and support services, but the gains were overtaken by increasing demand.[19]

The evidence presented here shows that current response-based housing efforts are effective, however only to an extent. Homelessness programs should focus on holistic and sustainable approaches in conjunction with response-based efforts. An all-encompassing approach, consisting of response-based and prevention strategies, is needed for more meaningful and effective services for the prevention of homelessness and the management of those who are already homeless.

Future directions at the policy level

In keeping with the international trend and evidence in reducing homelessness, Australia is shifting away from crisis-based responses that manage the effects of homelessness to focus on preventative strategies that maintain people who are at risk of homelessness in sustainable housing.[20]

The benefits of preventative strategies are long-term and cost-effective. In a report on the Supported Accommodation Assistance Program,[21] almost all clients at imminent risk of homelessness who received support to retain their current tenure remained housed after 12 months. Furthermore, a cost-effectiveness analysis on this program found that the cost of health and justice services is higher for clients of homelessness programs than in the general population, however, the potential cost offsets by providing assistance to these clients is substantially greater than the cost of support.[21]

Women and children escaping domestic and family violence are particularly vulnerable to homelessness, with the majority of women seeking assistance from homelessness support services in Australia for this reason.[5] They are therefore a major target for preventative strategies and initiatives. An evaluation of the ‘Staying Home Leaving Violence’ (SHLV) initiative,[22] which involved intensive case management, an integrated system with partnership with key agencies and elements of community awareness, showed success in supporting women to maintain tenancy in situations of domestic violence. The authors concluded that Australia should implement provision of homelessness prevention schemes that are as extensive as the current provision of refuge and crisis accommodation. Furthermore, an unrestricted eligibility criteria, good social marketing and the provision of both practical and emotional support were identified as key elements of an effective preventative strategy in this cohort.

Based on this evidence on current and previous strategies for reducing homelessness, both responsive and preventative services are required. In saying this, there is an overall scarcity of evidence regarding the structure and effectiveness of preventative strategies, as few preventative strategies have been implemented in the past. Consequently, there is currently no clear model to aid in the design and execution of new preventative programs.[23] However, what evidence there is shows that preventative strategies hold promise for long-lasting, cost-effective reform, and as more programs of this kind are implemented, their effectiveness can be evaluated and the information used to shape future policy and practice. Housing services alone are not sufficient in addressing the issue of homelessness, and should always work in the context of a supportive framework that aims to maintain people in their homes.[23]

Current best practice for the identification, prevention and management of homelessness for medical practitioners and health care workers

Health practitioners can play a significant role in reducing homelessness through early interventions, preventative strategies and responsive strategies. Their role can be divided into three key areas of action:

  1. identification of those at risk of becoming homeless, particularly where a health issue may result in homelessness;
  2. initiation of preventative care in those at risk of becoming homeless, including referrals to non-clinical support services;
  3. and provision of targeted healthcare towards those already experiencing homelessness.

The first step in the prevention of homelessness in the healthcare setting is to recognise those who are at risk of becoming homeless.[24] Key risk factors include mental illness and substance abuse; marital breakdown and a history of abusive relationships, transitions out of institutionalised care and financial difficulty.[25] In young people, the three groups most at risk of homelessness are Indigenous school students, young people from single parent and blended families, and teenagers who have been in state care and protection.[26] The Indigenous population is continually over-represented in the homeless population, especially in remote areas, where 71% of clients at specialist homelessness services were of Aboriginal and Torres Strait Islander descent.[3]

Furthermore, gaining a good social history can facilitate in the identification of at-risk patients. Patients may not always present to their general practitioner with these social issues as their chief concern, therefore routine questions around mental health, substance use, occupation status, family relationships, financial stressors and current living situation should be used in every consultation, regardless of the presenting complaint.

In some situations however, obtaining a helpful social history and assessing risk based on this history may prove challenging for medical practitioners. For this reason, tools such as the Homelessness Assets and Risk Screening Tool (HART) from Canada have been developed.[27] The HART consists of a patient questionnaire and includes questions on current housing status, income and education and social supports. The HART was evaluated in a clinical context and showed promise in identifying risk and protective factors in individuals in the community.[27] The HART and similar tools could therefore be used to identify at-risk individuals in the setting of general practice or community service.

Enquiries about social history and housing status should extend beyond general practice. The National Affordable Housing Agreement[4] has put forward a ‘no entry into homelessness’ policy as part of its strategy for reducing homelessness. The policy has a focus on the hospital setting as an opportunity for enquiring into a patient’s housing situation and ensuring that they are discharged with housing arrangements in place. A study conducted in the United States [28] showed that assessing the housing status of a patient at discharge was independently associated with higher rates of discussions about cost of medications, physical activity levels, diet, transportation, and mental health follow-up.

In those identified to be at high risk of homelessness, it is then important to address the health and social issues specific to that person in order to prevent their relationships, jobs and housing situations from being compromised. A large proportion of this action involves referral, for example to mental health services, addiction clinics, social workers and financial counsellors.[29] The Homelessness Australia webpage also contains a useful list of specialist services for referral of at-risk patients.[30]

In addition to recognising and managing those at high risk of homelessness, clinicians should also be able to provide services to those who are already homeless. The medical care of a homeless person requires an understanding of both their specific needs and the barriers they face to healthcare. A recent report on a healthcare provision program for the homeless in the Netherlands[29] identified a need for the care of homeless patients to be holistic and multi-faceted. A narrow focus on the patient’s acute physical problems resulted in patients who are homeless feeling neither heard nor understood, which negatively affected the frequency of their service use. Treating only the presenting complaint is of little value as homelessness can impede on adherence to treatments and lead to reoccurrence of and worsening of health problems.[31]

In response to the need for holistic care, practitioners in the afore mentioned Dutch program also increased cooperation with institutions such as addiction centres, mental health care institutions, case management organisation, domiciles, employee recruitment centres and welfare institutions as the program progressed. This allowed practitioners to address social problems, that were often strongly linked to the patient’s current health issue, through quick and efficient referrals. In addition, liaising with homeless shelters also improved treatment adherence as shelter staff were able to supervise medications and encourage clients to attend follow-up appointments.[29]

In addition to understanding the healthcare needs of a person experiencing homelessness, practitioners should also be aware of the barriers they face in accessing healthcare. Over half of people who are homeless have mental health and substance abuse issues requiring counselling or treatment, but they are less likely to access health services due to inability to afford co-payment, inadequate insurance coverage, prioritising health below housing and food and lack of information on what help is available.[32] While the three former barriers call for changes to public policy, the latter barrier is an issue that health workers can directly help to address. Acquiring and passing on knowledge of the services available is a simple yet effective way to provide practical help to those who require it.

Many of the issues faced by homeless people, including domestic violence, mental illness and substance abuse, are deeply personal and sensitive in nature. When doctors practise empathy, such as mirroring the patients’ nonverbal cues, patients feel more comfortable and give fuller histories. [33] Furthermore, compassionate management of homeless adults in hospital has been shown to decrease repeated visits to the emergency department.[34] Indeed, the importance of empathy and a humane focus on individuals who are homeless may be underestimated. Most importantly, empathy is a component of a clinical encounter that anyone can offer, including students who might lack the knowledge and expertise to provide clinical advice. One does not have to be a policy-maker or a healthcare worker to make a positive impact on a homeless person’s life. Towards the end of our conversation, I asked Myra if there was anything one could give to someone like her that was better than money. Her answer came without hesitation, “say a kind word. Don’t look down on them. When people walk past, read my sign, and ignore me – that hurts. But a kind word really helps.”

Conclusion

A paradigm shift in the approach to reducing homelessness is occurring in Australia, with an increased focus on preventative strategies that identify risk factors, prevent homelessness at its source and support families and individuals to maintain tenancy. Increasing the funding allocated for prevention-based programs will allow reach to larger populations sustainably and exert a greater effect. However, as long as there are still people affected by homelessness, provision of affordable housing and homeless support services will continue to be an essential part in the larger homelessness reduction strategy.

In the health care setting, identifying and addressing underlying social issues, such as domestic violence or mental illness, should be a fundamental part of every clinical encounter. Healthcare practitioners are suitably positioned to recognise the risk factors for homelessness and taking appropriate preventative action to ensure that their patients stay safely housed. Furthermore, when health is the last priority, the provision of targeted, accessible, holistic and compassionate healthcare is more important than ever. It is by this combination of prevention, targeted support and collaboration between governments and service providers that the health of homeless persons may be improved and the overall prevalence of homelessness reduced.

Cecilia Xu

Cecilia is a third year medical student at Monash University in Melbourne. Homelessness is an
issue that she has felt strongly about for a long time, but felt lacked the knowledge and con-
fidence to act on her concerns. It is her hope that this article will offer practical suggestions
for improving healthcare for the homeless population and empower current and future health professionals like herself to be a part of the solution to homelessness.

Acknowledgements
Conflict of interest declaration

Conflicts of interest

No conflicts of interest declared

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4. Australian Government Department of Families, Housing, Community Services and Indigenous Affairs. The road home: a national approach to reducing homelessness [Internet]. Canberra (AU): Australian Government; 2008 [cited 2015 Mar 25]. 80 p. Available from: https://www.dss.gov.au/sites/ default/files/documents/05_2012/the_road_home.pdf

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22. Spinney A. Home and safe? Policy and practice innovations to prevent women and children who have experienced domestic and family violence from becoming homeless [Internet]. Victoria (AU): Australian Housing and Urban Research Institute; 2012 Nov [cited 2015 Apr 1]. 111p. Available from: http://www.ahuri.edu.au/downloads/publications/EvRevReports/AHURI_ Final_Report_No196_Home_and_safe_policy_and_practice_innovations_to_ prevent_women_and_children_from_becoming_homeless.pdf

23. Culhane DP, Metraux S, Byrne T. A prevention-centred approach
to homelessness assistance: a paradigm shift? Hous Policy
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25. Echenberg H, Jensen H. Risk factors for homelessness [Internet]. Ottawa (ON): Canadian government; 2009 Feb [cited 2015 Apr 1]. Publication No. PRB 08-51E. Available from: http://www.parl.gc.ca/content/lop/researchpublications/prb0851-e.pdf

26. MacKenzie D, Chamberlain C. Youth homelessness in Australia 2006 [Internet]. Victoria (AU): Commonwealth of Australia; 2008 [cited 2015 Apr 1]. 61p. Available from: https://www.dss.gov.au/sites/default/files/documents/05_2012/youth_ homelessness_report.pdf

27. Tutty LM. On the brink? A pilot study of homeless assets and risk tool (HART) to identify thsoe at risk of becoming homeless [Internet]. Calgary (AB): Calgary Homelessness Foundation; 2012 [cited 2015 Apr 1]. 85p. Available from: http://www.homelesshub.ca/ResourceFiles/HART%20Pilot%20 Report%20Final%202012.pdf

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Health in Low-Resource Settings: A Case for Public Health Measures in Nairobi’s Informal Settlements

Volume 10 Issue 2
Review
Peer reviewed article

 

Abstract

Child mortality remains a significant concern globally with 6 million deaths in children under 5 years of age in 2012. In relation to Millennium Development Goal (MDG) 4 to reduce vaccine-preventable disease mortality and morbidity by two-thirds by the end of 2015 compared to 2004, Sub-Saharan Africa is unlikely to reach this tar- get with the current projection. In Kenya, childhood mortality remains highly elevated and this can be correlated to a number of risk factors including poor physical environments, limited access to resources and medical facilities, lack of maternal welfare and antenatal care, and outbreaks of infectious disease. This is especially evident in low resource settings such as informal settlements, or slums as they are colloquially referred to, in Kenya’s capital, Nairobi. Despite there has been some effort to address the health and living conditions of slum dwellers, more actions are required to improve the health and quality of life in this population. Some fundamental examples include interventions relating to immunisation programmes, water sanitation, and safe waste removal. Diversity in racial and ethnic origins, cultural taboos and sensitivities must be considered when formulating policies and interventions. This article will explore and discuss barriers and focus on strategies and changes that can be implemented to raise the health status. In particular, immunisation strategies will be examined and discussed as a major intervention in the minimisation of childhood mortality rates.

Introduction

A UN-Habitat (United Nations Human Settlements Programme) report projects that one in three of the world’s population will live in urban informal settlements by 2030. [1] In Nairobi, there is significant rural to urban migration with a significant proportion of population growth being directed into the slums. More than 60 percent of the city’s population of more than 3 million resides in slum communities, which occupy only 5 percent of the total residential land area. This rapid rate of population growth in urban areas is concerning as it exceeds the rate of possible economic development [2] and is not accompanied by equivalent socio-economic and environmental development. [3]

The UN-Habitat defines slum as a community characterised by insecure residential status, poor structural quality of housing, overcrowding, inadequate access to safe water, sanitations and other infrastructure. [4] It is associated with a high concentration of poverty and substandard living. There is also insecurity of tenure and marginalisation from the formal sector, including basic health services. It is an area of concentrated disadvantage.

Slums are characterised by population density and diversity where the population is often transient, thus erecting unique barriers which stand in the way of achieving health, especially in the context of continuing care. [5] In the context of Nairobi, the city is comprised of seven divisions which contain over 78 informal settlements with Kibera, Korokocho and Kasarani making up the top three slums in terms of population. [2]

Disaggregated urban data shows health outcomes in slums are often worse than similar groups in rural communities, especially with regards to infant and under-five mortality rates. [6] A number of factors attributed to poor health outcomes include limited access to healthcare services, lack of finances, and poor health seeking behaviours. [1] The rapid increase in population density further exacerbates the social and medical problems in these resource poor settings. [2] In particular, vaccine-preventable infectious diseases, which often progress to end-stage diseases, are a major burden for the communities as they may require high-level care and treatment. [4]

Child immunisation has been identified as a key factor in the prevention of many communicable diseases, as it is considered and has been proven to be the most cost-effective and efficient method of preventative health. [7] The increased rural to urban migration is associated with a decline in health due to negative trends in immunisation and lack of access to resources such as clean water. [7] Due to the complex nature of slums, factors such as cultural appropriateness cost, and accessibility must be considered for successful health interventions.

The Nature of Informal Settlements in Nairobi

Physical Environment

Nairobi, the capital of Kenya, is situated in the South West of the country. It is Kenya’s largest city with a population of over three million people. [8] The annual rate of population growth in Nairobi is 4.3 percent, which is primarily due to the rural- urban migration, also known as the ‘urbanisation of poverty’ with 75 percent of the population growth occurring in informal settlements.

Over 70 percent of the population in Nairobi resides in informal settlements where the physical environment is hazardous to health and is characterised by: a lack of basic services such as roads or waste disposal; [2] substandard housing; illegal or inadequate building structures; overcrowding; and a high population density. [5,8] The dwellings are generally poorly constructed with temporary materials that have been carried away by the floods during wet season. [2]

Despite the Kenyan government owning all land upon which these informal settlements stand, it continues to not officially acknowledge these settlements. [5] This translates to a near absence of any formal or official basic government services or facilities including schools, clinics, running water, electricity, or proper lavatories. [3] In the rare instances that these facilities do exist, they tend to be privatised services in which cost erects a barrier for access. [3]

Waste disposal and water sanitation facilities are absent, along with any formal services providers such as basic healthcare. These poor living conditions leave a negative impact on the health of the residents as there is limited access to safe drinking water, sanitation, garbage and sewage treatment. All of these factors add to the increased prevalence and spread of pathogens, thus perpetuating constant infection and risk of an epidemic in slum dwellers. [2, 5]

Health and Social Services

Private clinics and private pharmacies are the most popular destinations for health-seeking individuals. However, these private institutions are generally managed by unlicensed or poorly trained professionals, sometimes non-professionals, and are often associated with poorer health outcomes. [6,9]

The health and disease pattern of the slum dwellers is congruent with the physical environment of the informal settlement. Water, in particular, is concern with difficulty with access, cost, and quality. The access points for water collection is only located far from their houses, and water collection may even only be available on certain days and times. These barriers result in resident using sewage for bathing and washing, or using other sources, such as borewater and rainwater. All of these sources are highly contaminated and perpetuates the spread of waterborne diseases. [3]

Legal Issues and Crime

According to Mutisya and Yarime, the Kenyan government policies have yet to focus on making low-cost housing available, or providing populations within these informal settlements with viable long- term alternative which have further exacerbated the growth of slums. [3] In particular, informal settlements have been excluded from city authority planning and budgeting processes. Furthermore, the people who undergo the rural to urban migration in search of employment often have no realistic alternative to life as slum dwellers.

This results in a state of hopelessness which leads to an environment and a population who are vulnerable to maladaptive coping mechanisms such as self-medicating with alcohol, addictive substances and drugs. In addition, difficulty accessing education, employment, or recreational facilities translates to unlimited free time, which further increases their risk to alcohol, drugs, and crime, which is prevalent in informal settlements. [10]

Adding to the list of social issues within slums is the increase in commercial sex workers, and easy access of a list of drugs and substances including bhang (marijuana, cocaine, glue, petrol, and chang’aa (an illicit local brew believed to be responsible for both morbidity and mortality in users). [10]

Employment

Due to the complex nature of the illegal status of the slums and the residents, health and social services are virtually non-existent within these settlements. [10] For the same reasons, slum dwellers are often excluded from the usual benefits provided to or required for formal sectors. In essence, slum dwellers are often employed and exploited on a day-to-day basis on low wages. [3,11]

In a study published by La Ferrara, the main source of income for slum dwellers takes the form of hawking, short term day employment, and the operation of small businesses without licenses. Something positive within these informal settlements are these ‘self-help groups’ that are comprised of sub-populations, in particular women, who support each other and pool together their resources to build social capital for start-up projects. [11]

Education

The education level in populations in informal settlements is low. Only 14 percent of the population have completed high school, and
33 percent have not attained education beyond primary school. [2] A mere 2 percent have achieved post secondary school education. Within the slums, schooling facilities are inadequate and often inappropriate. Most schools are initiated as business ventures and do not meet the requirements for a learning institution. Moreover, attendance remains low hence perpetuating the vicious cycle of low education and poverty.

Often school are initiated as business ventures and do not meet their requirements as learning institutions. The class size ranges from 50 to 60 students, and are often lead by unqualified teachers. [2]

Millenium Development Goal 4 and Sustainable Development Goal Note #1

The target of Millennium Development Goal (MDG) 4 is to reduce the under-five mortality rate by two- thirds between 1990 and 2015. There is overall progress with MDG 4, but Sub-Saharan Africa is amongst the regions showing the least progress in reducing the child mortality rate. Statistics show an increasing trend of child death within the first month of live in these regions due to many factors including: [12] high communicable disease prevalence and transmission (constant risk of epidemic); [2] overcrowding; poor hygiene; contaminated water sources. [4,13] With the expiration of the MDGs imminent, it is unlikely that the target will be reached in Kenya. Neonatal mortality rates are especially grim in the slums of Nairobi. The under-five mortality rate in Nairobi slums is 156 per 1000, which is greater than any other urban site within Kenya. [1]

It is equally important to consider the sustainability of any health interventions that are implemented to improve the status of public health in urban informal settlements in Nairobi. In accordance with sustainable development goals (SDG) Note 1 titled “Leave no one behind and provide a life of dignity for all”, improving the health of vulnerable and at-risk populations can help improve their standard of living and quality of life by reducing any disabilities or limitations stemming from chronic end-stage diseases that are easily preventable. [13] For example, at risk populations are vulnerable musculoskeletal injury and their chronic sequelae, [13] mental illnesses, complications of substance abuse, and chronic infections, all of which can negatively impact their psychological and physical ability to find and retain employment, or the ability to care for their self and family. [13] It is imperative that effort and energy is diverted into prevention strategies to stop precipitating events leading to poor health from occurring. Strategies such as vaccination and maternal education beginning from the antenatal period have been shown to be effective in improving neonatal mortality rates, and improve the health status of children.

At present, informal settlements comprise 43 percent of combined urban populations in all developing countries. [6] The urban regions are home to 78 percent of the population in the least developed countries. Current trends show a significant continuing shift towards urbanisation of population in one-third of the world’s population projected to live in urban informal settlements by 2030. [6] Hence, it has become increasingly important to address the issues leading to concentrated disadvantage in slum dwelling populations including: physical environments hazardous to health; lack of health and social services due to the illegal nature of slums; increasing crime rates; and poverty of opportunity in education and employment. [2,10] Recognising informal settlements into government planning and budgeting will assist in building the necessary basic infrastructure (roads, water sanitation, sewage treatment, and waste disposal), and fund primary healthcare centres which is expected to have a positive impact on the health status of the slum population.

The Evidence for Immunisation as a Health Intervention

According to WHO, immunisation remains one of the most successful and cost effective health interventions to date, [14] with an estimated six million deaths prevented worldwide annually.[15] WHO also estimates that 2.5 million deaths amongst children under 5 years of age worldwide are prevented annually through immunisation against diphtheria, tetanus, pertussis, and measles. [12] The expanded programme on immunisation (EPI) in Kenya is primarily funded by the Kenyan Government and the GAVI Alliance (International organisation funded by public and private sectors for the increase of vaccination coverage. [16]

Immunisation programmes have a positive effect on public health and disease control through eradication and elimination of communicable diseases with potentially fatal outcomes. [17] For example, smallpox has been successfully eradicated globally through population immunisation and surveillance for health and outbreaks. Elimination involves high levels of immunity in the population whereby transmission no longer occurs indigenously, and imported cases no longer result in sustained transmission leading to epidemics. Furthermore, immunisation also have a positive health impact, not only on the population being vaccinated, but also in reducing disease incidence amongst non-vaccinated individuals. This indirect effect, known as ‘herd immunity’, [9,18] occurs when transmission of the disease is decreased in a population with high levels of immunity, thus essentially breaking the chain of infection. Herd immunity have been demonstrated in Gambia with Hib vaccine (for the prevention of influenza caused by the pathogen Haemophilus influenze type b) coverage of approximately 70 percent of the population, there were similar findings in a West African Community vaccinated against Pertussis, commonly known as Whooping Cough. [19]

There is compelling evidence in favour of vaccinations for the reduction of death and disease, as well as minimising the associated burden to
the health care system. There is also mitigation of disease severity with multiple studies showing evidence of decreased severity with shorter duration of illness in vaccinated populations in comparison to unvaccinated populations. [15, 19- 21] On an individual basis, there is a reduction in the burden on health and better prevention of chronic sequelae from vaccine-preventable infectious disease.

Current National Immunisation Programme in Kenya

The Global Immunisation Visions and Strategy (GIVS) was approved and endorsed in the World Health Assembly in 2005. The primary objective
of GIVS aligns with MDG 4 and SDG Note 1 in terms of reductions in morbidity, mortality and disability due to life threatening infection from vaccine-preventable diseases by two-thirds. The Division of Vaccines and Immunisation (DVI) under the Ministry of Public Health and Sanitation of Kenya have formulated a multi-year plan running from 2011 to 2015. To minimise and prevent children from succumbing to infectious diseases that are prevalent in the community, especially low resource settings, a specific programme for infants has been formulated to reduce childhood mortality rates. Immunisations included in this programme include vaccines against tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, hepatitis B, Haemophilus influenza type b, measles, and pneumococcus51. All of these diseases are highly infectious and are significant contributors to child mortality rates. The immunisation schedule for Kenya also has additional vaccinations, such as yellow fever, for children in high-risk populations and districts. The vaccines are provided free of charge to the recipients.

The African Population and Health Research Centre (APHRC) facilitates the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) which runs research projects and data collection on longitudinal Maternal and Child Health within the Korogocho and Viwandani slums of Nairobi. [6,9] The NUHDDS project enrolled women in these areas which have given birth since September 2006, and administered a questionnaire about the vaccination history of their children. Data was collected from 1848 children aged 12-23 months who were expected to receive all the WHO- reccommended vaccinations. [9] Compared to the estimated global DTP3 (diphtheria-tetanus- pertussis3) immunisation coverage of 83%, [22] there are regions in Sub-Saharan Africa where communities are significantly undervaccinated.
[23] Within Kenya, the number of children who are reported to have received complete vaccination range from 48.5 percent in the North Eastern regions, and 85.8 percent in the Central regions. [24] Focussing on Nairobi, 74 percent of 12-23 month old are reported to have completed the WHO recommended vaccination programme, [24] but the percentage drops to 44 percent for children living in informal settlements. [6]

In this particular study, Mutua et al, found that protective factors for complete vaccination according to the WHO recommended guidelines include older maternal age, maternal education (primary school), low parity with previous vaccination nation with older siblings, birth taking place in a health facility, and attendance of antenatal and postnatal care follow-up. Maternal age under 20, high parity, and education levels lower than primary school were identified as risk factors. [9] The study concludes that children living in slums are underserved with vaccinations with the limited and lack of access to public health facilities flagged as a major barrier. [9] This is an important consideration to take into account when formulating new public health policy.

In addition to the routine vaccination schedule, the Kenyan Ministry of Health also conducts supplemental immunisation activities (SIA) to identify and minimise gaps in health and increase the vaccination rate. Essentially, the aim of SIAs is to address inequities in the vaccination coverage, especially in sub-populations, who were not targeted or were missed with regards to the
routine vaccination programmes. This may be achieved by delivering the standard vaccination schedule and catch-up immunisations. Other
goals of the SIAs include documenting the coverage and epidemiology of health within the targeted populations in addition to micronutrient supplementation (Vitamin A, zinc and electrolytes) to boost the general health and immune status. [25]

Vulnerable populations living in the slums benefit the most from SIAs due to their poor vaccine coverage with routine programmes. The SIAs were also able to reach the small percentage of the previously unreached population in high-coverage districts. [25]

Vaccinations are primarily given in fixed temporary sites, most often in venues such as schools, churches and mosques. [25] Due to the informal and often illegal nature of the slums, there is very little infrastructure and few facilities contained within the complex. As a result, there is the implication of decreased rates of health seeking behaviour and vaccination due to the physical barrier of distance. This argument is supported by a study which demonstrated a general trend of mothers with unimmunized children living the furthest from vaccination sites, as well as comprising the lower end of the wealth and social status. [26] Furthermore, as shown in Bangladesh there is evidence to show increased vaccination coverage amongst children who are within close proximity to vaccination venues and clinics. [27,28]

Funding of the GIVS Expanded Programme on Immunisation

The targes of the EPI of the Kenyan DVI are to increase vaccination rates through routine immunisation of children with outreach strategies with particular attention diverted at sub-populations with elevated risk factors, such as children in the lowest socioeconomic brackets and slum residents. The particular EPI has secured over $46 million of funding in 2011, and the amount will increased to $91 million by the end of 2015. In addition, the Kenyan Government, and the GAVI Alliance, other significant financial donors include WHO, UNICEF, and foreign aid. [6, 23, 29] According to WHO Global Health Observatory Data, the expenditure for public health in Kenya is 4.49 percent of their Gross Domestic Product (GDP) or USD 14.35 per capita which remains low on the global scale despite increasing from previous years. [30] The low funding is a key factor leading to and perpetuating poor health status and outcomes. overflow effects of poor health conditions include loss of productivity and decreased socioeconomic growth in communities. Vulnerable populations include slum dwellers, especially due to an increased risk factors associated with absolute poverty, high susceptibility to famine, overcrowding and disease outbreak.

The Australian Government has made some contributions to projects and programmes that assist in achieving the MDGs on a global scale.
The fundamental objective of the former AUSAID programme is to help people overcome poverty through multi-lateral pathways: microscopic and macroscopic finance and economics strategies: health and community engagement; and funding of basic supplies and health provisions. [31] Australia’s Official Development Assistance (ODA) target of 0.37 percent of the gross national income totalling USD 5251 million in the financial year of 2013 – 2014 was met. [31] This translated to USD 429 million donated to Africa and the Middle East, with USD 93 million being allocated to Kenya. However, with recent changes to AUSAID being amalgamated under the Department of Foreign Affairs and Trade (DFAT), funding to the Sub- Saharan programme has been cut. The anticipated budget for 2013-2014 of $249.9 million has been slashed to $133 million resulting in the many programmes under this particular portfolio to be completed earlier or have reduced funding[31]. The funding is projected to decrease, and will fall well below the internationally recommended target (ODA target of 0.7 percent of the gross national income) set by the United Nations as a strategy towards meeting the MDGs.

Despite the funding cuts to the Sub-Saharan African programme, the Federal Australian Government has pledged $250 million over the five year period of 2011-2015 towards the GAVI alliance, with further ongoing support of another $250 million contribution over 2016-2020. [31]

GAVI estimates over 7 million lives have been saved since the implementation of GAVI programmes for children in developing nations.

Recommendations

The limited and lack of public health infrastructure in the informal settlements within Nairobi are a major barrier to poor health seeking behaviours and health outcomes in particular in relation to vulnerable population such as women and children. It is estimated that 21 percent of children under five in Sub-Saharan Africa are moderately or severely underweight. This proportion is increased in children living in slums. [31]

Despite the establishment of the EPI and the national immunisation schedule for infants and children, barriers to accessing health services and vaccinations still exist. Common themes include limited maternal education, young maternal age, physical distance, and monetary constraints. With regards to physical barriers, the delivery of antenatal care and immunisation are quite centralised with fixed facilities and posts within Nairobi city. Strategies to address this issue to implement public health facilities within the informal settlements or outreach services which does increase the cost of delivery. Many studies have shown compelling evidence in favour of publically funded health facilities and with associated positive outcomes in health, [31] thus comprehensive policy making and significant efforts towards building a public health system in slums must be undertaken to help in closing the gap in health disparities.

Furthermore, the establishment of public health facilities within the informal settlements bring along other benefits to the community. There is creation of opportunities for education, training, empowerment, and employment. The opportunity for up-skilling and employment can assist in reducing some of the financial and societal burdens associated with living on or below the poverty line and reduce the unemployment rate within informal dwellings. 48 percent of Sub-Saharan Africans live on less than $1.25 each day, and residents within slums are overrepresented in this statistic. [31]

Another major advantage of training local people is the flow-on effect of education and awareness trickling out into the wider community. The intended effects are the dissemination of information relating to health and disease implications, raising awareness of risk factors, and more important, the preventative measures involving hygiene and nutrition that can be implemented without specialised equipment. In a population that has been displaced with very little social or community networks and support, community ownership and access to information will lay the foundations in re-establishing connections and reduce gaps in knowledge for health.

Conclusion

A multitude of factors impact the state of health and wellbeing in low resource settings, such as in the context of informal dwellings in Nairobi. At present, the projection of progress of MDG 4 is not on track for the targets to be reached by 2015, thus child mortality prevention strategies and implementation requires further discussion and efforts at the post- 2015 agenda meetings.

Many long-standing issues exist including malnutrition, overcrowding, high disease prevalence, and poor access to resources. These issues have a detrimental influence on the health status of the residents of the Nairobi slums, and require long term solutions requiring extensive planning. Immunisation is one of the most cost effective and efficient strategies that can be implemented rapidly and can vastly minimize many of the harmful factors skewing towards infectious diseases and poor health outcomes. In addition, the EPI also supports SDG target of providing a
life of dignity for all, especially through improved health of at-risk populations. An emphasis on the DVI having establishments in and working together with the local community should be highlighted as evidences indicate the positive effect of community integrated approaches to healthcare, especially in low resource settings, and to negate cultural barriers which may otherwise impede the delivery of essential immunisations.

Phoebe Shiu

Phoebe Shiu is a 6th year medical student studying at James Cook University,
Queensland. She has a special interest in Global Health and is looking forward to working with underserved populations. Phoebe travelled to United Nations Environments Assembly in Kenya as part of a Global Voices delegation, which further sparked her interest in sustainability in healthcare and policy making. In the future, she hopes to combine both travel and medicine by volunteering and working overseas.

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[30] WHO U. Global immunization data. 2013.
[31] Australian Government. Department of Foreign Affairs and Trade. Aid Program Performance Report 2013-14: Sub-Saharan Africa Program.

Healthcare in the Wake of Cyclone Pam

Issue 10 Volume 2
Review
Peer reviewed article

 

Abstract

This article discusses healthcare needs and provision in the third world nation of Vanuatu. The major focus of the article is on how healthcare needs have been affected in the aftermath of Tropical Cyclone Pam, a category 5 storm that devastated the country this year on March 13th. The article discusses developments in healthcare in Vanuatu leading up to this natural disaster as well as the immediate response to it and expected healthcare requirements.

Main article

Australia – the lucky country. Few of us genuinely appreciate just how true this well-known saying is. We have political stability, an effective welfare program, a trustworthy judicial system and education available to all. We can also lay claim to one of best healthcare systems in the world. Our life expectancy is the 8th highest worldwide and we have 1 doctor per 312 people.[1] Even in our most remote areas there is the option of transfer to a tertiary facility, with care that is equal to the best provided anywhere in the world. While there are obviously aspects to work on, we are, on the whole, incredibly privileged.

Our geographic location, however, includes many less privileged countries where healthcare is, at best, rudimentary. One of these countries recently gained significant, if fleeting, publicity in the aftermath of Tropical Cyclone Pam. An archipelago nation of more than 80 islands 2000km from Australia’s eastern coast, Vanuatu is home to around 270,000 people.[2] I was fortunate enough to call Vanuatu home for 6 months as a volunteer on one of the outer islands and also spent several weeks as a medical student in the capital’s Port Vila Hospital. Vanuatu and Australia were different in many ways, but as a medical student, the differences in healthcare funding and provisions were the most striking. While Vanuatu is one of our closest neighbours, its healthcare system could scarcely be more distant.

Prior to the devastation caused by Cyclone Pam, healthcare in Vanuatu was able to support the rudimentary needs of the country. Vanuatu’s 270,000 citizens were serviced by 4 regional hospitals and 2 main referral hospitals.[3] There were only 49 doctors in the country, equaling less than 1 doctor per 5,000 people and fewer than 350 nurses practicing in the whole country in 2012.[4] Life expectancy was ranked 101st globally[4] and healthcare expenditures were just $167 (international dollars) per person per year[5] (compared to $4068 per person per year in Australia).[6]

Healthcare services in Vanuatu are centred almost exclusively in the two largest cities; Port Vila and Luganville. Almost all of the country’s health professionals are located in one of these two centres. Smaller health centres and dispensaries are scattered throughout the country, with most staffed by one or two nurses or volunteers with limited training who cater to around 1,000 people.[4] Tertiary services are non-existent, and patients must be referred to Australia or New Zealand for any advanced treatment.[4] Another significant complicating factor in Vanuatu’s healthcare system is the country’s ‘double burden of disease’. The incidence of non-communicable diseases has increased significantly as diets and lifestyles have changed throughout the country (particularly in urban areas) but communicable diseases still contribute significantly to morbidity and mortality in both urban and rural areas. The main causes of death in 2010 were closely divided between non-communicable (ischaemic heart disease, diabetes and stroke), and communicable and nutritional causes (including diarrhoeal diseases, tuberculosis, pneumonias and malnutrition).[7]

All statistics aside, the reality of practicing medicine in such a resource-poor environment cannot be understood until it has been experienced. Vanuatu’s most advanced imaging modalities are X-ray and ultrasound which are available only in the two major hospitals, and many blood tests have to be sent to Australia for analysis. Once a diagnosis has been made it is not uncommon for crucial medications to be unavailable. Patients who require complex surgeries must be flown to Australia or New Zealand to receive care. As very few locals can afford such arrangements, funding often comes from the Vanuatu government and/or private donors. Unfortunately, the available funds are insufficient and only a small proportion of those in need can access such treatments.[4] In the few short weeks that I spent in the Vila Central Hospital, I saw several patients die from diseases that are preventable and/or treatable in Australia. I also saw diseases that have been all but eradicated from Australia and other western countries, including rheumatic fever, malaria, and tuberculosis. While this may sound like a difficult environment in which to practice medicine, the smaller hospitals and dispensaries have even fewer resources.

In spite of these difficulties, health outcomes in Vanuatu have steadily improved over the last 25 years.[7] A government driven program for improving health and increasing numbers of medical professionals in the country has been the main force behind these changes.[4,8] Morbidity and mortality from communicable diseases have decreased yearly since the 1980’s as vaccinations and clean water have become more widely available.[7] Immunisation rates have increased, resulting in a significant decrease in childhood mortality rates and improvements in antenatal and perinatal care have caused similar decreases in maternal and infant mortality.[4] Unfortunately, these tentative advances are now in grave danger of being lost.

On the 13th of March 2015 Tropical Cyclone Pam, a category 5 storm, tore through Vanuatu, wreaking havoc as it went and leaving devastation in its wake. It is estimated that 90% of the population of Vanuatu’s capital, Port Vila, became homeless overnight. Some reports stated that around 70% of outer island inhabitants were left in a similar situation.[9] Electricity was lost in those few urban places that had it, clean water sources were contaminated and vital crops were flattened.[9] The country’s main hospital, Vila Central Hospital, was evacuated and some of its wards are still closed today. A large proportion of medical supplies including medications, vaccinations, and basic equipment were also damaged or lost in the storm.[9] These losses in conjunction with structural damages to healthcare facilities add up to over US $7 million.[10] This has left Vanuatu’s medical professionals almost entirely reliant on international aid to provide even the rudimentary level of care that they had achieved prior to Cyclone Pam, let alone meet the additional demands which have emerged in its aftermath.

As Vanuatu rebuilds after Cyclone Pam, the burden of disease is expected to shift dramatically. The significant advances in the fight against nutritional and communicable diseases in recent years will be largely lost.[10] The contamination of water supplies, when combined with overcrowding in emergency shelters, will create an ideal environment for the spread of many infectious diseases that Vanuatu has only recently started to control.[10,11] The destruction of crucial water tanks has drastically limited access to safe water supplies, with damage to an estimated 90% of tanks and sanitation facilities in affected areas.[10] This has already led to an increase in the prevalence of diarrhoeal diseases, which is expected to continue for
the foreseeable future.[10] The widespread destruction of Vanuatu’s crops will have both immediate and long-term effects on public health. [10] Malnutrition and vitamin deficiencies are conditions that were only recently controlled
and the sudden loss of almost all agriculture in the affected areas is likely to result in a mass resurgence of such diseases as are commonly seen in post-disaster settings.[7,10] In addition, Vanuatu’s immunisation rates for diseases such as diphtheria, typhoid, and hepatitis A are much lower than those enjoyed in Australia,[4] meaning that healthcare workers will have an even greater task than otherwise anticipated.

In the years leading up to Cyclone Pam, the Vanuatu Ministry of Health had worked with significant success to eradicate mosquito breeding sites, drastically reducing the number of malaria cases.[11] The utter destruction wrought by the cyclone will undo most, if not all, of the hard work on this project by creating an ideal environment for mosquitos to multiply. This, in turn, will likely result in a significant increase in the incidence of malaria and dengue fever, as was recorded after a similarly devastating earthquake and tsunami struck Vanuatu in the early 2000’s. [11]

All of these challenges come at a time when the government of Vanuatu is least able to manage them. Damage estimates alone, based on similar disasters in other Pacific nations, run between US $248 million to $316 million.[10,12] This is money that Vanuatu simply does not have, and while significant international aid has been forthcoming, with Australia, as the biggest donor, pledging $50 million,[13] current totals and ongoing projections indicate that the total aid provided to Vanuatu will likely fall short of that which is required.[12] The population’s immediate concerns are focused on food and shelter, and even within the health sector the focus is on rebuilding what was damaged by the cyclone. This means that no real provision or funding has been allocated to long-term disease prevention at this time.[10] Economic concerns are compounded by the fact that Vanuatu’s two main industries, agriculture and tourism, have been the most severely affected by the cyclone.[12] In some cases, the damage caused to Vanuatu’s agriculture can be rectified quickly but some crops, including kava – one of Vanuatu’s biggest export crops, take several years to grow to maturity.[12] Many resorts and tourist attractions are still closed in Port Vila and the island of Tanna (one of Vanuatu’s biggest tourism areas and also one of the worst affected by Cyclone Pam), and it will be many years before the income provided by tourism matches pre-cyclone levels.[10]

The Ni-Vanuatu are a resilient people who have made significant advances economically, medically, and politically over the last few decades, but they are still reliant on international aid.[14] Their healthcare, while greatly improved, remains at a much lower standard than that of developed countries like Australia.[5,6] Cyclone Pam has destroyed much of the infrastructure of this beautiful country and, in the space of

a few hours, managed to undo years of work achieved by the people of Vanuatu. In the coming years, healthcare needs will change dramatically, and Vanuatu’s reliance on international aid has suddenly and drastically increased.[10,11] Unfortunately, as is often the case in international disasters, the extensive news coverage of the crisis lasted only a couple of weeks. While that period brought with it an inspiring influx of aid from many countries, decreased news coverage has led to a waning in international awareness and foreign aid.

The plight of many of Vanuatu’s 270,000 citizens remains dire. It will take the country years, if not decades, to completely recover from Cyclone Pam.[10] Infrastructure, tourism, agriculture and healthcare have all been set back significantly, and international support in the form of economic aid is vital to the rebuilding effort.[10,11] This will involve thousands of people, millions of dollars and many years to complete. Because of the financial situation in Vanuatu it will need to be an international effort involving governments, volunteer organisations and, perhaps most importantly, the support of tourists returning to this still beautiful country to support the economy. Vanuatu still has much to offer, with its stunning beaches, tropical rainforests, and beautiful oceans but most importantly, its unique and rich culture and the unfaltering positivity and generosity of its people.

Emma Davey

Emma is a final year medical student at Monash University. She has a keen interest in global health and has been lucky enough to travel to Vanuatu several different times, including a med- ical elective in her 3rd year in the Vila Central Hospital. Emma was prompted to write this after Tropical Cyclone Pam devastated Vanuatu in March this year to raise awareness of the health- care situation of one of Australia’s closest nations.

Acknowledgements

NAD

Conflict of interest declaration

I declare that I have no conflict of interest regarding the contents of this article.

References

1. Australian Bureau of Statistics [internet]. Canberra: ABS; April 2013. Australian Social Trends – Doctors and Nurses [cited 2015 March 20]. Available from: http:// www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features20April+2013#p2aspx

2. World Vision [internet]. Australia: World Vision; July 2008. Country Profile – Vanuatu [cited
2015 March 20]. Available from: http://www. worldvision.com.au/Libraries/3_1_2_Country_ Profiles_-_Asia_Pacific/Vanuatu.pdf

3. Commonwealth Health Online [internet]. Cambridge: Commonwealth Health Online; 2015. Health Systems in Vanuatu [cited
2015 March 19]. Available from: http://www. commonwealthhealth.org/pacific/vanuatu/health_ systems_in_vanuatu/

4. World Health Organisation [internet]. Geneva: collaboration between WHO and Ministry of Health, Vanuatu; 2012. Health Service Delivery Profile Vanuatu 2012 [cited 2015 March 21]. Available from: http://www.wpro.who.int/health_ services/service_delivery_profile_vanuatu.pdf

5. World Health Organisation [internet]. Geneva: WHO; 2012. Countries – Vanuatu [cited 2015 March 21]. Available from: http://www.who.int/ countries/vut/en/

6. World Health Organisation [internet]. Geneva: WHO; 2012. Countries – Australia [cited 2015 March 21]. Available from: http://www.who.int/ countries/aus/en/

7. GBD Profile: Vanuatu [internet]. Seattle: Institute for health Metrics and Evaluation; 2010 [cited 2015 March 20]. Available from: http:// www.healthdata.org/sites/default/files/files/ country_profiles/GBD/ihme_gbd_country_report_ vanuatu.pdf

8. World Health Organisation: Western pacific region. Tenth pacific health ministers meeting; Health workforce development in the pacific. Apia, Samoa; WHO; 2013 July 4 [cited 2015 Sep 14]. 23 p. PIC 10/10. Available from: http://www. wpro.who.int/southpacific/pic_meeting/2013/ documents/PHMM_PIC10_10_HRH.pdf

9. UNICEF Australia [internet]. UNICEF; 2015. Cyclone Pam: UNICEF Australia emergency update for Monday, March 16 [cited 2015 March 22]. Available from: http://www.unicef.org.au/ Media/Media-Releases/3–2015-March/Cyclone- Pam—-Emergency-update-Monday,-March-16.

10. Government of Vanuatu. Vanuatu Post- disaster needs assessment: Tropical cyclone Pam, March 2015. Port Vila, Vanuatu; Government of Vanuatu; 2015 March [cited 2015 Sep 10]. 172 p. Available from: https://www. gfdrr.org/sites/default/files/publication/Vanuatu_ PDNA_Web.pdf

11. Global Health Group [internet]. Eliminating malaria in Vanuatu. San Francisco: Global Health Group; August 2013 [cited 2015 June 25]. Available from: http://static1.1.sqspcdn.com/ static/f/471029/23665701/1381362226433/ Vanuatu.

An update on HIV Technology: What’s the latest? Are we far from a cure?

Volume 10 Issue 1
Review
Peer reviewed article

 

Abstract

HIV/AIDS has wreaked havoc across the globe since its discovery in 1981, when patients were first clinically identified with the disease. Since then, medical advances have enabled improved antiret- roviral therapy (ART) and management protocols. Furthermore, a significant number of global health organisations highlight HIV/AIDS as a priority area for research and global management. Even though there is no current HIV vaccine, there is significant research occurring into the development of an effective vaccine. However, there are a variety of challenges with creating a vaccine that needs to be addressed. The HIV prophylactic methods that are being implemented in parts of the world include male circumcision, topical microbicides, oral pre-exposure prophylaxis (PrEP) and the use of ART as prevention. Novel treatments for HIV such as neutralising antibodies, ‘shock and kill’ approaches and gene modification are currently being researched through pre-clinical phase trials and small clinical trials. The preliminary evidence is promising for such novel treatments and hence with further research they have the potential to be used as viable treatment options. With the advent of new technologies, finding a cure for HIV is slowly becoming a more realistic goal but despite all of these progressive measures, the global burden of HIV remains immense.

Introduction

The cure for HIV/AIDS remains evasive since the discovery of the condition in 1981, however there have been several major breakthroughs in HIV treatment and prevention interventions over the years.[1] For instance the breakthrough of mother-to-child transmission prevention in 1994 and the introduction of triple combination antiretroviral therapy (ART) in 1996 following the Vancouver 11th International Conference on AIDS. [2,3] Triple combination ART is still the main form of treatment today. In addition, the degree of protection medical male circumcision provided against acquiring HIV infection is well-supported by Randomised Control Trials (RCTs) from 2005 onwards,[4] and topical microbicides having a role in reducing HIV acquisition is supported by RCTs such as the 2010 trial by Karim et. al.[5]. Furthermore, the introduction of oral PrEP occurred following strong supporting evidence from RCTs since 2010,[6,7,8,9] and lastly treatment with ART used as prevention has been highly supported by the 2011 landmark study by Cohen MS et. al.[10] Evidently, there has been extensive ongoing research into HIV treatment and prevention. However there is currently no cure for HIV or any vaccine that works effectively in humans and hence research continues today into newer technologies such as gene modification and the ‘shock and kill’ approach. This article will explore the epidemiology of HIV/AIDS and then delve into the recent advances in HIV/AIDS prevention and treatment including potentially promising future therapies.

The current statistics and epidemiology According to statistics published by the World Health Organisation, approximately 35 million people worldwide were living with HIV/AIDS in 2013.[11] It was estimated that 1.5 million people had died from AIDS in that year alone.[11] Sub-Saharan Africa continues to be the most severely affected region, accounting for 71% of the global population living with HIV/AIDS. Fortunately, the expansion of the HIV/AIDS epidemic has steadied in recent years, as have the number of AIDS related deaths.[11]

The Kirby Institute’s latest Annual Australian Surveillance Report of HIV, viral hepatitis and sexually transmissible infections, revealed that the HIV rates in Australia are the highest they have been in twenty years.[12] The report further stated that there are now more than 26 000 people living with HIV in Australia and that one in seven Australians are unaware they have the infection.[12] This increase in Australia’s HIV rates has been attributed to casual unprotected sex between male partners.[12] As of the end of 2013, the number of new cases of HIV on a state/territory basis indicated that New South Wales, Victoria and Queensland have the greatest numbers in descending order respectively.[12] On a positive note, the number of HIV cases caused by unsafe intravenous drug usage is now down to 2% in Australia. This achievement was reached through the widespread introduction of the safe disposal of needles and syringe programs.[12]

An update on HIV vaccinations

The development of a vaccine that can be prophylactic or therapeutic is one of the major methods considered and heavily researched for managing the HIV epidemic.[13] This section will focus primarily on the research surrounding preventative vaccines and also the potential for vaccines to provide a ‘functional cure’.

The pursuit for a safe and efficacious preventative vaccination has been challenging and limit- ed by a variety of factors. Importantly, immune correlates of HIV control are currently not clearly defined.[14] Thus, success of the vaccine is difficult to determine. The importance of identifying immune correlates of HIV is necessary for future research on vaccinations, to ensure that outcomes in efficacy trials can be measured and compared. Various markers have been considered previously, including virus-specific T-cells and humoural immune responses, however con- founding factors prevent a direct causal relation- ship from being identified. [14]

To date, there have been six vaccine efficacy trials conducted. Of these trials, only one study was able to demonstrate efficacy with the vac- cine.[15] This is the RV144 study which used the canarypox vector vaccine. This trial was a community-based double blind, randomized and placebo-controlled trial conducted in Thailand. [16] Participants of this study were at risk of contracting HIV infection heterosexually. Whilst efficacy with this trial was established, there are many limitations with broadening the results of this study to the wider community. The population sample size was small and thus the study is low in power. Despite this, the RV144 study enabled further research for identifying immune correlates of HIV infection risk.[17] A case-control analysis conducted by Haynes & Gilbert et al, aimed to identify cellular and antibody correlates of HIV infection risk.[17] This correlates study was hypothesis-generating and suggested that IgA antibody binding to envelope proteins is inversely related to the rate of HIV infection. In addition it was found that IgG antibody binding to variable regions 1 and 2 of HIV enveloped proteins, may be directly correlated with the rate of HIV infection. Whilst these findings may inform future research in the area, the study rightly recognised its limitations and highlighted that further clinical vaccine efficacy trials or animal models must be developed in light of this information for true identification of correlates of HIV infection risk.[17]

Up until now several strategies have been trialled in developing a preventative HIV vaccine. The use of live attenuated vaccines for HIV has been discussed and is a contentious issue. The major concern was that any attenuated vaccine has the potential to result in infection.[18] Examples such as the live attenuated polio vaccine causing paralytic poliomyelitis were stressed.[18] Additionally, a study on gay men who became infected with a naturally attenuated form of HIV, were later found to have compromised immune function over time.[18] These observations support the view that live attenuated HIV vaccines have a capacity to cause HIV infection. The current strategy in developing a vaccine is to create an immunogen and vaccination protocol that induces both a broadly reactive and cell mediated immunity as well as a neutralising humoural response. The aim behind this, is to ensure that the vaccine is active at potential infection sites and post-infection.[15]

Presently, there has been discussion surround- ing the use of vaccines in establishing a ‘functional cure’ in people already infected with HIV. Between 2008 and 2010 a trial using a peptide based therapeutic vaccine known as ‘Vacc-4x’ was conducted.[19] This was a phase 2 randomised and double blinded placebo controlled trial which recruited 136 participants across multiple sites in Europe and USA.[19] One group was assigned to receive the vaccine, whilst the other received a placebo. An article by Pollard and Rockstroh et al, explored the efficacy and safety of this vaccine.[19] It was established that there was no significant difference between groups in terms of efficacy.[19] Overall, whilst there was no benefit from the vaccination, it was established that Vacc-4x was generally safe and is worth considering for further investigation into a ‘functional cure’.[19] 

At this point in time, a vaccine for prophylaxis or a ‘functional cure’ remains elusive.[15] Un- fortunately, the majority of vaccines that initially seemed promising in the laboratory and then even in animal studies, eventually fail in human trials. However, research that delves into the discovery of potential HIV immune correlates will facilitate prediction of outcomes in future HIV vaccine efficacy studies.

Current methods of HIV prophylaxis

As there is no current vaccination that effectively prevents HIV transmission, antiretroviral medications are currently being used as prophylaxis in high-risk populations. In addition, new HIV prevention interventions including male circumcision, topical microbicides (e.g. tenofovir 1% gel) and oral pre-exposure prophylaxis (PrEP) are currently being implemented.[20] PrEP and ART for prevention especially, are two methods which are currently being considered for widespread global use due to their efficacy and safety.[10]

A 2011 study explored the prevention of HIV infection with commencing ART immediately once HIV positive status was recognised (ear- ly) rather than delaying therapy until CD4 count decreases below 350 or HIV related symptoms begin.[10] This study was conducted across nine different countries and observed couples whereby one partner was HIV positive and the other HIV negative.[10] Results of the study highlighted that early administration of ART was successful in reducing rates of HIV transmission via sexual transmission by a relative reduction of 96%.[10] However, the study also mentioned that there was an increase in drug-related side effects in those couples that commenced ART early.[10] The results further demonstrate that both the infected and uninfected individual benefit from this approach, thus ART for prophylaxis may be an appropriate public health strategy in managing the HIV pandemic.[10] This study has prompted a number of recent trials, two of which revealed favourable results, however some were terminated as non-adherence to antiretroviral regimes rendered the programs ineffective.[20] Hence, whilst the use of ART for prevention of HIV appears promising, drug stock outs, the cost of ART, adverse drug reactions and subsequent poor adherence to treatment regimes remains a challenge in implementing such programs glob- ally.

PrEP is a daily oral pill consisting of tenofovir and emtricitabine for people who are HIV negative but with a substantial risk of contracting HIV infection.[21] The ART used in PrEP are effective in blocking the pathways used by HIV to initiate an infection. The PrEP needs to be taken daily to ensure the levels of the medications remain at an appropriate level to prevent HIV infection. Several PrEP trials have demonstrated efficacy. The 2013 Bangkok Tenofovir randomized and double blind- ed study demonstrated that PrEP was effective in preventing transmission of HIV in people who inject drugs.[9] In addition, a 2012 study based in Botswana demonstrated that PrEP was successful in preventing HIV infection amongst sexually active heterosexual adults.[7] Recently, the US Public Health Service released ‘clinical practice guidelines for PrEP’ recommending that it be considered for all people who are HIV negative and at a high risk of contracting HIV.[22] Similar to using ART for prevention, PrEP adherence remains a challenge and adherence to the once daily pill is essential for efficacy.[22] The ‘clinical practice guideline for PrEP’ emphasizes the importance of adherence counselling and provides various strategies to improve adherence, including education.[22] Some recent studies have even considered the use of PrEP in the form of a long-acting injection every three months.[22]

Novel approaches to treating HIV/AIDS

Currently the mainstay of treatment for HIV involves the combination of at least three medications – i.e. ‘triple combination therapy’. The classes of these medications include; protease inhibitors, non-nucleoside and nucleoside reverse transcriptase inhibitors, fusion inhibitors and integrase inhibitors. The underlying mechanism of these medications combined, is to prevent HIV from entering CD4+ T-lymphocytes and from replicating.[23] These drugs do not provide a cure but are able to reduce the viral load, increase the CD4 cell count and thus keep clinical signs and symptoms at bay.[23] There is continual research into reducing the cost and adverse effects of ART as well as research into the cure for HIV. Two common research approaches are a sterilizing cure, where all HIV infected cells are eliminated, and a functional cure, whereby the individual does not require the use of ART in order to have life-long control of HIV. [24]

The 2014 AIDS conference discussed a new ‘shock and kill’ approach, which is a potentially promising sterilising cure for HIV. Its aim is to eliminate the barrier that our current antiretroviral medications have because of their inability to kill latent HIV infected cells. As ART currently stands, it is a life long medication regime for HIV positive individuals since HIV is able to remain latent in cells.[25] If the patient stops taking the medication, these latent viruses are able to activate and spread throughout the body.[25] Unfortunately ART does not have the ability to eliminate the inactive viruses because they are unable to recognise cells, which have been infected with dormant HIV.[25] The ‘shock and kill approach’ has been tested with a mice model and was successful.[25] The study involved injecting mice containing human immune cells with HIV and treating them with ART, latency reversing agents, broadly neutralising antibodies or an amalgamation of these treatments.[25] Latency reversing agents are medications that have the ability to activate latent viruses.[25] Neutralising antibodies, such as ones that neutralize AMV reverse transcriptase has been shown to significantly reduce viral load and markedly increase CD4+ T lymphocytes on immunological testing.[26] This seems encouraging, however the pilot study on neutralising antibodies of AMV reverse transcriptase is limited by its sample size and inability to be transferred to the general HIV population.[26] The mice in the ‘shock and kill approach’ study were treated with a combination of three different latency reversing agents and the broadly neutralising antibodies and consequently had no sign of viral rebound in blood levels after the treatment was ceased.[25] Based on this result, it is clear that preventing HIV from creating and maintaining an inactive reservoir will be a key component in finding a sterilizing cure.[25] However, it is important to contextualise this research as being evidence from mice models and appreciating its low predictive value for humans.

Incidences such as the famous ‘Berlin patient’ who is the only person reported to have been functionally cured of HIV in 2008,[26] have been extensively analysed and inspired avenues for research into novel treatments such as gene modification. The ‘Berlin patient’ had HIV and later was diagnosed with acute myeloid leukaemia and hence underwent stem cell transplantation with a donor who was homozygous for the CCR5Δ35 mutation.[26] Current research into gene modification involves the removal of key cells from people infected with HIV and genetically modifying these cells to resist HIV infection, then returning the modified cells to the infected individual.[27] The National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health is funding the research behind this technique.[27] The scientific reason- ing behind this method of treatment is based on observations that individuals who possess a genetic modification to the CCR5 protein are naturally resistant to HIV and when exposed to HIV these individuals progress to AIDS at a slow- er rate.[27] The CCR5 protein is a surface cell receptor that most variants of HIV use to invade the CD4+ T-lymphocyte. A recent trial involved genetic modification of CCR5 in 12 HIV infected individuals.[27] The protein was made non-functional and multiplied so that each individual had ten billion of their own CD4+ T-lymphocytes re-infused.[27] When measuring the outcome of this treatment all participants ceased their ART. Results indicated that all modified CD4+ T-lymphocytes remained protected from HIV. It is hoped that using this technology will allow individuals to control the virus without the use of medications.[27]

Conclusion

This article only captures a snapshot of the evolving technologies surrounding HIV prevention and management. The current safety status and efficacy of prophylactic HIV vaccines is yet to be established and remains controversial. However, research is now focussed on elucidating immune correlates of HIV, which will enable greater accuracy in efficacy vaccine trials. A HIV vaccine that can produce a ‘functional cure’ is also under consideration. There have been exciting break- throughs with HIV treatment and prevention over the years that are well supported by strong RCT evidence. This includes HIV prophylactic methods that are implemented around the world such as prevention of mother to child transmission, male circumcision, topical microbicides, oral PrEP and the use of ART as prevention. Triple combination antiretroviral treatment remains the mainstay of management of HIV today.

There is much less evidence for novel treatments such as the ‘shock and kill approach’ and gene modification in comparison to well-established preventative and treatment measures. However the preliminary evidence for such novel treatments is promising and the research is working towards discovering functional and sterilising cures for HIV. This is a rapidly growing field. Hence, med- ical students and practitioners alike should be encouraged to remain informed about new advances in HIV treatment and prevention to ensure patients receive the most evidence-based and optimal care. This is particularly crucial given the continuing global burden of HIV/AIDS. With the ongoing advancement of medical technology, it is hoped a cure for HIV will become a reality in the not so distant future.

Hayleigh Chiang & Rukaiya Malik

References

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3. The XI international conference on AIDS, Vancouver 7-12 July, 1996. A review of clinical science track B. Genitourin Med. 1996;72(5):365-369. 4. Auvert B, Taljaar D, Lagarde E et. al. Randomized, controlled interven- tion trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005;2(11):e298.

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6. Grant RM, Lama JR, Anderson PL et. al. Preexposure chemoprophy- laxis for HIV prevention in men who have sex with men. N Engl J Med.

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8. Baeten JM, Donnell D, Ndase P et. al. Antiretroviral prophylaxis for HIV-1 prevention among heterosexual men and women. N Engl J Med. 2012;367(5):399-410.
9. Choopanya K, Martin M, Suntharasamai P et. al. Antiretroviral prophy- laxis for HIV infection in injecting drug users in Bangkok, Thailand (the Bangkok Tenofovir Study): a randomized double-blind, placebo-controlled phase 3 trial. Lancet. 2013;381(9883):2083-90.
10. Cohen MS, Chen YQ, McCauley M et. al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6). 493-505.
11. World Health Organisation. HIV/AIDs Global Health Observatory Data. [Internet] 2014 [cited 2014 Sept 9]. Available from: http://www.who.int/ gho/hiv/en/
12. The Kirby Institute for infection and immunity in society 2014. HIV, viral hepatits and sexually transmissible infections in Australia Annual Surveil- lance Report. [Internet]. 2014 [cited 2015 Mar 27]. Available from: http:// www.kirby.unsw.edu.au.
13. Wang N, Li Y & Niu W, Sun M, Cerny R, Li Q, Guo J. Construction of a live-attenuated HIV-1 vaccine through genetic code expansion. Angew Chem. 2014;53(19):4967-4971.
14. Prado JG, Carrillo J, Blanco-Heredia J, Brander C. Immune correlates of HIV control. Curr Med Chem. 2011;18(26):3963-70.
15. Tomaras GD, Haynes BF. Advancing Toward HIV-1 Vaccine Efficacy through the Intersections of Immune Correlates. Vaccines. 2014;2:115- 35.
16. Rerks-Ngarm S, Pitisuttithum P, Nitayaphan S et.al. Vaccination with ALVAC and AIDSVAX to prevent HIV-1 infection in Thailand. N Engl J Med. 2009;361(23):2209-2220.
17. Haynes BF, Gilbert PB, McElrath MJ, et al. Immune-correlates analysis of an HIV-1 Vaccine Efficacy Trial. N Engl J Med. 2012;366(34):1275- 1286.
18. Blower SM, Koelle K, Kirschner DE, Mills J. Live attenuated HIV vac- cines: Predicting the tradeoff between efficacy and safety. Proc Natl Acad Sci USA. 2001;98(6):3618-3623.
19. Pollard RB, Rockstroh JK, Pantaleo G, et al. Safety and efficacy of
the peptide-based therapeutic vaccine for HIV-1, Vacc-4x: a phase 2 randomised, double-blind, placebo-controlled trial. Lancet Infec Dis. 2014;14:291-300.
20. Alistar SS, Grant PM & Bendavid E. Comparative effectiveness and cost effectiveness of antiretroviral therapy and pre-exposure prophylaxis for HIV prevention in South Africa. BMC Medicine. 2014;12(46).
21. Pre-Exposure Prophylaxis (PrEP). Centres for Disease Control and Prevention [Internet]. 2014. [updated 2014 Sept 30; cited 2014, Oct 12]. Available from: http://www.cdc.gov/hiv/prevention/research/prep/index. html.
22. Department of Heath and Human services USA and Centres for Dis- ease Control and Prevention. Pre-exposure prophylaxis for the prevention of HIV infection in the United States. [Internet] 2014. [cited 2014 Oct 12]. Available from: http://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf.
23. Salah S, Hajjar B & Essam R. A novel approach to inhibit HIV-1 infec- tion by actively neutralizing the antibodies of reverse transcriptase system. J AIDS Clin Res. 2014;5(310).
24. Rennie S, Siedner M, Tucker JD, Moodley K. The ethics of talking about ‘HIV cure’. BMC Med Ethics. 2015;16:18.
25. Haler-Stromberg, Lu CL, Klein F, Horwitz JA, Bournazos S, Nogueira L, Eisenreich TR, Liu C, Gazumyan A, Schaefer U, Furze RC, Seaman MS, Prinjha R, Tarakhovsky A, Ravetch JV, Nussenzweig MC. Broadly Neutralising Antibodies and Viral Inducers decrease rebound from HIV-1 latent reservoirs in humanised mice. Cell. 2014;158(5):989-999.
26. Yuki SA, Boritz E, Busch M et. al. Challenges in dectecting HIV persistence during potentially curative interventions: a study of the Berlin patient. PLoS Pathogens. 2013;9(5):e1003347
27. National Institute of Allergy and Infectious Diseases (NIAID). Genetic Modification of Cells Proves Generally Safe as HIV Treatment Strategy. [Internet] 2014. [updated 2014 Mar; cited 2014 Oct 5]. Available from: http://www.niaid.nih.gov/news/newsreleases/2014/Pages/CCR5mutation. aspx

Keeping the Promise: A Review of the Millennium Development Goals

Volume 10 Issue 1
Review
Peer reviewed article

Abstract

If there’s one quality the United Nations cannot possibly be accused of lacking, it’s ambition. The Millennium Development Goals stand as one such product of the UN’s idealism, eight limited and yet very well intentioned targets for global health progress by the year 2015. And now that 2015 has finally rolled around, how close have we actually come to meeting any of those goals?

The unfortunate reality is that while many nations have made remarkable health and social progress, a minority of countries will fail to meet any of the goals at all. Many of the most heavily affected constituencies lack the political will to strive for such changes, perhaps because it is the louder voices of developed nations that drives dialogue surrounding the MDGs.

However, regardless of the apparent naivety of such ambitious targets, the Millennium Development Goals have been necessary because they provide exactly what its name suggests: a goal that we have to continually keep striving for. It hasn’t been fifteen years without significant and measurable progress, and perhaps that is more important than whether or not the UN is aiming too high.

If there’s one quality the United Nations cannot possibly be accused of lacking, it’s ambition. The Millennium Development Goals stand as one such product of the UN’s idealism, eight limited and yet very well intentioned targets for global health progress by the year 2015. Adopted in September 2000, the MDGs have aimed to address many of the indisputably pressing health and environmental issues of the 21st century, and have been described by the University of Manchester’s Professor David Hulme as ‘the world’s biggest promise.’[1] The eight MDGs are as follows:

1. To eradicate extreme poverty and hunger 2. To achieve universal primary education
3. To promote gender equality and empower women

4. To reduce child mortality
5. To improve maternal health
6. To combat HIV/AIDS, malaria, and other diseases
7. To ensure environmental sustainability
8. To develop a global partnership for development

The nature of the goals being set wasn’t exactly unprecedented, but the international community’s financial commitment to attempting to meet them has been; in 2005, the G8 nations agreed to cancel US$40 to $55 billion in debt owed by some of the world’s poorest countries. [2] The UN’s secretary-general Ban Ki-Moon has hailed the MDGs as ‘the most successful global anti-poverty push in history’[3], though some would argue otherwise; some view the MDGs as a warm, fluffy and ultimately hollow gesture with good intentions, while other more radical critics feel the MDGs actively distract the international community from more effective measures and issues of greater importance, such as finding working alternatives to capitalism.[1] So now that 2015 has finally rolled around, maybe we can be- gin to put the debate to rest when we finally have some more concrete statistical evidence.

But therein lies one of the biggest problems with assessing the effectiveness of the MDGs. The reality is that it’s very difficult to track the exact extent of progress in many countries where data is limited, or entirely absent[4] – countries that are often the ones most desperate for change. And it hasn’t always been a straightforward fifteen years for governments and humanitarian organisations. Since the turn of the millennium, we have seen Timor-Leste become a sovereign state following years of occupation, a war-torn Sudan splintered into two separate nations, and the Arab’s world’s pursuit of democracy leave a steadily growing trail of death and destruction in its wake. Much of India and Southeast Asia was left to pick up the pieces following the catastrophic 2004 Boxing Day tsunami, while Haiti is still recovering from the devastation of the 2010 earthquake. Accord- ing to UN data, the number of newly displaced persons has tripled since 2010, with developing nations shouldering the greatest burden.[5] There have been setbacks, some manmade and others natural, and ones that truly highlight that we can’t possibly achieve the MDGs without peace and international cooperation. So in spite of these shortcomings, how close have we actually come to meeting any of these goals?

There has legitimately been some remarkable, if uneven, change over the last fifteen years. According to the UN’s 2014 MDG progress report[5], as well as the African Development Bank[6] and Center for Global Development[4], a number of their targets have indeed been met, while others still face significant challenges.

Goal 1: Eradicate extreme poverty and hunger

While ‘eradicate’ might not be the right word, UN data suggests that we have actually met the first component of goal 1: to halve the proportion of people living in ‘extreme poverty’, defined as those living on an income
of less than US$1.25 a day, between 1990 and 2015.[5] In 1990, 36% of the world lived under such conditions, in comparison to the 18% in 2010.[5] It’s an extraordinary statistic at first glance, though much of the apparent success is owed to China, a country that has witnessed a veritable social revolution over the last two and a half decades. Today, 12% of its 1.35 billion inhabitants live in extreme poverty, in contrast to the 60% of China in 1990.[5] Certainly, the numbers overlook those that aren’t necessarily living in extreme poverty, but regardless, it is significant change. However, the statistics don’t look nearly so good in other parts of the globe; the UN’s most recent estimate of the proportion of people living on less than $1.25 a day in Sub-Saharan Africa remains at 48%, just 8% down from the corresponding figure in 1990.[5], With Africa’s dramatic population growth, the number of people living in extreme poverty has actually increased, rising to 410 million in 2010 from 290 million in 1990 (excluding North Africa).[6] Even worse is knowledge that the proportion of people living in extreme poverty has worsened in eight African nations: Central African Republic, Nigeria, Madagascar, Zambia, Kenya, Guinea Bissau and Côte d’Ivoire.[6] It may be some improvement in terms of percentage, but it’s evidence that the international community’s current approach to tackling poverty in many parts of Africa isn’t working well enough.

Goal 2: Achieve universal primary education

The second MDG has aimed to address the less than complete rates of primary education throughout the world, particularly aiming to reduce the gap in education between that of males and females. The last fifteen years have marked some dramatic increases in enrolment rates throughout the developing world, with an average improvement of 7%.[5] Most significant is the improvement in Sub-Saharan Africa[6], increasing to 78% in 2012 from 60% in 2000[5], though there are still significant disparities between individual countries, with eleven countries having net enrolment rates of less than 75%.[6] Once again, however, the apparent improvement in the numbers somewhat obscures a less favourable reality; with booming birth rates worldwide, the 60 million children out of school in 2007 stood at a similar 58 million in 2012.[5] A disproportionate 50% of these children live in conflict-affected areas[5], feeding that vortex of poverty and violence much of the developing world knows too well.

Goal 3: Promote gender equality and empower women

It’s too easy to think of the MDGs as being only applicable to developing nations, but reducing in- equality between women and men stands as equally critical in the developed world. It’s another area where progress is being made, but the disparity is still apparent. Women still remain underemployed in comparison to men in non-agricultural sectors, modestly improving worldwide from a 35% share to a 40% share of paid positions.[5] The global time-related underemployment rate, a measure of those willing and able to work more hours, stands significantly higher amongst women in most regions of the world, including developed countries.[5] Wage disparity is also a significant problem in much of the world, and particularly Africa; of the 54 African countries, only in Egypt, Uganda, The Gambia, Ghana, Malawi, Zambia Burundi, Botswana and Benin do women earn at least 75% of what men in similar positions are paid.[6]

Women’s political involvement still remains poor worldwide, though some parts of the world have shown dramatic improvement. As of 2014, women hold 24% of political seats in national parliaments in North Africa, in stark contrast to 3% in 2000.[5] Five countries still remain with no female representation whatsoever: Palau, Qatar, Tonga, Vanuatu and Yemen.[5] Of all the seats in the developing world, 21% are now occupied by women, only 4% behind the alarming 25% of seats in developed nations.[5] It may be the 21st century, but the glass ceiling remains firmly in place for many women worldwide.

Goal 4: Reduce child mortality

The sad reality is that the MDGs’ target to reduce the under-five mortality rate from 1990 to 2015 by two-thirds has appeared to fall short. It hasn’t been without significant progress, however; the global under-five mortality rate dropped to 48 per 1,000 in 2012 from 90 per 1,000 in 1990.[5] This improvement has coincided with far higher rates of measles vaccination worldwide, although recent progress appears to be stagnating. Most regions, barring Sub-Saharan Africa and Oceania, reduced mortality rates by at least half, resulting in 17,000 fewer under-five children dying everyday.[5] Interestingly, improvements have been noted at all income levels and in both developed and developing nations.[5] It’s no small consolation, but there is still so much more to be done.

Goal 5: Improve maternal health

Going hand in hand with goal 4, goal 5’s aim to reduce maternal mortality rates by three-quarters has also failed to be met. In spite of this, as of 2012 we have seen a 45% reduction worldwide since 1990[5], with 68% of births in the developing world being assisted by a trained professional, in contrast to only 56% in 1990.[5] Sub-Saharan Africa remains the most heavily affected region
in the world, accounting for 62% of maternal deaths in 2013.[5] Sierra Leone is the most heavily burdened country in the world, with a stagger- ing 1,100 deaths per 100,000 live births – in plain terms, more than one in a hundred live births results in the death of the mother. This stands in contrast to Belarus, Israel and the Scandinavian nations, countries that have amongst the lowest rates worldwide at between 1 and 4 deaths per 100,000 live births.[7] Few of the goals so well illustrate the shocking disparity between developed and the most disadvantaged nations.

Goal 6: Combat HIV/ AIDS, malaria and other diseases

While HIV incidence has declined significantly since 2001, many parts of Africa remain crippled by devastating infection rates. As of 2012, a record 35.3 million people are living with HIV worldwide, with new infection rates continuing to exceed AIDS-related deaths. [5] Condom use amongst males and females engaging in higher-risk sex in Sub-Saharan Af- rica remains very poor, at an estimated 57%, in contrast to the 95% target set by the UN General Assembly in 2001.[8] However, access to antiretroviral therapy has been dramatically improv- ing annually, with an unprecedented 1.6 million additional patients receiving treatment in 2012. The UN estimates that, given current trends, the target 15 million patients receiving ART by 2015 could be a reality.[5]

Closely tied to HIV/AIDS prevalence, reducing rates of tuberculosis has been another significant MDG target. 1.1 million of the 8.8 million patients diagnosed in 2013 were also HIV-positive, and 75% of the 8.8 million from Africa.[6] Despite this, worldwide, the number of new cases of TB per 100,000 is dropping, with 87% of newly diagnosed patients in 2011 being treated successfully.[5] Whether or not these trends can be maintained in the face of the rising threat of multi- drug-resistant tuberculosis remains to be seen.

With increased use of anti-malarial interventions, the world has seen a 42% decline in malaria mortality rates between 2000 and 2012.[5] Over that period, an approximate 700 million insecticide-treated bed nets were distributed throughout Sub-Saharan Africa, once again the most heavily affected region in the world. How- ever, only an estimated 36% of the inhabitants of these countries have access to a bed net[5], highlighting the enormous gap that still needs to be bridged.

Goal 7: Ensure environmental sustainability

In terms of progress, Goal 7 arguably stands as the most disappointing of
the MDGs. It’s 2015, and millions of hectares of forest continue to be destroyed annually, while carbon emissions continue to rise dramatically as parts of the developing world begin to industrialise. Though developed regions have observed a slight reduction in carbon emissions, dropping from 14.9 billions of metric tons in 1990 to 13.3 billions of metric tons in 2011, emissions in the developing world have spiked, now contributing more emissions than the developed world with 18.9 billions of metric tons in 2011.[5] Perhaps it’s one of those things that have to get worse before it can get better, but it’s still a pressing concern being entirely overlooked by too many countries, Australia included.

Goal 7 also includes the specific target to halve the proportion of the population without consistent access to basic sanitation and clean drink- ing water, and there has been some remarkable global progress made in that field. In 1990, an estimated 24% of people worldwide did not have access to clean water, in comparison to 11% in 2012, achieving the target before schedule. [5] Despite this, 45 countries will still fail to meet those targets, twenty of which are from Africa[6], again emphasising the considerable disparity between different countries and regions of the world. Moreover, the sanitation target will fail to be met, 2.5 billion people worldwide still without access to adequate facilities, a very modest 7% improvement from the 2.7 billion in 1990.[6]

Goal 8: Develop a global partnership for development

The final MDG focuses on maintaining strong and functional ties between nations, and admittedly suffers from some of the MDGs’ most poorly defined targets; target 8A is a prime example of this, supposedly aiming to ‘[d]evelop further an open, rule-based, predict- able, non-discriminatory trading and financial system’.[5]

The Organisation for Economic Co-operation and Development (OECD) states that as of 2013, developed countries net ‘official development assistance’ sat at an all-time high of US$134.8 billion, or a combined 0.9% of the developed world’s gross national income.[9] Impressive figures, perhaps, but equally ones that remind us of the MDG’s dependence on foreign aid that can only reach so far. A more enduring change is the significantly decreased debt burden on developing countries; in 2000, 12% of exports from developing nations were external debt payments, in contrast to 3.1% in 2012.[5]

On another positive note, the UN notes that In- ternet access throughout the developing world is rapidly increasing, with two-thirds of the world’s Internet users living in developing regions. An es- timated 20% of Africa’s population are online, as of 2014, up from 10% in 2010.[5] Even still, more than four billion people worldwide are yet to use the Internet, a likely consequence of insufficient access and affordability for many individuals.

2015 and beyond

So the results are in – or at least as much of it as we’re going to get with incomplete data – and the findings are somewhat mixed. The unfortunate reality is that while many nations have made remarkable health and social progress, as we can see, at the opposite end are nations such

as the Democratic Republic of Congo and Côte d’Ivoire, countries that will fail to meet any targets at all.[4] The MDGs may be eight undoubtedly worthwhile targets, but they also fail to address the root causes of poverty and social inequality. Moreover, many of the most heavily affected constituencies lack the political will to strive for such changes, perhaps because it is the louder voices of developed nations that drives dialogue surrounding the MDGs.

Another question that stands is whether or not these positive trends will be able to continue in the face of fluctuating foreign aid, although 2013 marked a rebound from two years of diminishing volumes.[9] The Guardian’s Liz Ford has de- scribed the MDGs as essentially ‘targets for poor countries to achieve, with finance from wealthy states’[10], while the Center for Global Development called them ‘overly-ambitious goals’ with ‘unrealistic expectations’ on foreign aid.[11] It’s very easy to be a cynic, and maybe understand- ably so; even the UN have acknowledged the ‘gaps and disparities’ between their idealised vision of 2015 and the projected reality.[5] But it hasn’t been failure without measurable progress, and perhaps that is more important than whether or not the UN is aiming too high.

In September of this year, the United Nations will aim to finalise the specifics of the Sustainable Development Goals, the proposed successors to the MDGs. The SDGs will purportedly aim to ‘[b]uild upon commitments already made’ by the MDGs, but with an additional focus on implementing ‘action-oriented’ strategies that support long-term, sustainable development.[12] It’s a topic that cannot possibly be explored in an ad- equate level of detail here, and certainly warrants an essay of its own. Perhaps the SDGs will be able to address the shortcomings of the MDGs’ programs and 2030 will be the year we eliminate inequality for good – or at least we’ll be closer to making that dream a reality. Regardless of the apparent naivety of such ambitious targets, the Millennium Development Goals have been necessary because they provide exactly what its name suggests: a goal that we have to continually keep striving for. We’ve needed the MDGs to continually remind us of the promise we’ve made ourselves and the fact that we are determined to keep it.

Aaron Kovacs

 

References

1. Hulme D. The Millennium Development Goals (MDGs): A Short History of the World’s Biggest Promise [Internet]. Manchester: Brooks World Poverty Institute, University of Manchester; 2009. Available from: http:// www.bwpi.manchester.ac.uk/medialibrary/publications/working_papers/ bwpi-wp-10009.pdf

2. Mutume G. Industrial countries write off Africa’s debt. United Nations Africa Renewal [Internet]. 2005 Oct [cited 2015 Mar 4]. Available from: http://www.un.org/africarenewal/magazine/october-2005/industrial-coun- tries-write-africas-debt

3. United Nations. The Millennium Development Goals Report 2013. New York: United Nations; 2013. Available from: http://www.un.org/millennium- goals/pdf/report-2013/mdg-report-2013-english.pdf

4. Center for Global Development. MDG Progress Index: Gauging Coun- try-Level Achievements [Internet]. Washington, D.C.: Center for Global Development; 2011 [accessed 2015 Apr 4]. Available from: http://www. cgdev.org/page/mdg-progress-index-gauging-country-level-achievements

5. United Nations. The Millennium Development Goals Report 2014. New York: United Nations; 2014. Available from: http://www.un.org/millennium- goals/2014%20MDG%20report/MDG%202014%20English%20web.pdf

6. African Development Bank. MDG Report 2014: Assessing Progress in Africa toward the Millennium Development Goals. Addis Ababa: Economic Commission for Africa; 2014. Available from: http://www.afdb.org/filead- min/uploads/afdb/Documents/Publications/MDG_Report_2014_11_2014. pdf

7. World Health Organization, UNICEF, UNFPA, The World Bank & United Nations Population Division. Trends in Maternal Mortality: 1990 to 2013. Geneva: WHO Press; 2014. Available from: http://apps.who.int/iris/bitstre am/10665/112682/2/9789241507226_eng.pdf

8. United Nations General Assembly. Declaration of Commitment on HIV/ AIDS. New York: United Nations; 2001 Jun 27. Report no.:S-26/2. Avail- able from: http://www.un.org/en/development/devagenda/hiv.shtml

9. Organisation for Economic Co-operation and Development. Aid to developing countries rebounds in 2013 to reach an all-time high [Internet]. Paris: OECD; 2014 Apr 8 [accessed 2015 Apr 4]. Available from: http:// www.oecd.org/newsroom/aid-to-developing-countries-rebounds-in- 2013-to-reach-an-all-time-high.htm

10. Ford L. Sustainable development goals: all you need to know. The Guardian [Internet]. 2015 Jan 20 [cited 2015 Mar 25]; Global Devel- opment. Available from: http://www.theguardian.com/global-develop- ment/2015/jan/19/sustainable-development-goals-united-nations

11. Clemens M, Moss T. CDG Brief: What’s Wrong with the Millennium Development Goals? Washington, D.C.: Center for Global Development; 2005 Sep. Available from: http://www.cgdev.org/files/3940_file_WWMGD. pdf

12. United Nations. Sustainable development goals [Internet]. New York: United Nations; 2015 [accessed 2015 Mar 20]. Available from: https:// sustainabledevelopment.un.org/topics/sustainabledevelopmentgoals

War on the Female Body: Rape and Sexual Violence during Conflict

Volume 10 Issue 1
Review
Peer reviewed article

 

Abstract

Sexual violence has an enormous burden on individuals and communities worldwide. Women and girls are particularly vulnerable, with one in three women globally estimated to experience physical or sexual violence in their lifetime. Rape and sexual violence has severe physical and psychological consequences in any circumstance. This article focuses on rape as a weapon of war, the sociological impacts of which can be widespread and long-lasting. This is especially due
to the ensuing terror and disruption to livelihoods, relationships and morale. A recent example explored in this article was the rapes of over 200 women and girls in October 2014 by Sudanese military forces. Doctors and health workers can provide sensitive medical care to victims of sexual violence. However, medical care is only a fraction of the individual’s healing; the coordination of psychological and community support is integral to addressing their needs holistically, and can help potentially bridge barriers in accessing services.

Introduction

In October 2014, over 200 women and girls in the town Tabit, Sudan were raped by Sudanese government troops, according to Human Rights Watch report.[1] Witnesses described uniformed soldiers systematically looting, beating residents, and raping women and girls in their homes and on the streets.[1] The civilian attacks and mass rapes were denied by the Sudanese government, and the town intimidated and repressed against speaking out about the crimes, with some even restricted access to medical care following rape. [1]

Sexual violence is a major human rights and pub- lic health issue worldwide.[2] It causes serious physical and psychological suffering, and can have long-lasting and widespread impacts on individuals and communities.[2] Sexual violence is broadly defined as any sexual act, attempted sexual act, unwanted sexual comments or advances against a person’s sexuality by means of coercion such as physical force, intimidation, or blackmail.[2] Sexual violence encompasses a spectrum of manifestations including rape by intimate partner or non-partner, forced abortion and female infanticide, sexual abuse of children and people with intellectual disabilities, female genital mutilation, forced prostitution and sexual trafficking.[2,3] Another form of is that which occurs during armed conflict [2], such as the use of rape as a weapon of war. Rape in conflict settings is used as a militarised strategy to weaken and dehumanise enemies, attacking identity and social bonds. It is also employed as a means of terror and ethnic cleansing.[3]

Whilst sexual violence is perpetrated against both men and women, it particularly affects women and girls. One in three women globally will experience physical and/or sexual violence by an intimate partner or non-partner, according to the World Health Organisation (WHO).[4,5] Women and girls are especially vulnerable to violence and discrimination in societies and cultures which lim- it their social status and control. Violence against women is an expression as well as reflection of gender inequitable norms, and disparities in opportunities and empowerment. Thus, if violence against women is ever to be eliminated, it is imperative to address the root issue of gender inequality.

This article is a response to the mass rapes in Tabit, exemplifying the intertwinement of health and human rights issues associated with rape in conflict settings. For such a horrific act of bru- tality, it has been met with relative silence and response nationally and internationally. This reit- erates that sexual violence remains an under-rec- ognised issue, despite its devastating effects and widespread prevalence. In addition, this article examines medical and social implications for victims of sexual violence, barriers in accessing services and the role of doctors, health workers and communities in providing appropriate care and preventing the perpetuation of violence.

Sexual Violence During Conflict: Rape as a Weapon of War

Rape and sexual violence occurs during times of peace, however it escalates during armed conflict and humanitarian crises.[6] This causes extensive physical and psychosocial trauma not only to the individual victims, but to their families and communities. This amplification of dam- age throughout communities contributes to the rationale and effectiveness of militarised rape in inflicting widespread, long-lasting harm. The female body is thus more than mere spoils of war; when considered communal property, they serve as strategic targets through which to weaken morale and debilitate community bonds.

History shows us examples of women and girls targeted for sexual violence during conflict. During World War II, Japanese soldiers abducted and forced into sexual slavery an estimated 100 000 to 200 000 women from Korea, China and the Philippines.[3,7] For centuries, sexual violence was considered an inevitable side effect of war, rather than a preventable or punishable human rights violation. This changed following the recognition of rape as a war crime, following post-WWII Tokyo war trials.[3] However, rape and sexual violence occurred during armed conflict throughout the late 20th century, including in Bangladesh, Uganda, Sierra Leone and the Democratic Republic of Congo.[3,8] Rape was also used as a means of ethnic cleansing, with mass rapes of Tutsis by Hutus in Rwanda [9], and systematic rapes of women in the former Yugoslavia to terrorise civilians into fleeing.[3] Since the Rome Statute of the International Criminal Court in 1998, rape and other forms of sexual violence are considered crimes against humanity.[10] During conflict and humanitarian crises, sexual violence manifests in two major forms. The first is militarised sexual violence, distinguished as strategic, systematic and perpetrated partly or fully by government and/or state military forces. Examples include systematic rapes of civilians, such as those in the former Yugoslavia and Tabit, Sudan in 2014. The second form is opportunistic sexual violence, the abuse of women and girls at increased vulnerability due to conditions attributed to conflict and insecurity.[6] This includes sexual assault of women and girls collecting firewood, food or water. This is a particular issue in camps for internally displaced persons (IDP) and refugees in Sudan and neighbouring Chad during the ongoing conflict in Sudan.[8] Due to limited resources in heavily populated camps, families are forced to venture beyond the confines to forage for food and supplies, despite the risk of assault. Under such conditions, some families perceive that women and girls collecting firewood risk ‘only’ rape by Janjaweed militias, whereas men will almost certainly be killed.[8] It is also reported that women and girls at IDP or refugee camps may be forced to exchange sexual favours for food and necessities, including to peacekeepers and authorities supposedly responsible for their protection.[6]

Humanitarian Crisis in Sudan and Mass Rapes in Tabit

Conflict between government and rebel forces in Sudan has spanned over a decade since 2003. This has been driven by political and ethnic tensions, as well as long-standing struggles for scarce land and resources.[8,11] Villages have been destroyed, with inhabitants slaughtered and terrorised. Many attacks are racially targeted due to Fur, Masalit or Zaghawa ethnicity, pre- dominant groups composing rebel forces known as the Sudan Liberation Army (SLA) and the Justice and Equality Movement (JEM).[8] These form a resistance against a government they feel marginalises interests of non-Arab populations. Ongoing issues with insecurity, loss of livelihoods and mass displacement have resulted in over 300 000 deaths due to direct violence, disease and starvation, with around 2 million internally displaced persons and refugees fleeing to neighbouring Chad.[11,12]

Attacks against civilians in the village Tabit in the Darfur region of Sudan over three days commencing October 30th, 2014 are a brutal example of rape used as a weapon of war. According to over 130 witness interviews con- ducted and cross-referenced by Human Rights Watch, the attacks – including rapes, beatings and detainment – were perpetrated systematically by armed, uniformed Sudanese government soldiers. [1] Witnesses reported that soldiers entered houses, accused residents of links with rebels, detained or removed men and raped women and girls in their homes. During night at- tacks, men were reportedly forced out of house- holds and taken to distant locations, leaving women extremely vulnerable. Most victims were raped multiple times, often by multiple men, and in front of their families or friends. Even children were not spared from the violence, with victims and witnesses describing rapes of girls under 18.[1]

In addition to severe physical and psychological trauma inflicted on the village, intimidation from government authorities has contributed towards ongoing fear and repression. Residents have allegedly been deterred against speaking out about the crimes under threats including beatings and imprisonment. One interviewee likened the situation to “living in an open prison”, with military presence day and night and the prevention of female residents from exiting or visitors from entering.[1] The Government of Sudan and local authorities have publicly denied the crimes, as have some local traditional leaders, possibly under coercion. Members of the community have been instructed not to speak about the incident, especially not to Human Rights Watch or African Union United Nations peacekeepers.[1] This silencing and deprival of justice, with the crimes left unpunished, has been a further insult over- shadowing the attacks.

Another serious issue has been the deterrence and prevention of sexually assaulted women and girls from receiving medical care at clinics and hospitals. According to the report, some women have not sought help due to fear of arrest and further abuse as punishment for disclosing the rapes. There is also the belief that many doctors work for the government or that clinics are ob- served by intelligence staff. Others describe local authorities refusing to assist victims to access medical doctors, intimidating health professionals and punishing families attempting to bring rape victims for medical attention.[1]

Medical Implications of Rape

Survivors of rape and sexual violence often suffer various physical and gynaecological problems as well as psychological distress. Substantial evidence exists regarding adverse health consequences. These include gynaecological complications [13,14], sexually transmitted infections [15,16], unwanted pregnancies [14], unsafe abortions [16], post-traumatic stress disorder and depression (Table 1).[16] Victims may also experience fear and shame [3], and face ostracism from their partners, families or community. [2,9] Their suffering may also be exacerbated by limited access to health services, or social taboo surrounding sexuality and sexual violence. Fistula, chronic pelvic pain and infertility are gynaecological complications caused by rape. [13,16] Conflict-related sexual violence is significantly more likely than non-conflict sexual violence to cause fistula (traumatic or obstetric) or chronic pelvic pain, according to a study in the Democratic Republic of Congo.[14] Traumatic gynaecological fistula is an extremely debilitating injury involving abnormal communication be- tween the reproductive tract and internal organ, usually bladder or rectum.[17] Due to resulting urinary and/or faecal incontinence, women are often shunned and alienated by their communities. Particularly violent sexual assault such as gang rape or the use of foreign objects during rape leads to such fistulas.[17]

Unwanted pregnancy and unsafe abortions are also possible consequences of rape. In their inability to access medical care during conflict, desperation may drive women to endanger their lives with unsafe abortion [6], especially in countries where abortion is illegal. Abortion may also be an urgent matter in order to prevent the manifestation of rape as a visible, socially taboo pregnancy, particularly in cultures where female chastity is linked with family honour. In addition, pregnancy may serve as a distressing physical reminder of assault to the mother, and children born out of rape are at higher risk of neglect and malnutrition [6].

Another medical consequence of rape in conflict is sexually transmitted infections including human immunodeficiency virus (HIV). Risk of HIV transmission is increased in violent, forced rape due to the likelihood of tearing and breaching the vaginal or anal mucosa.[2] It has been speculated that mass rapes contribute to increased HIV epidemics in conflict-affected countries with high HIV prevalence. Limited evidence is available, how- ever one study investigating the impact on HIV incidence in African countries estimated increases of 5 infections per 100 000 females per year in four out of seven countries studied, including Sudan.[15]

Table 1: Medical complications of rape and sexual violence [3,13,17]

Sexual violence in any context causes severe physical, emotional and psychological suffering for victims. Depression, suicidal thoughts, post-traumatic stress disorder, anxiety, feelings of humiliation and fear, social withdrawal, inability to fulfil maternal roles and substance abuse are all adverse outcomes related to rape and sexual abuse.[9] Overall poorer physical and mental health, combined with stigma of sexual violence, contribute to the difficulty victims face in access- ing healthcare and support. Furthermore, these issues may be exacerbated in conflict settings, especially in situations where victims endure or witness more extreme forms of violence. Med- ical care and mental health services, difficult for victims of sexual violence to access even during times of peace, become more inaccessible during conflict due to strain on resources or destruction of infrastructure.

Doctors and other health workers are in a unique position to provide medical care to victims of sexual violence, as well as facilitate access to appropriate psychological and social support services (Table 2). In addition, documenting evidence such as sperm and DNA samples can assist legal proceedings, including identification of attackers where appropriate and with consent. [2,7] Victims should be approached with utmost care, dignity and sensitivity, with awareness that their injuries may be deeper and more extensive than tangible physical complications. Care should be taken to ensure consultation and physical examination causes as little distress as possible. Furthermore, underreporting of rape and sexual violence is common due to innate sensitivity and other personal or social factors, and victims of sexual violence may present with injuries, infections or pregnancy without initially disclosing they have been raped. Thus, medical professionals should be vigilant for signs of aggression or sexual assault, including genital bruising, lacerations or mutilation; missing patches of hair; and bruising on the arms, chest or forehead.[3]

Table 2: Medical response to sexual violence [2]

Whilst medical attention has valuable role in caring for victims of rape and sexual violence, it forms only a fraction of the individual’s process towards healing. The implications on mental health may be long-lasting, and social consequences such as blaming, fear and stigmatisation are a profound cause of suffering, as well as contributing to difficulty in breaking silence about sexual violence and seeking help. Integrated health, legal and community services are a potential means of increasing ease of access to support services. For example, rape crisis centres may provide various services including immediate and follow up medical care, counselling, forensic evidence, legal assistance, community support and education programs.[2]

Social Impacts of Rape During Conflict

The prominent social aftershocks of rape drives the use of militarised sexual violence, a weapon intended to shame and debilitate populations. The intimate link between female chastity, marriage and family honour is viciously exploited when rape is perpetrated on a mass scale.[6] It is used during conflict as a strategic act of terror, humiliation and dehumanisation, a means of destroying community bonds and morale. Local leaders, male community members and parents of children assaulted may feel extremely disempowered or unable to protect their families. Many victims are killed during the assault, others that survive may be blamed, stigmatised or rejected by their communities.[9]

Systematic rape is also employed as a brutal means of ethnic cleansing.[12] Women’s bodies, perceived as communal property, are targeted for impregnation in order to extinguish or pollute blood lines and cultures. This has been exemplified by racially targeted sexual violence during conflict in Darfur, Sudan. Friction between Arab and non-Arab ethnic groups contributes to targeting of civilian populations of Fur, Masalit and Zaghawa ethnicities. Surveys from a retrospective study revealed increased use of racial epithets during combined attacks by Sudanese government soldiers and Arabic Janjaweed militia against ethnic African women (p<0.001). Racial terror and sexual violence is compounded in statements such as, “We will kill all men and rape the women. We want to change the colour…Ar- abs are the husbands of those women”.[12] Moreover, ethnically targeted attacks in Sudan are not merely isolated incidents. Systematic raids of non-Arabic villages by Janjaweed militants, at times in combination with Sudanese government troops, appear to have occurred on a mass scale.[8] A consistent pattern indicative of the systematic nature of these attacks has been described by survivors: raiding forces surround villages, their arrival often signified by sexual assaults of women and girls gathering firewood or water. Men and boys are killed, women and girls raped by attackers entering house to house or gathering groups at a central location. Finally, fleeing survivors, mostly female, are pursued and assaulted as they seek safety in the surround- ing mountains, towns or entering IDP or refugee camps.[8]

The aftermath of fear and terror from rape during conflict can have dire and long-lasting consequences. Women and girls in fear of sexual abuse may be reluctant to leave home and participate in normal routine, crippling the ability of households and communities to function and thrive. Education may be affected when children are afraid to walk to or attend school. House- hold malnutrition and poverty may be intensified when women are afraid to collect firewood, food or water in fear of assault. Economic status and employment is similarly compromised when men are afraid to work or unwilling to leave wives and daughters alone at home.[16] Such sociological impacts are amplified on a mass scale when sexual violence is enacted against large populations. This principle of widespread incapacitation contributes to the continued use of rape as a militarised weapon of war.

Ethnic tension and discrimination is also a major barrier in the provision of and access to medical care in Sudan. Under the former Criminal Procedure Act, in order for patients to legally receive treatment, they were required to obtain a medical evidence form from police, known to withhold forms from individuals of certain non-Arabic tribes.[18] Health workers have also been pressured and intimidated as a deterrent against car- ing for these ethnic populations. An example is the harassment, detainment and interrogation of health workers at the Amel Centre for Treatment and Rehabilitation of Victims of Torture in Darfur. The centre is a non-government organisation providing free legal and clinical services to those affected by human rights violations, including numerous victims of violence (beatings, gunshot wounds) and rape, mainly from tribes of non-Arabic ethnicity. As many as 1 in 2 women who attended from 2004-6 disclosed sexual assault (49.3%), most commonly gang rape (86.1%), and this was potentially an underestimation of the true scope of sexual violence as the majority of patient records at the time were male (252/325 = 77.5%).[18]

Broadly speaking, community involvement is vital in fostering an environment where victims can safely access services and support they need and taking action to prevent perpetuation of sexual violence. Having the support of their community can have a profound influence on healing and protection against further stigmatisation and discrimination. Communities have the capacity to implement measures to prevent the perpetuation of sexual violence, for example through education in schools, support for women’s groups, inclusion of women in decision-making and public awareness campaigns to reduce stigma and acceptability of sexual violence (billboards, radio and television, theatre, public meetings).[2] Integration of sexual violence education with other health and social issues such as reproductive health, HIV, and general violence issues may also help to ease into discussion of sexual violence in settings, especially in situations where it is a sensitive issue.[2] Community activism contributes towards reducing stigma and changing public acceptability of sexual violence.

Conclusion

Sexual violence causes an enormous burden on individuals and communities worldwide, however it remains highly stigmatised and under-recognised. Victims of rape and sexual violence may endure a magnitude of physical and psychosocial consequences. This burden may be deepened by barriers accessing health services and community support, as well as victim blaming, stigmatisation and ostracism. Rape and sexual violence in conflict zones can be particularly debilitating due to weakened social infrastructure, widespread violence and presence of arms, mass displacement and loss of livelihoods, and increased baseline levels of violence against women throughout the population.

The mass rapes of women and girls in Tabit, Sudan are a gross violation of human rights and an unspeakable act of cruelty. It is unspeakable on multiple levels, from the silencing of victims and traumatised communities, to the silence of the international community about the atrocities and others committed throughout the decade of conflict in Sudan. Women and girls continue to be targets of sexual violence, especially due to disparities in opportunities and social status. If we ever hope to reduce the occurrence of sexual violence, it is absolutely crucial that we empower communities and take local and international action to address root causes of gender inequality. As current and future doctors, it is important to maintain awareness that sexual violence is intrinsically linked with personal factors and sociocultural issues. Medical attention is only a part of the individual’s healing process, with psychological and social factors equally as important. Coordination of appropriate health and community support can help address the individual’s needs holistically as well as bridge potential barriers in accessing services. Victims commonly encounter difficulties in accessing care for various reasons, and even those able to access care may not initially disclose sexual violence, and may need careful prompting once a safe environment and trust has been established. Thus a level of vigilance for signs of sexual violence should be maintained to help identify women at risk. Sexual violence may be silenced at first, however by seeking to understand, listening for warning signs and taking appropriate measures, doctors can help to heal and give victims a voice.

Carrie Lee

References

1. Loeb J. Mass Rape in Darfur. United States: Human Rights Watch, 2015 February 2015. Report No.

2. Grug EG, Dahlburg LL, Mercy JA, Zwi AB, Lozano R. World Report on Violence and Health. Geneva: World Health Organisation (WHO), 2002. 3. Swiss S, Giller JE. Rape as a crime of war: A medical perspective. JAMA. 1993;270(5):612-5.

4. World Health Organisation/London School of Hygiene & Tropical Medicine/South African Medical Research Council. Global and regional estimates of violence against women: Prevalence and health effects of intimate partner violence and non-partner sexual violence. 2013.

5.World Health Organisation/London School of Hygiene and Tropical medicine. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva: 2010.

6. Marsh M, Purdin S, Navani S. Addressing sexual violence in humanitarian emergencies. Global Public Health. 2006;1(2):133-46. 7. Watts C, Zimmerman C. Violence against women: global scope and magnitude. The Lancet. 2002;359(9313):1232-7.

8. Gingerich T, Leaning J. The use of rape as a weapon of war in the conflict in Darfur, Sudan: Program on Humanitarian Crises and Human Rights, Franc̦ois-Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health; 2004.

9. Stark L, Wessells M. Sexual violence as a weapon of war. JAMA. 2012;308(7):677-8.
10. Kivlahan C, Ewigman N. Rape as a weapon of war in modern conflicts. BMJ. 2010;340:c3270.

11. Olsson O, Siba E. Ethnic cleansing or resource struggle in Darfur? An empirical analysis. Journal of Development Economics. 2013;103(0):299- 312.

12. Hagan J, Rymond-Richmond W, Palloni A. Racial targeting of sexual violence in Darfur. Am J Public Health. 2009;99(8):1386-92.

13. Frljak A, Cengic S, Hauser M, Schei B. Gynecological complaints and war traumas. Acta Obstetricia et Gynecologica Scandinavica. 1997;76(4):350-4.

14. Dossa NI, Zunzunegui MV, Hatem M, Fraser W. Fistula and other adverse reproductive health outcomes among women victims of conflict-related sexual violence: a population-based cross-sectional study. Birth. 2014;41(1):5-13.

15. Supervie V, Halima Y, Blower S. Assessing the impact of mass rape on the incidence of HIV in conflict-affected countries. AIDS. 2010;24(18):2841-7.

16. Clifford C, Slavery SM, editors. Rape as a Weapon of War and it’s Long-term Effects on Victims and Society. 7th Global Conference Violence and the Contexts of Hostility Budapest(5-7 May 2008); 2008.

17. Salim F. Holdstock-Piachaud Prize essay. War and the systematic devastation of women: the call for increased attention to traumatic gynaeco- logical fistulae. Medicine, Conflict & Survival. 2012;28(2):125-32.

18. Tsai AC, Eisa MA, Crosby SS, Sirkin S, Heisler M, Leaning J, et al. Medical evidence of human rights violations against non-Arabic-speaking civilians in Darfur: a cross-sectional study. PLoS Med. 2012;9(4):e1001198.

Multidisciplinary Health Practice for Indigenous Communities

Volume 10 Issue 1
Review
Peer reviewed article

 

Abstract

The complex interaction of behavioural risk factors, historical events, and social determinants of health, compounded by barriers to accesses for health services, have been recognized as the causes of gaps in Indigenous health. The relatively poor health status of Indigenous communities demands integration of conventional medicine with local perspectives and cultural values. This article puts forth perspectives of students from different health related disciplines for resolving problems of access to healthcare for Indigenous Australians. It is hoped that the accounts in this article will serve as a starting point for dialogue on the institution of multidisciplinary healthcare teams.

 

Introduction

Indigenous health represents one example of community-based practice which demands for a marriage between conventional medicine and an appreciation of local perspectives and cultural values. Medical professionals should appreciate that the increasing levels of complexity means that help from experts from different industries could be fruitful. Hence, one solution is to create a multidisciplinary team comprised of people with medical and other expertise to tailor specific and sustainable solutions towards certain health issues. Multidisciplinary teams have been known to increase the levels of innovation as well as improving implementation in the scopes of knowledge, skills, and abilities. [1] The Royal Australian College of General Practitioners (RACGP) recognises that multi- disciplinary care is highly crucial to improve the primary healthcare services for Australians as it helps General Practitioners (GPs) to provide “continuous, close, and respectful therapeutic relationships with patients.” [2, p. 454] How- ever, according to the World Health Organization, the definition of multidisciplinary practice extends beyond the patients themselves. They explained the concept as the provision of the highest quality of care by working together with the patients, families, caregivers, and the surrounding communities. [3] The institution of multidisciplinary teams in healthcare practices has raised numerous questions regarding its efficacy, which is measured by patient satis- faction as well as the hospital admission and re-admission rates for those hospitalized at home. [4,5] The following will present Indigenous health access as a sample case study of how multidisciplinary teams can be utilized to generate some recommendations for the local communities.

The Aboriginal and Torres Strait Islander population, which makes up 3% of the total Australian population, [6] has been faced with numerous inequalities over the years, especially in the healthcare sector. Recent surveys show that the median age of Indigenous Australians is 21 years, which is 16 years less than the median age of non-Indigenous Australians. [7] Their life expectancy is also lower by 10 years as compared with non-Indigenous population. Furthermore, the low socioeconomic status of many Indigenous individuals increases their likelihood of engaging in practices that can elevate their risks of major health complications. The Australian Institute of Health and Welfare (AIHW) stated that Indigenous Australians are twice as likely to be daily smokers and 50% more likely than non-Indigenous population to drink alcohol at chronic high risk levels, which are two risk factors that predispose to cardio- vascular diseases, chronic kidney disease, and type 2 diabetes. [7] Despite the widespread passion for “Closing the Gap” advocated by the Australian government, the discrepancies in the health outcomes between Indigenous and non-Indigenous communities remain, which means that more work is needed in the area. [8]

Various studies illustrate the under representation of Indigenous people across the three tiers of Australian Healthcare System, [9-10] which encompasses preventative medicine, primary accesses represented by GP consultations, and accesses to hospital-based and further treatments. As an example, on the preventative side, the immunisation coverage of Indigenous children in 2009 aged 5 years (78.2%) was lower than that of their non-Indigenous counterparts (82.7%). [7,11] In terms of hospital access, 26% of Indigenous Australians aged 15 years and over are faced with difficulties in accessing these services due to their rural and remote residence. [7] Multiple factors, such as financial, linguistic, and cultural barriers also give rise to challenges in accessing primary health services as simple as GP consultations. [12-13]

These problems can be considered to be stemming from the differences between Indigenous communities and non-Indigenous health practitioners, especially in terms of cultural values and opinions of a good healthcare system. As an example, health workers and policy makers tend to focus on improving physical environment and the healthcare system, put- ting aside the issues of trust and respect, which are paramount for Indigenous patients. [14] It is hard not to consider how the historical and intergenerational trauma of the Half-Caste Act, and other historical Government policies, has contributed to Indigenous people’s dis- trust in health and welfare services. [15] Racial discrimination in policies, institutional structures and social networks has led many Indigenous people to live in closed, isolated communities. [16-17] Even after the National Apology of 2008 and affirmative actions to promote Indigenous health, many Indigenous Australians are being ‘caught between two worlds’ as they live with ambivalent identities. [18-19]

The complex interaction of behavioural risk factors, historical events, and social determinants of health, compounded by barriers to accesses for health services have been recognized as the cause of gaps in Indigenous health. [7] Together these issues raise the integral question of how can different perspectives from different disciplines be integrated to improve Indigenous health access? This article presents the various problems related to Indigenous people’s ac- cess to primary health care services. It builds on perspectives of students from different disciplines and considers an institution of multidisciplinary healthcare teams as an effective option for collaborative approach to problem solving. It is hoped that the following accounts from students of medicine, molecular biology, social work and business will enrich readers’ thinking about the various approaches to understanding and dealing with problems experienced by Indigenous people.

Problems of Healthcare Access – A Medical Perspective
For most Australians, primary and community health services represent the frontline of the health care system and are provided by GPs and allied health professionals. General practice services serve as a direct measure of access to primary care. [9] According to the Bettering the Evaluation and Care of Health (BEACH) survey over five-year period from 2001 to 2006, only 1.5% of total GP consultations were with Indigenous patients, even though they account for 2.5% of the total population as of 30 June 2006. In addition, a comparison study con- ducted in the Townsville Aboriginal Community Controlled Health Services (ACCHS) sector has showed GP cases in Indigenous population are more complicated and challenging compared to mainstream general practice. On average, 1.65 problems were managed per consultation in ACCHS, whereas 1.45 problems needed to be managed in mainstream GP. [20]

It is proposed that language and cultural differences have been the main barriers limiting Indigenous people’s access to GP services. [12-13] In 2008, 11% of the Indigenous Australians who spoke a non-English language at home had reported difficulty communicating with English speakers. This rate was markedly increased among older Indigenous people (aged 55 and over), which makes up 24% of the Indigenous population. [7]

Additionally, cultural barriers remain a prominent issue in relation to access to healthcare. Indigenous and non-Indigenous Australians hold different perspectives of health and wellbeing. [13] A research study found that non-Indigenous health workers believed that improving the physical environments and the healthcare system would be the most effective ways of breaking the cultural barrier. However, Indigenous Australians consider sincere and open interpersonal relationships that are based on trust and respect to be crucial in medical practice [14] This study concluded non-Indigenous doctors and Indigenous Australians hold very different opinions about health care and many doctors were misguided when it came to how to provide culturally appropriate health care for Indigenous patients. Fortunately, we now have more Indigenous people joining the health care profession [21] and they are a critical source in demonstrating to non-Indigenous health staff culturally appropriate practices.

One possible solution to address this issue of cultural differences is early in doctors’ during medical training. Medical schools should integrate this issue into their curriculums and implement Indigenous rotations to give medicals students more exposure to Indigenous health care. In fact, in 2004 the Committee of Deans of Australian Medical Schools (CDAMS) developed an Indigenous Health Curriculum Framework with the purpose to provide medical schools with guidelines for how to successfully implement and deliver indigenous health content in medical education. Specific strategies include recruiting more Indigenous people as medical educators; inviting Indigenous guest speakers; integrating Indigenous elements into case-supported learning (CSL) or problem-based learning (PBL) and community visits. [22]

In addition, continued education post-medical schools are equally essential. There are now a considerable amount of workshops and conferences pertinent to Indigenous health available to health professionals, given by organisations such as National Aboriginal Community Con- trolled Health Organisation (NACCHO). [23] Practising doctors should be encouraged and motivated to regularly attend these conferences that serve as a reminder on how to provide the best care for Indigenous population, as well as keeping them well-informed on the latest trends in Indigenous health care.

Over the past decades, through the employment of more Indigenous health workers and culturally competent non-Indigenous staff, health promotion campaigns specifically tailored for Indigenous Australians, and increased utilisation of interpreter services, [12] we are finally “closing the gap” in terms of GP service usage. In 2009-10, the number of GP services reimbursed by Medicare was similar between Indigenous and non-Indigenous populations (approximately 5,630 and 5,550 per 1000 population, respectively). [9] Nonetheless, this is only the tip of the iceberg. Indigenous Australians are still doing poorly in other sectors of the healthcare spectrum such as preventive and hospitalised care. The road ahead is still full of obstacles.

From empirical data to solutions: A molecular biology perspective

Even though Australia is a pioneer in molecular diagnostics and drug development technologies, there has been a grave paucity of such studies or ventures tailored to Indigenous Australians. This deficiency is particularly exacerbated in the case of genetic studies, [25] mainly due to Indigenous communities finding a lack of benefit and fearing risk of further persecution based on their genetic background, particularly in insurances. One such case was seen in New Zealand with the ‘warrior gene’ fiasco of 2006, which led to an unintended racial discrimination against the Maori community by media incorrectly labeling them as aggressive and prone to risk-taking. [26] Such debacles can how- ever be evaded by implementation of culturally sensitive ethical frameworks and protocols as recommended by Kowal et al., [25] which can help adapt medical researches to benefit Indigenous Australians.
In addition, research focus and investments should be targeted towards the factors that can impact Indigenous health access and outcomes. For example, recent research has suggested that Indigenous people with mixed ancestry see increased incidence of rheumatoid arthritis as compared to persons with strictly non-Aboriginal ancestry. [27] In addition, a recent and record first genomic study of Indigenous people also reported a genetic risk for high body-mass index and type 2 diabetes in Indigenous communities. [28] The knowledge of such risk factors and trends in public health can be used to design specific treatment, as exemplified by Anderson et al., [28] by discovery of specific genes found in affected individuals whose genomes they sequence. Each of these studies when combined together can be used to form short-term and long-term treatment goals by clinicians and associated organizations.

Problems of Healthcare Access – A Social Work Perspective
In terms of primary health services, it has been shown that racial discrimination plays a crucial role in hindering Indigenous people from med- ical consultations as 22% of them reported racism from health providers. [17,29] Hence, there is a need for healthcare providers to establish trust with Indigenous communities at different levels in the Australian healthcare system, which can be done by respecting their social values. As an example, medical and allied health professionals must appreciate Indigenous peoples’ strong association to land, [30-33] extended family/kinship networks and affiliation to local languages that collectively form important aspects of their identities. [32- 33]

Social work practice rests upon the multi- dimensional approach that appreciates the interactive nature between an individual and various aspects of their environments, such as psychological, spiritual, social, and cultural. [34] In addition, social work practice also encapsulates commitment to values of respect and social justice, which mandates the recognition of historic and racial disadvantages that can adversely affect behaviours, social determinants, access to health care services and health status of Indigenous populations. [35] For medical practices, social workers can facilitate groups engaging in critical reflection to encourage realisation of personal and culturally constructed biases, [36-38] which is deemed to prompt empathetic practice and modification of service protocols to address Indigenous needs.

The multiple identities of different generations of Indigenous people calls for working in partnership with them so that they can be included in defining their problems as well as identifying and instituting solutions. [20,34-35] Roles and responsibilities in teams are defined by legal and ethical boundaries, but they are highly influenced by social norms and situational realities. [37] Social workers can contribute by encouraging mutual aid in teams and driving efforts towards affirmative action for Indigenous communities.

Strategic Use of Indigenous Health Funding: A Financial Perspective
In 2008-2009, healthcare expenditure for the Indigenous population was 1.39 times higher than that for non-Indigenous people. However, high prevalence of certain health problems and geographical challenges raise questions as to whether more spending is required along with the need for a more strategic use of Indigenous health funding to improve health services and accesses for Indigenous Australians. [41] Professor Geoffrey Dobb, the Vice President of Australian Medical Association (AMA), high- lighted that it is now the responsibility of all the governments and health service providers to strategically target funding to ensure that Indigenous people get the access to the right health service in the right place at the right time. [42]

Decisions made by both the funders and the providers should be based on returns from investments, including individual and community health gain, equity, as well as the incorporation of cultural security, which is defined as “the delivery of health services of such a quality that no one person is afforded a less favour- able outcome simply because they hold a different cultural outlook”. [43, p.45] Moreover, to improve the priority setting process by the funders and the providers, there is a need to make use of better evidence and data, especially economic evaluations. It has been suggested that more education on the credibility of economic evaluation by training staff in health economics would improve the use of economic evaluation evidence. [38]

Contracts in the context of Indigenous health provision is defined as the arrangements which specifies the services or other activities the government funders are obtaining on the behalf of the community, including the amount of funding, reporting and other accountability required. The currently applied funding and accountability arrangements have been particularly criticised for being excessively fragmented and complex, especially in terms of administrative and reporting requirements. [44] The contracts should accommodate uncertainties, such as the possibility of sudden changes in service demand, while maintaining care quality and continuity. As opposed to the old-fashioned classical contracting, relational contracting recognises the contractor-supplier interdependence, and is characterised by greater flexibility and cooperation, as well as reliance on trust and mutual accountability. This approach can potentially reduce administrative costs and improve healthcare performance. [44] So far, the reformation progress from classical contracting to relational contracting has been slow, and it is also still too early to assess on outcomes. But on a positive note, the provision of community governance and delivery on the basis of negotiation and agreed standards represents an important milestone towards an authentic partnership approach between communities and governments. Moreover, it also opens the possibility of a better integration of healthcare provision by both the community-controlled sector and the mainstream health system in a more practical sense, rather than simply in the form of high policy principles. [45]

Conclusion

Access to primary healthcare for Indigenous Australians presents a complex problem and to yield sustainable and effective solutions, each of the factors contributing to the problems have to be considered by seeking advice from experts in different industries. The four accounts from different postgraduate students in medicine, molecular biology, social work and business, addressed a portion of the problem surrounding Indigenous healthcare access. However, it high- lights the varying perspectives and approaches that exist which are outside the scope of practice for medical practitioners. For example, it is important to acknowledge the roles of social worker in taking care of the patients’ wellbeing post-treatment and ensuring that they have the access to various supporting facilities crucial to their treatment. The roles of financiers and accountants are also important in providing financial access as well as creating cost-effective solutions that can be easily adjusted for different circumstances. Lastly, molecular biology represents an important part of science towards the health industry for specific targeted treatments that can be provided to patients quickly by knowing their underlying genetic predispositions, hence saving costs and time.

Access to primary healthcare for Indigenous Australians presents just one of the many health challenges that calls for experts from different industries to collaborate and formulate sustain- able solutions. This collaboration has the potential to create avenues for greater learning, re- flections, and knowledge transfer, and ultimately lead to better health outcomes for patients. We hope that the above accounts from students of different disciplines could be a starting point to appreciate the importance in integrating a multidisciplinary team in tackling ongoing local and global health problems.

Ayesha Aziz, Hadrian Pranjoto, Mingkun Guan, Nicolas Adrianto Soputro & Rahul Vivek Rane

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28. Anderson D, Cordell H, Fakiola M, Francis R, Syn G, Scaman E et al. First Genome-Wide Association Study in an Australian Aboriginal Population Provides Insights into Genetic Risk Factors for Body Mass Index and Type 2 Diabetes. PLoS ONE. 2015;10(3):e0119333.
29. Paradies Y, Cunningham J. Experiences of racism among urban Indigenous Australians: findings from the DRUID study. Ethnic and Racial Studies. 2009;32(3):548-573.
30. Gray M, Coates J, Yellow Bird M. Indigenous social work around the world. Aldershot, Hants, England:Ashgate; 2008.
31. Graham M. Some Thoughts about the Philosophical Underpinnings of Aboriginal Worldviews. Australian Humanities Review. 2008;(45):181- 194.
32. Bourke E. The first Australians: Kinship, family and identity. Family Matters. 1993;(35):4-6.
33. Grieves, V. 2009, Aboriginal Spirituality: Aboriginal Philosophy, The Basis of Aboriginal Social and Emotional Wellbeing, Discussion Paper No. 9, Cooperative Research Centre for Aboriginal Health, Darwin.
34. Harms L. Understanding human development. South Melbourne, Victoria: Oxford University Press; 2005.
35. AASW Code of Ethics. Brisbane: Australian Association of Social Workers. 2010
36. Bernard D. The use of groups in social work practice. London ; Boston: Routledge and Kegan Paul; 1975.
37. Leonard B. Groups for growth and change. New York: Longman; 1991.
38. Furlong M, Wight J. Promoting “Critical Awareness” and Critiquing “Cultural Competence”: Towards Disrupting Received Professional Knowledges. Australian Social Work. 2011;64(1):38-54.
39. Paradies Y. Defining, conceptualizing and characterizing racism in health research. Critical Public Health. 2006;16(2):143-157.
40. Nakata M, Nakata V, Keech S, Bolt R. Decolonial goals and pedagogies for Indigenous studies. Decolonization: Indigeneity, Education and Society. 2012;1(1):120-140.
41. Korff J. How Aboriginal people use healthservices [Internet]. Creative Spirits. 2015 [cited 13 June2015]. Available from: http://www.creatives- pirits.info/aboriginalculture/health/how-aboriginal-people-use-health-services
42. Indigenous Health Funding Must be Better Targeted. Targeted News Service 2011 Jun 24.
43. Otim M, Kelaher M, Anderson I, Doran C. Priority setting in Indigenous health: assessing priority setting process and criteria that should guide the health system to improve Indigenous Australian health. International Journal for Equity in Health. 2014;13(1):45.
44. Dwyer J, Lavoie J, O’Donnell K, Marlina U, Sullivan P. Contracting for Indigenous Health Care: Towards Mutual Accountability. Australian Journal of Public Administration. 2011;70(1):34-46.
45. Dwyer J, Boulton A, Lavoie J, Tenbensel T, Cumming J. Indigenous Peoples’ Health Care: New approaches to contracting and accountabili- ty at the public administration frontier. Publi Management Review. 2013;16(8):1091-1112.

Non-Communicable Diseases in Kenya

Volume 10 Issue 1
Review
Peer reviewed article

 

Abstract

Non-Communicable Diseases (NCDs) stand as one of the world’s most challenging health, social and economic issues. [1] The speed at which NCDs have risen has created a mammoth global problem, and it is predicted that by 2030 they will overtake infectious diseases as the leading contributor to dis- ability adjusted life years in LMICs. [2] Astonishingly, almost three quarters (28 million) of NCD deaths globally now occur in low- and middle-income countries each year [2]. Fighting NCDs is intrinsic to im- proving the lives of all people, however, it is also an incredibly complex issue that is entrenched within a country’s social, economic and physical environments. Kenya is one such low-income country that is experiencing rapid NCD growth. Throughout this piece, I draw upon some personal experiences I had during a 4 week elective in Kenya to highlight the complex issues at play and identify some barriers against improvements being made.

Non-Communicable Diseases (NCDs) stand as one of the world’s most challenging health, social and economic issues. [1] The speed at which NCDs have risen has created a mammoth global problem, and it is predicted that by 2030 they will overtake infectious diseases as the leading contributor to disability adjusted life years in LMICs. [2] During a 4 week elective in Kenya
in December 2014, I was prompted to reflect
on my own perception of NCDs in the global context. This short exposure, although neither extensive nor comprehensive, inspired me to learn more about the issue of NCDs in low to middle income countries (LMIC) and has helped me understand the many factors complicating the global fight against NCDs. Throughout this piece, I will draw upon some experiences I had in Kenya to highlight the complex issues at play and identify some barriers against improvements being made.

What are NCDs?

NCDs can be defined as chronic diseases that are not transmissible. They constitute a large group of diseases that are of long duration,
and generally slow to progress, with the 4 main types of noncommunicable diseases being cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes. [3] Common risk factors for developing these chronic diseases such as poor diet, a sedentary lifestyle, exposure to tobacco and harmful use of alcohol are near ubiquitous, contributing to the rapid rise of NCDs globally and impacting on many other areas of human and economic development. While the traditional understanding of NCDs portrays it as a problem of the old and wealthy, the new reality is that the burden of diseases from NCDs lies disproportionately in LMICs. [4] Contrary to popular opinion, available data demonstrate that nearly 80% of NCD deaths occur in LMICs. [2] Since the landmark 2011 UN Summit, [5] there has been a greater appreciation of the emerging burden of NCDs in LMICS. However, despite repeat calls for action, the NCD burden is increasing unchecked.

Social Determinants of Health

The social, economic and physical environments in developing countries afford their populations much lower levels of protection from the risks and consequences of NCDs than in high income countries (HIC). [6] In many countries, harmful drinking and unhealthy diet and lifestyles occur both in higher and lower income groups. However, high-income groups can access services and products that protect them from the greatest risks while lower-income groups can often not afford such products and services. [6] A recent report identified four broad reasons chronic disease are on the rise in the African region. These were rapid unplanned urbanization, little understanding of the risks that come with a chronic condition like heart disease, lack of access to healthcare and cost of treatment. [7]

In Kenya, health expenditure remains less than 5% of gross domestic product (GDP) [8], with curative rather than preventative health continuing to receive the highest share of the total health sector budget. [8] As a comparison, Australia spent 9.67% of GDP on health in 2012 – 2013. [9] Importantly, Kenya’s figure sits significantly less than the 15% goal set out in the Abuja Declaration of 1989. [10] A 10 year review of the Abuja Declaration, which was signed by heads of state of African Union countries to improve the health sector, revealed that there has not been appreciable progress in terms of the commitments that African Union governments, including Kenya, make to health, or in terms of the proportion of gross national income the rich countries devote to official Development Assistance. [11] This disproportionate economic commitment to tackling health, and subsequently NCDs, is disparaging and highlights the lack of action in this key area.

The transformation of the food sector is another example of how the economic environment has perpetuated the rise of NCDs. Studies have shown how food environments and access to convenience foods in developed countries have contributed to higher rates of obesity, diabetes and cardiovascular disease. [12] What is concerning is that the harmful habits that stubbornly resist public health measures in HICs are shared between all countries, shaped in part by national and global food production and a variety of marketing forces that drive global epidemics of NCDs. The sale and promotion of tobacco, alcohol, and ultra-processed food and drink (unhealthy commodities), transnational corporations [13] are all driving factors. In Kenya, the fight against these diseases is further complicated by cultural factors, including the perception of overweight and obesity as signs of prosperity. [7] Whilst the transformation of the food sector and concurrent growth of supermarkets has shown to provide some financial benefits to rural farmers, [14] ready access to cheaper, higher calorie but not necessarily healthy food options presents a growing challenge.

The effect of this food environment transformation can be seen in the modern paradox that many developing countries suffer from undernourishment on the one hand, and obesity and diet-related diseases on the other. The lack of investment in nutrition [15] has also created a burgeoning challenge that complicates an already difficult issue. A UN taskforce mission in 2014 revealed that, alarmingly, 18% of Kenyan pre-school children are now obese, with around 30% of Kenyan adults overweight and around 9% obese, [6] while malnutrition statistics from 2009 showed 35% of children under five years were still stunted (defined as being less than -2 standard deviations from the height-for-age of the WHO Child Growth Standards median), 16% were underweight, and 7% were wasted. [16] In the African region, the rate of stunting remained at 39% in 2013.

NCDs in Kenya

In Kenya, NCDs account for 27% of deaths suffered by those aged between 30 and 70 years, with the potential to reduce productivity, curtail economic growth and trap the poorest people in chronic poverty. Prevalence and mortality data is either unavailable or have a high degree of uncertainty due to lack of national NCD information. [17, 18] However, 50% of all hospital admissions and 55% of hospital deaths in Kenya are estimated to be due to NCDs. [19] As with many developing countries, medical care is not readily accessible to the majority of the  citizens, with primary health care implementation since the Alma-Ata Declaration in 1978 lagging behind despite government level commitments. [20] On top of the pervasive economic factors at play, the impacts of this are broad, as inability to access affordable and safe primary care services leaves little opportunity for health promotion and preventative medicine which are cornerstones in the fight against NCDs.

Many aspects of the underfunded and under- resourced healthcare system that struggles to deal with NCDs became apparent during
my stay. The multitude of barriers stacked up against the provision of basic healthcare, not just NCDs were apparent. Immersed in the hospital’s organised chaos, I watched on with admiration as the staff worked tirelessly without complaint and access to basic equipment (including CT machines and reliable supply of blood for transfusions). Day to day, as doctors worked within the constraints of a system stretched to its limits, it seemed that NCDs had fallen
on the wayside of their priorities. However, the devastating effects of NCDs though could not be denied and were a frequent encounter during my 4-weeks there.

The case of cervical cancer, a noncommunicable disease with an infectious origin, is just one example of health disparity resulting from inequitable access to life saving technology, such as vaccines. In sub-Saharan Africa, cervical cancer remains the leading cause of cancer death among women. [21] Encounters with patients suffering from cervical cancer were unfortunately not rare during my elective. In a system where receiving palliative care involves  paying steeply out of your own pocket, and travelling 300 km to the national hospital, management of cancer was a helplessness- inducing experience for all. A sobering fact is that 80% of the women affected by cervical cancer live in developing countries. [22] This reality, and the numbers of women dying all over the world due to this potentially vaccine preventable disease is simply unacceptable.

Since it’s introduction in Australia through the HPV school vaccination program in 2007 there has been a 77% reduction in the HPV types responsible for cervical cancer. [23] Although we will not expect to see reduction in cervical cancer for a few more years, since cervical cancer usually develops over 10 years or more, health experts are confident of a decline and all current evidence is supportive of this. [23] Despite its effectiveness, cost remains one of the greatest barriers against introducing
this vaccine, among others, in developing countries including Kenya. [24] Other barriers include the underlying weakness of the health system in developing countries, lack of political commitment, weak information system, severe shortage of adequately trained health workers, lack of information about vaccines and the fear of vaccines. [24] It is clear that the issues at play at complex, but the injustice of not taking action against this is clear: with every 5-year delay in bringing vaccination to developing countries, 1.5 million to 2 million more women will die. [22]

In the face of a highly complex issue incorporating multiple diseases, there is a definite need for stronger health investment and public health programs to address awareness of the broad range of disease represented by NCDs. Resources, dedicated government bodies and funding are all necessary to improve knowledge of their risk factors, enable the implementation of programs to support prevention and initiate early management. These are all essential elements in the mitigation of NCDs.

Action Against NCDs

There are signs that awareness of NCDs is translating into action. The great levels of illness and death associated with NCDs has lead the Kenyan government to prioritise NCD prevention and control in its National Medium Term Plan 2014-2018;[25] the United Nations Development Assisted Framework 2014-2018 for Kenya; [26] and the Kenya third generation WHO Country Cooperation Strategy (2014-2019). [27] The need for a ground-up approach has also been recognised. A few groups involving Kenyan young professionals (including medical students) have been developed to help change the mindset of the population through free health screening initiatives and school based educational programs. [28] Their experience in Kenya highlights how such a network can empower the youth to have a substantive impact on the prevention and mitigation of NCDs in their local context.

It is clear that that fighting NCDs is intrinsic to improving the lives of all people, but it is also clear that the issue of NCDs in LMICs is incredibly complex. While some countries are making progress, the majority are off course to meet the global NCD targets. [21] The role of policy change, taxation, mass media and 25. African Development Bank Group. Country Strategic Paper regulation of foods in targeting NCDs and their risk factors are all pivotal when NCDs are seen as part of an industrial epidemic. [13] As such, only by addressing the issues through a multi-sectorial response against NCDs and their risk factors can we make any real progress towards reducing or attenuating the occurrence of NCDs.

Joyce Shi

 

References

1. United Nations. High-level Meeting on Non-communicable Diseases. 2011; Available from: http://www.un.org/en/ga/president/65/ issues/ncdiseases.shtml.
2. World Health Organization. Global status report on noncommunicable diseases. 2010, World Health Organization.

3. World Health Organization. Noncommunicable diseases factsheet. 2015.
4. Hosseinpoor, A.R., et al., Socioeconomic inequality in the prevalence of noncommunicable diseases in low- and middle-income countries: results from the World Health Survey. BMC Public Health, 2012. 12: p. 474.

5. United Nations, Resolution 66/2. Policatal Declaration of
the High-level Meeting of the General Assembly on the Prevnetion and Control of Non-communicable Diseases. In: Sixty-sixth session of the United Nations General Assembly. . 2011, United Nations: New York.
6. United Nations. Kenya’s fight against noncommunicable diseases aims to improve health, strengthen development. 6 October 2014 8 June 2015]; Available from: http://www.who.int/nmh/ncd-task- force/unf-kenya/en/.
7. Dealing with the spread of chronic disease in Africa. Available from: http://novartis.com.bd/newsroom/feature-stories/2014/09/non- communicable-diseases-in-africa.shtml.
8. Group, W.B., Decision Time: Spend More or Spend Smart? Kenya Public Expenditure Review. 2014, World Bank Group.
9. AIHW, Health expenditure Australis 2012-13. , in Health an welfare expenditure series no. 52. 2014: Canberra.
10. Alwan, A.D., G. Galea, and D. Stuckler, Development at risk: addressing noncommunicable diseases at the United Nations high-level meeting. Bull World Health Organ, 2011. 89(8): p. 546-546a.

12. Babey, S.H., et al., Designed for Disease: The Link Between Local Food Environments and Obesity and Diabetes. 2008.

13. Moodie, R., et al., Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. Lancet, 2013. 381(9867): p. 670-9.
14. Chege, C.G.K., C.I.M. Andersson, and M. Qaim, Impacts
of Supermarkets on Farm Household Nutrition in Kenya. World Development, 2015. 72(0): p. 394-407.
15. UNICEF, Nutrition strategies and programmes in Kenya. 2011, UNICEF.
16. Macro, K.N.B.o.S.a.I., Kenya Demographic and Health Survey 2008-2009. KNBS and ICF Macro: Calverton, Maryland.

17. World Health Organization. NCD Country Profiles. 2011.

18. World Health Organization. NCD Country Profiles. 2014.
19. World Health Organization. Non Communicable Diseases:
An overview of Africa’s New Silent Killers. [cited 2015 26 April 2015]; Available from: http://www.afro.who.int/en/clusters-a-programmes/dpc/ non-communicable-diseases-managementndm/npc-features/1236-non- communicable-diseases-an-overview-of-africas-new-silent-killers.html. 20. World Health Organization. Report on the review of primary health care in the African Region. WHO regional office for Africa. 2008, World Health Organization.

22. Agosti, J.M. and S.J. Goldie, Introducing HPV vaccine in developing countries–key challenges and issues. N Engl J Med, 2007.

23. Vaccine, H. “Has the Program Been Successful?” Success of 2014-2018.National HPV Vaccination Program. [cited 2015 1 April]; Available from: http://www.hpvvaccine.org.au/the-hpv-vaccine/has-the-program-been- successful.aspx.
24. World Health Organization, U., World Bank, State of the world’s vaccines and immunization. 2009, World Health Organization: Geneva.
26. United Nations Development Group. United Nations Development Assistance Framework for Kenya 2014-2018. 2013.
27. World Health Organization. WHO Country Cooperation Strategy 2014 – 2019. 2013.

28. Matheka, D.M., et al., Young professionals for health development: the Kenyan experience in combating non-communicable diseases. Glob Health Action, 2013. 6: p. 22461.

A Global Approach to Combating Antibiotic Resistance

Volume 10 Issue 1
Review
A Peer Reviewed Article

 

Abstract

Globally, the medical profession is increasingly facing the problem of antimicrobial resistance. As antibiotic therapy continues to be a mainstay of curing infections, both developed and developing nations are dealing with the hard reality that its effectiveness is decreasing. A comprehensive global approach is thought to be the most effective way of slowing the progression of antimicrobial resistance. Broadly, there is a need to have stricter controls on the use of antibiotics not only in clinical practice, but also in the wider community, and in animal husbandry. This review focuses on the importance of developing a multifaceted solution that considers healthcare delivery, public health measures, pharmaceutical research, agriculture and global advocacy. The incorporation of antibiotic stewardship programs into hospital guidelines, the introduction of regulations dealing with non-prescription access to antibiotics and monitoring or banning the use of antibiotics in animal husbandry are necessary strategies to assist in combating antimicrobial resistance. Further, this article explores existing national and international campaigns that aim to raise awareness of antimicrobial resistance, and discusses current approaches in encouraging research and the development of new antibiotics.

Introduction

The discovery of antibiotics in the 20th century heralded dramatic changes in clinical practice. Among others, antibiotics were able to contain and treat infections in a more effective manner, and provided prophylactic cover when need- ed, allowing for complex procedures to be conducted in a safer environment.[1] Yet, as a consequence of such extensive antibiotic use, resistance to these very drugs is a public health problem that the medical profession is increas- ingly facing.[2] The threat of moving towards an era where the effectiveness of these drugs on which modern medicine is premised, could be permanently compromised, is a concerning one. [3] Resistance that develops in one part of the world, often rapidly spreads to others, causing difficulty in infection prevention and control.[1]

Judicious use of antibiotics is imperative in halt- ing the current trend of increasing antimicrobial resistance, and the solution should be multi-faceted, in recognition of the contributions of various stakeholders. Drivers of antimicrobial resistance include improper use of antibiotics in clinical practice, non-prescription access to antibiotics globally and the use of antibiotics in agriculture. [1] The introduction of antibiotic stewardship pro- grams into clinical practice has been associated with significantly reduced rates of antimicrobial resistance in some instances, and should be implemented globally where possible. Addition- ally, while non-prescription access to antibiotics is often endemic in developing nations, solutions which take into account the unique social, cultural and political context of these countries are likely to lead to the desired outcome of reducing the driver for resistance. Regulations for antibiotic use in other sectors are important, as are measures to encourage the pharmaceutical industry to invest in antibiotic research and development.

The Phenomenon of Antibiotic Resistance

Globally, the widespread use of antibiotics by doctors and health professionals has become a true characteristic of modern medicine. The implications of a “post-antibiotic era” due to the development of antimicrobial resistance would truly be far-reaching. Research currently suggests that there may be upwards of 20,000 potential anti- microbial resistance genes in the world.[3] The overuse of antibiotics is the major driver of selection pressure that contributes to the development of resistance.[4]

The rates of antimicrobial resistance development around the world are concerning, particularly for the treatment of common bacterial infections, such as respiratory, gastrointestinal and urinary tract infections. From an Australian perspective, the main antibiotic resistant organ- isms found are vancomycin-resistant enterococci, methicillin-resistant Staphyloccocus aureus (MRSA), multi-resistant Escherichia coli (E. coli), multi-resistant Streptococcus pneumoniae and multi-resistant Neisseria gonorrhoeae.[5,6] For in- stance, the incidence of MRSA in comparison to all reported S. aureas infections within the Australian community has doubled from 10 to 20% between 2001 and 2010.[7]

Globally, antimicrobial resistance is even more concerning. A study in Bolivia found that 76% and 44% of commensal E. coli from healthy chil- dren was resistant to nalidixic acid and ciproflox- acin respectively.[1,8] A study on Shigella isolates conducted in the Andaman and Nicobar Islands in India found that the number of drug resistance patterns, including resistance to newer genera- tion antibiotics, had more than tripled between 2000 and 2011.[4] Furthermore, fluoroquinolo- nes, a synthetic antibiotic, which heralded prom- ising results in relation to overcoming resistance has shown reduced efficacy in less than 30 years after its introduction.[8]

According to the World Health Organisation, there is quantitative evidence available regarding the harm caused to patients as a result of drug resistance in the treatment of tuberculosis – a common infection in developing countries.(8) Among the number of TB cases notified world- wide in 2010, it was estimated that there were 290 000 new cases of multi-drug resistant tu- berculosis (MDR-TB).[9] A study conducted in Mozambique using data from the National Tu- berculosis Referral Laboratory detected 58.3% resistant strains to at least one anti-tuberculosis drug and 43.7% MDR-TB strains isolated in culture during 2011.[10,11] Furthermore, exten- sively drug-resistant tuberculosis (XDR-TB) has emerged, which is resistant to second-line drugs and its prevalence is estimated to be approxi- mately 10% worldwide.[12]

These are but a few of the many examples of the implications of antimicrobial resistance. These show the immense speed at which antimicrobial resistance can develop, and they highlight the need for a concerted global effort to respond to it.

Addressing Antibiotic Use in Clinical Practice

The clinical environment, be it hospital or clinic, plays an important role in the management of antimicrobial resistance. These environments
are responsible for the appropriate provision and prescription of antibiotics, as well as for proper infection control. The first priority in managing any infection in a clinical environment is to control the transmission and spread of infection. This is essential since hospitals may sometimes con- tribute to the spread of nosocomial infections, through cross-infection between patients, and also through the horizontal transfer of antimi- crobial resistance. [13,14] The cornerstone of managing infectious patients in an environment such as this is curing the patient, while includ- ing the implementation of appropriate infection control measures, such as appropriate isolation and hand-disinfection practices.[13] Once these measures have been implemented satisfactorily, the focus turns to antimicrobial treatments. Of- ten, there are guidelines for the appropriate use of the antibiotics, with variable levels of evidence for the recommendations.[15] However, there is evidence that guidelines may be inappropriately adopted, as evidenced by the poor application of them with regards to urinary tract infections.[16] In Australia, the Online Therapeutic Guidelines for antibiotics guides clinicians. [15]

Inappropriate prescribing can lead to increased antimicrobial resistance, more wastage of health resources, and a greater risk of adverse effects for patients.[17] Misuse of antibiotics is partic- ularly common with respiratory presentations, where they are often wrongly prescribed for viral illnesses.[18]

As a result, it has become essential to establish hospital or clinic-based antimicrobial policies, which may be known as antimicrobial steward- ship programs. Various hospital antibiotic policies have been implemented globally since the threat of antimicrobial resistance emerged; however it was McDougall and Polk who formally defined the aim of antimicrobial stewardship programs in 2005.[19] The aim of the program is to regulate and monitor the prescription of antimicrobials in order to reduce further development of antimicrobial resistance, provide optimal patient care and decrease health costs.[19] These policies are premised on the education of healthcare professionals; to empower them to prescribe antibiotics appropriately, and to support them in their practice. Occasionally these policies may be extend- ed to restrict the availability of certain antibiotics. [13]

Antimicrobial stewardship programs have been recommended by various international and national healthcare organisations. In 2007, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) developed comprehensive recommendations regarding optimal antimicrobial use in acute care hospitals, in the form of antimicrobial stewardship programs.[20] In 2014, the Centres for Disease Control and Prevention (CDC) recommended all acute hospitals to implement an antibiotic stewardship program.[21]

From an Australian perspective, the first National Antimicrobial Resistance Strategy was published in June 2015, and aims to guide governments, healthcare institutions and agricultural sectors, among others, in reducing the development of antimicrobial resistance.[22] Additionally, every Australian hospital and day procedure service is now mandated to implement infection prevention and antimicrobial stewardship programs follow- ing the implementation of the National Safety and Quality Health Service Standards in 2013. In doing so, Australia is a global pioneer in mandat- ing requirements for better infection prevention and control.[22,23] Antimicrobial stewardship programs are important initiatives that are highly recommended by experts in the field.[1,5]

Education programs about antimicrobial stewardship can be used to great effect. This is evidenced by a significant reduction in antibiotic prescribing by GPs and non-medical prescribers in Derbyshire, England following a four-year initiative including educational seminars, antibiotic audits and ongoing GP support. The outcome was a lower than national average level of prescribing cephalosporins and quinolones. These programs are easy to organise and should continue to be encouraged.[17] Empowering prescribers to make informed choices about antibiotic use is ultimately the aim of these initiatives.

The effectiveness of policies such as the anti- microbial stewardship program depends on the co-operation of the entire healthcare institution, including multi-disciplinary support. Hospitals and primary care establishments both seek to gain from integrating these policies to be a core aspect of current accreditation programs.[1] Research has shown that codifying stewardship programs can successfully lead to a decrease in antibiotic use, while simultaneously reducing the burden of morbidity and mortality of infections. Evaluating the impact of existing antimicrobial stewardship programs is difficult, with no unifying metric to assess their effectiveness.[24] Further- more, primarily observational studies have been conducted to assess the effectiveness of antimicrobial stewardship programs, which are Level III evidence according to Australian Government National Health and Medical Research Council NHMRC evidence hierarchy.[25]

Studies have shown a statistically significant immediate reduction in the use of broad-spectrum antibiotics following the implementation of formal antibiotic policies and programs, such as antimicrobial stewardship programs.[26] For instance, a prospective 7-year study showed a statistically significant decrease of 22% in par- enteral broad-spectrum antibiotic use within a single teaching hospital.[27] Furthermore, a 2005 Cochrane systematic review showed that hospital-based interventions aimed at improving antibiotic prescribing through stewardship pro- grams successfully reduced both antimicrobial resistance and the development of nosocomial infections. Within this review, 77% of studies included showed a significant improvement in at least one clinical outcome (such as in-hospital or 28 day mortality), and multiple studies showed over 10% reduction in resistance development between intervention and control groups.[28] A retrospective cohort study conducted in a teaching hospital in North East Scotland found that implementation of antibiotic stewardship with fluoroquinolone and cephalosporin use resulted in a statistically significant decrease of prevalence of MRSA bacteraemia.[14] A well-rounded steward- ship program may be associated with decreased use of broad spectrum antibiotics, a reduced risk of infection transmission within the hospital and a decreased level of antimicrobial resistance. Healthcare workers in hospitals and clinics are therefore encouraged to be aware of antimicrobial stewardship programs and help promote its aims.

Monitoring Antibiotic Use in the Community

Globally, access to antibiotics is not always governed by prescriptions from medical facilities. Pharmacies, friends and family can also be sources of drugs for those seeking self-medication. Non-prescription access to antibiotics is present worldwide, but most commonly in nations outside of Europe, North America and Australia.[29] Developing nations in Asia and Afri- ca have been shown to have some of the highest rates of non-prescription access in the world.

For instance, the rates of antibiotic self-adminis- tration have been found to be as high as 74% in Sudan [30], 60% in China [31], and as low as 3% [32] in Northern European nations.

The strongest driver behind the prevalence of non-prescription access to antibiotics is the scar- city of medical resources in developing nations. As a result, minimally trained or unskilled person- nel often act as healthcare workers, and take on the role of antimicrobial prescribing.[33] There are numerous problems associated with this status quo. Often, those dispensing the medications have little medical knowledge to guide them, which may lead them to select inappropriate antibiotics in light of local resistance patterns.[34] Rates of adverse effects due to antibiotics are also more common, and are associated with the lack of medical screening for allergies in less than 17% of cases, as well as with a lack of knowledge of potential side effects. [29,35] In addition, many studies have shown consistently that these antibiotics are more likely to be administered as single dose therapies, as opposed to the full course. Potentially due to financial concerns, these drug regimens are popular in developing nations, but are associated with greater resistance potential.[32]

Regulation and legislation are pivotal in combat- ing this issue. Limiting access of non-prescrip- tion antibiotics within the community is likely to reduce the rate at which antimicrobial resistance develops. Yet developing nations pose unique challenges. Often, the regulatory capacity of the nation might be limited, and legislation unen- forceable. Indeed, non-medical prescribers may well be the only access point to life-saving drugs that members of society with poor access to for- mal healthcare have. As a result, an outright ban on non-prescription sales is likely to cause more harm in the short-term.[2] Hence, measures must be taken to ensure that drug restriction does not come at the expense of the health of patients.[1] Advocacy and political leadership to ensure the incorporation of an antibiotic stewardship pro- gram into existing health infrastructure could be an effective start to safer antibiotic use.

In addition to addressing non-prescription antibiotic use, the key issues of infection control and prevention must also be addressed. For example, improving primary health care and basic health infrastructure may reduce the prevalence and spread of infections, thereby reducing the need for antibiotic use. Furthermore, vaccination programs remain as a key prevention strategy to avoid unnecessary antibiotic use in the future. In the United States for instance, the use of the pneumococcal conjugate vaccine against the drug-resistant Streptococcus pneumoniae has significantly reduced rates of infection, and as a consequence, the use of antibiotics as well.[36] Yet, with high numbers of unvaccinated children in developing nations, there is a greater range of bacterial infections that require antibiotic use. [2] Finally, developing nations may lack social infrastructure, such as access to clean water and sanitation, which contributes to the spread of infections.[2]

Addressing antimicrobial resistance at the community level needs to consider the social, economic and political structure unique to countries so that the best solution be identified and implemented.

Antibiotic Use in Animal Husbandry

The development of antimicrobial resistance does not only occur in humans. The animal industry is also an important stakeholder in this global phenomenon. Widespread use of antibiotics in animal husbandry poses the risk of transmission of resistant bacteria from animals to humans. In many countries around the world, antibiotics are authorised for use in animals, and are available over the counter. Transmission from animals to humans may occur through exposure to animal products, or less commonly through environmental routes such as exposure to manure and biological solids.[1] In the past two decades, increasing legislation has been introduced in specific countries to restrict the use of antibiotics in animal husbandry to address this problem.

For instance, the use of antibiotics in animal rearing was phased out in the European Union in 1999[37] and was associated with a reduction in antimicrobial resistance among faecal enterococci in animal populations, which proved that it was potentially possible to reverse the effects of antimicrobial resistance. In fact, rates of multi-drug resistant Enterococcus faecium in US poultry declined from 84% to 17%, after organic feed was implemented.[38] Furthermore, international organisations such as the World Health Organisation, the United Nations Food and Agriculture Organisation and the World Organisation for Animal Health are currently working together to create guidelines regarding the appropriate use of antibiotics in animal rearing.[37] The creation of a “No-Feed Antibiotics” label on consumer products could provide an incentive for the agricultural sector to reduce their use of antibiotics, particularly if this certification is produced in association with governmental departments of agriculture.[39]

Antibiotics – The Way Forward in Antibiotic Development

In the 20th century, antibiotic discovery was at an all-time high. More than 20 classes of antibiotics were discovered in a span of just over 30 years[40], in what can be characterised as “the golden age of antibiotic discovery”.[1] Since then however, antibiotic development has stalled dramatically. Indeed, there was a 32-year gap (1968 – 2000) between the discoveries of two novel antibiotic classes.[41] During this time, the focus for pharmaceutical companies moved from discovering new classes of antibiotics to instead developing analogues, a decision associated with the reduced side effect profile of analogue drugs. Additionally, a new antibiotic has a relatively low profit potential, as compared to a drug of a different therapeutic class.[41] This too, likely contributed to the decrease in interest in the pharmaceutical industry to fund and invest in antimicrobial research, especially as the regulations for approval for new classes of antimicrobials have become stricter.[40] As a result of this decline in research and development into new antimicrobials, there has been a significant loss of knowledge and infrastructure in the industry with regards to antibiotic development and this is predicted to take time and effort to re-build.[40]

There is a need for antibiotic development to be- gin anew. Suggestions currently being proposed and discussed at international conferences include revising the regulatory requirements for approval of medications, offering pharmaceutical-friendly patent protection and even providing direct financial investment.[42] The European Medicines Agency has relaxed its current guide- lines for clinical antibiotic trials and the US Food and Drug Administration (FDA) is considering altering their regulations with regards to generic antibiotics.[1,39]

Other potential approaches include considering value-based pricing of new antibiotics, which could incentivise pharmaceutical companies to invest in drug development. This particular ap- proach promises developers a cut of the savings to healthcare costs that would be achieved if the current burden of morbidity and mortality of resis- tant infections is reduced by new drug discovery. [39]

Increasing Awareness Globally

Awareness about antimicrobial resistance is certainly building worldwide, with national campaigns such as the European Antibiotic Aware- ness Day, US Get Smart About Antibiotics Week, Canadian Antibiotic Awareness Week, and the Australian Antibiotic Awareness Week being established as annual traditions.[43] Aiming to target both consumers and healthcare professionals, initiatives such as these impart knowledge on the necessity of using antibiotics prudently and judiciously, as well as on the need for co-operation to halt the trend of increasing resistance.

Conclusion

If left unchecked, the current trend of antimicrobial resistance suggests that a post-antibiotic era is not far off; a world where infections currently treated with antibiotics may carry a high level of morbidity and mortality. As discussed in this article, it is imperative that a multifaceted solution be raised where possible. These include incorporation of antibiotic stewardship programs into hospital guidelines, introduction of regulations to deal with non-prescription access to antibiotics, monitoring or banning the use of antibiotics in animal husbandry, global advocacy, and incentivisation of the pharmaceutical industry to engage in new antibiotic research.

Ultimately, if access to life-saving antibiotics is not to be compromised by the development of resistance, global co-operation is essential to this end. As the WHO World Health Day 2011 pro- claimed, when it comes to antimicrobial resistance, “no action today, no cure tomorrow” – the time to act is now.

Swetha Prabhakaran

 

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