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

Review article

Salwa Sayeed & Damindri Fernando



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

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

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

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

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


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

Poverty and mental illness

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

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

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

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

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

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

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


Limitations and further areas of research

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

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

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

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

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



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




Conflicts of interest

None declared



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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


State of emergency: a call to action on environmental issues

Feature article

Ike Schwartz

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

A cause that affects us all

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

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

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

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

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

Ineffective Leadership

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

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

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

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

Community level organisation, and hope for a healthier future

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

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

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

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

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

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

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



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

Photo credits

Image 1: public domain, accessed from

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

Conflicts of interest

None declared



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

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

Available from:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


The Gaza Healthcare System

Feature Article

Qazi Sarem Shabab



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

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

Overview of the health system in Gaza

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

Power crisis and drug shortage

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

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

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

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

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

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

A financial crisis causing a clinical crisis

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

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

Insufficient access to treatment and the dilemma of referrals

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

Water supply and food shortage

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

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

Mental health in Gaza

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

The role of the international community and health professionals

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

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



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




Photo credit

Image 1: public domain, accessed from

Conflicts of interest

None declared



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

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

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

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

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

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

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

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



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

Feature Article

Marisse Sonido


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

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

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

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

Healthy ageing

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

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

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

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

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

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

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


Barriers to care

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

Geographic accessibility

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

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


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

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

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

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


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


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

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

Final thoughts

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



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

Photo credit

Sonido family

Conflicts of interest

None declared



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

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

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

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

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

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

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

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

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

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

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

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

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



Cancer Drugs: The Controversial Cost


Tessa Tan



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

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


A question of value

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

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

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

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

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

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


Access in low-middle income countries (LMIC)

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

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

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

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



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





Photo credit

Image 1: public domain, accessed from

Conflicts of interest

None declared



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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

Current Situation

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

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

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

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

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

Medical Crisis

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

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

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

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

Role of Health Professionals in Social Justice

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

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

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

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


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

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

Jumaana Abdu

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

Photo credit

EU/ECHO/Pierre Prakash

Accessed from

Conflicts of interest

None declared



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

2. United Nations (2017). UN scales up response as 270,000 flee Myanmar into Bangladesh in two weeks. Retrieved from

3. United Nations (2017). UN report details ëdevastating crueltyí against Rohingya population in Myanmarís Rakhine province. Retrieved from

4. OHCHR Zeid Raíad Al Hussein (2017). Interviews with Rohingyas fleeing from Myanmar since 9 October 2016. Retrieved from

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

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

7. Médecins Sans Frontières (2017). Myanmar: International humanitarian access to Rakhine State must urgently be permitted. Retrieved from

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

LGBTIQ peoples’ experiences of and barriers to healthcare



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

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

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

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

As such, this article will outline:

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

2) Key health issues affecting LGBTQIA+ individuals; and

3) Recommendations for improving access.

Social determinants of healthcare access for LGBTQIA+ individuals

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

Individual and interpersonal

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

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

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

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

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


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

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

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

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

Key LGBTQIA+ health issues 

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

Mental health

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

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

Sexual health

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

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

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


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

Improving access

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

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


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

Salwa Barmaky and Alexander Lee

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

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


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

Photo credit

©2008 laverrue, accessed from

Ryan melaugh, accessed from

Conflicts of interest

None declared



1. Australian Bureau of Statistics. General Social Survey: Summary Results, Australia, 2014 2014 [cited 2017 September 9]. Available from:

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

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

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

5. World Health Organisation. International Statistical Classification of Diseases and Related Health Problems 10th Revision 1992 [updated 2016. 10:[Available from:

6. Australian and New Zealand Professional Association for Transgender Health. Standards of Care  [Available from:

7. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender and gender nonconforming people 2011 [Available from:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

29. Ryan E. Access to justice for young transgender Australians: Laywers Weekly 2017 [Available from:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Surrogate /sʌrəɡət/

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

The status quo

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

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

Objections to commercial surrogacy

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

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

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

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

Undesirable consequences

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

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

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

Harm minimisation

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

A suggested solution

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

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

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

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

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

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

Challenges of decriminalisation of commercial surrogacy

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

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


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

Emily Feng-Gu and Keyur Doolabh

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

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


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

Photo credit

Conflicts of interest:

None declared



1.Company H. The American Heritage Dictionary entry: surrogate [Internet]. 2017. Available from:

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

3. Baby Gammy case reveals murky side of commercial surrogacy [Internet]. The Conversation. 2014 [cited 1 October 2017]. Available from:

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

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

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

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

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

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

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

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

12. Fact sheet – International surrogacy arrangements [Internet]. [cited 1 October 2017]. Available from:

13. Birth, adoption and surrogacy [Internet]. [cited 1 October 2017]. Available from:

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

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

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

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

18. Circle Surrogacy. Anticipated Costs for Gestational Surrogacy [Available from:

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

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



Polio vs Politics: The Case of Pakistan


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

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

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

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

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

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

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

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

Key Messages

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

Jeanine Hourani

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

Photo credit

Sanofi Pasteur / Almeena Ahmed / Sanaullah Afridi, accessed from

Conflicts of interest

None declared



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

2. WHO. Does polio still exist? Is it curable? 2017 [Available from:

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

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

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

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

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

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

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

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

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

12. SBS. Opinion: Aid workers are not a target, and never should be 2017 [Available from:

13. The Guardian. Syria ëthe most dangerous place on earth for healthcare providersí 2017 [Available from:

Turning up the Heat


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

The birth of an idea

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

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

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

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

Turning back time

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

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

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

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

Fuelling a movement 

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

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

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

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

Blossoming ideas

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

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

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

Pop goes the bubble

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

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

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

Renewable energy: a brave new world of investment

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

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

The power of smaller players  

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

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

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

Key messages

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

Tara Kannan

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

Conflicts of interest

None declared



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

2. Do the Math [Internet]. 2017 [cited 15 September 2017]. Available from:

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

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

5. Carroll R. Major University Divests $18 Billion Endowment From Coal Companies [Internet]. HuffPost. 2017 [cited 15 September 2017]. Available from:

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

7. Go Fossil Free. Divestment Commitment [Internet]. Go Fossil Free. 2017 [cited 15 September 2017]. Available from:

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

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

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

11. Phillips T. China builds worldís biggest solar farm in journey to become green superpower #GlobalWarning [Internet]. The Guardian. 2017 [cited 15 September 2017]. Available from:

12. Liter of Light. Liter of Light – About Us [Internet]. Liter of Light. 2017 [cited 15 September 2017]. Available from: