Interview with Dr Ben Harkin

INTERVIEWERS:
BEN SMYTH — COMMUNITY ENGAGEMENT PROJECT OFFICER
HENRY SUNDRAM — COMMUNITY ENGAGEMENT PROJECT OFFICER

Centre for cOMMUNITY cHILD hEALTH (CCCH) — THE ROYAL CHILDREN’S HOSPITAL

At the Centre for Community Child Health, we’re striving for equitable health and developmental outcomes for all children. The Centre has been committed to improving the lives of children and families for the past 25 years and we will continue to lead efforts to achieve equitable outcomes until this vision becomes reality.

The Centre provides leadership on the health and wellbeing of children aged 0–8 years. It aims to: 

  • improve development outcomes for Australian children;
  • advance equitable health for disadvantaged children;
  • and promote positive early life conditions for children.

Ben Harkin is a Fellow in Community Child Health, undertaking The Victorian Training Program in Community Child Health at CCCH. 

This program provides clinical and theoretical training in developmental-behavioural paediatrics. Fellows develop individual learning goals for the year, and are paired with mentors who have expertise in clinical practice, population child health research, public health and policy development, and program development and evaluation. Moreover, an emphasis is placed on clinical training that occurs within community and specialist outpatient clinic settings. 


What was your educational and career path like, and how did you eventually transition into medicine and paediatrics?

I had a very unusual path into medicine. I came to medicine much later in life as a mature-age student (early to mid-30s). Before that, I did a Masters of Public Health—which I embarked upon because I needed to do more tertiary education closer to applying for medical school and it seemed to be a logical thing to do. 

But prior to my Masters, I hadn’t done any science or anything in that field since I left school. I went to Melbourne University and did an arts degree, then as I had an interest in the performing arts, I auditioned for different drama schools in Australia and attended the Western Australian Academy of Performing Arts. Following which, I worked for about 10 years as an actor, director and producer. 

Then when I was in my early 30s, I was thinking about my future and what I would be doing in 10 years time, and I thought, ‘the thing I’m doing now, I’m done.’ And then I thought: ‘what am I going to do with the rest of my life?’ I rang some mates who were doctors and said, ‘I’m in my mid-30s, how do I become a doctor?  Is it possible?’ They said, ‘sure, you have to sit the GAMSAT and can apply as a mature age student.’’ So that’s what I did. Remember that it’s never too late to shift to something else and that skills you have in one career can also be transferred to other careers.

Being a doctor isn’t just having a knowledge base—it involves patient relationships, working in management teams and hospitals. 

I attended medicine at the University of Western Australia and they had a version of the course where we crammed in all the basic science stuff as a cohort of 60 mature-age students in seven months and then joined the undergrads in the clinical years. What was interesting about that cohort is that about a third of them were from non-science, non-medical backgrounds. 

For me and others who don’t come from a medical background, the first seven months were just crazy—it felt like my brain was exploding every day, getting around concepts like the Krebs cycle and biochemistry. But once we hit the wards and began clinical work, those of us who had non-medical backgrounds started to feel a bit better and do quite well because our patient interactions were influenced by our life experience.

The moral of the story is that if you would like to change your pathway, be aware that you bring a lot of different things to your practice as a doctor. Being a doctor isn’t just having a knowledge base—it involves patient relationships, working in management teams and hospitals.

What advice would you give to medical students who are unsure about which fields they would like to pursue? More generally, what advice would you give to those who are unsure about which career path to follow?

The experience of a med student is that you never know anything because you’re always being asked by someone who knows more than you. I remember saying to one of these senior people, ‘I’m so sick of just feeling stupid all the time’ and he said, ‘Don’t worry, that’s your entire life in medicine; there’s always going to be someone in the room who knows more than you.’

What’s interesting about medicine though is that there’s a niche for every personality type and interest; it’s so broad. Because of that breadth, it’s impossible to know everything about everything. People have different approaches to this: some people prefer a more generalist approach where they get to do a lot of different stuff and have a certain level of knowledge across a broad base, such as general pediatricians and general practitioners, and then other people like to drill down and know everything about a particular field and subspecialise. 

A useful thing to ask is: how does your brain work? Do you like to know a lot about a specific thing or do you prefer a more general approach? Then what type of medicine do you like to do: the kind of procedural-based, practical stuff; or more patient interaction? 

The other important thing is to look at other people in the career that you’re wanting to pursue. This applies to everything in life, but with medicine, certain personality types are drawn to certain specialties. But also those specialties create a world that encourages that personality type. You can look at the physicians or surgeons that are in the area of medicine you want to go into and think, ‘Are these my people?’

Find something that you’re interested in and talk to people who are in the field. What’s their daily experience? What are the good things and what are the crappy things about the job? Because there will always be good things and bad things. For me, before working in developmental paediatrics, I couldn’t quite find my niche in medicine. When I started working more specifically in developmental paediatrics, I kind of thought, okay, here are my people. This is where I fit.

This applies to everything in life, but just to talk about medicine: certain personality types are drawn to certain specialties. But also those specialties create a world that encourages that personality type. You can look at the physicians or surgeons that are in the area of medicine you want to go into and think, ‘Are these my people?’

What is your typical day like? Does it vary or do you have a particular structure that you follow? 

I’ll talk very briefly about a day in the hospital, which is not what I’m in now but what I’ve done for many years. As a junior doctor, you’re the one that often gets all the jobs done, you’re the engine that makes the team work. There are more senior doctors who are making management decisions and discussing with colleagues and deciding what investigations or other tasks might need to be organised by the junior doctors. They also coordinate the team and make sure everyone works well together. So that’s your basic nine-to-five day. There is also an after hours component in big hospitals, where you will be covering the care of patients from a number of teams that you may not necessarily be involved in on a day to day basis. 

The work I’m doing now is more outpatient-based and so I see kids and families from a range of cultural backgrounds with very complex social backgrounds, lower socioeconomic status and trauma. These kids may have developmental/behavioral difficulties such as delayed speaking, autism spectrum disorder, behavioral dysregulation, ADHD, a whole lot of things. Basically, if someone identifies a kid who’s at risk of not developing, they come to me for an assessment and I try to work out what’s going on. I have a couple of days in a community clinic, one day involved in cases where children have a background of Child Protection involvement and another day working with mental health services. 

So my current work is not about sick kids in the hospital. It’s not just getting them in, making them well and sending them home, it’s a much longer process. This is stuff where I see kids over months to years and try to slowly make improvements.  Since every kid’s different, each child is a bit of a detective case to suss out and a large part of that is working with the families to understand their experience, and the child’s experience within the context of the family, school, larger society.

What was your journey like through training and how have these experiences influenced your practice? 

For those readers who might be medical students, your exams are ongoing and you always continue to study and learn. Certainly, there are people in medicine who have incredibly bright minds and think in incredible ways, but there are also people who have different strengths. I don’t think you have to be a genius to be a doctor but you must be smart enough to know how to study and particularly be able to apply yourself consistently. One thing you need to get through medicine is to be able to persist because it’s a long slog. 

In order to work well in this area of medicine, you have to recognise the toll it takes, and be able to offload and accept that. This is an important part of your training. It’s very enjoyable, but it’s also very intense.

In terms of training once you have graduated from medical school, most of our basic pediatric training is geared towards acute medicine (although interestingly enough, many general pediatricians working in the community will not see these acute presentations). The first part of training is fascinating but also very challenging. There are certainly some difficult times along the way in terms of really hard exams you need to pass, challenging patients and family interactions, and really sick kids. 

Therefore it is important that you have people who support you and ways you can balance your working life. Certainly many of us have found ourselves at points where we feel burnt out. It used to be a problem that people didn’t want to address but now we are becoming more aware that, in order to work well in this area of medicine, you have to recognise the toll it takes, and be able to offload and accept that. This is an important part of your training. It’s very enjoyable, but it’s also very intense. Therefore, make sure you take care of your own mental health so that you can work and take care of others. 

Advanced training is where you become more specialised and where you try to become the type of doctor you want to be now that you have a solid foundation of knowledge. This is where you can work out what areas of medicine you want to work in. I’m currently a part of the Victorian Training Program for Community Child Health, which focuses on development and community pediatrics, which basically means I just get to play with kids all the time whilst assessing their development!

You mentioned that this year is giving you a chance to hone in on the areas you’re interested in. I was reading up on the training program and it said that the trainees set personal training goals, and they work with a mentor to realise them. So my question is how did you go about setting those goals and the mental challenges that were associated? 

One aspect is, you need to meet the training requirements. There are certain things you’ve got to tick off so some of those goals are about, ‘Okay, I need to do X, Y, and Z to make sure that I’ve done these specific things for these six months so that I’m accredited.’ 

Typically, minimum training time is probably about six years but most people spend more than that because you can’t really string everything together nicely. Often there are times within the training where you need to work in a particular area of pediatrics to progress but you might not be able to pick up the specific job to fulfil that requirement. So although you’re working as a doctor, it doesn’t necessarily progress your training. So you need to be setting goals and having your mentor keeping you on track to fulfil the training requirements.

Then the other consideration is more about what sort of things do you want to get out of your time? This is where you and your mentor get to have a bit of a philosophical discussion about life in medicine, what is your area of interest and how are you managing the work/life balance, because it becomes pretty all-consuming. That’s one of the biggest challenges that you’re going to talk to your mentor about. If you can, try in your current studies to find a really good way of working effectively and efficiently. It’s a great skill to have—the more efficient you are, the more downtime you’ll have in the future. 

It’s always important to remember that you’ve got a rotating roster of doctors in the hospital and part of that reason is so that people finish on time and can hand it over to the incoming team. So don’t feel that everything has to be perfect before you leave. Remember the perfect can definitely be the enemy of the good!

From your meetings with those more senior physicians and supervisors/mentors, were there any gems that you’ve incorporated into your practice?

That’s a great question. I think one of the things to remember about medicine is that you can’t know everything and what is important to know and the way in which you work  varies depending on the area of medicine you work in. So for working in an ICU or an ED, there is an immediacy to this area of medicine. There are emergencies that happen and you need to be able to react, and think quickly and efficiently. In lots of other types of medicine, particularly physician’s training, you generally have time to consider the options, research, and plan your approach. 

So a great bit of advice I got was recognising that you don’t have to have all the answers immediately. Often in medicine, you recognise that you’ve got some time to consider the issue and knowing how to get the information that you don’t have is the more important skill. 

Also knowing that you don’t necessarily need to be the one with all the answers. It’s important to remember that it takes a team to effectively manage a patient, whether that’s an acute medical team or in an outpatient setting, the best way to practise medicine is always in a team. 

If the lighting guy is asleep then the stage is dark and it doesn’t matter what you do as an actor, no one’s going to see you.

Forgive the comparison, but this parallels with a performance of a play. It takes a team. If the lighting guy is asleep then the stage is dark and it doesn’t matter what you do as an actor, no one’s going to see you. You’ll find that this applies to most aspects of life. 

Although one aspect of medicine is about acquiring knowledge and applying it to patients,  the other aspect is effectively communicating to both your team and the patient as well. So another gem is that as a junior doctor, the best residents are the ones who know how to communicate well and get stuff done. 

When it comes to medicine or any other career pathway, always try to find ways to venture outside your comfort zone and expand your thinking. I spent the last two years working in remote Western Australia in the Kimberley Region traveling to small Aboriginal communities. I had to adjust and reset my mind to working in clinics there. Adapting to these different environments definitely informed my practice and made me a better doctor. It was a great experience and I would encourage you to always find that opportunity to venture to greater depths because we grow by pushing ourselves to our limits.

Research or patient care: what should you do with a Biomedical degree?

BY STELLA LIU — DIRECTOR OF COMMUNITY ENGAGEMENT

Biomedical research is a high-impact field with large returns to society that merits consideration as a career pathway. Biomedical researchers endeavour to improve health by investigating how the human body works. Those who pursue this career pathway can find themselves in academia, where they improve tools and techniques, study healthy biological processes, and interrogate the causes and progression of disease. Others land roles in industry, which generally involves generating and evaluating treatments for human diseases and disorders, for commercial applications. Although the road to becoming a biomedical researcher is long and arduous, it is incredibly fulfilling and offers highly interesting work for the intellectually curious.


What is Biomedical Research?

Biomedical research can broadly be divided into several categories:

Improving tools and techniques

  • The process of conducting research is the crux of a biomedical research career, wherein there is a consistent need to improve current tools and techniques or develop new ways to understand biological processes. A notable example of this is CRISPR gene editing, for which Emmanuelle Charpentier and Jennifer Doudna were awarded the Nobel Prize in Chemistry in 2020. CRISPR is now commonly used to generate genetically accurate mouse models of disease, which has direct treatment applications.

Studying healthy biological processes

  • Knowledge of the most basic human processes, such as how cells function or how the immune system operates, is critical to the progress of biomedical research. University of Melbourne alumni Macfarlane Burnet is considered a scientific hero in this area. He developed the theory of clonal selection, which continues to serve as the foundation of immunology research. However, funding and support for this avenue of research is difficult due to ambiguous real-world applications.

Studying diseases and conditions of interest

  • Biomedical research primarily involves studying a particular disease/condition and the mechanics behind disease progression. This includes research to discover the causes of disease (e.g. bacteria, genetic mutation). Studying the interplay between diseases or conditions of interest and normal biological processes is crucial to determining treatment options.

Generating possible treatments

  • Knowing the cause of a particular disease/condition doesn’t guarantee that we will find an effective treatment. Generating treatment options can be based on knowledge of the disease/condition, but it can also rely on trial and error. For example, a promising approach to developing a new COVID-19 vaccine involves screening tens of hundreds of nanobodies to find one which can block SARS-CoV-2.

Preliminary evaluation of possible treatments (preclinical research)

  • Potential treatments are first examined “in vitro” outside of living organisms. This is an isolated environment which does not represent the complex interactions of a living being. Treatment options can then progress to the “in vivo” stage where tests are conducted on laboratory animals such as mice. This can recapitulate complex human biology, which gives valuable information about the effectiveness of a treatment before it progresses to clinical trial.

Clinical trials

  • Highly rigorous treatment studies are conducted in humans before a treatment can become widely available. Clinical trials come in different phases, with early phases being focussed on safety and later stages on the efficacy of the treatment. The goal of biomedical research is to generate information from the above categories and bring treatment options to clinical trials.

Why Biomedical Research?

Beyond the processes themselves, biomedical research offers the chance to make a tangible impact on society. Through research, we can offer significant improvements to health with a comparatively small investment of resources (time, money, effort etc). For example, it is estimated that reducing cancer deaths by 1% will save the US an estimated $500 billion. We are commonly exposed to organisations or events promoting support for biomedical research, such as Daffodil Day or MS Walk, but this can skew public perception of how research works. Research that involves studying foundational biology or improving research techniques is essential to treating these highly popularised diseases, but it can often be underfunded or understaffed. These “neglected research areas” have the capacity to offer massive returns in the form of quality adjusted life years (QALYs). For example, anti-aging research tackles issues such as cancer, neurodegenerative disease and cardiovascular disease from the foundation and aims to increase healthy lifespan. This is a far better approach to solving age-related deaths compared to mainstream research which typically promotes prolonging unhealthy lifespan. However, this is not as attractive for public funding or well-intentioned individuals who enter research to “cure cancer”.

Being a biomedical researcher is extremely satisfying, especially for anyone with a curious mind who is up for an intellectual challenge. Biomedical researchers spend most of their career doing self-directed work. Researchers, as early as Honours students, have the opportunity to work and direct their own project. They maintain their independence, creatively develop their own unique experiments and have substantial input on what they do. Furthermore, every day presents a new opportunity to satiate curiosity, whether that be investigating a new question, using different techniques or technologies, or collaborating with researchers across the world from different disciplines. The most successful researchers have intense intellectual curiosity, but also display high levels of resilience. Academia is highly competitive, and researchers must overcome setbacks, which can include a failed experiment or a rejected paper. A good researcher is also able to position themselves to build strong professional relationships and collaborations, which will help with securing funding, publishing ground-breaking papers in top journals, or working in the most prestigious labs. Although intelligence is important in a multitude of careers, it is particularly crucial for success in the interdisciplinary and complex field of biomedical research.

Good researchers are hard to come by, but without dedicated scientists and innovative minds, no amount of funding will solve the world’s most pressing biomedical issues.

Seeing as biomedical researchers often come from science or biomedicine degrees, medicine can be seen as an attractive career alternative which offers a similar intellectual challenge and a general sense of helping society. However, whilst doctors create a tangible impact in the lives of the patients they treat, they are limited in their ability to scale up their impact to match that of research breakthroughs or major policy changes. It is widely accepted that the “social determinants of health” (e.g. education, social-economic status) plays a far greater role in health outcomes than medical professionals do. Furthermore, doctors and health resources tend to be concentrated in areas of least need, a concept summarised by the “inverse care law”. As such, the incremental addition of an extra clinician into an oversaturated field has diminishing marginal returns. Shockingly, Dr Gregory Lewis from Cambridge estimates that an additional doctor will only add 4 QALYs for every year that they work, an impact which can be matched 30 fold by simply donating 10% of their salary to effective organisations that fight global poverty.

People likely to succeed in medical school have the potential to make a far greater impact outside medicine. 80,000 hours — an organisation which researches careers with the largest positive social impact — recommends that for those interested in medicine, the highest impact opportunities can be found in biomedical research. Good researchers are hard to come by, but without dedicated scientists and innovative minds, no amount of funding will solve the world’s most pressing biomedical issues. Dr John Todd, a Professor of Medical Genetics at Cambridge believes that “The best people are the biggest struggle. The funding isn’t a problem. It’s getting really special people” and would rather turn down substantial funds in exchange for a good researcher for his lab. This suggests that large grant options are still unable to attract top researchers, and that top researchers are more valuable than any state-of-the-art lab equipment purchased with grants. If you have the potential to succeed in biomedical research, this is a highly effective career pathway where you will likely have more impact than alternative pathways with the same degree.

Food for thought: Exploring the complex relationship between diet and health

BY SRESHTA SHERI — PRESIDENT

Food has long been a part of the story of humanity. Our relationship with food has changed in significant ways over thousands of years but perhaps the most dramatic changes have occurred only in the last 50 years. Food has gone from merely a means of survival to a key aspect of the human experience with a huge role in culture, comfort, and health. Even though diets hold a sacred space in the story of humanity, they may also be underpinning what is turning out to be one of the most destructive healthcare challenges of the modern era the rise of overweight and obesity.

Increased adiposity and obesity are increasingly linked to many other diseases such as type 2 diabetes, cardiovascular disease, and some types of cancer. The challenge that these non-communicable diseases (such as heart disease, diabetes, stroke, and cancer) present are vast and significant, representing a great burden on resources not only in Australia but across the globe, with the epidemic spreading to developing nations. Amongst the plethora of environmental changes that have arguably contributed to this crisis, a marked nutritional transition stands out.


Ancient Bodies in a Modern World  

In many ways, our bodies are engineered for a world of scarcity, now struggling in a world of abundance. Food scarcity was something we had to deal with for much of human history — every meal was crucial in ensuring our survival. It was in our biological best interests to be hard-wired to seek out calorie-dense foods and optimise our fat storage for times of food shortage. It was not unusual for humans to go without food for long periods of time throughout much of human history. Our biology has evolved over thousands of years to optimise for this food scarcity by having metabolically advantageous genetic adaptations that allow for the deposition of fat as an efficient store of energy.

However, the past 50 years a blink of an eye in evolutionary terms have seen significant changes to our diet in industrialised economies. The presence of ultra-processed, high fat, high sugar foods is ubiquitous and worryingly accessible. Bodies that were fundamentally wired for scarcity are today placed in a world of full fridges and pantries. With the effects of increasingly sedentary lifestyles compounding the problem, poor diets have arguably wreaked havoc on human health. Two-thirds of our nation’s adults are overweight or obese and the challenge of non-communicable diseases is one of the biggest burdens on the healthcare system. Our bodies being out of their depth in this modern food landscape only scratches the surface of this problem the challenges of the ‘obesogenic’ environment are underpinned by economic, political, and sociocultural factors that are deeply ingrained in our society.

In many ways, our bodies are engineered for a world of scarcity, now struggling in a world of abundance.

How did we get here? 

The obesity epidemic is more than just a diet problem, it is a deeply rooted systemic issue that plagues the lower socioeconomic classes. Increased adiposity and obesity are diseases that disproportionately affect those in the lower socioeconomic classes. From a nutritional perspective, the lower socioeconomic classes are often deprived of access to affordable, fresh, and nutrient-dense produce whilst being inundated and often targeted by fast food and unhealthy options which may be the only options in some cases.

Big Food (corporate food and beverage companies) represents some of the most powerful and destructive entities in the world when it comes to public health. Funding scientific research, financing political campaigns, lobbying, and financing campaigns are some of the ways in which these large companies yield their power. Ultimately, the problem with our diets is hardly an individual one it is deeply intertwined with political, social, and economic factors that need to be considered. 

Where to from here?

The future presents significant challenges not only for our diets, but food sustainability globally. By the year 2050, we will have 10 billion mouths to feed. Rethinking our global food system will be inevitable as new challenges emerge concerning agriculture and sustainability. From a health perspective, addressing our diet is perhaps one of the most important issues to tackle in the journey towards a healthier human population and reducing the burden of non-communicable diseases. The sociological challenges are many in this arena, but huge strides of progress continue to be made nonetheless. From huge changes such as the plant-based movement to the work of grassroots organisations that are involved in health promotion, fixing our diets is a shared responsibility that must be championed for a healthier society.

Pathways to achieving SDG 3

BY BEN GRIFFITHS — COMMUNITY ENGAGEMENT PROJECT MANAGER

The world is simultaneously facing both a climate crisis and the harsh reality of global poverty, both of which require urgent action from all of us to resolve. However, pursuing one goal — either ameliorating global poverty or combatting climate change — can often involve exacerbating the other. For example, the Global South pursuing the fossil-fuel based industrialisation and development paradigm of the Global North would cause devastating global warming. The inverse can also be true, wherein aggressive climate change mitigation policies can stifle the growth of low-income countries and deprive their governments of the tools necessary to alleviate their citizens from the deprivations of poverty. Given the urgency and extreme consequences of both issues for sentient wellbeing, compromising on either the planet or human development is fundamentally undesirable.


SUSTAINABLE DEVELOPMENT (SD)

This dilemma has created the impetus for the sustainable development movement, defined by the 1987 Brundtland Commission as ‘development that meets the needs of the present without compromising the ability of future generations to meet their own needs’. Critically, this movement addresses the intertemporal dynamics of human development and climate change, which is often characterised by a tradeoff between meeting the present development needs of the current generation and mitigating the future ecological and sentient damages of anthropogenic climate change. The sustainable development movement has culminated in the establishment of the 2030 Sustainable Development Goals (SDGs), which includes 17 goals to be achieved by 2030 that represent ambitious targets for holistic global improvements in development, while aiming to be compatible with the current ecological crisis. 

Overcoming this intertemporal challenge — and hence achieving sustainable development — represents a substantial task that requires intelligent policy and action at all levels of society. Meeting the global and systemic needs posed by the SDGs is unlikely to be achieved by a single hero or actor, purely by their nature as ‘wicked problems’. Wicked problems are complex and multifaceted issues with no simple solutions, thus necessitating substantial resources, time, commitment, and collaboration from a range of stakeholders. This can and should include intergovernmental organisations, NGOs, national governments, the private sector, civil society, communities, and individuals. Not only do these crises necessitate this level of collaboration (even if some approaches place disproportionate emphasis on particular stakeholders), but the collaboration itself is an opportunity to mobilise whole-of-society responses towards unified goals, thus building solidarity and the collective infrastructure to face other similarly global problems.

CRITIQUES OF SUSTAINABLE DEVELOPMENT

As with any idea, it’s important to engage critically with sustainable development to assess its merits and improve or alter its scope, application, and framing accordingly. 

Given the simple and broadly applicable nature of SD, a degree of ambiguity can result wherein SD and its composite terms have a variety of competing definitions and framings. Failing to agree on a coherent and consistent definition of a framework has practical implications in contexts such as the thresholds for what constitutes a “sustainable” environment or which metrics should be employed to evaluate “development” progress. 

Should a local council build a community centre, homeless shelter, family planning clinic, or preserve the existing environment on a block of land? Should a low-income country pursue manufacturing-led industrial policy which has been demonstrably effective even though it results in greater emissions?

However, it is nonetheless important to create space for diverse and critical perspectives with the understanding that development is not a “one size fits all” phenomenon and solutions need to be contextually specific and culturally appropriate. SD doesn’t necessarily capture this need in its mainstream application, as many of its core tenets are rooted in narrow eurocentrism, such as the dichotomisation of society and nature, which contrasts with cultures that adopt a more integrated view. This has led to the creation of alternative frameworks such as ‘buen vivir’ in Latin America and greater pushes to improve the inclusivity of SD. 

Beyond the above concerns, SD has been critiqued for being limited on the basis that it doesn’t engage with the notion that a more fundamental disruption to the economy may ultimately be necessary. This also extends to the lack of embeddedness of structural critiques made by postcolonial and feminist thinkers regarding power dynamics or the focus on agency and individual freedoms made by Amartya Sen. While attempts have been made to incorporate these views within SD, it is apparent that further work is required to refine SD. Moreover, it is critical to recognise that SD is not an exhaustive framework, which necessitates an approach whereby SD is used in conjunction with structural considerations alongside varying approaches and lenses.

There are also some more practical concerns within SD that warrant further consideration. For example, SD doesn’t address how to prioritise goals when contradictions emerge. This necessitates broader social conversation about how to make this prioritisation in either a general or contextual basis. Many scenarios will result in some objectives being hampered or neglected by pursuing others. Should a local council build a community centre, homeless shelter, family planning clinic, or preserve the existing environment on a block of land? Should a low-income country pursue manufacturing-led industrial policy which has been demonstrably effective even though it results in greater emissions? These tangible concerns among others have been responded to by either developing heuristics and principles such as ‘polluter-pays’ and the ‘precautionary principles’ or through building agreement within specific contexts. The latter approach seeks to build best practice on a per-issue basis such that solutions are contextually appropriate.

Given these issues and various responses to them, it’s important that SD is ultimately seen as a discourse wherein further conversations about framing, implementation, and competing perspectives can be found.

SDG 3

Source: Our World in Data, Healthcare Access and Quality Index, 2015
Source: Our World in Data, Death rates from air pollution, World, 1990 to 2017

In order to further explore the SDGs and evaluate progress towards them, SDG 3 (Good health and wellbeing) will be analysed given that it is a relevant objective for Strive as an organisation, as well as students in the public health space. SDG 3 aims to “Ensure healthy lives and promote well-being for all at all ages”, involving 13 ambitious health-related targets, and is measured using 28 indicators. These targets range from reducing maternal and child mortality, fighting communicable and non-communicable disease, to preventing and treating substance abuse. These represent broad and effective goals that target a range of health outcomes, including requirements that all countries must pass to ensure that equitable and just progress is achieved. 

Inclusive institutions are progenitors of development, climate change has the potential to wreak havoc on global health, and the equitable nature of the targets makes them impossible to achieve without resolving inequities.

Tracking the achievement of this goal is a monumental task itself, requiring comprehensive and consistent data collection across every single country. Many of the indicators have data available for them, but there are a few without any high-quality data sources, and many regions of the world — such as sub-saharan Africa — consistently lack high-quality data for most indicators. This is a reflection of ongoing data inequality issues that impede the ability to evaluate and create targeted development initiatives. Within the purview of these limitations, steady progress has been made across most targets before 2020, such as maternal and infant mortality, life expectancy, sanitation, malaria, as well as HIV/AIDS reduction. However, much more progress is required to reach the targets by 2030. The need for greater progress has been magnified by the onset of the COVID-19 pandemic, which has directly created additional health problems. This then creates downstream health effects by reallocating health resources to combating a pandemic, while exacerbating substance abuse, mental health, and domestic violence due to the need for lockdowns and the ensuing economic recession. The combination of these factors alongside the disruption of medical supply chains has been a devastating blow to the achievement of SDG 3 amongst others, which requires immediate and substantial long-term action to alleviate and propel the global community towards greater public health. If you would like to further investigate SDG 3 as well as progress towards the other 16 SDGs, Our World In Data has a comprehensive and open-source SDG tracker that uses high-quality data to evaluate progress towards each goal.

It is also worth emphasising that each goal has not been designed as a set of discrete objectives, and that there are important interrelations and causal chains between SDGs, such that there are co-benefits to achieving any particular goal as well as to encourage holistic development. This can be seen in the context of SDG 3, where achieving goals such as eliminating poverty (SDG 1), zero hunger (SDG 2), and clean water and sanitation (SDG 6) result in greater health outcomes. This is a two-way causal link given that these goals themselves improve as greater health outcomes are achieved. Interrelations extend beyond bi-directional causality, as goals such as climate action (SDG 13), reducing inequality (SDG 10), gender equity (SDG 5), and strong institutions (SDG 16), serve as prerequisite foundations for meaningful health outcomes to be achieved. This is because inclusive institutions are progenitors of development, climate change has the potential to wreak havoc on global health, and the equitable nature of the targets makes them impossible to achieve without resolving inequities. This underscores the importance of an approach that targets all goals simultaneously, so as to achieve the desired metrics, which are ultimately reflective of lived human experiences that need to be improved in a multidimensional way. 

How can we achieve SDG 3?

The COVID-19 pandemic has reinforced the importance of public health and the need for global collaboration in a time where many nations and people fragment and turn insular. The next 10 years of progress towards SDG 3 will need to be characterised in the context of amending the long term damages of COVID-19, both in terms of public health and the global insulatory effects of quarantines. 

Governments and IGOs will need to focus on the disproportionate effects the pandemic has brought upon already marginalised groups and low-income countries, while reestablishing and building upon development programs that were sidelined in 2020.

The private sector also has a role to play, with the healthcare industry and adjacent sectors being of particular importance, not just to SDG 3, but to each goal. The SDG industry matrix team produced a report outlining how the healthcare and life sciences sector can contribute to each SDG, via the principles of preventative healthcare, healthcare resilience, universal health coverage, and environmental sustainability.

Civil society and activist groups are critical elements for the democratisation of SDG negotiation and policy, through having the capacity to apply pressure and bring perspective to large and powerful stakeholders. These groups are also essential to mobilise the general public to be aware of and engage with SDG implementation.

For the sake of brevity, there are many other important stakeholders that can contribute towards SDG achievement or minimise their own harm such as industry associations, individual health professionals, and community organisations. It is through these stakeholders that extensive collaboration will be required to mobilise the whole-of-society response necessary to achieve the SDGs, including SDG 3.

What can you do to achieve SDG 3?

We live multidimensional lives and our impact should reflect that. There are numerous contexts and spaces that we occupy that can be mobilised for positive social change. Below are examples of how you can use your resources, social circles, student status, political lives, and future careers to contribute positively to the achievement of the SDGs. For a more comprehensive look into the multidimensionality in our lives, I have written a previous article about making an impact in the face of climate change.

As a student:

  • Take development and sustainability electives
  • Involve yourself with student organisations that contribute towards the SDGs such as Strive, MUHI, Melbourne Microfinance Initiative, Enactus, model UN society, and many more
  • Engage in student politics and university SDG initiatives. For example, the University of Melbourne does not currently feature on The Times Education’s university SDG performance ranking and it’s incredibly important that we encourage the university to feature in these evaluative initiatives and contribute more meaningfully
  • Take your time as a student to learn and engage yourself with various facts, experiences, and perspectives in an open and empathetic way

As a professional:

  • Pursue careers that directly advocate for or contribute to the SDGs
  • Encourage your workplace to adopt more sustainability initiatives
  • Contribute to the SDGs through a side hustle or social enterprise

Using your resources:

  • Divest from fossil fuels and companies that contribute negatively to public health
  • Donate to effective organisations that are SDG oriented, and meet high standards
  • Volunteer your time for positive social causes
  • Make more socially conscious consumption decisions and live a low GHG emissions lifestyle (plant-based diet, use public transport, minimise waste, use renewable energy when possible)

As a political constituent:

  • Attend peaceful and socially responsible protests
  • Factor public health, climate change, and development into your voting decisions
  • Attend community meetings and contact your local representative to achieve SDG alignment in your community
  • Run for office on an SDG-oriented agenda

Beyond these tangible actions, it’s equally important to raise awareness and have conversations about these issues with your friends and family. Moreover, forming social groups that care about these issues will help to build a sense of community, while ensuring that your contribution is more engaging, fun, effective, and manageable. It is only with a large coalition of informed and engaged people that we can overcome global issues together and build a better future for everyone.

Strive’s Teams — Looking Forward

Hear from Strive’s Program Managers as they shed light on their teams’ exciting and impactful projects for Semester Two. We’re excited to see you at our events and volunteering opportunities!


Strive Conference

A photograph from Strive’s Annual Conference in 2018

The Strive Conference is an annual event that captures our core values of health promotion and education via a panel with key leaders in the public health ecosystem and a case competition on a pertinent public health issue. For the first time, Strive is excited to announce that we will be collaborating with Melbourne University Health Initiative and 180 Degrees Consulting Unimelb on the case competition aspect of Strive Conference 2021!

The Global Health Case Competition (GHCC) will be an interdisciplinary case competition, involving students from multiple faculties, where participants will be prompted to provide a solution to a case study. This year, we aim to provide a case study that focuses specifically on the youth mental health crisis and the mental wellbeing of University of Melbourne students.

We look forward to seeing you at the GHCC workshop on the 6th of September and Finals Night on the 16th of September!

Make sure to stay tuned via our Facebook page for more information and updates regarding Strive Conference 2021.


University Engagement

The University Engagement team aims to promote wellness among our peers and local community through informative speaker sessions and interactive activities. Our goal is to create an environment to encourage healthy lifestyles within the campus community, improve health literacy on campus, and create an environment for students to meet others who are passionate about public health topics. During Semester 2, we have planned many exciting activities for students, such as a trip to Queen Vic Market and a speaker session about health literacy during COVID-19. In addition, we hope to increase campus awareness of Strive’s initiatives and find some amazing speakers for the case competition!

Brianna Heinken

My name is Brianna Heinken and I’m currently a 2nd year Bachelor of Biomedicine (Neuroscience) and Diploma of Languages (Spanish) student at the University of Melbourne. I’m passionate about health literacy, policy-making, mental health, and making an impact in the lives of others. In my free time, I like to get active outdoors, spend time with family and friends, explore the world, and read books. You can catch me around campus and I’m always ready to have a chat about our University Engagement initiatives or public health!


Publications

The Publications team is responsible for creating publications that inspire students while empowering them with the knowledge and awareness to contribute positively to global public health. So far we’ve achieved this via the creation of Regimen: Striving for Global Health, of which you are currently reading an article within Edition 3. Each edition so far has featured articles written by our committee, and interviews with leading public health professionals. Topics have ranged widely, including explorations of pediatrics, advice for students, climate change, equitable vaccine distribution, and personalised medicine. This semester we look forward to continuing to publish Regimen while writing the case study for the GHCC.

Ben Griffiths

My name is Ben Griffiths and I’m currently a 4th year Bachelor of Commerce (Economics) and Diploma in Languages (French) student at the University of Melbourne. I’m passionate about policy, public health, climate change, international collaboration, and finding ways to combine these interests to make a tangible impact. In my spare time I like to play guitar, learn more about the world, hang out with friends, and write articles. You can find more of my current and previous writing at Cainz, ESSA Unimelb, Melbourne Microfinance Initiative, and LSE International Development Review.


Storybook

The Storybook team aims to promote healthy-eating associations within preschool children through the creation of a nutrition storybook, and provide parents with an easy-to-read and accessible resource on nutrition and meal prep. We have also been working on virtual COVID-19 health & hygiene and physical activity workshops. During Semester 2, we are working on translating the storybook to three predominant languages in Melbourne (Mandarin, Arabic, and Vietnamese), disseminating the workshops to primary schools, and creating an in-person format of the health & hygiene workshop for use after the pandemic. Additionally, we hope to engage in more team building activities and partake in the Strive case competition! 

Shanaya Ramchandani

Hi! My name is Shanaya Ramchandani and I am a third-year Bachelor of Biomedicine student, majoring in Pharmacology. I am passionate about medical research, in particular cancer pharmacology (have published four peer-reviewed papers), mental health treatment and neuropharmacology, as well as infectious disease treatments. I have also been heavily involved in charity, and outside university, I run a non-profit clothing initiative based in Singapore, called wear:change, consisting of fifteen team members. I am also an Indian Classical Dancer, and enjoy painting, cooking, cocktail-making, and hanging out with friends during my free time! 


Nutrition Initiative

Semester 2 will see the fruition of the Nutrition Initiative’s in-person workshops. Our main focus will be delivering workshops to schools in north and west Melbourne. We aim to host 1 workshop per month and adapt our program as we go. We are fortunate to informally partner with Sanitarium Australia, who have generously donated resources to support our workshops. It is very important for us to collect feedback through post-workshop surveys so we can achieve this goal. We also hope to refilm our video workshops, which the film from our first attempt was unfortunately corrupt. However our primary focus is the in-person workshops, hopefully running 6 times throughout semester 2. 

Jessica Louise Parry

Hi there, my name is Jessica Louise Parry and I manage the Nutrition Workshop initiative of Community Engagement at Strive. My interest in nutrition science and education is what propelled me to apply for project management with Strive. I am currently a Masters student researching vitamins in plants with mass spectrometry. I am really excited to apply my research when teaching nutrition to children.


University Engagement

The University Engagement team aims to promote wellness among our peers and local community through informative speaker sessions and interactive activities. Our goal is to create an environment to encourage healthy lifestyles within the campus community, improve health literacy on campus, and create an environment for students to meet others who are passionate about public health topics. During Semester 2, we have planned many exciting activities for students, such as a trip to Queen Vic Market and a speaker session about health literacy during COVID-19. In addition, we hope to increase campus awareness of Strive’s initiatives and find some amazing speakers for the case competition!

Brianna Heinken

My name is Brianna Heinken and I’m currently a 2nd year Bachelor of Biomedicine (Neuroscience) and Diploma of Languages (Spanish) student at the University of Melbourne. I’m passionate about health literacy, policy-making, mental health, and making an impact in the lives of others. In my free time, I like to get active outdoors, spend time with family and friends, explore the world, and read books. You can catch me around campus and I’m always ready to have a chat about our University Engagement initiatives or public health!


Strive Clinic

In Semester 2, Strive Clinic is looking to strengthen our relationship with Bolton Clarke and deliver more CPR workshops to elderly people across the country via Zoom, and hopefully have an in-person session so we can make it as interactive as possible! We’ve received feedback that the workshops (that are run by students from multiple disciplines) are highly valuable and informative for the recipients so far! 

In addition, we also look forward to attending the Avalon Centre drop-in sessions again once COVID allows, and get back to providing basic health check-ups and wound care for people who come by, whilst also providing our student volunteers the opportunity to refine their skills. 

Finally, we hope to help out those applying for medical school by running our annual mock MMI workshops! That will be coming up soon so stay tuned.

Audrey Lui

Hello! I’m Audrey, the Director of Clinic for 2021. I first got involved with Strive in 2018, as much of Strive’s mission aligned with my interests—promoting health literacy and improving access to healthcare in the community. As such, I am also involved in volunteering outside of uni as well as various clubs within uni. I’m currently a 2nd year medical student and I really hope my extracurricular experiences and lessons can enhance my interaction with patients as well as colleagues in the future!


Exploring co-benefits of climate change in the context of global health

By Ben Griffiths — Community Engagement Project Manager

Source: Pixabay

Understanding the links between climate change and public health is paramount to comprehending the potential devastation that communities could face and building a foundation for tangible action. Various aspects of climate change have been observed to produce deleterious effects on public health. This article will examine the effects of climate change on public health, the impact of public health interventions on climate change, and the co-benefits to health observed in responses to climate change. 

The impacts of climate change on health are truly plethoric, with dramatic current and projected effects from a variety of climatic and human factors. Below are a few factors that contribute to negative health outcomes:

Air pollution

As one of the leading causes of death and health risk globally, air pollution is a major silent killer. Ambient particulate matter in the atmosphere from fossil fuels and coal has been linked to heart attacks, asthma, stroke, hypertension, lung cancer, and miscarriage amongst other ailments. These millions of annual deaths are inexorably linked to climate change through fossil fuel use, which will continue to escalate and result in further deaths unless full decarbonisation is achieved. Moreover, household air pollution both exacerbates climate change through burning solid fuels and causes millions of deaths annually. Burning solid fuels such as coal, wood, and dung for household use is disproportionately employed in low-income communities that are reliant on this energy source, thus leading to disproportionate negative health implications as well.

Natural disasters

Climate change is causing an increase in the frequency and intensity of natural disasters globally, with dramatic consequences for sentient wellbeing and human health. Natural disasters can have wide-ranging health consequences through disrupting supply chains of medical supplies, death and bodily injury, displacement, infectious diseases, damages to clean water systems, and consequently mental health challenges.

The Asia-Pacific region is particularly subject to risk, with countries such as Vietnam, the Philippines, and Japan facing significant disaster risk, as well as small island developing states like Kiribati facing dramatic sea-level rise. While the Asia-Pacific region faces risk due to being in the tropics and along major fault lines, most regions of the world have begun to experience significant and escalating risks. Dramatic sea-level rise is projected to affect coastal communities globally and different combinations of increasingly regular and severe natural disasters create unique challenges for each region.

The stark reality of the damages caused by natural disasters was brought to where many of us live, work, and study when the devastating bushfires arrived in Australia early in 2020. The fires resulted in at least 33 direct deaths, hundreds of deaths in indirect excess mortality, trauma to firefighters and those directly impacted, biodiversity loss, and reduced air quality. These all present challenges to healthcare systems that will be magnified in future years when Australia faces concurrent disasters that occur more regularly and severely.  A recent report from the Grattan Institute outlines the effects of climate change on public health, with particular focus drawn to the recent bushfires and future steps to be taken.

Photography by fvanrenterghem/Flickr
Heat

Global warming is causing sustained increases in temperatures, which are projected to result in 75% of the world’s population experiencing deadly heat waves by 2100 and some areas of the world becoming uninhabitable for human life. This has the potential to cause global disruption and additional strain on healthcare systems during hotter periods, with potentially existential consequences for sentient life in the long-term.

Sustained heat exposure can result in heat exhaustion, heat stroke, and the exacerbation of existing health problems such as heart failure.

MALNUTRITION

Through increased drought, natural disasters, ocean acidification, soil degradation, pollution, and the spread of infectious diseases, climate change will have a substantial negative effect on agricultural yields and the nutritional value of crops. This leads to malnutrition both from a lack of food availability and decreased quality of the food that does exist.

Once again, low-income nations will be affected disproportionately by food and nutrient scarcity, thus necessitating justice-based approaches to climate change that are cognisant of this inequity.

Co-benefits

These substantial negative health implications of climate change should act as an impetus for action so that they can be avoided through a combination of adaptation and mitigation measures. However, it is also worth noting that many of these climate change interventions result in considerable public health co-benefits that reach communities immediately. This is a much more compelling motivator relative to simply avoiding the damages of climate change, which are often perceived to be conceptually abstract and long-term. It is worth noting that while this article has a health focus, co-benefits of climate action can extend to “increased energy security, job creation, and reductions in poverty and inequality”. Moreover, adaptation efforts that build community resilience for future disasters also improve adaptability to current disasters and health issues.

Policies and initiatives that deliver health co-benefits are wide-ranging, with opportunities emerging across the spectrum of decarbonisation possibilities and industries. Given the plethoric range of policy possibilities that couldn’t easily be summarised in a single article, only a few of these initiatives will be outlined.

Renewable energy transition

Fossil fuel use is the primary means through which climate change manifests, and a transition towards alternative sources of energy is fundamental to mitigating future harm. Beyond merely averting harm, such a transition has the potential to improve human lives and avert needless deaths through resultant improvements in air quality. For example, three million premature deaths by 2040 could be averted with a 7% increase in investment in a “Clean Air Scenario”. Reducing the amount of ambient particulate matter and ozone in the air would result in significant quality of life improvements as the aforementioned negative effects of air pollution are minimised and outdoor spaces become less polluted.

There are also simpler shifts of energy use that can make a profound impact on climate change, public health, and economic development. For example, national programs that transition solid fuel cooking utensils to low-emissions stove technology could save millions of lives and avoid millions of tonnes of greenhouse gas emissions.

Photography by Andreas Gücklhorn/Unsplash
Increased use of active and low emissions transport

Transport represents 21% of overall CO2 emissions, which both necessitates decarbonisation of this sector while presenting opportunities to improve public health. For example, the electrification of transport in addition to increasing public transport use can decrease emissions while increasing air quality. Encouraging increases in active transport methods such as walking and cycling results in greater cardiovascular health, lower overall morbidity, and greater mental health outcomes in addition to the previously mentioned benefits to health and the climate.

Dietary choices

Agriculture represents 26% of overall CO2 emissions, a substantial portion of which is animal agriculture. Industrialised animal agriculture is currently unsustainable, using inefficient levels of water and land, while resulting in substantial methane and CO2 emissions and a number of other negative environmental impacts. Moreover, the greatest sources of environmental degradation—red meat and processed meat—are also the sources of animal agriculture with the most negative health implications. Diets with large amounts of animal agriculture—in particular red and processed meat—are associated with health risks including heart disease, stroke, and higher overall morbidity relative to plant-based diets. This dual benefit to health and the environment merits a shift towards diets with more fruits, vegetables, nuts, seeds, and beans, with the greatest positive impacts associated with an exclusively plant-based diet.

Greening cities

Creating more urban green spaces doesn’t only provide an aesthetic benefit. Increased numbers of trees in cities are a valuable source of carbon sequestration and a shared space that allows a city’s denizens to connect with nature. Beyond these benefits, green spaces also reduce the “urban heat island effect”, provide psychological benefits, and reduce water runoff that is associated with disease spreading, land degradation, and polluted waterways.

Photography by Michael Sotnikov/Flickr

Final remarks

Climate change advocacy often takes the form of justifiably warning about impending devastation and framing climate action through the lens of avoiding or mitigating harm. Reframing the issue through co-benefits discourse may prove to be more effective as it shifts the conversation from advocating sacrifice for the greater good to improving the planet through corresponding improvements to society that we should all want to pursue, irrespective of the looming spectre of climate change.

Personalised Medicine: A new frontier of healthcare?

By Rachel Lim — Community Engagement Officer

For years, physicians have strived to consider the environmental, behavioural and genetic factors that may affect a patient’s health and disease management in order to provide precise and impactful care for each individual. However, it is only recently that we have been able to skyrocket this goal to the next level, with the term ‘personalised medicine’ rising to the forefront. Personalised medicine in the twenty-first century mainly refers to the use of genomics to optimise medical care and outcomes for each individual, enabling physicians to customise patient care in an unprecedented way. This approach has become prominent due to the exponential increase in the availability of genetic sequencing, testing, and data storage, accompanied by an increase in technological innovation and decrease in sequencing costs. This has enabled three major domains in clinical medicine to be accelerated, including the field of pharmacogenomics, genetic predispositions for common diseases, and the identification of rare disease-causing genetic variants.

Pharmacogenomics

Pharmacogenomics refers to the study of how genes modulate drug responses in different individuals. This is because variability of genes within the human population exists due to DNA polymorphisms and epigenetics. This causes changes in protein structure, function, or the amount of protein produced, which inevitably impacts how a person responds to a drug. Thus, if we are able to understand which DNA variants correspond to abnormal production of body proteins, we will be able to identify drug responders and non-responders, avoid adverse reaction events, and optimise drug dosage. 

For example, 40% of metastatic colon cancer patients are unlikely to respond to the typical drugs prescribed for colon cancer such as cetuximab and panitumumab, because these patients have tumours with mutated KRAS genes. Hence, being able to identify patients who are unlikely to respond to these drugs will enable us to save time and increase their rate of survival by immediately prescribing an alternative drug which they are predicted to respond positively to. In particular, this is important in cancer where different individuals have different genetic mutations present in their tumours, and hence targeting an individual patient’s tumours allows us to maximise efficacy and treatment benefit, while limiting the risk of adverse side effects.

Genetic predispositions for common diseases

Certain genetic variants lead to an increase in an individual’s risk of developing a particular disease. Thus, valuable research has been conducted into genetic factors that when combined with other environmental factors, can result in the development of a common disease. For example, type one diabetes occurs due to immune-mediated destruction of insulin-producing beta cells, causing insulin deficiency which results in unattenuated blood glucose levels. Type one diabetes affects over 18 million individuals worldwide and there are on average seven new cases a day in Australia

Source: WebMD

A genetic risk factor that has been identified which confers the highest risk of type one diabetes is having HLA-DQ2 and HLA-DQ8 alleles. It has been hypothesised that these alleles lead to the production of HLA molecules which do not interact properly with the body’s T cells in the thymus, thus allowing for self-reactive T cells to escape into the body’s periphery instead of being eliminated. Hence, if we can sequence a patient’s genome and identify these alleles, we can predict the patient’s risk of developing type one diabetes. With this powerful knowledge, physicians can more easily prescribe preventative measures to avoid the development of this condition. This allows for a shift in emphasis from reaction to prevention, in which we manage the root of the cause, rather than sticking to a Band-Aid solution. This can have a significant effect in reducing the costs generated by the disease burden on society, as well as individual health and economic costs on the patient and their family. Additionally, disease risk can be stratified so that high risk individuals are targeted more efficiently, allowing resources to be better utilised and early or prophylactic treatment to become more available.

Source: KPI Ninja

Identifying rare disease-causing genetic variants

Rare genetic diseases collectively affect 25 million people globally  and hence there is substantial merit in identifying genetic variants that cause these rare diseases. In Australia, a disease is considered rare if it affects less than 5 in 10,000 people. An example of a rare disease is cystic fibrosis (CF), in which the CFTR gene is mutated, subsequently affecting the production or function of the CFTR protein. This has a widespread impact throughout the body, resulting in many debilitating effects including lung disease, failure to thrive, and abnormal electrolyte composition in sweat. In fact, this condition has been recognised by midwives for hundreds of years by tasting the salty sweat on an infant’s brow, with the infamous saying that “an infant that tastes of salt will surely die”. 

Source: Firstcry

Fortunately, we have made leaps and bounds in identifying the genetic cause and consequences of cystic fibrosis, and the median life expectancy of people with CF has increased from a few months in the 1950s to over 40 years of age presently. Scientists have also created cystic fibrosis gene panels to detect the 175 most common genetic variants that cause cystic fibrosis, and this screening test can be performed on infants so that early treatment and management can commence promptly for affected newborns.

Considerations and drawbacks

Despite the many benefits and potential of personalised medicine, there are also several issues and challenges that we need to consider. For instance, infrastructure requirements such as the collection and storage of genomic data are a major hurdle. At the moment, we do not have sufficiently large, secure databases to store such information, nor is there enough funding and research going into this technological challenge. Additionally, there are privacy and ethical issues that arise as the genetic information of an individual is very personal and sensitive material that larger and more powerful organisations might exploit. There are also legal disputes as to who owns the genomic data collected and who is allowed access; questions that we must consider and create laws to govern.

Another major issue is the potential of personalised medicine to exacerbate inequalities. Although the cost of genomic sequencing is decreasing, there are still significant expenses that must go into the collection, sequencing, and interpretation of genomic data. Hence, it is foreseeable that equal access and affordability may not be available initially, which can drive increased disparities between countries and different socioeconomic groups. Considering the substantial benefits of personalised medicine, this may lead to a deepened poverty cycle which may spiral to become inescapable.

Illustration by durantelallera / Shutterstock

Moving forward

Personalised medicine is still a developing approach to clinical medicine that has a bright prospect in the future, despite its issues and challenges. It signifies a momentous change in patient care that aligns with the rise of the Information Age, and places us in a position to employ preventative medicine and improve the quality of life for patients. Moving forward, personalised medicine can be largely enabled by electronic health records, which will allow clinicians and patients to share and integrate relevant genomic information, supporting interdisciplinary care and management. Adequate regulatory frameworks and data management protocols must be established to protect personal rights and secure health data flow.

Additionally, healthcare training in technology, data analysis and genomic interpretation must be prioritised so that healthcare workers are able to understand and communicate this information to patients and the wider public. There is also an accompanying need for an increase in general health literacy so that patients have a greater awareness of their choices and are able to understand and appropriately consent to their desired management plan. Thus, it is through innovation, regulatory frameworks, education and commitment to equal access that personalised medicine will truly thrive and have a profound impact on healthcare globally.

Strive x Cainz public health debate: “decriminalising all drugs is an effective public health policy”

DEBATE – Strive Student Health Initiative x Cainz:

Disclaimer: The writers in this article are competitive debaters, and therefore the views expressed may not necessarily represent their beliefs or the beliefs of any organisations they represent.

1st Affirmative Writer – Henry Sundram, Community Engagement Project Officer

Greetings, my name is Henry Sundram and I’m currently completing my second year of a Bachelor of Arts, majoring in English and History alongside a Diploma in Languages (Indonesian). I joined Strive with the hope of helping advance the collective health of the community, especially the disadvantaged. I enjoy reading, bushwalking and all things cricket!

In recent years, there has been a significant movement to decriminalise all drug usage as a method of effectively advancing public health. We critically differentiate between drug legalisation, which involves government regulation of all drug markets and distribution, and drug decriminalisation, which centres on not prosecuting drug users whilst maintaining the illegality of drug manufacturing and selling. Policies of drug prohibition have failed as public health policies because they have largely failed to reduce drug consumption. By shifting the governmental lens on drug use from one of criminality to that of a health issue, public health outcomes will be improved.

Throughout history, forms of drug consumption have occurred in almost all societies whom “actively seek addictive drugs” for use in religion, medicine or recreation. Given the inherent tendency for drug consumption in societies, drug policies must reflect this reality to have meaningful public health outcomes. Drug prohibition has abjectly failed to reduce drug usage within societies and therefore failed as a public health policy. This failure may be attributed to the disjunct between prohibition’s idealistic aims of total drug elimination and the social realities of ever-present drug usage. Given that demand for drugs will always exist, parallel markets which supply and distribute illicit drugs will also exist, regardless of the efforts of law enforcement which US$100 billion per annum is expended on globally. The motivations behind drug prohibition is to “protect the health and well-being” of citizens. However, in Australia, there was a 55-fold increase in the number of heroin overdoses between 1964 and 1997 after the federal government prohibited the drug, reinforcing the ineffectiveness of prohibition at reducing drug use as a public health outcome.

Given the failures of drug prohibition, we logically turn to supporting the decriminalisation of all drugs as an effective alternative policy for advancing public health. Decriminalisation policies recognise the realities of drug consumption in societies and shift their focus from punitively prosecuting drug users to minimizing drugs’ potential harm. Decriminalisation destigmatises drug addiction as family members and friends are less likely to negatively judge drug users and are more willing to support and assist in their recovery because the user’s actions are no longer criminal. Accompanying this social destigmatisation, not prosecuting drug users enables them to seek medical assistance more openly for addictions without fear of repercussion. This would likely reduce demand for illicit drugs, increasing public health outcomes as dependents recover. In contrast, prohibitive-drug policies, which issue criminal records to drug users, often condemn them to further economic and health deprivation. The possession of a criminal record significantly reduces one’s employment opportunities, increasing the likelihood of poverty which is closely associated with poorer health through increased drug use, reduced access to healthcare services and poorer-quality food.

Ultimately, the irreconcilable failures of drug prohibition as a public health policy leads us to the alternative of total decriminalisation of drugs which will advance public health by encouraging more drug users to seek treatment.

1st Negative Speaker – Melanie Suriarachchi

Melanie is a Bachelor of Commerce student with an interest in public policy, politics and the ever-evolving global markets. In her spare time you can find her delving into her creative side either card-making or baking. 

The rising movement to decriminalise all drug use as a means of drastically improving public health outcomes is best described as idealistic. In order for decriminalisation to be a viable option to address concerns relating to drug use, there are many obstacles that need to be addressed first, which in a perfect world may be easy to address, however, can prove to be tricky in modern day societies. Whilst we understand that drug prohibition may not be the most robust measure to further public health outcomes relating to substance related issues, it provides a certain assurance as a ‘tried and true’ system to control addiction related issues within society.

The affirmative team asserts given the inherent tendency to consume drugs by those ‘actively seek addictive drugs’, drug policies should reflect this reality in order to further health outcomes relating to substance use. Hence, taking into consideration the ‘inherent tendency’ of some individuals to consume drugs, it may be considered a disservice to them to decriminalise drugs, as it provides them greater access to the substances that they may be wanting to avoid, especially in circumstances of rehabilitation. By decriminalising all drugs, it puts those who are going through a rehabilitative phase in great harm as they may not be able to control the environments they encounter, which could possibly lead to relapse and further trauma.

Moreover, to counter the argument addressing the ‘abject failure’ of drug decriminalisation, a 2001 Australian study of 18–29-year-old individuals by the NSW Bureau of Crime Statistics and Research demonstrates that prohibition did work to deter drug use. Of the subjects who had never used cannabis, 29% cited illegality as their reason for not using. 19% of those subjects who had stopped using cannabis stated that illegality of the substance was their reason for ceasing use. However, the most alarming statistic revealed that 91% of those currently using cannabis said that they would increase their usage if it was to be decriminalised.

Whilst decriminalisation may work to destigmatise drug addiction, the affirmative team fails to recognise those individuals who have biological predisposition towards drug addiction, making them more vulnerable to drug abuse. If there are measures such as legal prosecution are not in place, they probability that those individuals start to experiment with drugs is heightened, placing them in greater risk for continued substance abuse. When working to decriminalise all drugs, the health system needs to be prepared to handle the current drug addicts as well as the inundation of new addicts in order to provide fair access to the appropriate resources needed for those experiencing drug addiction, overdoses and withdrawals, as well as supporting family members and friends with a loved one who is suffering from an addiction.

Moreover, using basic economic theory, decriminalising all drugs will ultimately lead to a surge in the supply in drugs within the community, effectively leading to lower prices of such substances which may result in a greater temptation for individuals to experiment.

Fundamentally, whilst drug prohibition may not be the most efficacious system to improve health outcomes related to drug use, it is the system that many countries continue to utilise in order to address such issues. If public health outcomes relating to substance abuse were to be prioritised, the first measure to put in place would be greater access to support for addicts and the family and friends of addicts relating to both physical and mental health. It is foolish to believe decriminalisation would improve health outcomes without placing the ‘middle measures’ in place and trialling those initiatives first.

REference List:

Alcohol and Drug Foundation. (28 April 2021). Decriminalisation vs. Legalisation. https://adf.org.au/talking-about-drugs/law/decriminalisation/decriminalisation-detail/

Weatherburn, D. (2014). The Pros and Cons of Prohibiting Drugs. Journal of Criminology, 47(2), 176–189. https://idhdp.com/media/362647/1408-weatherburn-article.pdf

Drug Free Australia. (n.d.) Arguments Against Drug Legalisation. https://www.drugfree.org.au/images/pdf-files/library/Drug-Free-Australia/Taskforce_Arguments_for_Prohibition.pdf

2nd Affirmative Writer – Ben Smyth, Community Engagement Project Officer

Hi there, my name is Ben Smyth and I’m in my third year of Bachelor of Science, majoring in Psychology and also completing a diploma in Computing. I’ve always enjoyed writing and helping others refine their writing; this ties in with a burgeoning interest in public health. I’m also an executive member of Students for Sensible Drug Policy (SSDP) Unimelb, a student organisation that advocates for harm reduction and evidence-based drug policy reform. When I have the time, I enjoy boxing, singing, listening to podcasts, and playing video games.

The negative team suggests that decriminalizing all drugs will give individuals who “inherently” want to consume drugs greater access to substances they may want to avoid. However, drug use per se is not problematic to public health, but drug dependency is problematic and leads to poorer health outcomes. Legal drugs such as alcohol and caffeine can provide benefits while posing minimal risk to health; it is when addiction develops that the risk of poor health outcomes increases and an intervention is required.

Moreover, the legalization of relatively dangerous drugs such as tobacco and alcohol seems a farce when considering the criminalization of relatively benign drugs such as cannabis. Instead of arbitrarily criminalizing some drugs, all drugs should be decriminalized.

The negative team goes on to argue that due to lack of legal disincentives in decriminalization, addiction-prone individuals may become more vulnerable to drug abuse. However, since decriminalizing all drugs, Portugal has seen reductions in problematic use and drug-related harms. Therefore, apart from merely reduced problematic use, the decriminalization of drugs will help reduce drug-related harms ostensibly due to better access to education and medical care.

The negative team states that due to economic theory, decriminalization will lead to a surge in drug supply. Despite an increase in illicit drug seizures by Australian police forces over the past decade, the availability of drugs has been largely unaffected. There is simply too much demand and too many suppliers for prohibition of drugs to have effects on the market. The prohibition of alcohol in the USA was built on the utopian ideology of a drugless state, but ultimately led to an increase in crime and no meaningful reduction in alcohol use.

The vast majority of individuals who use drugs (legal or otherwise) do so rationally, recreationally, and sensibly. Policies should focus on the minority of users who develop dependence disorders. The real disservice to addicts is not providing them the opportunity to rehabilitate without risk of prosecution. Imagine the difference in public health if all the money now spent on arresting people and judicial processes was instead provided to drug treatment and support services.

REference List:

Buchanan, J. (2017). 72 Misleading Assumptions. Retrieved from Drugs, Human Rights & Harm Reduction: https://julianbuchanan.wordpress.com 

Hughes, C. E., & Stevens, A. (2010). What can we learn from the Portuguese decriminalization of illicit drugs? British Journal of Criminology, 50(3), 999-1022. doi:10.1093/bjc/azq038  

Stafford, J., & Breen, C. (2017). Australian Drug Trends 2016. Findings from the Illicit Drug Reporting System (IDRS). National Drug and Alcohol Research Centre. Sydney: UNSW Australia. Retrieved from https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/national-idrs_2016_finalwith-customs.pdf 

Taylor, S., Buchanan, J., & Ayres, T. (2016). Prohibition, privilege and the drug apartheid: The failure of drug policy reform to address the underlying fallacies of drug prohibition. British Society of Criminology, 16(4), 452-469. doi:10.1177/1748895816633274 

Vumbaca, G. (2016, July). Decriminalisation Is The Only Way To Arrest Australia’s Drug Problem. HuffPost Australia. Retrieved from https://www.huffingtonpost.com.au/gino-vumbaca/decriminalisation-is-the-only-way-to-arrest-australias-drug-pro_a_23013350/ 

 2nd Negative Writer – Vedanth Shah

My name is Vedanth, and I am a first year Commerce student at UniMelb. I am a member of CAINZ and currently hold the role of General Committee. I enjoy reading, playing sports mainly soccer, and have an interest in Economics.

The affirmative side have outlined that drug dependency is the core issue we are faced with, as it can cause health, financial and wellbeing issues. By legalising drugs, we are only providing the broader community with a gun and asking them not to shoot. If you take away the gun, they are deterred from shooting. This is the basis of decriminalising all drugs. If the community doesn’t have easy access to drugs, then it will deter most people from consuming potentially harmful and dangerous drugs. Initially the drugs may not be addicting in nature, but it opens up a gateway to harder, stronger drugs. Under the affirmative sides model, they suggest that decriminalised drugs will be safe and monitored, however, when people look for harder, stronger drugs after getting a feel for the “softer” drugs, they will face the downwards spiraling consequences from consumption of drugs. 

The affirmative side also brought up the example of Portugal decriminalising drugs, however this is only part true. Drugs are not freely available, nor can they be freely sold, instead the only difference in Portugal is that the offence for possession of a narcotic substance has been changed from a criminal to a civil offence, and under this legal framework citizens can still be fined for possession.

The relaxation of the law in Portugal may seem a minor change but had large significant impacts on Portugal’s economy and productivity. The relaxation of the law in 2011, resulted in a 1.7% fall in GDP in 2011, and a further 4.1% fall in GDP in 2012. This fall in GDP is no consequence, in fact many experts believe the laziness of citizens due to higher drug consumption, after the immediate relaxation of drug laws, resulted in a fall in labour productivity, and hurt the countries GDP.

By continuing with the current status quo, we avoid the large health, wellbeing and economic issues that may arise from the legalisation of drugs. Less people will have access to a potential self-destructing weapon, which by all means will keep the broader community safer and happier.

REference List:

Ceicdata.com. 2021. Portugal Labour Productivity Growth, 1996 – 2021 Data. [online] Available at: <https://www.ceicdata.com/en/indicator/portugal/labour-productivity-growth#:~:text=Portugal%20Labour%20Productivity%20dropped%20by,2020%2C%20averaging%20at%200.96%20%25.&text=The%20country’s%20Labour%20Force%20Participation,to%2058.70%20%25%20in%20Dec%202020.>. 

Drugfoundation.org.nz. 2021. Mythbusters: Drugs are legal in Portugal. [online] Available at: <https://www.drugfoundation.org.nz/matters-of-substance/may-2013/drugs-are-legal-portugal/>. 

En.wikipedia.org. 2021. Arguments for and against drug prohibition – Wikipedia. [online] Available at: <https://en.wikipedia.org/wiki/Arguments_for_and_against_drug_prohibition>. 

Laqueur, Hannah. “Uses and Abuses of Drug Decriminalization in Portugal.” Law & Social Inquiry, vol. 40, no. 3, 2015, pp. 746–781., www.jstor.org/stable/24545832.

3rd Affirmative Writer – Sonia Truong, Design Officer

My name is Sonia Truong and I am a first-year Bachelor of Biomedicine student at the University of Melbourne. I am interested in public health issues related to climate change and planetary health.

The affirmative team would like to begin by reminding the negative team that the debate thus far has concerned decriminalisation, not legalisation, which may rectify any misconceptions from the negative team regarding Portugal’s current drug policy. In the context of decriminalisation as an effective public health policy, one of the negative team’s own sources states that “Portugal stands as a global leader of evidence-based policy grounded on the principle of harm reduction”. We agree with their source that the decriminalisation of drugs demonstrably improves health outcomes and results in reduced drug use, addiction, overdoses, and HIV infections. This contrasts with the baseless and unevidenced “gateway drug” assertions reminiscent of doomed-to-fail 1930’s prohibitionists.

We would also like to correct the negative team by clarifying that Portugal’s drug decriminalisation occurred in 2001, not 2011, and that the entire continent was in recession during 2011. Is the negative team claiming that the 2001 decriminalisation of drugs caused a recession in Greece with a near decade-long delay? It seems much more coherent to suggest that the Eurozone debt crisis which impacted the entire continent is more responsible for Portugese economic woes than harmful stereotypes regarding people who use drugs. Nevertheless, this is a non-sequitur that distracts from the significant public health gains resulting from this public health policy.

If the negative team truly wishes to address the risks posed to individuals vulnerable to drug misuse, they may like to consider the serious harms inflicted on these individuals under the current punitive system: the stigma of a criminal record, denial of employment and housing, and the trauma associated with arrest and incarceration, all of which are inextricably linked to poorer health outcomes. Compared with the approach of drug decriminalisation, which approach sounds more pragmatic and humane?

This public health policy does not lend itself to simplistic and shallow analogies of “giving someone a gun and asking them not to shoot.” The regime of drug prohibition undermines the efforts of individuals to seek treatment for their drug use, not only because of stigma associated with drug use but because of legitimate fear of criminalisation. How is the negative team proposing that people who use drugs seek help when they are at risk of prosecution for doing so? Rather than spending exorbitant sums of money on law enforcement and wilfully depriving people with health issues of the help they need, resources could be redirected to provide earlier intervention and appropriate treatment and medical services to people with drug use problems. In the interest of public health, drug decriminalisation is a step in the right direction—and one that is long-overdue.

3rd Negative Writer – Vickram Mehtaanii

Vickram is a third year Bachelor of Commerce student majoring in Accounting and Management. In his spare time, Vickram can be found in the gym, trying his hand in the kitchen or watching football (soccer).

The negative team is well aware of the difference between legalisation and decriminalisation and understands that the debate concerns decriminalisation of all drugs, which is why we stand firm with our views. Drug decriminalisation is not the answer and will never be, at least not in the interest of public health. We understand that so long an act is considered a crime, most people will tend to stay away from “committing the crime”. We do not understand why the affirmative team has drifted away from the main topic and given so much importance to Portugal’s economic woes. If the affirmative and negative team both want an effective public health policy where less people consume drugs, less people get addicted to drugs, and less people overdose on drugs, then it is necessary that the consumption is considered a crime, as it always has been. Importance needs to be given to prevention than thinking of the cure first.

We understand that it is necessary to protect the welfare of those vulnerable to drug misuse, however, we also understand that we need to look after the health of all and therefore, consumption of drugs needs to be considered a crime. Otherwise, drugs would be much more easily available, which would then lead to a lot more people consuming drugs who have so far chosen not to as it is considered a “crime”. The same people who have resisted the consumption of drugs would be keen to explore what it is like to consume drugs, if it would not be a crime anymore. It is basic common sense: more people consuming drugs would lead to higher chances of drug misuse, addiction, and overdose. This would have a significant impact on those around them, including their family and friends, who would be affected both mentally and physically by the abusers. Moreover, this would have an impact on the future offspring as well as they may have some kind of disability from birth. Furthermore, the larger number of people addicted to drugs would lead to a higher crime rate, as a lot of addicts would indulge in criminal activities to purchase drugs. Surely, those who really are worried about their criminal record, employment and housing, trauma associated with arrest and incarceration would choose to not consume drugs. The point stands, prevention is better than cure.

Obviously, a better policy needs to be brought in place where those individuals who would like to seek treatment for their drug use get proper help, instead of straight off being treated as criminals. However, decriminalisation of consumption of drugs is NOT the answer to that. The negative team understands that the “cure” side of the public health policy needs to be looked into, but remains firm on the “prevention” side. Therefore, in the interest of public health, the negative team holds ground for criminalising the consumption of all drugs.


Affirmative Team Editor – Ben Griffiths, Community Engagement Project Manager

My name is Ben Griffiths and I’m currently a 4th year Bachelor of Commerce (Economics) and Diploma in Languages (French) student at the University of Melbourne. I’m passionate about policy, public health, climate change, international collaboration, and finding ways to combine these interests to make a tangible impact. In my spare time I like to play guitar, learn more about the world, hang out with friends, and write articles. You can find more of my current and previous writing at Cainz, ESSA Unimelb, Melbourne Microfinance Initiative, LSE International Development Review, and Strive Student Health Initiative.

Negative Team Editor – Emily Hartley

Hi everyone! My name is Emily and I am a current penultimate year student studying Bachelor of Commerce with majors in Finance and Economics. As a digest writer at CAINZ, I am able to tie together my childhood passion for writing and the qualitative and quantitative aspects of finance and economics. I am excited to deliver to you a range of articles throughout my time as a writer.

HIV/AIDS epidemics in developed nations: Evaluating mitigation strategies

By Stella Liu, Community Engagement Director

The human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) epidemic has wreaked havoc on humans for decades. HIV has claimed 33 million lives since it was first identified, with an estimated 38 million people currently living with the disease. Although developing countries within central Europe, central Asia, the Pacific, the Middle East and North Africa account for 95% of new HIV infections, HIV/AIDS persists within key populations in developed nations, including men who have sex with men (MSM), injection drug users (IDUs), commercial sex workers (CSWs) or clients of CSWs. HIV/AIDS distribution amongst populations in developed countries indicates persisting socioeconomic disadvantage. 

Increases in HIV virulence can only be prevented by targeting high-risk CSWs, and addressing characteristics underpinning treatment non-compliance. Health systems in developed nations cannot solely rely on free universal healthcare and advanced biomedicine. The ongoing AIDS epidemics and the resulting health burden on developed nations can only be resolved by socioeconomic development, health policy initiatives targeting high-risk groups, and improving ease of access for lower socioeconomic status (SES) populations.

Socioeconomic Status (SES)

Given that HIV/AIDS epidemics in developed nations originated from resource-poorAfrican countries, the impact of poor SES on HIV infection risk must be understood. Intriguingly, initial HIV epidemics in sub-Saharan Africa predominantly affected high-income well-educated individuals. By the early 2000s however, HIV infection predominantly occurred within poorer low-education populations. This demographic shift was due to behavioural changes within highly educated and wealthy gay communities, although poorer, less-educated communities have not undertaken similar changes. Distribution of HIV in developed nations is heterogeneous, with concentrated HIV epidemics in impoverished urban areas. In such regions within the US, HIV prevalence reaches as high as 5%, well above the national average. 

There are similar concerns regarding HIV prevalence among low SES groups in Australia, primarily gay and other homosexually active men, Aboriginal and Torres Strait Islander people, people who inject drugs, people in custodial settings, sex workers, and people from culturally and linguistically diverse (CALD) backgrounds. Socioeconomic disadvantage leads to risky health practices such as substance use and reduced condom use which amplifies HIV infection risk. As such, HIV prevalence is characterised by key indicators of SES: education, annual household income, poverty level, employment, and homeless-status. 
Hopelessness is a major contributor to HIV-risky behaviour among all at-risk groups aside from MSM. Substance abuse and unprotected sex is concerningly high among low SES individuals who exhibit a lack of hope for future improvements. Education is universally protective for all areas of SES as it mitigates hopelessness by increasing economic opportunity. As such, education improvements for low SES individuals has the potential to reduce HIV prevalence in developed countries. Ultimately, health systems must look beyond a biomedical understanding of HIV infection and resolve the socioeconomic determinants of HIV/AIDS epidemics.

Commercial Sex Workers (CSW)

Healthcare systems must shift their focus to CSWs, a low SES population at high risk of HIV.  HIV is transferred in blood, semen, rectal and vaginal fluids, and breastmilk. Thus, infection predominantly occurs in sexually active individuals. Increased rates of HIV transmission among CSW populations concerningly favours HIV virulence, as this allows the virus to frequently mutate, leading to more virulent strains. For CSWs and clients of CSWs who have multiple sexual partners, rapid HIV replication provides selective pressure that favours higher infectability and increased survivability. Thus, host survival becomes insignificant for the survival of HIV and accordingly, more virulent HIV strains quickly incapacitate the host immune system and AIDS progression occurs quicker

In developed countries, low SES individuals facing economic insecurity engage in ‘survival sex’; high-risk sexual behaviour with multiple partners, possibly without condom use, to meet basic financial needs. However, whilst CSWs generally have a higher HIV infection risk, legal brothel sex workers, unlike illegal street workers, are able to mitigate these risks through behaviour changes. Women working in brothels generally support and care for one another, and the business’ management can establish a safe client atmosphere with consistent condom use. For street CSWs however, it is up to the sex worker themselves to demand condom use. Faced with physical threat and coersion from clients, absence of legal protection, social isolation, and no community support, practicing safe sex easily becomes challenging. Social pressure from clients and challenging economic situations push street CSWs to believe that the cost of demanding condom use is greater than any health benefits.

Disappointingly, Australia’s sex industry predominantly consists of migrants from Thailand, China, or South Korea who’s working rights are compromised an uncertain immigration status or language barriers. Thus, they resort to street sex work rather than legal and safer brothel work. The lifestyle of street workers is an additional indicator of low SES, as they report higher levels of drug, alcohol, and cigarette use than brothel workers. With sharing needles and drug paraphernalia further contributing to the HIV risk of-street CSWs, it is clear why HIV/AIDS remains prevalent among this low SES group. 
Public health systems need to address systemic issues that influence this evolution. Other indicators of low SES – primarily homelessness and heavy drug use –  are seen in high-risk CSWs. Given that street CSWs face a lifestyle of irregularity, instability, and social isolation, maintaining the requirements for brothel employment can be difficult, even with the relevant working rights. Thus, education is necessary to change these behaviours and improve the economic opportunities for high-risk CSWs.

Access to Therapies (HAART)

The 1980s North-American AIDS epidemic was a period of uncertainty as healthcare professionals were unable to cure or control the disease. Stigma and rejection surrounding homosexuality, intravenous drug use, poverty, racism, and fear of contagion hindered support for HIV/AIDS prevention and research, leaving affected individuals unable to seek appropriate treatment. Slowly, HIV/AIDS research progressed, and by 1984, the viral cause of AIDS was identified, and laboratory HIV tests became available. 

Although HIV testing is now widely available in developed countries, low SES groups still face difficulties in receiving a diagnosis. Late AIDS diagnosis and healthcare delivery is a significant issue in Australia, with 55% of all cases remaining undiagnosed until progression to AIDS. Unsurprisingly, this mainly affects heterosexual individuals from CALD populations who faced socioeconomic disadvantage. These individuals were typically diagnosed in routine screenings during pregnancy, or following symptoms of AIDS. Healthcare systems in developed countries need to be wary that healthcare remains inaccessible to some populations, and stronger efforts are needed to ensure equitable access for low SES groups. 

The 1990s saw a paradigm shift in the treatment of HIV/AIDS. Highly active antiretroviral therapy (HAART) could reduce viral loading of HIV and increase white blood cell count, transforming it into a chronic disease rather than a death sentence. HAART has the potential to eliminate transmission between sexual partners, serving a dual purpose of treatment and prevention. However, the effectiveness of HAART has been questioned following studies that failed to show a decline in HIV incidence following treatment implementation. The possible connection between reduced HAART compliance within low SES populations and these results must be investigated
In the UK, low SES is strongly associated with HAART non-compliance, with the US showing a similar trend regarding SES and virological and immunological outcomes. More shockingly, in Canada where universal healthcare is provided free of charge, 40% of patients with HIV/AIDS related deaths never accessed treatment. As developed countries are capable of treating HIV/AIDS, it is unacceptable that benefits of medical innovation are not accessed by certain populations. Adverse effects of low SESgo beyond inability to pay for treatment, but rather individuals with knowledge, money, or social connections are disproportionately benefiting from advanced health systems. HAART, despite reducing overall HIV/AIDS deaths, has exacerbated health inequalities for low SES groups. In resource-rich countries, poverty, addiction, depression, and homelessness prevents HIV affected individuals from adhering to HAART medications despite access to health infrastructure, whilst unfavourable attitudes towards healthcare providers further damages health outcomes.

Key Conclusions

HIV infection and transmission are ultimately mitigated by-behavioural interventions. Whilst biomedical advances provide more options for HIV/AIDS prevention and treatment, safer sex and adherence to treatment regimes relies on individuals adopting behavioural and lifestyle changes that maintain health and reduce infection. Developed European countries spend approximately €1 million to treat HIV/AIDS, representative of around 1% of the total healthcare costs of these countries. This is a significant economic burden given the low HIV/AIDS prevalence within these populations, and despite these efforts, AIDS epidemics persist within these developed countries. 
A purely medical approach fails to address the stigma and discrimination, stress, trauma, and lack of social support for marginalised low SES populations which inherently increases their HIV risk. Developed nations must shift resources towards HIV prevention in impoverished urban areas, and provide community level and structural interventions to improve socioeconomic conditions. Programs such as Medicaid in the US and universal healthcare in other nations have reduced HIV/AIDS mortality, and can be built to include interventions specifically targeting lower SES groups with fewer accessible resources. Social services that address drug use behaviour, homelessness and poor education can work in conjunction with healthcare systems that provide treatment options to ultimately reduce and eliminate AIDS epidemics within developed countries. HIV/AIDS continues to be a global public health risk and speaks to the worldwide threat of infectious disease. Only by reconciling the biological understanding of HIV/AIDS with the socioeconomic determinants of infection and transmission, can developed-nations set an example of effective HIV/AIDS prevention.

Global COVID-19 vaccine inequity: Are we moving forward?

BY Kin Peng Soo, Community Engagement Project Office

Disclaimer: Due to the evolving nature of both the pandemic and COVID-19 vaccines, new information may continue to emerge. The following article is therefore accurate as of 20/05/2021.

Source: Getty Images
Introduction

With the development and distribution of multiple COVID-19 vaccines, the end of this pandemic is in sight; at least for wealthy countries. Variations in the rollout of vaccines being dependent on region and wealth has further highlighted the stark global inequities that have plagued the world for generations. Although many resource rich countries can look forward to being completely vaccinated by the end of 2021, many resource poor countries will likely be waiting until 2023. This is the direct result of many factors, including logistical difficulties, vaccine nationalism, and bottlenecks in supply.

Comparison of vaccine technology

An understanding of how the COVID-19 vaccines differ is imperative to grasping the conditions that give rise to logistical inequities. The two main vaccines that are currently being distributed in Australia are the Pfizer/BioNTech mRNA vaccine and the AstraZeneca/Oxford viral vector vaccine. Although they both aim to provide the same results, their approach differs greatly as the Pfizer vaccine is based on entirely new technology whilst AstraZeneca adopts an approach first developed in the 1970s. 

Our body’s immune system has developed over many millennia and is the most effective tool at clearing infections. Vaccines work by delivering the schematics of a virus or bacteria to the immune system so they can prepare for a real attack in advance. The various COVID-19 vaccines differ in the way they deliver these schematics. Pfizer’s mRNA vaccine when injected into the human body introduces instructions on how to make harmless SARS-CoV-2 proteins, which is the virus that causes COVID-19. These instructions, known as mRNA, will then enter some of our own cells which begin to produce the harmless COVID-19 proteins. Our immune system then recognises these COVID-19 proteins, thus priming it for any future attacks from real SARS-CoV-2 viruses. On the other hand, the Oxford/AstraZeneca vaccine uses viral vector technology, whereby a benign virus enters our cells to deliver these schematics for the SARS-CoV-2 proteins. Although the delivery mechanism is very different, the results should be the same in theory.    

Vaccine efficacy has been a very contentious issue over the past months with a continued influx of new data regarding each vaccine. We know from research published in the American Journal of Preventive Medicine that an efficacy rate of at least 80% or higher is needed to extinguish an epidemic without additional measures such as social distancing, quarantines, or mask use. The latest data suggests that in the prevention of COVID-19 transmission, Pfizer and AstraZeneca vaccines have efficacies of 95% and 76% respectively. However, due to the research being conducted at wildly different points of the pandemic and under different conditions, these numbers must be taken with a grain of salt. What we do know is that both vaccines are extremely good at preventing severe infections that lead to hospitalisation, intubation, and even death, which are the most important factors in reducing the burden on our health systems.

Logistics

A working vaccine is only the first step in moving past this pandemic as there is little use for a vaccine that cannot be distributed to those who need it. Due to the fragile nature of vaccines, a cold chain is required to maintain its potency. Most vaccines, including AstraZeneca’s, can be stored in fridges between 2-8oC however, the new mRNA technology requires continuous storage at temperatures of -70oC. At these temperatures, the vaccine is only guaranteed to last up to six months. Transporting the vaccine at these temperatures is almost impossible as they are moved in dry ice cooled shipping containers where they only last ten days. To worsen the issue, they are packed in containers of 5000 doses and only survive for five days when stored in standard vaccine freezers found at most vaccination centres. The challenge of distributing these 5000 doses within five days  is compounded by the need to coordinate a second dose within three weeks after the first dose. These logistical issues are difficult to navigate in resource rich countries such as America and Australia and are nigh on impossible for resource poor countries.

Adapted from Yale Medicine

The issue of cold chains is one element of a larger system of inequities between resource rich and poor countries. Most countries will not be able to distribute the Pfizer/BioNTech vaccine and will thus have to turn to more conventional vaccines such as AstraZeneca. Much like the personal protective equipment (PPE) crisis observed at the start of the pandemic, we are seeing immense difficulties in obtaining these critical products. The misuse of money and power derived from panic buying and hoarding continues to put many lives at risk.

Justice, morality, and the benefits of an equitable distribution

“Rich nations representing just 14% of the world’s population had bought up more than half (53%) of all the most promising vaccines”

BBC News

When faced with crisis and adversity, the natural human response is one of greed and selfishness in an effort to protect one’s interests. Vaccine nationalism is yet another example of how resource rich nations continue to serve their own interests at the expense of the resource poor. However, this moral injustice leading to the unnecessary death of thousands will have reciprocal deleterious effects on the rich. After globalisation, the economies of the rich and poor became increasingly intertwined. Indeed, many global supply chains are reliant on the goods and services provided by lower income countries. The longer the delays in vaccine rollout for these countries, the longer these lockdowns will last, thus exacerbating any current supply bottlenecks. COVID-19 is estimated to cost the world economy between $1.8 trillion and $3.8 trillion, with rich countries set to take more than half of this pain. It is therefore in the best interest of all countries to ensure an equitable distribution of vaccines.

The achievement of an equitable distribution is being tackled by the Coalition for Epidemic Preparedness Innovations (CEPI), Gavi (The Vaccine Alliance), and the World Health Organisation (WHO) in a co-led initiative known as COVAX. It has currently been able to deliver 38 million doses to 98 countries (source). While this represents a positive start, America alone has been able to deliver 265 million doses (as of 12/05/21). The supply bottleneck of vaccines presents a significant distribution challenge. This can largely be attributed to the intricacies of patent law hampering global production of vaccines. Many countries such as India, China, and the Philippines with large-scale vaccine production capabilities  do not have the rights to manufacture and distribute them to countries in need. In this time of crisis, a mutual agreement needs to be made wherein these capable countries are able to produce vaccines while ensuring patent holders are adequately compensated.

See here for a more in-depth look into the patent law.

In conjunction with these issues, COVAX faces further challenges following the plausible link between the AstraZeneca vaccine and rare blood clots. As more affluent countries scramble to get their hands on more Pfizer vaccines, COVAX — which is heavily reliant on AstraZeneca due to the aforementioned logistical difficulties of delivering Pfizer — is facing further delays in rollout. Several countries involved with COVAX have already decided to suspend the use of AstraZeneca citing possible side effects. This isn’t a reasonable cost-benefit analysis as the risk of patients dying from COVID-19 in many countries heavily outweighs the risk of developing one of these rare blood clots. However, this unfortunate link will remain a roadblock and will likely cost the lives of many.

Along with the moral and economic benefits that equitable vaccine distribution provides, China and Russia are also using their vaccines as a form of diplomacy. China and Russia are filling a gap other rich countries have left during their preoccupation with vaccine nationalism. China has learnt from its failed attempt at PPE diplomacy which was plagued with quality control issues, and is successfully donating their vaccines in a bid to strengthen ties and forge new partnerships. Meanwhile, the US and EU lag behind, only pledging donations to poorer countries and regions recently.

Source: Getty Images

COVID-19 has brought to light the difference in access to quality healthcare between low and high income countries. Epidemics are not uncommon phenomena with many regions and countries being ravaged by them. The difference between COVID-19 and other diseases such as tuberculosis, Ebola, and malaria are that it impacted not only the poorer countries but the more affluent ones as well. If we compare the responses to COVID-19 and tuberculosis — a disease that claimed the lives of 1.4 million people worldwide in 2019 — rich countries were able to source, develop, and mobilise PPE, life saving drugs, and vaccines at unprecedented speeds. Meanwhile tuberculosis — which has a readily available vaccine and treatment regime — consistently appears in the top ten causes of death in low to middle income countries.

Conclusions

The inequitable distribution of resources is a long-standing issue that has been exacerbated by the COVID-19 pandemic. Vaccines have been the latest addition to this growing list of life saving measures that remain out of reach for lower income countries. Richer countries must recognise that altruism is not the only reason to support others during this pandemic as there are tangible economic and political advantages to be gained. Addressing the larger long-standing issues of health access in poorly resourced areas is more challenging and complex, which requires structural changes. This would involve an increase in human, material, and financial support through collaboration in addition to changing the internal environment through education, training, and leadership.