Global health

Conference delegates participated in five thematic workshops with the aim of discussing and making practical recommendations for action. The themes and recommendations of these workshops were as follows: Globalisation and healthEncourage political advocacy for Australia’s commitment to the Millennium Development Goals (<www.developmentgoals.org/>) and recognition of the links between and inequities in health, security and economic development. This should occur at the highest political levels — the Prime Minister’s Department, the Department of Foreign Affairs and Trade (which could devote part of its website to these issues <www.dfat.gov.au/>), and the Australian Agency for International Development (AusAID <www.ausaid.gov.au/>). Galvanise non-government organisations (NGOs) to advocate issues of health and economic development. Such NGOs could include the Australian Council for Overseas Aid, as well as others with little international involvement at present (eg, the National Heart Foundation and the Cancer Council) which could be encouraged to work in the Asia Pacific region. Urge the Confederation of Australian Industry and the Business Council of Australia to consider health and economic development issues in their overseas ventures. Subject all treaties, covenants and agreements ratified by the Australian Government and by private sector agencies to health impact assessments. Encourage the transfer of quality, relevant Australian health research (eg, on tobacco, injury prevention) to developing countries. Develop the small pool of international health expertise by providing more training opportunities in the Asia Pacific region and a career structure with Australian and multi-national organisations involved in international health. Anthony I Adams Retired Professor of Public Health and Medical Administrator Avoca Beach, NSW AarrATnetspeed.com Emergence of global health strategiesRegard global health strategies as an opportunity to begin to redress the inequitable distribution of global resources, which can threaten social and economic stability and the health of people in all countries. Use many different discussion forums (eg, World Health Organisation, national medical associations, learned colleges) to prepare policy options for implementing these strategies. Mobilise multiple constituencies (eg, citizens’ groups, medical associations) to work with governments, organisations such as the UN, and international NGOs to influence the development and implementation of their global health strategies. Strengthen the role of civil society (ie, non-government elements of society) to determine the goals, priorities, and resource distribution of such global organisations. Peter E Baume Honorary Emeritus Professor, and Chancellor Australian National University, Canberra, ACT chancellorATanu.edu.au Marilyn J Wise Executive Director, Australian Centre for Health Promotion School of Public Health, University of Sydney, Sydney, NSW Human security, conflict and healthInvite the Australian Government to create a standing committee of relevant government departments and civil society representatives to consider global health issues in developing public policy (including foreign policy). Encourage the Australian Government to introduce the concept of human security into official foreign policy (as Japan, Canada and Norway have done). Form a coalition of academics and development practitioners to conduct a dialogue on health and development and to promote evidence-based policies. Develop a media strategy to improve public understanding of the issues and interests around global health. Build the study of global health and conflict into relevant undergraduate curricula and invite university schools of public health or health sciences to create opportunities for students to gain overseas experience by, for example, accrediting overseas units and placements, and facilitating internships with multilateral organisations, such as the World Health Organization and the World Bank. Undertake research and advocacy on conflict-related issues critical to public health, such as arms control. Sue Ingram Senior Policy Fellow, Policy and Practice Division Institute for International Health, Sydney, NSW singramATiih.usyd.edu.au Development and humanitarian aidCreate a "Coalition for global health" to:engage in dialogue on future policy formulation within AusAID. (This could influence a health issues and trends paper presently being developed as the basis for a new AusAID health policy.) form a strategy group that meets quarterly and would drive the global health agenda forward. develop a public information strategy that is based on policy goals, addresses public opinion, uses multimedia channels of communication, and identifies advocating champions. develop a mechanism for supporting public discussion that also identifies funding opportunities and targets the next generation of health and other relevant professionals. conduct an annual symposium on global health that continually evaluates progress and identifies ways forward. Heather B Macdonald Health Adviser, AusAID, Canberra, ACT heather_macdonaldAtausaid.gov.au Human rights and equity in health policyStrengthen ethical and human rights awareness in AustraliaThrough evidence-based advocacy, strengthening of organisations and public discussion. This could include an Australian Bill of Rights enshrining social, cultural and economic rights, so that society collectively thinks about and acts on these issues; and ethical considerations are taken into account in political and policy formulation processes. Strengthen Australian awareness of the ethical and human rights aspects of global healthThrough the development of such awareness in health, development and foreign policy professionals; support for the appointment of clinical ethicists in teaching hospitals; commitment to equity and diversity in health representation, employment and practice; and honouring Australia’s international human rights obligations, so that equity in health is realised, both nationally and globally. Seek to achieve an aspirational element to Australia’s foreign policy and international assistanceThrough influencing political and policy development processes, so that Australia acts to achieve the common good, globally as well as domestically. Elizabeth A Reid Visiting Fellow, Gender Relation Centre RSPAS Australian National University, Canberra, ACT elizabeth.reidATrunbox.com

The Global Health and Foreign Policy articles in this issue of the Journal leave us in no doubt that the answer to the question posed in the Symposium title is an emphatic “Yes”! There is a great deal of scope for Australian engagement. Symposium participants outlined some practical steps to strengthen the links between health and foreign policy by: broadening the public policy agenda; engaging civil society more closely in the policy debate; and improving public understanding of global health issues. What is needed to develop and advance this agenda? There was overwhelming support from Symposium participants for the creation of an Australian Coalition for Global Health (name yet to be determined). The broad purpose of such a Coalition would be to advocate for (i) considering health implications in developing Australian foreign policy and trade agreements, and (ii) reducing global health inequalities. It was agreed during the Symposium that, to achieve this goal, a small coordination group should be formed, which would comprise participants from non-government organisations, academia, the private sector and interested individuals. Nominations have been sought for this coordination group, the purpose of which would be to advise on the creation of the Coalition and the organisational arrangements underpinning it, as well as to examine possible funding options, agree on an appropriate name, develop terms of reference, and formulate a work program. The coordination group will meet over the next few months, with a potential launching of the Coalition by mid 2004. The strategic pathway the Coalition adopts to argue the case for increased importance of health in foreign policy will be critical. As articles in this issue highlight, there are many ways of viewing the prism. One current strategy promotes national self-interest, with a particular focus on topical issues such as controlling the international spread of infectious diseases and bioterrorism. Such a strategy may resonate with governments; however, there is a risk that broader global health considerations would be constrained by this limited agenda. Conversely, while a strong humanitarian and human rights-based approach might be more in tune with the beliefs of many of those advocating greater consideration of health in foreign policy, such arguments have not held much sway in the Australian political context in recent years. A promising pathway is proposed by McInnes (page 168).1 He argues that, in an environment in which national boundaries are of decreasing importance, “narrow conceptions of the national interest have become less relevant, and a more internationalist and communitarian perspective is required”. This strategy treads a fine line by arguing that Australia’s national interest is best served if our Asian and Pacific neighbours enjoy good health, robust economies, and good security. What is evident is that, unless a strong, active and broad-based advocacy group is formed in Australia, the considerable enthusiasm and desire for action evident at the September 2003 Global Health and Foreign Policy Symposium will dissipate.

Michael A Reid

Current international instability has promoted health to the foreign and security policy agenda; however, health is narrowly conceived in terms of promoting the national interest and defending the state, particularly from the risks of infectious disease and bioterrorism. This development involves the risk of global health being co-opted into an international agenda that focuses narrowly on security concerns rather than on broader global health issues. An alternative construction places greater emphasis on shared humanitarian values in a globalised world. This offers a more equal relationship between health and foreign policy and allows a broader range of issues (eg, trade in goods and services affecting health) to be considered in bringing together global health and foreign and security policy.

Colin J McInnes PhD

Although there appears to be no Australian foreign policy statement on health, much of our existing foreign policy has health implications, ranging across security, economic, political and humanitarian objectives. Humanitarian motives have influenced Australia’s foreign-aid policy, but our aid program, like our wider foreign policy, has a large national interest component. A generalised approach to health and foreign policy activities is difficult given the disparate direct and indirect links between foreign policy and global health issues, and the various official and unofficial interests and responsibilities involved. The greatest benefit may come from the health community making its own judgements on health priorities and seeking to engage in specific terms with foreign policy makers.

Stuart Harris BEc (Syd), PhD

Recruitment by wealthy countries of health personnel from developing countries is threatening the viability of crucial health programs in poor countries, especially in sub-Saharan Africa. Australia has participated in this “brain drain”, although the extent and impact of this on different countries has not been adequately assessed. Australia depends on overseas-trained doctors to fill vacancies in public hospitals and private practice, particularly in rural and outer suburban areas where locally trained professionals are reluctant to work. Australia should adopt national strategies to minimise harm and maximise benefits of skills migration; concerted international action will also be required.

Mark L Scott BA · Anna Whelan PhD, AFCHSE · John Dewdney MD, SM, DPH · Anthony B Zwi MB ChB, PhD, AFPHM

Building better health. A handbook of behavioural change. C David Jenkins. Washington DC: Pan American Health Organisation, 2003 (Available free, xvii + 378 pp). ISBN 92 75 11590 7. David Jenkins set out to produce an easy-to-read introductory text on behaviour change in support of health promotion, and to a large extent he has succeeded. The style is readable and the text provides a theoretical framework, a clear examination of the epidemiology of common problems, and plenty of practical examples. It steers clear of scientific controversy, as befits a book intended for, among others, "a school teacher, a town council member, a dedicated parent". The disappointing aspect is what he does not include, given the role of the World Health Organization in such radical rethinking of health strategies as the Declaration of Alma Ata and the Ottowa Charter. The authors of those statements would be disappointed — health promotion is much more than just behaviour change. Despite the history of Latin American radicalism throughout the 20th century, Professor Jenkins charts a rather safe and conservative course. Tackling "hunger epidemics", he suggests better methods of food storage and handling, the introduction of new crops, cooking classes, and more productive fertilisers. All well and good, but what of the basic problem of landlessness throughout the Americas? Why no mention of people like Paulo Freire, who used basic literacy work to enhance political awareness in precisely the way that this book does not? Jenkins suggests reducing firearms-related injuries by keeping guns locked away, to add "cooling-down" time to the process readying them for use. He never mentions what might seem obvious to everyone outside the United States — limiting ownership of firearms by the citizenry in the first place. I would recommend this book to the health workers and community members who are its target audience — but with the proviso that they do not read only this book, and that they use it for reference and not as their primary inspiration. James F P BlackHead of Epidemiology Victorian Infectious Diseases ServiceMelbourne, VIC

James F P Black

Health and foreign policy — unlikely bedfellows? Perhaps . . . Current world interest in the ties between security, poverty, health, human rights, globalisation, and trade was an important backdrop to the symposium on Health and Foreign Policy: Scope for Australian Engagement, held in Sydney on 18–19 September 2003. Whether such a meeting would have taken place before the 2001 attack on the World Trade Center in New York is a moot point. Nevertheless, conference delegates were keen not to focus primarily on the “war on terror”, but rather, on “upstream” issues of social justice, equity, development, conflict prevention and human security. Opening addresses by the Honourable Professor Marie Bashir (Governor of New South Wales) and Kay Patterson (then Federal Minister for Health and Ageing) both stressed the imperatives for closer links between health and foreign policy. The symposium was co-hosted by the School of Public Health and Community Medicine, the University of New South Wales (UNSW), and the Institute for International Health, University of Sydney. The Nuffield Trust, United Kingdom, supported student attendance and brought a dynamic team from the UK to engage Australian academics and policy makers. Nearly 140 people with backgrounds in aid and development, trade, the pharmaceutical industry, non-government organisations, health services, international relations, human rights, and public health met to formulate ideas for better links between these unlikely partners. “There can be no new consensus, no new order, no stability, without tackling the appalling poverty that afflicts nearly a half of the world’s population.” — Tony Blair (quoted by Sir Alastair Goodlad at the pre-symposium meeting in Canberra)1 The symposium followed a key meeting in Canberra organised by the Nuffield Trust with the Australian Department of Health and Ageing, and attended by Australian and British policy makers in health, foreign policy and aid, academics, and Australian Foreign Minister Alexander Downer. Mr Downer stressed that, to deal effectively with issues such as the burden of ill health on economies, HIV/AIDS, sudden acute respiratory syndrome (SARS), and the availability of drugs for common diseases, “global health can no longer be the preserve of national health ministries . . . global health is a foreign policy issue”.2 Governance and capacity building were identified as crucial to ensuring that weak states can deliver health services, are supported to avoid collapse, and can tackle poverty. GlobalisationAt the Sydney symposium, Dr Kelley Lee (London School of Hygiene and Tropical Medicine) defined globalisation as: a set of processes intensifying human interaction across economic, political, sociocultural, environmental and technological realms. These changes are evident across spatial, temporal and cognitive boundaries. As examples, she highlighted the risk of emerging anti-microbial resistance and its accelerated spread as a result of global travel and international trade. Similarly, obesity and related health problems are reaching low- and middle-income countries, associated with rising consumerism and decreasing local food security. Professor Ron Labonte (University of Saskatchewan) described the immense effect of globalisation on health within and between nations, such as the impact of global trade in processed food. He also highlighted the limitations of departing from an “upstream” focus on determinants of health, health promotion and primary healthcare, to more “downstream” responses to disease. Stuart Harris (Emeritus Professor of International Relations, Australian National University [ANU]) drew attention to the inevitability of some health considerations creeping into the foreign policy domain. The SARS epidemic revealed how emerging infections can rapidly, systematically and severely affect trade, tourism and perceptions of risk and safety. Global epidemics of HIV/AIDS, the unfinished agendas of tackling malaria, tuberculosis and child health problems, and the emerging problems of chronic disease, mental health and injuries and violence continue to pose significant challenges. Professor Kalinga Tudor Silva (University of Sri Lanka) highlighted the links between growing globalisation and collective violence. There is mounting concern with how disease undermines economies and weakens states, with potential consequences of instability and violence. International governing structures no longer seem adequate to address such complex challenges. Health and human rightsChris Sidoti (Human Rights Council of Australia) and Elizabeth Reid (Gender Relations Centre, ANU) propelled health and human rights to the centre of the debate. While the right to health is not an absolute right, it is a right to be “progressively realised”. It includes the right to control one’s body and the right to equality of healthcare access. Specific rights often articulated include access to quality maternal, child and reproductive healthcare, healthy workplaces and natural environments, disease prevention, treatment and control (including access to essential medicines), and access to safe and potable water, sanitation, and nutrition. In 1990, the Commission on Health Research and Development (COHRED) described the 10/90 disequilibrium — only 10% of research and development spending is directed to the health problems of 90% of the world’s population. The Special Rapporteur of the Commission on Human Rights argues that the very neglected diseases and the 10/90 disequilibrium are human rights issues. Symposium discussions displayed solid commitment to ensuring better access to basic drugs in developing countries. Delegates also learned and voiced concern that Australia has introduced restrictive policies, especially with respect to reproductive health. For example, partner organisations of the Australian Agency for International Development (AusAID) are prohibited from using funds for “activities that involve abortion training or services, or research, trials or activities which directly involve abortion drugs”.3 The Australian Government has also stopped funding to the World Health Organisation’s Human Reproductive Programme and the Population Council (Dianne Procter, Chief Executive Officer, Australian Reproductive Health Alliance, personal communication). These policies are more restrictive than domestic policies, are in tune with those of the United States, and appear to influence practice and values in recipient countries in ways that arguably conflict with international human rights law. Conference delegates pondered the ethics of applying stringent conditions in foreign assistance while not applying the same standards at home. Humanitarian and development assistanceThe generalised decline in development aid funding was seriously challenged. Despite the internationally accepted benchmark that 0.7% of gross national product (GNP) per capita be spent on international assistance, the US contributes about 0.1% and Australia 0.26%. The UK has recently and dramatically reversed its steady decline in development funding, as described by Dr Julian Lob-Levyt (Department for International Development, UK). The UK commitment to poverty eradication, a more humane globalisation and the United Nations Millennium Development Goals4 were widely applauded. There has been a shift toward humanitarian relief funding directed at addressing instability and collective violence, but this emergency response has limitations, especially in influencing longer-term development. Professor Anthony Zwi (UNSW) elaborated several reasons for the decline in development aid: the end of the Cold War (as the value of propping up client states in the developing world is less apparent in our era), difficulty proving the direct benefits of aid funding, critique of the role of the state, and generalised cynicism about internationalism. That links exist between poverty, sociopolitical instability and inequity seems a logical notion. Yet, as Sue Ingram (Institute for International Health) pointed out, the evidence base for these links and for development assistance as a means to break them is not particularly strong, warranting further research and debate.5 Underlying concerns at the meeting were the rising trends in inequity in health and healthcare. There is disturbing evidence that health sector reform and macroeconomic structural adjustments within a globalising world may have contributed to increasing inequity within and between various countries. Examples include the 10/90 disequilibrium and the negative effect on the household economies of poor countries of having to pay more for healthcare. Various conference delegates expressed concern with AusAID’s stated objective of primarily benefiting Australia,6 given potential and actual conflicts of interest between this objective and the development needs of the poorest nations. Delegates supported proposals endorsed by the Development Assistance Committee of the OECD. These proposals were to ensure that aid is less tied to the country providing assistance and more to the development and poverty eradication needs of the beneficiary country. Towards an Australian global health coalitionThe symposium ended with a call for a much more vigorous engagement by Australian stakeholders in shaping global health issues. All were challenged to rediscover pride in Australia’s contribution to global health, aid, development, and human rights and to put behind the period in which harsh approaches to refugees and asylum seekers had shamed Australia’s international reputation. The meeting concluded with a commitment to take this forward by establishing an Australian coalition on global health, which will promote new thinking and seek an aspirational, progressive content to Australia’s aid program.

Anthony B Zwi PhD, FFPHM · Michael A Reid

This is a brief account of my six months in Afghanistan in 2003. I worked as the Médecins Sans Frontières (MSF) project doctor in the western province of Herat, spending alternate weeks in Herat City and in Kushk-e-Kohna, a sparsely populated district some two hours north of the provincial capital by four-wheel drive. I arrived in February, just over two years after the US-backed overthrow of the Taliban. Herat is now controlled by its Emir and Governor, Ismail Khan, who rules beyond the reach of Afghanistan’s central government. With a private army of sixty thousand men and control of customs revenue from trade with Iran, it is no wonder he has not, despite invitation, joined the government of Hamid Karzai. His unchallenged power and the considerable wealth at his disposal have in fact made Herat relatively more stable and prosperous than the rest of the country. It is February, and the winter snows are just thinning as I arrive to work in the mobile clinic in Kushk-e-Kohna, which I affectionately call “Kushk”, or “palace”, in the local language of Farsi. The name clearly harks back to a more prosperous time, for there is no palace to be found in this district of sixty thousand people. The inhabitants have mud-brick houses and live mostly off subsistence farming, growing wheat (Box 1) and raising livestock (Box 2). They have lived like this for generations, and life was little different under the Taliban, although now it is evident that young girls are going to newly built schools. There are only two doctors for the entire population — myself and an Afghan doctor recently recruited by MSF. Dr Mohammad Amin has recently graduated, and is enthusiastic about working with MSF, learning English and broadening his knowledge. Before 2003, locals had to gamble on the only “healthcare” available — drugs sold in private pharmacies by untrained “drug sellers”. And so it is that after a week I begin getting used to the hundreds of patients presenting every day, many having walked for hours, thronging around the makeshift consultation room and desperately pressing to be seen (Box 3). The mobile clinics are situated across the district, with MSF’s base in the district centre of Kooklam. We visit one or two villages each day, staying until dusk. Each clinic is one to two hours’ drive from Kooklam over rough terrain and is visited every two weeks. The crowds are becoming more manageable as we begin using mass consultations to get through the large numbers of patients, seeing thirty at a time and triaging by casting an eye across the crowd to identify the seriously unwell. In so doing, Jodie, the expatriate Australian nurse who is assisting me, spots an unconscious child and distressed father. The four-year-old is clearly very unwell. His head is arched back, and the petechial rash across his upper chest confirms the diagnosis of meningococcal meningitis for us. Without pathology services or a hospital nearby, we treat him with an intramuscular dose of oily chloramphenicol, which will slowly be absorbed over the next week. We urge the boy’s father to take him to Herat City Hospital, but he doesn’t have the four dollars to hire a taxi, nor can he leave his wife and children unaccompanied at home. Afghan culture dictates that any woman must be accompanied by her husband or a male relative, and so her husband stays. I find it difficult to overcome the sense of despair and helplessness in treating an often fatal illness in a day clinic, but hope for some response regardless. It is therefore with joy and surprise that we see little Nazamuddin two weeks later, alive and well, on our return to the village for another round of consultations. I had not seen chloramphenicol used like this before, but am told that it has been used successfully in meningococcal outbreaks in Sub-Saharan Africa. Our feeding program runs concurrently in the old storeroom next door. Forty children are getting supplementary food and standardised medical care today. They receive a corn/soy/bean mix, iron/folate tablets, vitamin A, mebendazole and antibiotics on their first presentation. They are treated for malaria if febrile. Any severely malnourished children (who should really be in a hospital), will at least get some treatment to optimise their chances while remaining at home, and will be seen by us on a fortnightly basis. These children will get oily chloramphenicol, the wonder-drug, when they first present, and a special nutritional supplement, PlumpyNut, of which they are quite fond. It is a so-called “ready-to-use therapeutic food” containing peanut. Jodie oversees the activities, but the Afghan staff have it running like clockwork, undressing and weighing the children, crushing their tablets into a paste, and giving parents cards to pick up the food bags and to record their children’s progress. Our health educator is speaking to the crowds about hygiene and diarrhoea. The outreach workers are busy screening new patients for malnutrition, and occasionally I review one who appears particularly unwell. Tuberculosis seems to occur everywhere. Many patients have bought antituberculous drugs from local pharmacies, taken them for a few weeks, then stopped taking them because of the expense. No-one has been formally diagnosed, and several don’t have TB at all, but the fear of it is great, as they have seen relatives become weak and die. Patients I diagnose can’t go to Herat, where MSF’s directly observed short-course treatment (DOTS) TB program1 has just commenced. So all I can do is entreat them not to buy more TB combination blister packs from Pakistan, telling them that they will get resistant TB and that they should wait for a rural TB program to start (although this is certainly years away). I wish I could offer them the services of our Herat TB program, which is a runaway success — I am heartened to see many patients who were initially brought to us in wheelbarrows now looking completely well. For me, their deep gratitude is humbling and heart-warming. The consultations en masse become an unexpected forum to talk to Afghan women about their mental health. There is one psychiatrist for the entire province of two million people, so discussing mental health is unheard of in this conservative, desperately poor district. When women present in great numbers, all complaining of “body pain”, we decide to see them together to explain the nature of their illness. Body pain, as a complaint, is hardly known in Western countries, yet is a common complaint of southern Asia and the Middle East. Women, and sometimes men, report months or years of head, shoulder, back, leg and arm pain. In a country that has suffered twenty-five years of civil war, it is clear that psychological trauma, grief and personal loss contribute greatly to how this problem manifests.2 I therefore find myself in an unusual position — male, foreign and non-Muslim, yet privy to the private traumas of rural Afghan women. Some have lost husbands, and many, many have lost children. Nasima is heavily pregnant and pleads with me to keep her child alive, as she has lost eight previous children in pregnancy or in the first year of life. In Afghan society, no woman is complete without bearing children. Through her clothes, I feel her abdomen. I feed my stethoscope under her clothing to auscultate, without revealing her skin. Through all this she keeps her headscarf across her face, and speaks quietly from behind her hand. We prescribe what we give all women in late pregnancy: ferrous sulfate, folate, and multivitamins. It is a rural tradition to cut the umbilical cord using the heel of a shoe, with its obvious risk of causing neonatal tetanus. We therefore urge her to visit the MSF clinic in the district centre for her first tetanus vaccine, and advise against the traditional practice. Unfortunately, the four-hour ride by donkey to the clinic is a difficult prospect for a woman eight months pregnant. There are other misconceptions to overcome. Afghan women throw away colostrum, critical for a newborn, giving a child water or tea for two to three days. Such ideas are entrenched, but as expatriates we are regarded somewhat as magicians, and listened to intently. Abdul Rafour, a man in his forties, is being led into our dusty consultation room. He removes his dark glasses, and we realise he has no eyes. His face is a patchwork of scars. He has been a victim, some years earlier, of one of Afghanistan’s ten million landmines. He complains to me of deafness and inability to sleep, and it is soon clear that he suffers from post-traumatic stress disorder and bilateral chronically perforated ear drums. What can I do for him? Nothing at all. I call the next patient in. Today’s drive home takes two hours in a three-car convoy (Box 4), mostly along a dry riverbed. I listen to my portable CD player as I take in the serene vista of the foothills of the Hindu Kush mountain range. There are twelve of us squeezed into the landcruisers: expats and Afghanis, drivers, a translator, a feeding centre supervisor, outreach workers, a health educator, a registrar, a doctor’s assistant and a scooper for the food distribution. We’re all sitting on or around our portable gear: tables, chairs, mats, medication, dressings, height boards and scales. On the way home there is more room, as we have distributed over three hundred kilograms of food during the day. Arriving at our compound (Box 5), we play cards, then volleyball. I fit in a quick snooze and some reading by lantern light until dinner (rice, eggplant, tomato and bread). I go to bed early, to the familiar, vibrant singing of the Afghan staff outside. Afghanistan has given me a profound insight into the challenges of aid work in a country ravaged by twenty-five years of civil war. The US-led attack on the Taliban in 2001 was only the most recent trauma in a long history of terrible conflict. What is emerging now is a tenuous and fragile peace, with ongoing conflicts between rival warlords, guerilla attacks by Al Qaeda and Taliban remnants, and no effective unified government or military force. In this context, the challenges of aid work are only partly medical. Many of the obstacles to bringing health to the Afghan people have to do with politics, security, culture and trust. For Afghanistan, the first incremental steps are being made to tackle the appalling health situation, but there needs to be a foundation of stability, security, economic growth and basic education before significant inroads can ever be made. It is a country with a burden of disease that is mostly preventable, a country poisoned by land mines, and where the fundamental right of access to basic medical care is still an unattainable aspiration for most. Most importantly, if Afghanistan is to leave behind its tragic past, its plight must not be forgotten by the international community.

Brett A Sutton

Finding a niche and fulfilment in Australia When the MJA contacted me about writing a “perspective”, I was initially delighted, thinking that it would be related to my research in breast cancer testing. When the word “personal” entered the discussion, I hesitated, then agreed — I owe that much to my mother, my teachers, and Priscilla. My migrant background has, in many ways, given me a broad perspective of what a community is, and I have grown up comfortable with seizing the best of different cultures. At 38 years of age, I tend to see life as a series of challenges and opportunities, and I feel very fortunate that, in Australia, I have always had sufficient support to make the most of these. My twin brother Hadi and I were born in Beirut, Lebanon, into a relatively wealthy family, the youngest of six children. I guess one could say we had everything — loving parents, private schools, and a huge apartment in the heart of Beirut. There was never any plan to migrate to another country. When I was about 6 or 7 years old, things started to go wrong with my parents’ health. First, my mother, then in her early thirties, developed renal failure that rapidly deteriorated, necessitating a transfer to Melbourne under the care of a Dr Priscilla Kincaid-Smith, with a view to transplantation. She was supposed to return soon after, but never did. Then, within about 8 months, my father suffered a heart attack and died. I was later to hear from my mother about her wonderful Australian renal physician, who had treated her kindly and broken the news of my father’s death to her while holding her hand. Because of my mother’s very favourable experience with her medical care, she naturally wanted to remain where she had received her transplant, and it was decided that we would join her in Australia. It was to be another 3 years before we were re-united with my mother. It was a painful time, and, while we were looked after by various members of my mother’s family, my oldest sister Sahar (then aged only 13 years) had responsibility for taking care of “the twins”. The cost of care for six children during that time consumed nearly all our resources. When I arrived in Sydney, aged almost 11 years, I thought that this was the most wonderful place in the world (and still do), although I could not speak a word of English. There seemed to be an abundance of everything, plus a backyard with pets! In retrospect, being re-united with my mother was what largely influenced my view of my new country. I found most things easy to learn and, having had a bilingual education (I spoke fluent French and Arabic at the time), English was a relatively easy language for me to learn. By the end of my first year at school, I was communicating well, had made a few friends, and was topping my class in science. At school, and to a much lesser extent at university, there was the inevitable taunting, and the occasional “wog” labelling. It rarely affected me, and in many instances I chose to ignore it. My school teachers were very encouraging, and within a few years had put me on the school debating team. Debating was an extremely arduous task, as I still “thought” in Arabic, yet had to express myself in English. My mother, like many people of non-English-speaking backgrounds, had a strong belief that, armed with education, you could do almost anything. She wanted me to do well enough in the Higher School Certificate (HSC) to gain entry into medicine (and of course would talk of why I should become a renal specialist!). I studied hard and expected to do well in the HSC, but was surprised to come first in my school, and gain entry into medicine at the University of Sydney. It feels as if Sydney University has always been a part of my life, from medical school until the present. During my undergraduate days, and through the three postgraduate degrees I subsequently completed at this university, I rarely encountered discrimination and felt generally happy. Yet, until I commenced the clinical years, I was unsure about whether to continue with medical school, as the non-clinical years gave me little indication as to whether I would enjoy providing care for people. Lidcombe Hospital was a teaching hospital at the time, and a great place to learn the art of clinical care. The tutors were enthusiastic, and we had a particularly inspiring medical tutor who seemed to know more medicine than the textbooks. By the time I completed my medical degree in 1987, I was fairly sure I wanted to be a doctor (but one with little interest in kidneys!). I was also sure that I had found the perfect partner. However, having been brought up in a strict Moslem family, boyfriends were not allowed, let alone Italian–Australian ones. We announced our engagement amidst strong (but short-lived) objections from both his family and mine, and my fiancé, along with my mother and siblings, celebrated my graduation in 1988. I completed my internship and a year of residency at Concord Repatriation General Hospital, a wonderful hospital to work in for general medical rotations, especially for unfortunate souls like me who were undecided about specialising. The internship included a secondment to Auburn Hospital, with its culturally diverse community, where I frequently saw Arabic-speaking patients in the emergency department. They genuinely appreciated being able to communicate with their doctor without a third party, and there were occasions when particularly sick elderly patients would grab my hand to kiss it, a gesture of appreciation in many Arab cultures. During my internship, I got married, and managed to celebrate with two wedding ceremonies, a Moslem one and a Catholic one. Early in 1990, I accepted a position as a breast clinician in one of Sydney’s private breast centres (Sydney-Square Breast Clinic) under the mentorship of Dr Joan Croll, one of Australia’s pioneers of mammography. Being able to help women with breast symptoms, who generally felt very vulnerable, and to spend time discussing management options with them, was very rewarding. I was soon convinced that this was the medicine I wanted to practise long term. Around that time, the methods of breast cancer detection were evolving, and our unit was one of the pilot sites for Australia’s breast-screening initiative, as well as one of the first centres to use ultrasound-guided needle biopsy. There was much to learn and do, and clinicians like me who were responsible for “triple testing” of breast abnormalities (by clinical examination, imaging and biopsy) were called “breast physicians”. Life events 1965 Born in Beirut, Lebanon 1972 Mother is transferred from Beirut to Melbourne for a renal transplant 1973 Father dies of a heart attack 1976 Siblings and I migrate to Australia and are reunited with my mother in Sydney 1988 Graduate in medicine from the University of Sydney Marry in two wedding ceremonies (Moslem and Catholic) 1988–89 Internship and residency at Concord Repatriation Hospital 1996– 2002 Medical Director (and, subsequently, Director), MBF’s Sydney-Square Breast Clinic 1997 Graduate Master of Public Health 1998 First child (Nadine) is born 1999 Graduate Master of Education 2002 Move from private practice to NSW Breast Cancer Institute, and the Royal Hospital for Women Complete PhD thesis: Accuracy of mammography and ultrasound in women with breast symptoms Second child (Laura) is born 2003 Graduate PhD Senior Lecturer, Screening and Test Evaluation Program, School of Public Health, University of Sydney I was 30 years old and had worked in multidisciplinary breast services for several years when I was appointed Medical Director of the Sydney-Square Breast Clinic. Although a little anxious about the responsibility, I was eager to do a good job and ensure that we provided a high standard of care to our patients. It was in this phase of my medical career that I first experienced some discrimination. The team of more than 40 staff was generally supportive, but I was aware that a few of my peers did not consider that I had the appropriate profile for the role. It was difficult to ascertain how much of this was due to my youth, my ethnicity, or perhaps my lack of a high profile, compared with that of my renowned predecessor Joan Croll. This was, however, transient. I remained in that role for 7 years, and during that time I combined clinical work with postgraduate study and research in public health, and developed a research profile for the centre in breast diagnosis, particularly in breast imaging accuracy. My research mentor, Professor Les Irwig, changed my life. Not only did he teach me the skills for conducting research, he provided invaluable advice and tolerated my “I give up” tantrums through an MPH and a PhD in clinical epidemiology. Last year, after a short break to have my second child (the baby having arrived a fortnight after I completed my PhD thesis!), I switched from private practice back to the public hospital system. I currently spend half my time at the New South Wales Breast Cancer Institute, working in services that range from a “benign disease” clinic to a “metastatic breast cancer” clinic. I also consult at the Royal Hospital for Women’s breast centre, seeing women with predominantly symptomatic breast conditions. The rest of my time is spent at the School of Public Health at Sydney University, continuing breast cancer research. Maintaining the balance between clinical and academic work is certainly a challenge, but I think the greatest challenge is spending enough time with my family, and making sure that my Australian children grow up with an appreciation of both the opportunities that surround them and their mixed heritage. We live in a part of Sydney that is greatly enriched by Italian–Australian culture, and my children are able to learn Italian at the local school, celebrate Italian fiestas, and visit Casa d’Italia on a regular basis. I think there is less opportunity for them to discover their Lebanese heritage, and I wonder how I can change that — with my busy life I myself have become increasingly distant from it. In a few weeks’ time, I will sit the Public Health Physicians Fellowship exams. I consider my chances of passing to be slim — breast cancer control is but a tiny fraction of the broad field of public health medicine. However, I am optimistic because of the enormous amount of help I am receiving from the public health medicine community, my colleagues at the Breast Cancer Institute, my husband, and Julia, a fellow candidate for the exams, who has been coordinating our study group. At my PhD graduation earlier this year, my husband and oldest daughter (aged 5 years) celebrated with me. My mother was not there, but I think she would have been proud. She passed away many years ago, aged 54 years, 20 years after her transplant. A few weeks before she passed away, she asked me if I had ever met Priscilla Kincaid-Smith (but the answer was no, and I still haven’t met Priscilla).

Nehmat Houssami MB BS(Hons), PhD, MPH

Two generations of Santoros have served the Italian community of Melbourne for over 70 years My father, Soccorso Santoro, was born near Naples, Italy, in 1902. After graduation in medicine from the University of Genoa and internship at Alessandria, north of Genoa, he was called up for military service in the Battalion of Doctors and Pharmacists. On completing this service, he decided to travel around the world. As he spoke English well, and Italy was an ally of Britain in the 1914–1918 war, he took the sensible precaution of registering his Genoa medical degree in London, which allowed him to practise throughout the English-speaking world. Soccorso Santoro unveiling Dante, Melbourne, 1958 Soccorso Santoro (standing) at the official unveiling of a bust of Dante Alighieri (a gift of the Dante Alighieri Society to the City of Melbourne) in the Treasury Gardens. When Soccorso resigned as President of the Society after nearly 20 years, he received a gold medal “Società Dante Alighieri” for his long service and for promoting the Italian language. In June 1930, my father sailed to Australia on the Orient Line’s “Orama”. He arrived in Melbourne well equipped with the appropriate medical, surgical, obstetric and even dental instruments (his degree gave him the right to practise dentistry, although he never did). He started practice in the “Professional Chambers”, 110 Collins Street, Melbourne, in August 1930. In 1933, he married my mother, and in 1935 I was born. My father’s gross income in the previous year was £761 ($1522), and he stated in his 1935 tax return that as his “. . . practice consists of mainly Italians . . . scattered in all suburbs of Melbourne . . . , [his] average monthly mileage is 1200”. He noted that petrol was 1 shilling and seven pence (15 cents) per gallon (3.5 cents per litre)! My father’s practice was not easy. Most of his patients were working-class Italians, who would occasionally sit on the floor in the corridor outside his rooms, to the surprise of the specialists in three-piece suits and watch chains also practising in the building. My father spent a great deal of time translating for patients and accompanying them to specialists. This was an era of great respect for the family doctor, who was the confidant of many families. Migrants wanted someone who could understand them and their family ties. As their children mixed with local children, family strictness and unity broke down; many children refused to speak Italian and were desperate to be considered Australian. This rejection was upsetting to the older migrants, especially as they relied on the young to interpret. My father took me on home calls to the Italian families around Carlton. They would be roasting coffee or making spaghetti, ravioli, salamis or prosciutto, but all work would cease as the whole family became involved in prolonged conversation with my father about some medical problem. It was unusual for him to complete a home call in under an hour. My father was also involved in the Dante Alighieri Society, which promotes Italian culture and language, and was its president from 1931 to 1959. He was a delegate of the Italian Red Cross and responsible for financial donations, as well as the official doctor of the Italian Consul General in Melbourne and the Italian shipping lines. When war was declared in 1939, my father was interned in a camp at Tatura in Victoria. Through the efforts of my mother, an Australian citizen, he was released after 6 weeks, while other Italians remained for the duration of the war. The conditions were that he report to Kew police station three times a week, not travel more than 40 kilometres from Kew and not go near the beach on Port Philip Bay, as he might signal enemy shipping! He was allowed to continue practice in Collins Street, but no more than two other Italians were to be in his surgery or waiting room at the same time — as a meeting of four was defined as a conspiracy. Any other Italian patients were asked to “go for a walk around the block”. For the same reason, tennis could not be played at our home with other Italians. The prohibition on speaking foreign languages on the telephone restricted history-taking before home visits. Our home was searched for subversive literature, but the complete library of the Dante Alighieri Society, hidden under the house, was not found. Nevertheless, our family was treated with great courtesy by the authorities, and, the few times I visited my father at Tatura camp, I remember Australian soldiers giving me oranges and playing with me. In 1948, my father made his first trip back to Italy (a 96-hour plane flight) to see his family. Back in Australia, he continued to work tirelessly to promote the Italian community. For instance, he mobilised Italian clubs to donate to St Vincent’s Hospital’s building program in 1953 and presented 200 books by Italian authors to Melbourne Public Library in 1956. In 1960, the Italian language was accepted as a subject at the University of Melbourne, and an annual “Dr Santoro Prize” is given to the best student in first-year Italian. In 1960, my father received the honour of “Cavaliere Ufficiale” (Officer of the Order of Merit of the Republic) from the Italian government. In 1961, on a trip to Genoa, he suffered a heart attack and was admitted to the same hospital in which he had studied medicine. In the preceding months, he had contacted many of the 1926 graduates from the Genoa medical school to arrange a 35-year reunion. It was not to be. He died on 10 July 1961, aged 59, having practised in Collins Street for 31 years. Soccorso Santoro 1902 Born Serino Italy 1926 Graduates in Medicine from the University of Genoa, Italy 1927–28 Internship at Alessandria, north of Genoa 1928–29 Military service 1930 Registers as medical practitioner, London, and sails from Naples to Australia 1931–61 General practice, Collins Street, Melbourne 1933 Marries Vida Clancy (a nurse who trained at St Vincent’s Hospital), at St Ignatius Church, Richmond 1935 Attends British Medical Association 103rd Annual General Meeting and 1st Australian Congress (Melbourne); first Italian member of the BMA in Victoria (his copy of the Book of Melbourne Australia 1935, a review of contemporary medical practice written for this conference, is still in my possession) 1940 Interned as an enemy alien at Tatura, Victoria, for 6 weeks 1956 Official doctor for the Squadra Olimpica Italiana, in Melbourne for the 16th Olympic Games 1960 Cavaliere Ufficiale, Republic of Italy 1961 Dies Genoa, Italy, aged 59 years George Santoro 1935 Born Melbourne 1962 Graduate in Medicine from the University of Melbourne 1965–2001 Solo general practice in Richmond, Victoria 1970–2001 Nominated Medical Officer for Italian government, assessing Italian pensions and past work-injury claims 1976–99 Treasurer and President of the Medical Benevolent Association of Victoria 1977 Cavaliere, Order of Solidarity of Republic of Italy 1983 President, Victorian branch of the Australian Medical Association 1983–present Director, Medical Defence Association of Victoria 1984 Cavaliere Ufficiale, Republic of Italy 1983–96 Inaugural President, Italian Medical Society 1986–94 Federal Council, Australian Medical Association 1988–89 Chairman, Lord Mayor’s Fund for Metropolitan Hospitals and Charities 1989–97 Board Member and Chairman, St Carlo Complex for Italian Aged 1990 Member, Order of Australia 1994 Commendattore Order of Merit, Republic of Italy 1994–present Director and Treasurer, Melbourne Division of General Practice 1994–99 Board Member, Faculty of Medicine, University of Melbourne 1996 Current Member of Order of Australia Council (Governor General’s committee for Australian honours) The year after my father died, I graduated in medicine from the University of Melbourne. Internship at Queen Victoria Hospital and locums in a few Italian and Australian practices led me to practise in the inner, (at that time) industrial, suburb of Richmond, where many Italians lived and worked. There was no alternative to solo practice, as few general practitioners spoke Italian, and a non-Italian-speaking partner could not have shared the workload equally. I was on call 24 hours a day to a large group of patients, as my father had been. In this situation, deputising services were a godsend, and, in 1970, I helped develop a service which still operates today. In caring for the Italian community, not only is the capacity to communicate in Italian important, but so is the cultural understanding of illness. “Fire of St Anthony” explains the excruciating pruritis of shingles nicely, while an inability to weed or tend a vegetable garden suggests the shortness of breath of cardiac failure. I enjoyed my numerous home visits, which gave enormous insight into patient care. Taking a detailed medical history often revealed past medical misunderstandings, which had led to inappropriate medications and unhelpful stereotypes, such as “Mediterranean backache” and “Mediterranean gut ache”. I found it best to involve the patient and family and their opinions of the illness, its cause and treatment. Compliance with treatment is increased if combined with traditional management; dietary restriction is relished, as this supports the sick person being the centre of family attention. In my career, I have also found time for community service as office bearer of the Victorian branch of the Australian Medical Association and the Medical Benevolent Association. I also formed the Italian, Greek and Chinese medical societies and was the inaugural president of the Italian Medical Society for 14 years. Many ethnic doctors feel isolated from their Australian peers because of the unusual demands of their ethnic patients. I have a particular interest, as chairman of the board of a home for Italian aged, in the special accommodation needs of ageing migrants. I was very proud to be honoured by both the Italian and Australian governments for my contribution to the health and welfare of the Italian community. Recently, I have been involved with Dr Tony Mariani, current president of the Italian Medical Society, in producing a 300-page book on preventive medicine, in English and Italian, to assist migrants in lifestyle choices. With continuing migration to Australia, there is still much to be done toward compassionate primary medical care. My family’s contribution gives me great pride.

George R Santoro AM, MB BS, FAMA

In 1978, when I was a Fellow in Ophthalmology at the Johns Hopkins Hospital in Baltimore, I went to a seminar given by one of the senior faculty (Maurice Langham) about work he was doing on an unusual disease called onchocerciasis. Although I must have learnt about onchocerciasis at medical school and during my ophthalmology training, it was such an esoteric tropical disease in small print that it had made no perceptible impact on me. Actually, onchocerciasis is a fascinating disease. It is also called river blindness, as those who are affected live along rivers and streams. It affects about 20 million people; 99% of these live in Africa, with a few in Latin America (see Box 1).1 In endemic areas, half will become blind before they die and, at any one time, some half a million people with onchocerciasis are blind. Onchocerciasis has had a devastating impact in Africa. All but the poorest of the poor have abandoned the endemic areas. In the worst affected villages, everyone is infected by the age of 14 or 15 years.1 People go blind in their 20s and 30s, just when these subsistence-farming families are raising children. Once blind, parents often need to be led to their fields by their young children. This has a devastating effect on all aspects of the villagers’ lives. There have been various attempts to treat and control onchocerciasis. During the Second World War, tens of thousands of Australian and American soldiers fighting in the Pacific islands were afflicted with lymphatic filariasis. Wartime drug development led to the discovery of diethylcarbamazine (DEC) that would halt the progression of, and sometimes cure, filariasis. After the war, DEC was tried on some people with onchocerciasis and was found to have a temporary holding effect.1,2 DEC was better than nothing, but its use was limited, as many infected people had a severe reaction to the treatment caused by the sudden death of billions of microfilariae, the so-called Mazzotti reaction.3 Sleeping sickness or trypanosomiasis is almost invariably fatal. During the First World War a drug called suramin was developed in Germany that could save some people with sleeping sickness, although it was very toxic. It was tested and found to be effective against onchocerciasis, but 2%–3% of those treated died and so it was not widely used.4 The World Health Organization had started a major program to control onchocerciasis by spraying breeding sites to control the black fly vectors. This program started in 1974 in 11 countries in West Africa. Breeding sites in rivers and streams were “bombed” each week with the aerial application of larvicide. This was an effective, if slow and expensive, method of controlling the disease in open savanna but, because of problems with aerial access, it could not be used in rainforest areas. This was the state of play as I listened to Langham in Baltimore describe the human studies to treat onchocerciasis he had recently done in Africa. After the lecture, I suggested some clinical trials he could do. It seemed so simple to me then: get a small team of two or three people and a bit of equipment to examine people and do a prospective randomised trial. I had had great lab training at the Royal Melbourne Hospital under Peter Morris (later Professor Sir Peter Morris), and I had had an extraordinary experience of working in the field with Professor Fred Hollows when I travelled throughout outback Australia on the National Trachoma and Eye Health Programme. I little suspected how much I still had to learn, but Langham proposed that I should do the study and offered to help me put it together. Within a few months I was starting a study in Liberia and another in Guatemala. I teamed up with a young infectious diseases doctor, Bruce Greene, who was at Hopkins and later went to Case Western University in Cleveland. This was the start of a very successful collaboration. As there were only a few ophthalmologists working on onchocerciasis, I was soon appointed to a WHO Scientific Working Group on Filariasis that included onchocerciasis. In the 1970s, WHO had started a drug-screening program under their Special Programs for Training and Research in Tropical Diseases. Pharmaceutical companies could send interesting compounds to be tested in WHO-supported laboratories in selected universities to see if their new drug had an effect against some of the targeted tropical diseases. In 1983, I was asked to chair a new WHO Scientific Working Group on Onchocerciasis Chemotherapy. Since the Second World War, major drug companies have scoured the world looking for new antibiotics, many of which came from fungi. In 1978, a Japanese scientist collected a fungus species that was to revolutionise the treatment of onchocerciasis from beside a golf course in Kawano, Japan — I have been told it was from beside the fifth fairway. This fungus made a compound that was called in the lab MK 933. Later, it was called ivermectin. It was not good as an antibiotic, but it was a very potent killer of parasites. It went to a WHO test laboratory where it created some interest, but then it disappeared. It was the pharmaceutical firm Merck and Co. that developed ivermectin and started to market it for veterinary use. It is now a worldwide product used to treat heartworm in dogs, and a whole range of parasites in sheep, cattle, horses, pigs and other animals.5 Dr Mohammed Aziz worked for Merck. He was originally from Bangladesh, and had worked in Africa with WHO where he learned about onchocerciasis. He insisted that MK 933 be tried in onchocerciasis. Once the veterinary product was successfully launched, he got his way, and he did a small pilot study in Senegal.6 The results were published in the Lancet and picked up by the New York Times, Le Monde and other newspapers. This was the first time that I, and others in the field, had heard of this drug. The study was somewhat unusual. The results seemed to be too good to be true. How could any drug kill the microfilaria without producing the intense Mazzotti reaction we saw with every other drug that killed microfilaria? This did not fit with any conceivable clinical, laboratory or theoretical explanation at the time. Besides, the study patients were only lightly infected, the investigators had not worked on “oncho” before, the study was funded by a drug company, and it was published simultaneously in the newspapers and the scientific literature. Maybe it was just wishful thinking, or artefact. Soon a series of parallel, randomised clinical trials were planned to more fully evaluate this very exciting new drug. These studies started after some further patients were treated in an open dose-ranging study. Bruce Greene and I undertook a study in Liberia. We treated men who had become heavily infected with onchocerciasis while working as rubber tappers on a plantation. In this controlled trial, 10 men received ivermectin, 10 received DEC, and 10 took placebos. We were very anxious for the first few days, as we expected to see similar reactions to those seen in patients treated with DEC. Some animal studies suggested even worse reactions were possible with ivermectin. Maybe some people would even die. We were elated six months later when our results showed that ivermectin was at least as effective as DEC, but safer.7 The two other parallel studies came up with similar results.8,9 Subsequently, one partial answer emerged for the lack of a Mazzotti reaction. It seems that, rather than killing the microfilariae in the tissues, the microfilariae are paralysed and then pass through the lymphatic system and die in the lymph nodes. We went back to Liberia and this time treated 300 people, men and women, to test different doses. We followed this group for 2 years. A tiny tablet of ivermectin cleared the microfilariae almost completely and people’s skin and eye signs improved dramatically.10,11 The adult worms were not affected, so ivermectin needed to be given once every year. By August 1987, Merck had enough data to register ivermectin for use in onchocerciasis. The chairman of Merck, Dr Roy Vagalos, announced that his company would provide the drug at no cost to treat anyone with onchocerciasis, anywhere in the world, for as long as it was needed.12 This was an unprecedented and extraordinarily generous and courageous decision. Although Merck was selling huge amounts of ivermectin to treat animals, there were some 20 million people with onchocerciasis, and maybe 40 million who would need treatment. Treatment had to be continued for at least 10 years. This was a huge commitment when each pill was worth US$3. However, Vagalos knew that if Merck did not do something, this breakthrough treatment could never be afforded by those who lived beyond the end of the road, the poorest of the poor. Ivermectin was now freely available. But how could it be distributed to the millions who needed it? There were other questions to be answered: for example, would ivermectin have rare but serious side effects? And what would happen if pregnant women inadvertently took a tablet? We then started another study of 30 000 people in Liberia to assess the community acceptance and safety, and to work out distribution strategies. We monitored every person, every month, investigating and documenting all births and deaths. We kept track of people as they moved, we caught and examined the biting black flies, and we thoroughly examined all the children. This huge study was very successful and confirmed the safety of ivermectin: it could be distributed to nearly everybody in the community.13,14 We showed that by treating the whole community we could reduce transmission and the incidence of new infection in children.15 Initially, the dose of ivermectin was adjusted for each individual’s weight, so everyone had to be weighed, but later work showed that height could be used instead.16 If children could walk under the stick, they got one pill; if they were too tall, they got two. By 1989, when our last Liberian study was finishing, several government and non-government organisations coordinated by WHO had started delivering ivermectin in pilot projects. Although Merck would deliver boxes of ivermectin to the national port, it still cost between 5 cents and $5 a tablet to get the ivermectin up-country and into people’s mouths. A lot of work was done to develop cost-efficient ways of community-based distribution. To supervise the distribution of the donated ivermectin, Merck created the Mectizan Expert Committee.1,17 This joint committee was based at the Jimmy Carter Presidential Centre in Atlanta and included representatives from WHO and Merck, and other experts. I had the privilege to serve on this committee in the early 1990s. In 1990, a Houston software developer, John Moores, read an article about ivermectin in the Houston Chronicle. He was so taken by this story that he started a foundation to support this work. I was also fortunate to be on the Board of the River Blindness Foundation and eventually John Moores gave US$25 million to the Foundation. It became clear that a lot more money would be needed to distribute ivermectin in the 28 African endemic countries. The River Blindness Foundation, the Carter Centre and other non-government organisations convinced the World Bank to start a special program to distribute ivermectin in Africa, worth about $300 million.18 Another smaller program was set up for the six endemic countries in Latin America. In 2002, nearly 50 million doses of ivermectin were given away free: over four million doses a month, treating about 100 people every minute. Despite local disturbances and civil war, ivermectin distribution programs are active in 25 of the 27 endemic countries and currently reach 45% of the “Ultimate Treatment Goal”, the total number of people required to be treated (see www.mectizan.org). The number treated each year continues to increase at an almost exponential rate, and progress is closely monitored by the Mectizan Expert Committee, WHO and non-government organisations. The commitment and strategies are in place to reach everyone who needs treatment and to eliminate onchocerciasis by the year 2020. Success has many parents, and failure only one. Obviously, many people were involved in the ivermectin story, but it has been a great thrill to be one of them and to have been a part of what must be one of the most significant breakthroughs in tropical medicine in the past 25 years. 1: Onchocerciasis endemic areas Two onchocerciasis control programs provide onchocerciasis control in 30 endemic countries in Africa. (OCP — Onchocerciasis Control Program — initial area of vector control; APOC — African Program for Onchocerciasis Control — World Bank and WHO supported ivermectin distribution; OPEA — Onchocerciasis Elimination Program for the Americas — ivermectin distribution in Latin America). Reprinted from Reference 19 with permission. 2: Onchocerciasis fact file Cause Onchocerca volvulus, a filarial worm. Transmission Various biting black flies. Main African vector is Simulum damnosum. The flies breed along the river banks and in the rapids and fast-flowing streams. A female fly bites an infected person to take a blood meal, and becomes infected with a tiny microscopic worm – a microfilaria – that is less than a third of a millimetre long. Over a week or so, these microfilariae develop into infective larvae and can be transmitted when the fly bites another person. Life stages After entering the body, the infective larvae grow to become adult male or female worms. The males are only 5 cm or so long, but the females may be up to a metre long. The adult worms are wrapped together in a nodule like a ball of string. The worms reproduce sexually and the female releases tens of thousands of microfilariae every day. As the female can live for 10 years or so, she literally releases millions and millions of microfilariae. The microfilariae migrate throughout the host’s body, especially to the skin and the eye. In the skin they wait to be taken up by another black fly to continue the life cycle. If this does not occur within 18 months or so, the microfilariae die. There is no inflammatory response to live microfilariae, but dead or dying microfilariae provoke an intense local response. Disease manifestations Subcutaneous nodules (adult worms often attach to bones or joints) Skin changes: severe pruritus and rash, maculopustular reaction, pigmentary changes, atrophy Eye changes: microfilaria in cornea, anterior chamber and retina; uveitis; sclerosing keratitis; chorioretinal atrophy Liberian rubber tappers from one of the early onchocerciasis drug studies. Bruce Green (left) and Hugh Taylor standing at the back.

Hugh R Taylor AC, MD, FRANZCO

A long and proud history of health education in the Fiji Islands started in 1885 with the founding of the Suva Medical School, which became the Central Medical School in 1929 and the Fiji School of Medicine (FSM) in 1961. Today, FSM provides training in medicine and a wide range of other healthcare disciplines, including dentistry, pharmacy, physiotherapy, radiography, medical laboratory technology, dietetics and environmental health. Students come not only from the Fiji Islands, but from all Pacific Island countries (a population of about seven and a half million people). A particular problem has been that formal postgraduate training and continuing professional development have not been available for its graduates, forcing many Pacific Island practitioners to undertake specialist training overseas, with many choosing not to return to the Pacific. Thus, the Pacific Island countries and FSM itself have been heavily dependent on transient expatriate practitioners for delivery of care and medical education. Valuable though the contribution of such expatriates has been, it cannot substitute for local graduates. To address these and other issues, a Fiji School of Medicine Development Plan was developed in 1994 and endorsed by the Government of Fiji. A major recommendation was that “an effective postgraduate training program, and preferably one utilising the resources of Fiji and the Pacific Island countries, is the key to the revitalisation of FSM.” This was followed in 1995 by a meeting on Yanuca Island in Fiji, sponsored by the World Health Organization, involving consultants and government representatives from all Pacific Island countries. This meeting recommended establishing diploma and masters courses in anaesthesia, internal medicine, surgery, obstetrics and gynaecology, child health and population health. The Fiji government then requested, in discussion with the Australian Agency for International Development (AusAID), that FSM be included in the bilateral program of assistance between the two countries. In May 1997, AusAID appointed the Royal Australasian College of Surgeons (RACS) to manage the 5-year project with a budget of A$5.5 million, in partnership with the Royal Australasian College of Physicians and its Division of Paediatrics, the Australian and New Zealand College of Anaesthetists, the Australian Society of Anaesthetists, the Royal Australian and New Zealand College of Obstetrics and Gynaecology and the Universities of Otago and Melbourne. The aim of the project was to establish a postgraduate training program at FSM, involving local curriculum development to make it more relevant, and to reduce (although probably not eliminate) the need for doctors to travel to other countries for specialist training. Each of the five disciplines was to offer a 1-year diploma, giving a theoretical and practical background sufficient for providing care in Pacific Island countries with populations too small to support fully trained specialists. This diploma would also act as the introductory year for a 3-year masters program for those showing particular aptitude, and who wished to proceed to full specialist practice in larger Pacific Island countries. Selection into the diploma program would require a minimum 3–4 years’ experience after graduating from medical school, and support from the relevant Pacific Island Country authority. Progression from the diploma to the masters program would depend on achievement of a high standard during the course and examination. The FSM faculty was strengthened by the appointment of additional staff in each of the five disciplines, one of whom was appointed Coordinator of Postgraduate Studies (W B). These were supported by long-term advisers from Australia or New Zealand to interact with local staff in each of the five disciplines. Advisers spent full-time attachments in Suva for 18 months to 3 years, depending on the state of development of the specialty. The project was launched on 5 May 1997. The appointment of long-term advisers and local counterparts followed rapidly, and teaching began formally in all disciplines in 1998. In anaesthesia, a pre-existing diploma established with the help of the Australian Society of Anaesthetists was adapted to the more practically oriented and problem-based format used in all five disciplines. In paediatrics and obstetrics and gynaecology, FSM was able to build on diplomas from the University of Otago, which had been offered through the distance mode. In surgery, informal postgraduate teaching and course development had commenced in 1996. The agreed format for the curriculum was a series of modules designed to provide detailed learning objectives, with core and reference materials to allow the trainees to adopt a problem-solving approach to learning and clinical practice. The content was clearly defined at the diploma level in recognition of the fact that this might be the only formal training for trainees, in particular, from the smaller Pacific Island countries, and emphasis was given to the need for life-long learning and continuous professional development. At the masters level, subspecialty teaching was provided by visiting medical staff from Australia and New Zealand, who spent 2-week periods at FSM for direct teaching and to help develop the modules. A specific requirement for each masters trainee was the completion of a research project, supervised by staff in the discipline and the Research Director at FSM. In Suva, trainees in the diploma and masters program undertook clinical duties at the Colonial War Memorial Hospital. Diploma candidates from other Pacific Island countries were able to undertake their initial studies in their own country, provided there were adequate local facilities and clinical and academic supervision, with the last three months of the course undertaken in Suva for intense supervision and preparation for the examinations. Masters candidates are all trained in Suva, with an additional 3–4 months on attachment in Australia or New Zealand. Distance learning for postgraduate education and continuing professional development is a major issue. In 2002, FSM identified “flexible learning”, a process that is learner-focused, and, with the help of the University of the South Pacific and Professor Ian Rouse of Curtin University, is developing a Resource Centre that will collate all paper-based and electronic-based resources, improve delivery of internal services and coordinate workshops on flexible learning for staff at FSM. Distance learning should become more widely available in the future, as more and more FSM-trained specialists in general return to their own environments. GraduatesIn 1999 the University of the South Pacific, a distinct entity which awards MB BS degrees to FSM graduates, approved the awarding of a Master of Medicine (MMed) degree after review by independent external reviewers, and subject to a further review in the final year of the first cohort (2001). This was completed satisfactorily in August 2001, noting that the programs were “soundly based and well balanced in terms of targeted acquisition of appropriate expert knowledge, technical capacity, life-learning skills and problem solving ability”. It was noted that the academic level of the MMed degree was rightly set at a level which was equivalent to other MMed degrees in the South-East Asian area. The diploma remains an award made by FSM itself. By the end of 2002, 74 diplomas had been awarded (anaesthesia, 16; internal medicine, 13; obstetrics and gynaecology, 8; paediatrics, 17; surgery, 16; community and hospital practice, 4) and 14 candidates had completed the Master of Medicine degree (anaesthesia, 1, internal medicine, 3; obstetrics and gynaecology, 4; paediatrics, 2; surgery, 4). Of these graduates, 68 with diplomas and 12 masters graduates were practising in Pacific Island countries. ConclusionsWithin 5 years the FSM postgraduate training project, established with funds provided by AusAID, has facilitated the development of a viable and now largely self-sustaining program for postgraduate medical education for the Pacific Islands. All strategies for implementation have been fulfilled, although continuing support from authorities and individuals from countries such as Australia and New Zealand will be necessary if these achievements are to be sustained and advanced. A memorandum of understanding is under discussion between FSM and AusAID to facilitate such support.

Gordon J A Clunie DSc(Edin), FRACS · Eddie McCaig DSM, FRACS · Wame Baravilala MRCOG, FRANZCOG

Children in the new millennium. Environmental impact on health Geneva: World Health Organization, 2002 (vi + 141 pp). ISBN 92 807 2065 1. On World Health Day 2003, the World Health Organization called for “concerted action to protect three of our greatest assets: children, the environment and health”1. Dr Gro Harlem Brundtland, stated: “The biggest threats to children’s health lurk in the places that should be safest — home, school and community. Every year, over 5 million children aged 0–14 die, mainly in the developing world, from diseases related to their environments”. Children in the new millennium. Environmental impact on health presents these issues with disturbing clarity. The volume can be downloaded free from www.who.int and this site also contains a link to the Healthy Environments for Children Alliance (www.who.int/heca/en/). In just 141 pages we are presented with a depressingly pervasive summary of the key environment issues of our day, and children, especially poor children, suffer a disproportionate burden of this litany: Unsafe drinking water — two thirds of the world will live in “water-stressed” conditions by 2025. Poor hygiene and sanitation — diarrhoeal diseases have killed more children in 10 years than has armed conflict in 50 years. Catastrophic degradation of lands and fisheries — nearly 1 billion of us depend on fish for protein. Indoor and outdoor air pollution. Toxic chemicals — lifelong exposure to pesticides often starts in the womb. Warming habitats that favour insect vectors of killers such as malaria and dengue. This compendium of facts will be useful to teachers of public or environmental health. For each environmental threat the authors summarise proven remedies that can be applied at household, community, national and international levels. I would have liked more detail on the nitty gritty of negotiating multilateral environmental agreements, which must represent our best hope for their implementation. Most sobering is the realisation that nearly all of these harmful legacies bestowed on our children have their origins in human society — conflict, inequality, or our excessive and wasteful consumption. Christopher J MorganCentre for International Health Macfarlane Burnet Institute for Medical Research and Public HealthMelbourne, VIC 1. www.who.int/mediacentre/statements/2003/statement6/en/ accessed Apr 2003.

Christopher J Morgan

Risk factors and diseases in developing countries are becoming "westernised" Cardiovascular disease is usually considered to be the scourge of wealthy countries. However, the recent World health report1 draws attention to the increasing importance of cardiovascular disease in developing countries. The report identifies principal risk factors and diseases in regions of the world divided into three categories: developed countries, developing countries with low mortality rates, and developing countries with high mortality rates. It is no surprise that the leading risk factors contributing to disease, disability and death in developed countries are tobacco consumption, high blood pressure, high cholesterol level, overweight, low fruit and vegetable intake, and physical inactivity (Box 1). Coronary heart disease is the leading cause of death and disability, and stroke ranks third. In developing countries with high mortality rates (eg, Nepal, Myanmar, the Maldives and numerous African countries), factors such as underweight and unsafe sexual practice are more important than risk factors for non-communicable diseases. Nevertheless, tobacco consumption, high blood pressure and high cholesterol levels are still responsible for substantial morbidity and mortality (Box 1). The five leading causes of death and disability in these countries are HIV/AIDS, lower respiratory tract infections, diarrhoeal diseases, childhood diseases and low birthweight — coronary heart disease ranks eighth. Countries between these two extremes have rapidly changing profiles. In these low-mortality developing countries (eg, Cambodia, China, and Fiji), "developed country" factors have already outstripped traditional "developing country" factors in terms of importance for overall disease, disability and death (Box 1). In these countries, the juxtaposition of underweight with overweight as the fourth and fifth leading risk factors, respectively, starkly exemplifies the "double burden of disease" they carry. Following an upsurge in "developed country" risk factors in these countries, stroke is now the second most important cause of disability and death, and coronary heart disease the sixth. Unfortunately, the health services of low-mortality developing countries have not been able to adjust quickly enough to these changing disease profiles. The lack of epidemiological data on diseases and risk factors has hampered appropriate health service development and responses. A number of Australian organisations, including the Institute for International Health (IIH) at the University of Sydney,2 are trying to address these issues, with a focus on our neighbours in Asia and the Pacific region. The IIH has recently introduced initiatives, involving data collection and analysis, as well as technology transfer and capacity development, with partners in China, India and Thailand.3,4 The IIH has also worked with Asia–Pacific partners in multicentre trials and epidemiological studies, including the Asia Pacific Cohort Studies Collaboration (APCSC). The APCSC is a collaborative project that seeks to pool data from existing longitudinal studies with information on cardiovascular disease in the region. The project database now has data on 659 000 adults in eight countries (Box 2), making it one of the largest medical studies ever, and certainly the largest in the Asia–Pacific region. The collaboration aims to produce reliable regional estimates of the excess risks for coronary heart disease, stroke, total cardiovascular disease and all-cause mortality associated with a number of risk factors, and to accurately compare risk-factor associations between ethnic groups, age-specific groups and the sexes. After several years of compiling data, obtaining cooperation of key individuals and devising appropriate methodology, initial reports from the APCSC have begun to appear.5-7 These reports underline the increasing importance of cardiovascular disease in the less developed parts of the region, and show that the risk factors applicable in Australia are just as important elsewhere. This is a crucial finding that has not previously been established with large numbers. For instance, the analyses show that people with diabetes are about twice as likely to die from heart disease or stroke, regardless of whether they live in Asia or Australasia.5 Increasing levels of obesity across the region will lead to a considerable increase in diabetes and its sequelae, such as cardiovascular disease. Further, the research shows that younger people with diabetes have much larger excess risks for cardiovascular disease than older people. Asia, with its predominantly young population, can thus expect an even greater increase in cardiovascular disease than that anticipated in Australia. The challenge now is to use the results from the APCSC, and other relevant studies, as a starting point for tackling the global problem of cardiovascular disease highlighted by the World health report.1 In developing countries, substantial health gains can be made for relatively modest expenditures. In human terms, this means that much ill-health and millions of premature deaths can be avoided. As far as cardiovascular disease is concerned, a necessary step will be to develop accurate risk algorithms, specific to local situations.8 These algorithms would help in developing treatment and prevention strategies to target overall risk. For example, strategies to reduce salt intake and lower cholesterol level have been shown to be very cost-effective.1 Blood-pressure-lowering drugs are likely to benefit not only people with hypertension, but also normotensive people at high risk of cardiovascular disease.9 The ultimate aim will be to develop strategies with maximum benefit for minimum cost. This is especially the case in developing countries, where the conflicting demands on a meagre pool of resources make the need for cheap, finely-targeted strategies absolutely crucial. 1: The 10 leading selected risk factors for death and disability, by type of country1 High-mortality developing countries Low-mortality developing countries Developed countries 1 Underweight Alcohol consumption Tobacco consumption 2 Unsafe sexual practices High blood pressure High blood pressure 3 Unsafe water, poor sanitation and poor hygiene Tobacco consumption Alcohol consumption 4 Indoor smoke from solid fuels Underweight High cholesterol level 5 Zinc deficiency Overweight Overweight 6 Iron deficiency High cholesterol level Low fruit and vegetable intake 7 Vitamin A deficiency Low fruit and vegetable intake Physical inactivity 8 High blood pressure Indoor smoke from solid fuels Illicit drug use 9 Tobacco consumption Iron deficiency Unsafe sexual practices 10 High cholesterol level Unsafe water, poor sanitation and poor hygiene Iron deficiency 2: Geographical distribution of studies presently included in the Asia Pacific Cohort Studies Collaboration

Mark Woodward · Michael A Reid

To the Editor: Van Der Weyden has commented on the World Health Organization's Utopian definition of "health", first promulgated in 1948.1 In 1973, I addressed this matter in a speech to the All Nations Club in Sydney, and again in 1980 when presenting a paper to The Hope Foundation (a large charitable health organisation in the United States). For what it is worth, my suggested definition of "health" was: Health is a high level of physical, mental and social comfort appropriate to the age of the person concerned and attainable within the economic constraints of the particular environment. It seems we have some agreement, and I would like to see the WHO again consider definition!

Keith S Jones

In reply: I thank Sir Keith for his pragmatic proposal. The concept of health has individual and societal connotations. At its most basic level, it is the avoidance of pain and suffering. More broadly, it is a basic human resource for the pursuit of life's goals.1 But, as argued by Lewis and Leeder, "health is a good to be pursued, but not an absolute one" for the "functioning of social institutions does not require perfectly healthy citizenry, nor does the individual have to be perfectly healthy to take part in social life."2 As such the perfect definition of health espoused by the WHO is Utopian and removed from reality. It is, as poignantly captured by René Dubos, the "mirage of health", as "complete freedom . . . from disease is but a dream remembered from imaginings of a Garden of Eden."3

Martin B Van Der Weyden

Infectious diseases are still the dominating cause of death Papua New Guinea (PNG) has a population of about 5 million people, 85% of whom live in rural villages.1 Since becoming independent in 1975, PNG has experienced problems common to emerging nations of starting from a subsistence base and simultaneously seeking to achieve economic sustainability and nationhood as well as build systems of governance, defence, transport, communication, education and healthcare. Health system development has not kept pace with changing demands in PNG. Instead, primary health services have faltered, placing a heavier burden of disease on struggling secondary care facilities as opportunities for prevention and early treatment are lost because aidposts have closed or vaccination rates have fallen. Port Moresby, the capital and largest city, has a population of over 300 000. Port Moresby General Hospital (PMGH) is the country's major teaching and referral hospital, with 600 beds. Hospital-based studies of the causes of death and patterns of admissions to PMGH confirm that infections remain the major cause of adult hospitalisation and deaths in hospital, and that HIV/AIDS is now a leading cause of death in adult inpatients. Moreover, there has been no reduction since 1980 in the mortality rate of children under five years, and infectious diseases, predominantly pneumonia, are also the main cause of childhood deaths. Adults: Studies of medical records in the 1980s and again in the 1990s determined causes of death in adults admitted to medical wards and the intensive care unit at PMGH.2,3 The findings of these two studies are summarised in the Box. Malaria, tuberculosis, typhoid and pneumonia were the leading causes of death in patients in whom aetiology was determined. In addition, these same infections were suspected on clinical grounds to be the cause of death in more than half of those dying without confirmation of the cause. A further study in 2000 looking at reasons for medical admissions to PMGH (Dr G Tau, Chief Medical Officer, PMGH, personal communication) found infections remain the most common reason for admission, with tuberculosis being the most common (27%), followed by malaria (23%), pneumonia (15%), dysentery (12%), typhoid fever (8%), and HIV/AIDS (3%). According to statistics of the PNG Health Department, the reported national prevalences of tuberculosis, malaria, typhoid and other infections have not declined in the past three decades.1 Thus, the dramatic recent addition of HIV/AIDS has occurred against a background of no change in the high prevalences of other infectious diseases. As a result of cultural resistance, autopsy rates in PNG are very low, and, at the time of the two studies of causes of death,2,3 autopsy was performed in less than 3% of deaths. Needle autopsy, which, compared with full autopsy, is accurate in 77% of cases, appears to be an acceptable alternative for Papua New Guineans and could be applied to determine cause of death in the large numbers of patients who currently die from undiagnosed causes.4 In addition, better diagnostic facilities in microbiology laboratories would assist in diagnosing and treating infections earlier and more effectively. As economic prosperity increases, non-communicable diseases are becoming more apparent. New diagnostic facilities at PMGH — ultrasound, echocardiography and a private computed tomography facility — have markedly enhanced the ability to diagnose chronic, non-communicable diseases. Even allowing for this enhanced diagnostic capacity, the prevalence of these non-communicable diseases is increasing.1 Children: Reports on child health in rural areas of Papua New Guinea similarly indicate a dominance of infectious diseases. The major infectious diseases causing child mortality in PNG include pneumonia, measles, meningitis, malaria and neonatal sepsis. Between 1960 and 1980 the mortality rate for children under five years of age in PNG fell by an average of 3% per year, from 204 to 122 per 1000 livebirths. No improvement has occurred since then. By contrast, the mortality rate in this age group in East Asia and the Pacific region has fallen by 2.5% per year. The most optimistic figures for the current infant mortality rate, and the mortality rate in children under five years, puts the national rate at 77 per 1000 livebirths and 100 per 1000 livebirths, respectively; this represents no progress during the past decade. According to UNICEF, only four countries in the world have failed to improve the mortality rate among children under five years since 1980: Burma, Niger, Zambia, and PNG. The high child mortality rate is attributed to collapse of health service structure, law and order problems, closure of aidposts, deteriorating roads, and inadequate administrative assistance and support. Vaccine-preventable diseases, such as measles, whooping cough and Haemophilus influenzae infection, still kill children in PNG. Vaccination coverage is low and differs from province to province. According to figures in the National Health Plan, vaccination coverage averaged 64% for diphtheria–tetanus–pertussis and 60% for measles, while, in the Western Province, these proportions were only 30% and 27%, respectively.1 In a highlands province in 1997, coverage was about 33% for immunising doses of any vaccine.5,6 HIV/AIDS: The first case of AIDS in PNG was diagnosed in 1987. HIV in PNG is heterosexually transmitted and equal numbers of men and women are affected. Unprotected sex and a rising incidence of other sexually transmitted diseases and promiscuity have contributed to the rapid rise in cases of HIV/AIDS to epidemic levels. By the end of December 2001, 4700 cases had been reported.7 About A$200 million was committed to healthcare in the 2001 PNG National Budget, including $650 000 earmarked for HIV prevention and care. In addition, $20 million is being put into the National HIV/AIDS Support Project by AusAID. Some antiretroviral therapy is becoming available through UNAIDS. PNG faces the danger of following the experience of African nations, with the potential to lose half of its adult population to this disease. Investing in the future of the nation: PNG manifests the challenges facing many tropical nations where communicable disorders remain major causes of mortality and morbidity, but non-communicable diseases are becoming more apparent. This is in sharp contrast with Australia, where cancer, ischaemic heart disease and stroke are the leading causes of death (27.8%, 20.7% and 9.6%, respectively).8 In PNG, this background of infectious diseases is being overlaid by non-communicable diseases — hypertension, coronary artery disease and diabetes (Dr G Tau, personal communication).1 Declining health service efficiency has meant that HIV/AIDS has now taken hold, placing additional stress on an already skeletal system. The commitment of public resources to the control and alleviation of these problems needs to be seen as an investment in the future of the nation. Those responsible for the administration of healthcare may be encouraged from international experience that control of infectious diseases and lowering child mortality are achievable and worthwhile goals. Australian aid to PNG has been generous, with the estimated total aid to PNG for 2002–2003 being $351.4 million.9 Special attention should now be given to enhancing primary care services provided in the village aidposts and rural district health centres. At the same time, PNG requires continuing support from experienced clinicians and public health experts. It would be wise for Australian aid to support this and related workforce development. Australia has a special relationship with PNG. This should be used to work with PNG in the development and implementation of the PNG National Health Plan. Australian aid must be sensitive to the PNG political environment, and should not be provided without an explicit purpose or without clear accountability for its expenditure. In controlling the spread of HIV, tactics used in other countries to good effect, including the judicious and appropriate use of antiretroviral medications, need to be examined for their applicability in PNG. Admissions and deaths at Port Moresby General Hospital2,3 1984 study2 1994 study3 Total admissions 1242 2353 Deaths in hospital 120 (10%) 168 (7%) Preventable 7 0 Treatable 35 37 Ultimately fatal 31 71 Not determined 47 60 Number of deaths from confirmed infections 59/120 (49%) 80/168 (48%) Definitions Preventable: The cause of death is known and the illness is treatable or curable but the correct treatment was not given. Treatable: The cause of death is known and the illness is treatable or curable, but the patient died despite receiving the correct treatment. Ultimately fatal: The cause of death is known, but the illness is such that, despite treatment, it is ultimately fatal (eg, hepatoma). Not determined: The specific cause of death is unknown because the aetiological diagnosis could not be made.

Sirus Naraqi FRACP, FACP · Bairi Feling · Stephen R Leeder PhD FRACP

The outgoing Director-General of the World Health Organization, Gro Harlem Brundtland, has successfully returned health issues to the international arena. The new Director-General will have to cope with reduced control over funding, debate over WHO's mandate, and the relationships between WHO and other organisations. Despite the broad role described in WHO's constitution, many groups see WHO's mandate as narrowly directed at disease eradication. The method of choice for funding health programs has become public–private partnerships. These have the advantages of bringing private money, management expertise and research knowledge to bear on health problems, but rarely consider the health system as a whole, focusing instead on specific diseases. This has the potential to distort resource allocation and priorities. The international community needs to work to strengthen WHO and maintain its broad mandate to achieve the highest possible level of health for all people.

Michael A Reid · E Jim Pearse

Australia is one of the healthiest countries in the world, although we have a long way to go before the health of Indigenous Australians matches that of the population as a whole. In 1999–2000, the Commonwealth Government spent 8.5% of GDP on healthcare, ranking our health spending among the highest in the world. By contrast, many people living in our region are burdened by emerging epidemics, such as HIV/AIDS, diseases associated with economic and industrial development, and problems of communicable disease and nutritional deficiencies. For decades, many Australians have been working towards improving health in these developing countries by providing their knowledge and expertise. While the financial resources for healthcare are largely the responsibility of individual national governments, the international system plays an important role in assisting developing countries to improve their health standards. From our own experiences of working with AusAID and the World Health Organization on two projects to eradicate iodine-deficiency disorders in China and Tibet, we illustrate how health professionals can work with international aid agencies to deliver healthcare and make a difference to the lives of people in developing countries.

Mu Li PhD, MHSM · Creswell J Eastman AM, MD, FRACP

Access to basic health services was affirmed as a fundamental human right in the Declaration of Alma-Ata in 1978. The model formally adopted for providing healthcare services was "primary health care" (PHC), which involved universal, community-based preventive and curative services, with substantial community involvement. PHC did not achieve its goals for several reasons, including the refusal of experts and politicians in developed countries to accept the principle that communities should plan and implement their own heathcare services. Changes in economic philosophy led to the replacement of PHC by "Health Sector Reform", based on market forces and the economic benefits of better health. It is time to abandon economic ideology and determine the methods that will provide access to basic healthcare services for all people.

John J Hall MTH, FAFPHM · Richard Taylor DTM

Training and education of health workers remains an indispensable part of good health development in resource-poor settings. Many past training programs have failed to achieve significant gains in health outcomes because of poor selection of participants, inadequate methodology, and/or the influence of external factors in the health system or social environment. The solutions lie in better planning of "who" and "what" should be trained; effective methods based on adult learning principles; alternative methods that maximise learner input and locate training as close as possible to the workplace and its problems; appropriate inclusion of the community; and coordination with other health system interventions.

Christopher J Morgan DTCH, FRACP · Peter W Deutschmann MB BS, MPHC, FRACS

Australia enjoys high standards of healthcare and medical education. However, the same cannot be said for many of the countries in our region. As some of the articles in this MJA issue on Global Health reveal, Australian institutions, professional organisations and health professionals are involved in projects to improve health in poorly resourced countries, particularly through capacity building — assistance with training, education and other resources needed to increase a country's ability to meet its health needs. As there is no readily accessible listing of the involvement of our medical institutions and individuals in this work, we approached the medical faculties of Australian universities and our clinical colleges for their current initiatives in developing countries. What follows is an arbitrary cross-section of these activities. Medical schoolsFaculty of Health Sciences, University of AdelaideTwo general practice academics are establishing a department of general practice in Dharan, in eastern Nepal. They have had extensive previous experience in primary healthcare in Kathmandu, as well as in rural and urban general practice and Indigenous health in South Australia. Since January 2002, they have been at the BP Koirala Institute of Health Science at Dharan, teaching undergraduate students and creating a postgraduate training program in general practice (MD in Family Medicine). This is only the second postgraduate training program established for primary healthcare in Nepal. Adelaide University is providing support, including a teaching visit, a conference presentation and a planned three-month sabbatical exchange to Nepal in 2003. School of Medicine, Flinders UniversityFlinders' Rural and Remote Community Clinical School and Office of Education are assisting in medical education upskilling of Thai doctors, who, in turn, will be involved in a Thai government program aimed at overcoming a shortage of rural doctors. Over 10 years, 3000 extra students will be enrolled in Thai medical schools, and receive their clinical education in rural government hospitals. They will then be bonded to work in their local areas for three years after graduation. In Cambodia, the Director of the Rural and Remote Community Clinical School at Flinders is the delegation leader of an AusAID-funded project aimed at empowering the emerging Cambodian Medical Association to develop an Accreditation and Continuing Medical Education Program for its rural doctors. In East Timor, the Head of the Northern Territory Clinical School has acted as an advisor to the East Timor government on paediatric services and medical education. From 2003, Flinders will be offering a Master in Hospital Management degree in association with Nankai University in China, as there are no formal qualifications in health service or hospital management in that part of China. Finally, the Department of Medical Imaging has been involved in the training of radiologists from several developing countries. Faculty of Medicine, Health and Molecular Sciences, James Cook UniversityThe Faculty is conducting operational research to assist the government of Papua New Guinea (PNG) in investigating disease outbreak, and is also involved in a two-decade longitudinal study of PNG's epidemiological transition from a predominance of infectious to non-communicable diseases. A Lymphatic Filariasis Program in the Pacific Islands (in partnership with national ministries of health) has a strong capacity-building component for a number of countries, including the Federated States of Micronesia, Tuvalu, Fiji and Nieue. The program includes investigation of epidemics, development of improved diagnostic tests and vector control methods, and novel surveillance methods. An additional initiative involving Fiji is a protocol being developed to provide PhD scholarships for staff members of the Fiji School of Medicine. In East Timor, the Faculty is involved in World Health Organization research into intestinal helminths and lymphatic filariasis, including onsite training of laboratory staff in parasitology. University of Melbourne School of Medicine of the Faculty of Medicine, Dentistry and Health SciencesThe School is a founding partner of the International Medical University in Malaysia, and each year takes up to 12 students into third year to complete their training at the University of Melbourne. In a separate arrangement, from 2003, 20 Malaysian students each year will be sponsored by their government to undertake a bridging program before commencing medical studies at the School. Since 2000, one to five students per year have been sponsored by the government of Botswana to enter the Melbourne University medical course, after two years of premedical science at the University of Botswana. Other projects in Indonesia and Malaysia will aid existing and new medical schools in curriculum development, supply curricular materials and foster research collaboration and staff and student exchange. The School has 71 international higher-degree research students and 36 international higher-degree coursework students. Most of the latter are undertaking Master of Public Health degrees funded by AusAID. Finally, the Faculty contributes to an AusAID-funded program in Fiji for the development of postgraduate programs at the Fiji School of Medicine. Faculty of Medicine, Nursing and Health Sciences, Monash UniversityStudents from developing countries undertake postgraduate degrees at the Faculty. The 2001 cohort included students from Bangladesh (3), Cambodia (2), China (1), Fiji (3), India (8), Indonesia (28), Kenya (1), Lebanon (1), Malaysia (32), Mexico (1), Nigeria (2), Pakistan (1), Philippines (1), Sri Lanka (1) and Thailand (4). In addition, the School of Nursing has been managing a $1.2 million AusAID project to deliver the Bachelor of Nursing (Post Registration) by distance education to 40 nurses in eight locations in PNG. In 2000–2001, the Department of Epidemiology and Preventive Medicine delivered a Fellowship Program in the Master of Public Health Services Management to 25 Indonesian Ministry of Health officials. The program was funded by the Asian Development Bank for $1.7 million. In 2001, the Department of Epidemiology and Preventive Medicine, in collaboration with George Washington University (USA), inaugurated a Master of Health Science Management course at the Monash University campus in Malaysia. University of Queensland Faculty of Health SciencesOver the past 20 years, 500 graduates from 30 countries have been trained in the areas of tropical health and nutrition. In addition, to assist with capacity building in community nutrition, 40 Indonesian graduates have been trained in various areas of community nutrition. Links with PNG include bringing medical, nursing and other allied health workers to Australia for short courses, and working with the University of PNG in community medicine and curriculum development. The Faculty has also established close relationships with several medical schools in China (Wuhan, Shanghai and Wenzhuo), including the training of PhD students, whereas student exchanges and PhD training have been used to develop programs for health service delivery in Cambodia. Joint programs with the Queensland Institute of Medical Research include a program for the control of dengue in Vietnam, modelling of different interventions in schistosomiasis control, and a vaccine trial for acute respiratory disease in the Philippines. Faculty of Medicine, University of SydneyThe Faculty has a Masters/Graduate Diploma of Public International Health which was established in 2000 to meet a demand, both in Australia and internationally, for high quality public health training in resource-poor settings. Since 2000, the program has grown from 13 students to the 95 students currently enrolled. Since the course's inception, 42% of the students have come from developing countries, including China (4), Mongolia (2), Vietnam (7), Cambodia (2), Philippines (3), Thailand (2), Burma (1), Malaysia (1), Bangladesh (6), India (1), Nepal (1) and Bhutan (2), sub-Saharan Africa (4), the Middle East (1) and Central and South America (1). This program aims to provide students with skills in public health education, research and practice appropriate for developing countries. Students are trained in areas such as disease priorities, health and development, international health organisations, as well as in epidemiology, biostatistics and social science methods. Students can choose to specialise in areas such as project management, infectious and non-communicable disease control, health promotion, maternal and child health, health and culture. Most of the students from developing countries return to their own countries to provide public health expertise to governments and agencies. University of Tasmania School of MedicineThe School has accepted international students since the 1970s. Most are from Malaysia, with recent smaller numbers from Botswana. Currently, the School admits up to 20 international students into the first year of the medical course. The School formed a medical school partnership with the International Medical University, Kuala Lumpur, Malaysia, in 2000, and currently takes five students per year into the fourth year of the medical program. The School also has a partnership with the Kunming Medical College, Yunnan Province, China, providing elective exchange programs in both directions, as well as postgraduate training and collaborative research. In 2000, two scholarships for study in cardiovascular medicine in the United Kingdom were provided to University of Tasmania graduates from Malaysia and Sri Lanka. The recipients will return to their countries with postgraduate training in paediatric cardiology and management of ischaemic heart disease. Since 1984, a number of students with AusAID or other support have had postgraduate training in cardiovascular medicine, surgery, obstetrics and gynaecology, and through the Menzies Centre for Population Health Research (China, 4; Laos, 2; Thailand, 2; and Sri Lanka, 1). Faculty of Medicine and Dentistry, University of Western AustraliaIn 2000, 114 East Timorese medical students were forced to discontinue their medical studies at Indonesian universities. The university, together with the Committee of Deans of Australian Medical Schools and the colleges, is attempting to help these students complete their training and support the professional development of junior doctors. With the World Health Organization, the Mental Health Epidemiology Unit has organised training courses for over 400 participants from Vietnam, China, Bulgaria and Russia on the International Classification of Diseases and measurement instrumentation in epidemiological research on mental disorders. The Centre of Vision Sciences, Lions Eye Institute and Universitas Airlangga (Indonesia) have developed joint postgraduate teaching programs in Surabaya, Indonesia. Up to 25% of all Indonesian ophthalmologists have attended exchange information programs on practical diagnosis and treatment of eye diseases causing blindness. Clinical collegesAustralian and New Zealand College of AnaesthetistsFellows of the College provide educational support for healthcare in PNG by participating in the Medical Officer, Nursing and Allied Health Project. College Fellows also assist Royal Australasian College of Surgeons/AusAID surgical teams visiting PNG, Fiji and the Pacific Islands, and East Timor. The College provides a Visiting Professor in Anaesthesia and an examiner for the MMed (Anaesthesia) examination at the University of PNG, and awards prizes for the best undergraduate and postgraduate students in anaesthesia. The ANZCA Maintenance of Professional Standards (MOPS) program is available to PNG anaesthetists. At the Fiji School of Medicine, ANZCA provides an examiner for the MMed (Anaesthesia) examination and awards a prize for the best candidate. The MOPS program is also available to anaesthetists in Fiji. Australasian College of DermatologistsCollege Fellows have participated in AusAID's Pacific Islands Project, conducting clinics in Vanuatu, Samoa, Fiji and Tuvalu. College Fellows have also participated in the AusAID-funded Graduate Training Program at the Fiji School of Medicine. The College supports the training of African health officers in dermatology at the International League of Dermatological Societies Regional Dermatology Training Centre in Moshi, Tanzania. Past trainees have been from Uganda and Malawi. Two College Fellows have written a booklet, Skin disease in the Pacific (University of Sydney, 2000), for use in the Pacific Islands, and, in September 2002, two College Fellows conducted a three-day workshop for doctors and nurses in Suva, Fiji. Royal Australian College of General Practitioners For over 20 years, the College has run a conjoint examination with the Malaysian Academy of Family Practice, awarding successful candidates the Fellowship of the Royal Australian College of General Practitioners. The Continuous Home Evaluation of Clinical Knowledge (CHECK) program (a continuing medical education program) is distributed through several developing countries, and it is hoped to extend its reach to incorporate India, Myanmar and Indonesia. The College has had a long involvement with WONCA (the World Organisation of Family Doctors), especially in the Asia Pacific region. It provides strong support to many of the regional family medicine working groups and furthers WONCA's objectives of promoting tobacco control and prevention and management of HIV/AIDS in the region. Royal Australian and New Zealand College of Obstetricians and GynaecologistsTogether with the Pacific Society for Reproductive Health, the College is developing a Continuing Professional Development Program for obstetricians and gynaecologists in Pacific Island countries. The College provides educational input and teaching assistance for the Diploma and Master of Medicine (Obstetrics and Gynaecology) programs at the University of PNG and the Fiji School of Medicine. The RANZCOG supports young gynaecologists in the Asia and Oceania region to attend reproductive health scientific meetings (including the College's own Annual Scientific Meeting) and short-term training placements in hospitals in Australia and New Zealand. The College maintains a register of volunteers and responds to requests for locum and teaching placements in major regional hospitals in PNG and Fiji. From time to time, second-hand medical equipment is channelled to these hospitals. The College provides specialist input for meetings, workshops and health improvement programs run by obstetrics and gynaecology societies throughout Asia and Oceania. Royal Australian and New Zealand College of OphthalmologistsThe College coordinates Fellows' involvement in developing countries in providing both ongoing services and concentrated, practical training programs for ophthalmologists in these countries. In addition, funds have been allocated to provide university and hospital ophthalmology departments in developing countries with 120 free subscriptions to the College's scientific journal, Clinical and Experimental Ophthalmology. The College sponsors ophthalmologists from developing countries to attend and participate in the RANZCO's Annual Scientific Congress, and, in 2002, the International Congress of Ophthalmology in Sydney. A recently acquired laser and other equipment will be available to Fellows for use when working in developing countries, and a travel grant is available for registrars to enable them to attend overseas field trips in developing countries. Registrars have recently worked in Bali, Fiji, Tonga and Western Samoa. Royal College of Pathologists of AustralasiaThe College has active training programs in Hong Kong, Singapore and Malaysia, and has representatives from these countries on its Council. Although there are only 25 forensic pathologists in Australia, the College has a number of initiatives in this field. These include: responsibility for the Forensic Pathology Secretariat of the World Association of Societies of Pathology; initiation of a Diploma in Forensic Medicine designed for overseas graduates who are ineligible for Australasian qualifications; training of graduates from Sri Lanka, Kenya, Malaysia, Tanzania, Taiwan and Fiji in forensic pathology institutions around the country; assistance with forensic investigations in Bosnia, Kosovo, East Timor and Fiji; and establishment of inhouse forensic pathology training at the International Committee of the Red Cross in Geneva (during 2003). A Soft Tissue Tumour Registry, designed to assist with the diagnosis of soft-tissue tumours, operates at an international level, and includes a number of panellists in China. Royal Australasian College of PhysiciansThe College has an Asia Pacific Committee, with members from PNG, Fiji, Malaysia, Singapore, Hong Kong and Thailand. The committee promotes links with the Asia Pacific region, contributes to development projects, undertakes educational initiatives, and maintains a database of activities and College Fellows in the region. For the past seven years, the College has been the lead partner in a major AusAID-funded training project, the PNG - Medical Officer, Nursing and Allied Health Science Training Project. The project is aimed at strengthening the capacity of the PNG National Department of Health and the University of PNG to improve training in medicine, post-basic nursing and allied health sciences. The College annually provides visiting lecturers for the Master of Medicine Program in Malaysia and for educational programs in Fiji. It also contributes to other organisations' projects, including projects of the Royal Australasian College of Surgeons in the Pacific Islands and the Fiji School of Medicine. Royal Australian and New Zealand College of RadiologistsThe College is developing a radiology education centre for the South Pacific, based in Fiji, under the guidance of the World Health Organization and in association with international radiology and radiography societies. New Zealand and Australian radiologists make short visits to Samoa, Vanuatu, Solomon Islands, PNG and Fiji, providing education in image interpretation, management and client focus. The success of the visits is assessed by host country radiologists and radiographers. South Pacific radiologists are encouraged and financially supported to participate in the annual scientific meetings of the College. Further, the College is establishing a program to provide new, second-hand and superseded radiology textbooks to developing countries. Sources include publishers, radiologists, and practices. Australian College of Rural and Remote MedicineThe College supports a number of ongoing collegiate linkages in developing countries, based on providing information and educational resource sharing, as well as organisational and peer support. A current project involves working with the Cambodian Medical Association to strengthen professional development capacity. Initial work, including familiarisation visits, educational resource development and workshops, has been funded by AusAID. Royal Australasian College of SurgeonsIn the PNG Tertiary Health Services Project, specialist medical teams deliver surgical services that would not otherwise be available. Ongoing links between visiting surgeons and local personnel improve medical knowledge and skills in PNG. The Pacific Islands Project involves short term visits by specialists from 12 different specialties to 10 Pacific Island countries: the Cook Islands, Federated States of Micronesia, Fiji, Kiribati, Marshall Islands, Samoa, Solomon Islands, Samoa, Tonga, Tuvalu and Vanuatu. The teams provide clinical service, as well as training for local personnel. The Medical Equipment Maintenance Project covers seven Pacific Island countries, using formal and on-the-job training to improve equipment management practices, equipment reliability, and technical skills for local personnel. Interplast is a collaborative effort with Rotary, the Australian and New Zealand College of Anaesthetists and registered nurses to teach and deliver plastic and reconstructive surgical services to developing countries. The East Timor Project involves the placement of a full-time anaesthetist and general surgeon in Dili, as well as specialist surgical visits. This selection shows what is possible when individuals and institutions apply their resources to work in partnerships with countries with greater needs and fewer resources than Australia. It should serve as a challenge to each one of us, as doctors, to ". . . search and see if there is not some place where you may invest your humanity" (Albert Schweitzer).

Ruth M Armstrong BMed

The virus recognises the similarity of people on the planet. Scientists and policy makers must do the same. Helene Gayle (Director of the CDC's National Center for HIV, STD and TB Prevention) The AIDS epidemic is wreaking havoc and misery around the world and exposing the most awful inequalities and human frailties. In Australia, our population is relatively cocooned from this chaos (Box 1), although the conference heard of the established epidemic in our nearest neighbour to the north, Papua New Guinea, and the worrying emerging epidemic in Indonesia. Worldwide statistics can become numbing, causing human suffering to be ignored. Even for clinicians and researchers in the HIV/AIDS field, the magnitude of the problem is frequently too daunting to either comprehend or tackle in a useful way. However, the realities, and importantly the will, of good, hard-working people in the field were on display at the International AIDS Conference in Barcelona in July 2002. International AIDS conferences are amazing events, bringing the global issues surrounding HIV to the fore. They can be incredibly poignant, wonderfully motivating and equally frustrating all at the same time. Frequently, issues come into stark focus that challenge the status quo. Activists in the field of HIV/AIDS are not shrinking violets. Global access to anti-HIV medicationsWe must corner rich nations with the truth (Jeffrey Sachs, Economist and Advisor to the United Nations Secretary-General) The issue that galvanised many of the participants at Barcelona was the injustice of the lack of access to life-saving, but expensive, antiretroviral drugs in developing nations. In Barcelona, the momentum of providing global access to HIV/AIDS medicines gathered steam. The road to global access is likely to be long and full of pot-holes. The establishment of the Global Fund for AIDS, TB and Malaria provides a major focus for raising the estimated US$13 billion required per year to scale-up preventive approaches and to provide wide access to antiretroviral drugs in resource-poor nations. There was a real sense of holding political leaders accountable to ensure a more equitable future. In the words of Peter Piot, Executive Director of UNAIDS: Let's make the AIDS response truly political — let's bring forward the day when leaders who keep their promises on AIDS are rewarded with our trust, and those who don't, lose their jobs to those who will. Some political leaders were booed from the stage as the audience turned against their meagre or delayed responses to the epidemic. There have been successful pilot and expanding programs of antiretroviral treatment in several developing countries. There is growing unease that a poorly coordinated approach in the developing world will lead to the high levels of resistance to antiretrovirals now present in the developing world, squandering an opportunity to make a very major impact in these countries. Averting the errors made in antiretroviral therapy in the developed nations could potentially lead to more durable responses to antiretroviral therapy. These errors include serial monotherapy, sequential changes in the presence of imperfect HIV suppression, and decisions made to introduce new therapies on the basis of single equivalence studies measuring only short-term surrogate endpoints. The US-based AIDS Clinical Trial Group study, with 384 investigators, reported the first of the long-term strategy studies, in which outcome was based on time to first and second change of therapy in 980 individuals. This provides important information to guide treatment strategies across the globe. Essentially, the length of time to failure of first-line antiretroviral therapy was substantially longer with the initial combination of zidovudine, lamivudine and efavirenz, and the time to the second failure was substantially longer with either first- or second-drug regimens including zidovudine, lamivudine and efavirenz. No benefits of using four antiretrovirals over three were shown.1 For HIV-infected people with anti-retroviral resistance, the conference heard of encouraging efficacy reports of new drugs, such as tenofovir and T-20 (enfurvitide), as well as exciting preclinical information on integrase inhibitors. Unfortunately, the cost of these newer drugs will be prohibitive in developing countries. Not only are the treatment factors (regimen, the timing of commencement, affordable appropriate monitoring, support of adherence) important, but also support for training of healthcare professionals and commitment to ongoing funding for therapy is essential. The World Health Organization (WHO) report entitled Scaling up antiretroviral therapy in resource-limited settings continues to assist this process.2 Providing treatment for HIV is now thought to provide tremendous spin-offs for enhanced prevention. People with access to treatment are more likely to get tested for HIV infection and modify behaviour if found to be positive. Reductions in infectious virus load after treatment are likely to reduce transmission, although this is not yet definitely proven. Increasing use of medications is likely to drive global prices down. The problem of accurately taking all combination anti-retroviral therapy (adherence) continues to be shown to be a major factor affecting long-term success of therapy. To this end, an increasing number of studies of once-daily treatments are being reported. This offers practical options for improved adherence and intermittently delivered therapy (Box 2). No cureHIV treatments are most certainly not a cure. This was soberly brought home by a pioneering researcher in this field, Dr Robert Siliciano, from Johns Hopkins University, describing HIV as "intrinsically incurable". One problem lies with the dastardly ability of HIV to lie dormant in a population of cells called resting memory T cells. These cells are "designed to wait" for a lifetime to ward off previously encountered pathogens. It will prove very difficult to flush the virus out of these cells once it has taken hold. VaccinesThere is hope that a vaccine will eventually be developed that can prevent HIV infection around the world. Although this is one of the "star-wars", "high-tech" approaches to prevention, significant gains have been made in the last two years. There are three important considerations for an effective vaccine against HIV/AIDS — the vaccine must induce (i) T cell responses against virus-infected cells, (ii) neutralising antibodies against free virions, and (iii) mucosal immunity. Vaccines that induce high levels of T cell responses against HIV in animal model systems, although incapable of preventing infection altogether, are able to control viral replication for long periods. To prevent infection altogether, high levels of neutralising antibodies will be required. The induction of broadly reactive neutralising antibodies to HIV has proven very difficult, but there are now hints about potentially successful approaches. The virus is in the mucosal tissue during the first few days of infection. In 3–5 days the virus spreads and virus latency occurs. In 6–9 days the virus has spread systemically. An effective vaccine needs to work at the mucosal site of infection before systemic dissemination occurs. One major obstacle against engineering an effective vaccine is that HIV is capable of escaping both neutralising antibodies and cellular immune responses. Furthermore, there is no definitive HIV marker for protection. There were mixed reports on whether a vaccine could induce immunity across different subtypes of HIV-1 — cross-subtype T cell immune responses exist for T cell-inducing vaccines, but there are no vaccines offering a breadth of neutralising antibodies. The vaccine world is waiting with bated breath for the outcome, due to be released early in 2003, of the world's first efficacy trials in humans of HIV vaccines using envelope protein approaches with alum as the adjuvant. These trials have been conducted efficiently, albeit not without controversy, in 2500 subjects in Thailand and 5000 subjects in the United States and elsewhere. Controversies in these trials have included whether it was justifiable to proceed to human efficacy trials with vaccines that performed poorly in some preclinical studies; the provision of clean injecting equipment to trial participants; and the lack of provision of antiretroviral treatment to subjects who become infected during the trial. Encouraging reductions in risk behaviour have occurred during these efficacy trials; however, a sufficient number of seroconversions have occurred which, when the data are unblinded, should provide a robust analysis of efficacy. One final important point emphasised was that vaccine research should be complementary to, and not in competition with, therapeutic research. Other prevention approachesThe definition of insanity is doing the same thing over and over again and expecting a different result. Rita Brown (arguing for innovative programs to prevent the spread of HIV). In addition to enhanced standard prevention approaches of education, behavioural change, condoms (both male and female versions) and others, further exploration of biomedical approaches to prevention are being evaluated. Male circumcision appears to provide considerable protection from HIV, and observational studies and trials are now under way to evaluate this approach more rigorously in developing countries. Treatment of other sexually transmitted infections is now being evaluated (eg, control of herpes simplex with aciclovir) as a means of preventing HIV acquisition and transmission. Non-occupational postexposure prophylaxis with antiretrovirals is now common in many developed countries, although gathering data on its efficacy has been difficult. The spectre of pre-exposure prophlyaxis with antiretrovirals was also raised. Widespread use of antiretrovirals as pre-exposure prophylaxis has worrying implications for the development of antiretroviral resistance, but, if infection was completely prevented, resistance would not occur. Call for actionA recurring message at the conference was the need for decisive action now. As Helen Gayle said, quoting an African proverb: The best time to plant a tree was 20 years ago; the next best time is now. 1: Global distribution of the AIDS epidemic in 2001 Numbers of people living with HIV at the end of 2001 (and, in parentheses, those newly infected with HIV during 2001) as estimated by UNAIDS and WHO. Data available at: http://www.unaids.org/barcelona/presskit/graphics.html#global.htm (accessed October 2002, no longer available). 2: Once-daily HIV medications to overcome problems of adherence Currently available once-daily antiretroviral medications in Australia/USA Efavirenz Tenofovir Didanosine Ritonavir-boosted amprenavir Antiretroviral medications suggested for future development as once-daily medication Nevirapine Abacavir Other ritonavir-boosted protease inhibitors Atazanavir 3TC FTC T-1249 (fusion inhibitor) Stavudine XR (slow-release version of stavudine) 3: More quotable quotes from the Barcelona AIDS conference Helene Gayle (Director of the CDC's National Center for HIV, STD and TB Prevention, and of the Bill and Melinda Gates Foundation HIV/AIDS and Tuberculosis Program:When will justice come to Athens? Justice will come when those that are not injured are as indignant as those that are (quoting the Greek historian Thucydides). Suniti Solomon, Director, Centre for AIDS Research and Education, India:In Zambia, a widow must cry with only one eye (describing how women whose husbands die of AIDS must keep an eye on their assets, which are often seized by relatives of the deceased). Paul Farmer, Professor of Medical Anthropology, who has established a modern medical centre in a squatter settlement in central Haiti, and introduced antiretroviral treatment:Now my children are not ashamed to be seen with me (quoting a Haitian patient describing the reduction in stigma since starting antiretroviral treatment).

Stephen J Kent MB BS, MD, FRACP · C Jane Dale BSc, PhD · Anne M Mijch MB BS, FRACP

How a peace-loving suburban Sydney GP, practising primary prevention her way, ended up in solitary confinement I've always believed that it's part of my job description as a doctor for me to be aware of environmental issues and to address them as best as I can. So, I've been a long-time supporter of Greenpeace (www.greenpeace.org) and a member of the Medical Association for Prevention of War (in NSW, called Health Practitioners for Global Responsibility; www.mapw.org.au, mapwATmapw.org.au). And, since 1997, this desk-bound GP has worked as a volunteer "medic/deckhand" on Greenpeace ships, like the Rainbow Warrior, for a couple of months each year. As medic, I ensure that the ship's hospital, which doubles as my sleeping cabin, is ready for emergencies, illness or injury. It's well stocked, with resuscitation equipment, surgical supplies and drugs; we are prepared for anything, from draining a pneumothorax to flying out someone with a spinal injury. For example, I've attended to crew after they were "rained on" with heavy metal tools as they climbed up an oil tanker and treated hypothermia after cold water immersion. I also train crew in first aid, including resuscitation (and working out team approaches in emergencies) and practise primary care and preventive medicine, from mosquitoproofing the ship to discussing outbreaks of worms. When not working as a medic, I am under the charge of the bosun, who assigns me to deckhand jobs — for example, painting the mainmast, restacking the hold or standing watch (which involves working a night shift), with opportunities to improve navigation and radio skills. When the ship is engaged in protest actions, I can either stay aboard as part of the back-up crew or volunteer to be involved as an activist. I've been directly involved in several campaigns. My first was in Central America after Hurricane Mitch swept through in October 1998, where I worked alongside locals, hauling bulk bags of rice and beans, tents and boxes of clothing and medicines into wharfside sheds for later distribution. My most recent expedition, to Sweden, provided a very different experience. ProtestOn 4 June 2002, the Rainbow Warrior and her crew embarked on a protest involving the cargo vessel ms Fagervik, which had dumped a large amount of oil into the Baltic Sea in February 2001. Although evidence suggested that the Fagervik's spill had been deliberate, the local Swedish court had decided to prosecute the ship's owners for an accidental spill (with a small fine) rather than for a deliberate spill (a criminal offence). Greenpeace wanted to protest about the facts that deliberate oil spills are frequent (about 1000–2000 a year in the Baltic) and virtually go unpenalised. We believe that ship owners and industry should bear the full financial liability for the effects of oil discharges, whether or not intent can be proven. Our specific goal was to board the Fagervik en route to the port of Norrköping (about 160 km south of Stockholm). The action took place in the usual non-violent manner that Greenpeace is committed to. We spent the first day of the protest in a rubber Zodiac boat doing action manoeuvres — painting slogans, hanging banners, and getting "climbers" (those who climb up ships' hulls) on board the Fagervik. ArrestIn the early evening on that first day of the protest, I joined a few other protestors on board the Fagervik. As part of the protest, I chained myself to the boat, as did Kristina, a 27-year-old German. The Swedish police boarded the ship that same evening, and at 10 pm Kristina and I were arrested. We were charged with aggravated trespass and taken to the town lockup to be held in solitary confinement. It was an unprecedented reaction to a Greenpeace protest. We had been told, in the routine legal briefing before the campaign, that such a charge, with a two-year prison sentence, was possible but unlikely. More likely was a charge of minor trespass, with release within four days. Under Swedish law, there is no bail; one can be held in custody indefinitely until trial — which, I was told, could be many months off. In solitaryThat night, I was put into a concrete basement cell, 1.5 m by 3 m, that boasted a floor mat to sleep on and a drain hole, which others had clearly used as a toilet. I, too, later resorted to using the hole for the same purpose, as it could take up to an hour after pressing a buzzer before a guard would respond to take me to the actual toilet. The cell walls, floor and mat were encrusted with recent faeces and blood. Later, I found out that my dingy cell was more generally used as the "drunk cell", for those who were drug or alcohol affected when arrested. My watch and warm boat suit and gumboots were confiscated and I was issued cotton pants, a shirt and plastic scuffs to wear. I felt not only isolated but also powerless; contact with Kristina and my personal lawyer was denied me; later we presumed that this was because of a fear of terrorism; that there was a risk of "collusion" between my lawyer and myself (I was allocated a State lawyer). I was also denied direct contact with my family and it was days before I was finally able to make contact with the Australian consulate. The seamen's mission priest and the prison nurse were other eventual, permitted visitors. In the first few hours, I observed my fear and confusion growing. Then, I remembered Victor Frankl's words in his book Man's search for meaning: 1 Everything can be taken from [us] but one thing: the last of the human freedoms — to choose one's own attitude in any given set of circumstances, to choose one's way. I resolved to apply myself to keeping mentally clear and stable. I began by getting a rough idea of the time from my meal deliveries. Then, knowing the link between exercise and wellbeing, I began a workout program that encompassed every exercise I had ever learnt and devised ways of timing half-hour walking periods without a watch. I'd practised yoga and meditation for many years, and drew on that practice to maintain an attitude of acceptance and calm. It became an incredible comfort to me when, each day, the inner reality of the meditation space became stronger as my small, shabby and uncertain external world shrank in importance. Initially, what there was to read was in Swedish. Greenpeace members attempted to send books, music, and clothes, but not much was allowed through. So, I began drawing. One kind guard gave me pencils and paper, and would sharpen them on his shift, saying that he trusted me not to use them as a weapon. By the time I was released, one whole wall of my cell was covered with paper and my own huge mural of Sydney Harbour. The guards would stop by to see my drawings, and indeed they became friendlier during my imprisonment, sometimes offering me a second cup of tea in the day. A guard confided "I like what you do. Tonight I give 500 kronas ($100) to Greenpeace". Many asked whether I really was a doctor and one sought my advice concerning his dying father. Meanwhile, the small fiord township of Norrköping was anticipating a large and complex trial and Greenpeace continued the Fagervik protest for several more days, with a flotilla of small boats and climbers on board (as well as continuing arrests). Greenpeace also mounted a networked international campaign calling for our release. The media took hold of the story, with incredibly supportive coverage of our stance. ReleaseI was working at my wall, well prepared for a long stay, when a guard came into my cell to tell me that I was to be released forthwith. It was 14 June, ten days after our arrest. My reactions ranged from relief to confusion, knowing that a trial and possible further imprisonment lay ahead. The police superintendent came to my cell, shook my hand, and apologised for keeping us in cells intended for overnight use only. The guard on duty farewelled me with a hug, sorry to see us go. I thanked him for the pencils. Kristina and I emerged from the building to be met with banners, flowers and friendly faces I did not know from the Stockholm Greenpeace office. I still had no shoes and one large Swede gave me his sandals. Again, I found myself watching my reactions: ordinary things, like seeing the sky and breathing the air seemed wonderful. I'd been used to solitary silence and was now being interviewed by the mass media. On release, I learnt that during our imprisonment a large export company had announced it would not use the Fagervik or any "dirty" ships (ie, sea-polluters) for transport — I felt a deep sense of effort rewarded. On trialTwo weeks later, four Greenpeace activists, including myself, were found guilty of aggravated trespass and given a two-year suspended sentence. This means that, if we work in any future protest actions in Sweden, we risk getting arrested and having to serve out our sentence. We can understand some of the reasoning behind this sentence — a year ago, Sweden was shaken by violent anti-globalisation demonstrations in Gothenburg. However, we plan an appeal, as it's important to make a distinction between violent protest and the right to non-violent, thoughtful protest about community issues. In the courtroom, I was asked if I regretted my actions. Through a translator, I replied along these lines: I do not regret my actions. What I regret is the harsh reaction by this legal system to a peaceful protest. As a medical doctor in Australia, I see people dying of cancer and babies born with abnormalities. It isn't enough for me to just keep treating sick people — I also feel compelled to speak up about the issues behind some of these illnesses. I understand that pollution in the Baltic Sea is already so high that pregnant women are advised not to eat the fish from it. I believe it is important to encourage governments to enforce restrictions on industrial release of what is unsafe into the water, air and soil. PrivilegedSo, was going to prison worth it? It was a privilege to be able to speak and act for what I believe matters. Environmental issues are not remote from primary care, they are increasingly recognised as an integral part of it.

Elizabeth D Rickman MB BS

The first, and only, time I questioned my decision to spend seven months working with Médecins Sans Frontières (MSF) in Afghanistan was when I crossed the tarmac of Hobart Airport to board my flight there on 17 February, 1999. My decision to go had been driven partly by a growing frustration with the increasing bureaucratic constraints of general practice and partly by a desire to re-explore the challenges of Third World medicine. My first encounter, many years ago, had been in Bangladesh, where cases seemed to walk straight out of the pages of Bailey and Love's venerable Short practice of surgery. Now, I was headed for a very different country, which, as we all know, has been subject to 20 years of continuous and continuing warfare. About a million Afghans have been killed during this time and at least 700 000 people displaced within the country itself, as well as two to three million refugees to neighbouring Pakistan and elsewhere. Key health indicators place Afghanistan among the most unfortunate countries in the world (Box 1). Life expectancy — at just 45 years of age — and childhood and maternal mortality figures are nearly the worst in the world. The mission where I was to be stationed for the next seven months — in the village of Baharak in the very impoverished northeastern province of Badahkshan (Box 2) — had just reopened; it had been shut down in 1990 after the murder of a French MSF logistician. As I boarded my flight and the plane took to the air, I dismissed any misgivings about my decision and pondered what lay ahead. Based in BaharakAll MSF personnel are given detailed clinical, cultural and security briefings before deployment. These were to prove invaluable. Baharak is in one of the least developed areas of Afghanistan. The village and its environs are devoid of infrastructure — there is neither power nor reticulated water, no communications systems or drivable roads; all this lack is compounded by the further lack of any local governmental administrative structure and the fact that the area is prone to frequent local conflict. Our clinic consisted of a simple wood-and-mud-rendered structure divided into two parts (male and female, Box 3). Given its location, in addition to no power or running water it also operated without any pathology or x-ray service to speak of. So, clinical management was pragmatic — basic, old-fashioned case definition; and treatment in accordance with MSF/World Health Organization (WHO) protocols, facilitated by modern generic drugs and IV fluids held in our pharmacy (Box 4). The problems we dealt with were varied — each day would provide about 300 patients: one or two trauma cases and obstetric emergencies on a background of ever-present infectious disease and malnutrition. On occasion, we would be further challenged with rarer but equally life-threatening presentations of a more exotic nature, such as anthrax, haemorrhagic fever and retinoblastoma (Box 5). Types of traumaGuns and minesGunshot wounds, the result of frequent, ongoing clashes between rival Northern Alliance commanders, and mine injuries, a legacy of the past Soviet occupation (1979–1989), were a daily occurrence (Box 6). Afghanistan is the most heavily mined country in the world, with an estimated 10 million mines sown. As the front lines have shifted over time, so has control of the minefields, and complete confusion now reigns about the size, content and disposition of these fields, which kill or wound seven to 10 people in Afghanistan every day. Baharak was a Soviet garrison during the occupation, and had been particularly heavily mined in an effort to deter mujahidin attacks. Now, these mines accounted for many injuries and deaths we saw, particularly among children attending their animals in the surrounding fields. We generally provided first aid, with wound surgery conducted in the provincial city, Faizabad, three hours away by road. However, when the road to Faizabad was cut for security reasons, we needed to conduct surgery as best as we could manage at Baharak. With no formal surgical training, no x-ray machine, no blood, and only ketamine for anaesthesia, management was restricted to debridement or amputation and was very much a case of "flying by the seat of one's pants". StoningsI had known to expect injuries from land mines, but on only my second day in the clinic I also met with the unexpected. A man was brought to the clinic in extremis. He had been subjected to public stoning for adultery. His condition was incompatible with survival and a solemn reminder of the country's profound cultural standards. There were two other stonings (also for adultery and also fatal) during my time in Baharak. Women and mothersCultural factors, poor maternal nutrition and a lack of trained midwives in Afghanistan contribute to the country's high maternal mortality rate. It is the world's second worst, after Sierra Leone. A mother with anaemia and sepsis related to a five-day-old retained placenta typified the sorts of presentations to be dealt with on a daily basis. We were fortunate to have an English midwife with 20 years' experience in the Third World working with us. Cultural constraints did not allow me to examine female patients; at all times, they were required to be fully covered in their shalwar kameez. As necessary, the midwife would conduct the patient examination, relaying her findings to me from behind a screen. Infectious diseasesThe commonThe leading cause of child mortality was diarrhoeal illness and dysentery, which related to the absence of safe water and poor sanitation. In summer, the incidence of both dysentery and typhoid escalated dramatically; sporadic cases of cholera were also seen (Box 7A). The simple use of oral rehydration salts was lifesaving for many. Malaria accounted for about 35% of all the summer admissions. On our arrival, the tuberculosis program was almost non-existent. Poor compliance and the inappropriate use of drugs of poor quality, that had made their way from Pakistan to the local bazaar, also contributed to the problem. The disproportionate number of extrapulmonary cases confirmed our fears that the more infective active pulmonary cases were either not presenting or being missed (Box 7B). Leishmaniasis is endemic in Afghanistan, but invariably in the cutaneous, self-limiting "oriental sore" form (Box 7C). A few cases of the more serious visceral leishmaniasis, kala-azar, had been documented in the past, and we saw many patients with remittent fever and grossly enlarged spleens who often did not fit the patterns of chronic malaria, brucellosis or myeloproliferative disorders. More than likely, several of these patients were dying of treatable visceral leishmaniasis. The absence of any antimonials usually used to treat kala-azar related to the lack of information on the prevalence of this condition; the absence of any firm epidemiological work on this and other infectious diseases significantly hampers the development of an effective health strategy in Afghanistan. The rareOn occasions, I was confronted by rare but life-threatening conditions. Anthrax, a significant part of the germ warfare repertoire, is endemic in Afghanistan, and usually seen as the relatively benign cutaneous form. The systemic form is anything but benign. One unfortunate patient, who had handled a dead sheep a few days earlier, presented to our mission with the typical black eschar and oedematous swelling over one eye. He developed frighteningly progressive respiratory distress and died some hours later, despite aggressive doses of intravenous antibiotics. For me, pneumonic anthrax is now a case of "once seen, never forgotten". Then, one afternoon, I was asked to review a patient with uncontrollable epistaxis. The two health workers who were attempting to stem the bleeding were heavily contaminated with blood. Of greater concern to me was the fever, haematuria and petechial rash over the patient's body, including his soft palate. An infectious diseases colleague had warned me of the existence of Congo-Crimean haemorrhagic fever (CCHF) in Badahkshan and the serious risk of nosocomial transmission. Everyone was disinfected and the patient barrier-nursed as best we could manage. As always, treatment was fairly pragmatic. If the patient did have CCHF, there was little we could offer. The only treatable cause of such a presentation I could think of was a coagulopathy due to fulminating malaria and typhoid, so the patient was commenced on quinine and chloramphenicol. He survived, but developed paraplegia, presumably from a secondary spinal bleed. On completion of my mission in Afghanistan, I took a sample of the patient's serum back to Geneva (despite some misgivings about the ethical and legal implications of carrying such potentially biosensitive material about the world); immunofluorescence confirmed the presence of IgG antibodies to CCHF. Safe and secure?Security is an important concern for any MSF deployment. Strict SOPs (standard operating procedures) were adhered to, with regular HF (high frequency) radio skids to our head of mission in Tajikistan, the neighbouring country to the north. They had a rear link to Geneva by satellite phone. More often than not, deteriorations in the regional security situation were relayed by these means rather than by locals. Taliban offensiveDuring the July offensive, Taliban forces advanced rapidly on two axes nearby, one towards Faizabad and the other along the Panjshir Valley. At the same time, reports were received of a large group of Taliban gathering at Shah Salim Pass, on the border with Pakistan to the south. All United Nations flights to Faizabad were cancelled, so any rearward evacuation of our missions to Tajikistan was potentially threatened. In our MSF vests, my Swiss physician friend, Philippe, and I felt secure. We both thought we were about to witness a defining moment in Afghan history, but a brilliantly executed counterattack by the Northern Alliance commander Ahmed Shah Massoud thwarted the Taliban advance (Box 8). Northern AllianceWe shared a meal with commander Najmaddin Khan, at that time the second most important commander in the Northern Alliance after Massoud. I remember that he had a nervous tic and that the meal was interrupted frequently by calls on his satellite phone to other alliance commanders. On one occasion Massoud arrived by helicopter to visit Najmaddin; two hours later a Taliban MiG fighter plane bombed Baharak. Taliban intelligence was excellent; fortunately, their aim was not so good. Najmaddin was ambushed and killed in Baharak a month after I left Afghanistan. Massoud was assassinated by suicide bombers (posing as journalists) on 9 September last year — two days before the terrorist attacks in the US. Away from BaharakWakhan CorridorOne of the highlights of my time in Afghanistan was an exploratory mission into Wakhan, the poorest and most remote district of the country, located in the far northeast bordering Tajikistan (to the north), China (to the east) and Pakistan (to the south). If, in shape, the map of Afghanistan is thought of as resembling an irregular leaf hanging from a stem, then the stem would be the Wakhan Corridor. The district has an average altitude of 3000 metres and is subject to harsh climatic conditions. It is also devoid of any infrastructure, and the medical facility at Ishkashem is up to 10 days' travel by donkey from the more remote areas of the district. The first stop of our trip was to pay respects to the local Shah, who seemed a very reasonable man with the best interests of his people at heart. From there we travelled with his opium-addicted uncle, who facilitated our entrez to the villages (Box 9). Afghanistan is currently the world's leading supplier of illicit opium, providing a significant source of revenue for arms for military commanders, or, as one farmer put it, "the West sends us weapons, we send the West our white powder with respect" (Box 10). It soon became apparent that opium addiction was common in Wakhan, primarily as a substitute for non-existent health care. Its analgesic, antitussive and constipating effects provided a panacea for many of the area's endemic diseases. LathyrismOur predeployment briefing had mentioned a suspected case of lathyrism near the village of Khandud. Lathyrism is a neurological disorder, known since the time of Hippocrates. It is associated with the consumption of Lathyrus sativus — known locally as patak (and also known as chickling pea, grass pea and kesan dahl). Although very nutritious and cheap, this legume contains a potent neurotoxin, which eventually causes irreversible spastic paralysis, hyperaesthesia and paraesthesiae (Box 11). As we conducted primary health checks in various villages, we found that many locals complained of muscle stiffness, with examination revealing very obvious lower-limb clonus, consistent with lathyrism. Obviously, the condition was endemic. Most of the locals knew of the association between patak and lathyrism but continued to eat it out of economic necessity. OutbreakAs we progressed further into Wakhan, we had to abandon the vehicle and travel by horse. Many villages hadn't seen a foreigner for more than 20 years, including the village of Daghullaman. There, we investigated a report of an outbreak responsible for many deaths. At one stage, barely enough of the 300 villagers were strong enough to secure adequate water for the others. Active cases had a virulent flu-like illness, many with complicating pneumonia. We treated them empirically with the last of our dwindling supplies of ciprofloxacin, forearmed with the knowledge of a large but similar outbreak that had occurred a few months earlier along the Tajik border, and which WHO tests had implicated as klebsiella infection. Health surveyWe conducted a mid upper arm circumference survey, studying 365 children between 6 months and 5 years of age, confirming that about half of them were nutritionally at risk. Immunisation was non-existent, and measles accounted for a disproportionate number of deaths in childhood — 12 children in one house alone. A measles vaccination program was subsequently implemented in Wakhan by MSF. A spot of sportsOn the return journey from Wakhan, we made the most of an opportunity to take part in some fishing and hunting activities. The fishing was very productive and we followed the usual Afghan tradition of using rapidly expanding bait (Box 12). An ibex hunt was also conducted along traditional Afghan lines — using Kalashnikovs. The meat provided a welcome change from Wakhan bread and yoghurt. FaizabadThe final phase of my time in Afghanistan was spent assisting with the newly established mission in Faizabad (Box 13), aimed at developing the inpatient capability of Faizabad Hospital. This hospital was the only formal surgical facility in a district of 700 000 people, with a grand total of one operating theatre and two trained Afghan surgeons. The challenge of working there was made all the greater by the lack of blood cross-matching reagents, and the amazing situation whereby the more experienced of the two surgeons was only permitted to operate on the most difficult cases. Between times, he was kept in jail for the murder of his brother! What now?What does the future hold for Afghanistan, for MSF and for me? Afghanistan's long and continuous history of conflict is a tribal phenomenon fed by foreign interference, from the time of Soviet occupation to the current flow of arms from neighbouring countries to often rival military commanders throughout the land. I think that, in the current political and diplomatic milieu, the likelihood of a peaceful and united Afghanistan unfortunately seems unlikely. Further, a drought is now in its fourth year and about half of the country remains inaccessible to aid organisations. MSF, from its noble but humble beginnings in 1971, has grown to become the world's largest non-government medical organisation. Its stance of absolute neutrality enables it to meet its charter of providing independent humanitarian medical aid to populations in crisis and, in addition, advocacy; MSF was awarded the 1999 Nobel Prize for Peace. MSF continues to work in Afghanistan, although operations have been classified as a result of the antiterrorist measures taken after September 11, 2001. For me, the common threads of experiencing the Third World as a doctor have been not only the fascination of the medicine, but also the marvellous humility and dignity of the patients and the privilege of working alongside some very special people. 1: Afghanistan: key health indicators1,2 Population: 20.9 million Mortality (under 5 years): 26% Maternal mortality: 1.7% Life expectancy: 45 years Access to safe water (rural): 5% Access to adequate sanitation (rural): 1% Malnutrition (under 5 years): 35% Malaria: 3 million cases annually 3: Female outpatients department in Baharak. 4: Traction, Afghan style. 5: Retinoblastoma. 6: Mine injuries occurred daily. 7: Infectious diseases. A. Cholera, with skin turgor demonstrated. B. Tuberculosis of the spine leading to gross deformity. C. Leishmaniasis, also known as "oriental sore". D. Epistaxis associated with Congo-Crimean haemorrhagic fever (CCHF). 8: Local Baharak commander and troops. 9: Travelling the remote Wakhan Corridor. 10: The panacea opium. 11. Lathyrism associated with patak consumption. Fishing using ammunition for bait. 13: Faizabad street scene.

Robert A Simpson AM, RFD, MB BS, FACRRM