Global health

Alarge military truck slowly rolls up to the small emergency unit in Mullaitivu, a remote town on the north-eastern coast of Sri Lanka. In the back of the truck are two bodies. A young man and woman still entwined. Tied to each other with muddied strips of saree cotton, once vibrant and colourful. A double suicide pact outlined in a simple letter in the hands ...

Ruth Y Lim MB BS

Patients with drug-resistant tuberculosis will inevitably reach the Torres Strait or Australia’s mainland. To defend against this threat, all those who present to health services in Australia should have free and equal access to tuberculosis care.

Tony Kirby BSc(Biological Chemistry)

Change is one of the few certainties in medicine — but do we ride out change or ride with it?

Ann Gregory · Astika Kappagoda

More formal systems of global health training in Australia have the potential to create a cohort of doctors with the skills and knowledge necessary to engage in regional health challenges in a global context.

Rob D Mitchell MB BS(Hons), BMedSc(Hons) · Jennifer C Jamieson MB BS, BBiomedSci · Jake Parker BSc, MB BS, MSc(ClinPhysiol) · Fred B Hersch BSc, MB BS(Hons), MPH · Zoe Wainer BM BS, BHSc · A Rob Moodie MB BS, MPH

To the Editor: The article by Elkin and colleagues has certainly reheated the long-simmering debate about bringing highly trained international medical practitioners from other countries to provide health care in Australia. Yet, it does not discuss the clinical and cultural acclimatisation they need. There are many moral and social issues associated with condemning an IMG without helping them to adapt to their locality. The study ...

Shailja Chaturvedi

To the Editor: Elkin and colleagues acknowledged that “most [international studies] have found no association” between acquiring a medical degree overseas and being the subject of a complaint; however, their principal findings — which differ from these other studies — require care in interpretation. In the study by Elkin et al, the “clinical specialty was missing” for 75% of registered doctors. Yet, certain medical specialties are ...

Carlos Zubaran

“We cannot know the solutions until we first know the people … Most of us do not stay long enough or get close enough to the front line to ever be able to discover stories like this one.”

Krithika Murali MB BS, BMedSci

In a week when the presidential election was imminent, but Americans were more concerned with Hurricane Sandy and Halloween, an Australian visiting professor in New Orleans shares his observations of life and health in the United States and the ongoing recovery from Hurricane Katrina.

Charles S Guest Visiting Professor

Christmas may be a state of mind or a memory, to carry with you wherever you are“What is Christmas?” a 3-year-old boy eagerly asked his father. “Christmas, my son, is the time of the year when we celebrate the birth of Jesus Christ”, answered the father with a smile on his face. “But”, he then continued, “we also celebrate how wonderful life is by showing ...

Manda Kaled

Complex challenges call for action inside and outside the health care box. Inside the box, health workers can manage hypertension and diabetes and beat tuberculosis. But they need support from outside the box — leadership and adequate tools for their work.

Ian Maddocks MD, FRACP, FAChPM

The clinic of the Sudan Medical Relief Project (www.sudanmedicalrelief.org) is in Old Fangak, in what is now the Republic of South Sudan. In 2010, I spent 7 weeks working there with an American medical team, before being evacuated owing to increasing violence in the area. We flew with one backpack each from Lokichoggio, on Kenya’s border, into South Sudan. Our plane was a twin-engined Cessna with an ...

Benjamin H M Hunn BMedSc(Hons)

Objective: To estimate the risk of active tuberculosis (TB) in immigrants to Victoria, Australia, as a function of time since arrival and stratified by age group and region of origin.Design, setting and subjects: Longitudinal study of the incidence of active TB in Victorian immigrants, excluding New Zealanders, who arrived in Australia between 1975 and 2007. Victorian immigration data were used to describe annual arrival ...

Emma S McBryde MB BS, PhD, FRACP · Justin T Denholm BMed, MPHTM, FRACP

At birth, Moses Kharat was given a life sentence of poverty and suffering. Born a lower-caste Dalit in the rural Indian district of Buldhana, he would spend most of his childhood helping his family with hard labour, and was unlikely to ever know an education. Today, he is a medical doctor, and he reminisces about the day missionaries came to his village, providing him and others with the schooling and health care needed to break out of the cycle of poverty.

Bharat Ramakrishna BMedSci · Michelle Y Li BMedSci · Ray Wang BMedSci · Lily T Ho-Le BMedSci · James S Wei BMedSci · Henry R Jennens BMedSci

To the Editor: Murray and colleagues make an important call for the transition to more socially accountable medical education, and identify students as partners in this process.1 The Australian Medical Students’ Association (AMSA), the peak representative body for Australia’s 17 000 medical students, recently passed policy at its July council meeting that strongly aligns with this vision for educational and institutional responsiveness to community needs.2 For the past ...

Daniel Yore · Erica L Parker · Catherine G A Pendrey

Global health is, by definition, an area of great breadth and depth. There is enormous diversity in health systems and health outcomes, with life expectancy at birth varying from 82–84 years in Australia and Japan to less than 55 years in more than 20 African countries. Despite this diversity and difference, communicable diseases such as HIV and severe acute respiratory syndrome, and our more recent understanding of the ...

A Rob Moodie MB BS, MPH

There are no sirens. Nor is the silence disrupted by the rush of feet or frantic blue lights. Instead, our enduring patients arrive at the hospital gates on foot, most having travelled for many hours, if not days, through the unrelenting 40° C heat; the privileged cling to motorcycles already laden with firewood and kitchen utensils in anticipation of a prolonged admission. Through these same gates arrived ...

James D Smith

The postwar arrival of refugee doctors heralded changes to the Australian health workforce that we are still adjusting to todayInternational medical graduates (IMGs) are an important part of Australia’s health workforce, accounting for about 23.5% (n = 16 186) of all doctors in Australia today.1 The recruitment and placement of IMGs in rural areas is particularly vital to the provision of health services in rural Australia, where there ...

Daniel R Terry BNurs, MInternatHlth · Jessica J Woodroffe BA(Hons), PhD · Quynh Le PhD, MAppComp, MEdStud · Kathryn J Ogden MB BS(Hons), MPH, FRACGP

Work, as well as life, can lead to surprising placesIf someone had suggested in my medical student days that I would end up working where I do, I would have laughed. But, no one knows where experiences, conversations and opportunities might lead. Like many idealistic medical students, I did electives in areas of need. My first was in north-east Arnhem Land. Returning to lectures, I remember ...

Marianne E Jauncey BMed, MPH(Hons), FAFPHM

To the Editor: The HIV epidemic in Australia is changing. The number of new infections attributed to heterosexual contact has increased, and people from culturally and linguistically diverse (CALD) backgrounds account for a significant proportion of these diagnoses. In the period 2005–2009, 41% of new HIV diagnoses linked to heterosexual transmission were in people from ...

Augustine D Asante · Henrike Körner

Self-interest and global responsibility create a public health balancing act The treaty between Australia and Papua New Guinea (PNG) referred to as the “Torres Strait treaty” entered into force in February 1985.1 The treaty’s purpose is to provide certainty of the sovereignty and maritime boundaries between the two countries, including in the Torres Strait, where there are over 200 islands. The three major inhabited Australian islands of Boigu, Dauan and Saibai are situated several kilometres off the coast of the South Fly District of PNG’s Western Province (Box 1).2 In September 2009, the Australian Senate requested that the Foreign Affairs, Defence and Trade References Committee inquire into and report on matters related to the region and the treaty,3 including the administration and management of public health in and around the Torres Strait. Although the treaty excludes health access as a justification for travel, its free-movement provisions have contributed to a situation where access to Australian health services by people from PNG and public health issues — particularly those related to tuberculosis (TB), HIV/AIDS, cholera, dengue and malaria — have become major concerns. We present our analysis of the committee’s November 2010 report and highlight the increasing immigration, health, socioeconomic, cultural and human complexities that exist in the region. Such complexities require collaborative commitment between state and national governments from both sides of the border in formulating policy and providing resources. The Torres Strait treatyThe Torres Strait treaty established a Torres Strait Protected Zone. Within the protected zone, people who live in the coastal areas of PNG and Australians who are Torres Strait Islanders are permitted to travel across the border in accordance with their way of life as the traditional inhabitants of the region. Australia and PNG are divergent in wealth and development, and this divide has grown in the past 20 years. PNG has one of the poorest health records in the Pacific region and is unlikely to meet any of its health-related Millennium Development Goals.4 Communicable diseases are the major cause of death and illness across all age groups; life expectancy is 57 years;5 and 30% of children in PNG are considered to be moderately to severely malnourished.6 The health system in the remote Western Province is particularly poor.7 This area’s main health facility is Daru Island Hospital, which operates with poor infrastructure as well as ongoing staff and clinical supply shortages.8 The hospital lacks capacity to support rural areas in clinical outreach services.9 Western Province has been described as the “most economically depressed region of PNG”.10,11 Poor sanitation and water quality and limited disease-control activities result in outbreaks of infectious diseases such as malaria, HIV/AIDS and other sexually transmissible infections, TB and multidrug-resistant TB (MDR-TB).8 Unsurprisingly, the international border provides a bridge for emerging infectious diseases.9,12,13 To counter this, the treaty allows for border integrity as a public health priority — under its provisions, Australian or PNG authorities can close the border to limit or prevent free movement.14 All cross-border travel was restricted in 2009 because of the H1N1 influenza epidemic,15 and again in 2010 because of a cholera outbreak in Daru that killed 30 people.16 There is increasing alarm over the potential for a major public health crisis on Australian shores, such as MDR-TB spreading into vulnerable Aboriginal communities in north Queensland.9,12 Main committee findings related to health servicesTraditional inhabitants were exempt from usual immigration health checks at the Australian border in the Torres Strait: This exemption, under the treaty’s freedom of movement provisions, aroused locals’ “fear of likely transmission of serious diseases”. The committee highlighted that Unauthorised visitors who manage to land on the islands undetected . . . increase the risk of diseases being transmitted to people on the islands.17 PNG residents traversed the border for Australian health care services: Although access to health services is not classified as a traditional activity pursuant to the treaty, the reality was that people from PNG frequently travelled into Australia to receive treatment at Queensland Health clinics, particularly those located on the islands of Saibai and Boigu.17 Demand for Queensland Health services was increasing: Although data on the number of people from PNG who sought medical assistance in the Torres Strait were incomplete, there were “significant” and rising numbers receiving Queensland Health services. This caused a strain on Queensland Health services and subsequent access difficulties for Australian Torres Strait residents that contributed to local unease and tension.17 The committee found that the situation was complex, with “very strong push and pull factors” driving the trend for PNG residents to seek Queensland Health services.17 The factors included: A lack of health care services and resources in Western Province, and particular paucity in the South Fly District adjacent to Torres Strait. The proximity of Australian medical facilities for South Fly District residents. Queensland Health clinics on Saibai and Boigu islands are a 15–30-minute boat trip, costing about A$60 return for fuel, which was subsidised by the clinics.9 Daru hospital is a 2-hour boat ride, for which the cost of the fuel ranged from $180 to $240. Provision of health care by Queensland Health, with the support of the Australian federal government, to PNG residents who required urgent medical attention. This occurred on humanitarian and public health grounds, especially to prevent the spread of infectious diseases into Australia and throughout Western Province. Australia’s “level of care” extended to medical evacuations of people from PNG to the Australian mainland and Thursday Island Hospital,17 outside the Torres Strait Protected Zone. Only patients with acute life-threatening conditions were admitted (Box 2).15 Additional challenges identified by the committeeThe committee found that local Australian residents were concerned that Australia was sending a “mixed message” by allowing PNG residents limited access to Queensland Health services. That is, while the treaty did not allow movement for the purposes of accessing health care, Australia was nevertheless providing services on certain grounds. There was fear that this would set a precedent and foster demand for Queensland Health services, causing resentment among local Torres Strait communities and local health care managers because of the increasing use of resources. Further, Australian-based health professionals have experienced confusion over treatment protocols for visitors from PNG in the Torres Strait. The committee also acknowledged that the complex situation was muddied by the multiple government agencies operating in the region with overlapping portfolios (Box 3), resulting in inefficiencies in service provision, gaps in communication and problem planning, and potential resource mismanagement. The committee’s recommendations and the long road aheadSupport for PNG health care initiatives by the Australian Government: The aim of this recommendation is that PNG residents will eventually not need to seek Queensland Health services in the Torres Strait region. The committee acknowledged the long road ahead, particularly in the remote Western Province. While AusAID supports development of PNG’s health system substantially through cooperative capacity-building exercises, the differential between health services in Australia and PNG will persist into the foreseeable future. Reframing the health issues as a collaborative cross-border approach: Development assistance is primarily framed around a host nation’s needs. However, the Torres Strait situation warrants reframing as a regional cross-border issue and a specific project targeting the needs of both countries. This would need to move beyond the current model wherein the Torres Strait Health Issues Committee (known as the HIC), meeting twice yearly, examines health issues associated with the free border movement of PNG residents and Torres Strait islanders.7 Rather than the HIC, an adequately resourced, targeted project that deals with cross-border issues on both sides is needed, and one that particularly includes consultation with both PNG and Australian communicable disease physicians who work in the region. Increased monitoring of Australian development projects in Western Province: While the committee’s recommendation for greater accountability over how Australian development funding is spent appears to be reasonable, what is needed is a greater focus on results and mutual accountability over the outcomes that would result from a harmonised approach to this cross-border issue. Collaboration between all government agencies: The committee recognises that investment in health infrastructure by both the PNG and Australian governments in Western Province is insufficient. Continuing financial support is needed for maintenance so that the benefits of initial aid outlays are not lost — a recognition that is consistent with the redefining of sustainability in development.18 The committee encourages all agencies to work together in the use of resources, so “projects on both sides of the border should complement and strengthen each other”. The recognition that this is an “atypical jurisdiction” invites innovative solutions: the Torres Strait situation could be framed as a regional trans-border issue, and health authorities of Australia, Australian states, the Torres Strait, Western Province and PNG, as well as other stakeholders, could be invited to collaborate on developing a network of cross-border services, with defined objectives that address specific shared concerns. Given a long and continuing history of migration to the Torres Strait region from Asia and Melanesia,10 a broader regional approach could be justified. Experience from Australia’s tristate Aboriginal health services in Central Australia19 and from Mekong cross-border development collaborations20 provides appropriate models. Continued provision of services by Queensland Health to PNG residents in the foreseeable future: On humanitarian and public health grounds, the committee stated its full support for Queensland Health. Yet Queensland Health will need to be better resourced by the federal government as part of a collaborative strategy for health care services at this regional interface. Failure to recognise this as an international obligation will see Queensland Health’s commitment to communicable disease control compromised. The economic and public health implications for Australia of reducing current cross-border communicable disease strategies warrant urgent attention. This is already a demonstrable concern for Australian health professionals working in the region, with Queensland Health’s recent decision, on financial grounds, to close its TB clinics on Saibai Island. Review of Australian Government funding to Queensland to ensure it is commensurate with actual costs incurred: In view of the previous recommendation, it is unsurprising that the committee made this additional comment. Developing a cross-border project would enable clear costing of and responsibility for the agreed strategies, while building communicable disease control capacity within PNG and safeguarding Australian public health interests. ConclusionCurrent Queensland Health policy regarding access for PNG residents to health services from Australian health clinics — to provide acute services only — is in tension with public health imperatives and the long-term management of some chronic infectious diseases. Problems are compounded by the number of agencies and levels of government responsible for interlinked funding and health care provision bridging the border. Solving the problems demands a collaborative but innovative approach, with improved health services for the people of PNG in their own country as the long-term goal. In the interim, the Foreign Affairs, Defence and Trade References Committee report identifies a range of strategies and makes clear recommendations that will guide progress. These recommendations are enmeshed with concepts of health diplomacy, as international health issues have now achieved foreign policy priority.21 The risk of cross-border disease transmission in the Torres Strait is a clear demonstration that health is a global, rather than a local, agenda. People from PNG will continue to challenge the treaty provisions and seek lifesaving health services that are unattainable in their own country. A mother from Western Province making the 20-minute dinghy trip to a Queensland Health clinic seeking treatment for her young child with TB is unaware of any potential concerns of the Australian public — her need is urgent, and Australia has comparatively unlimited resources. This is the human side of the Torres Strait quandary, reminding us how intensely personal public health is, and how health and human rights arguments intersect.22,23 1 Map of the Torres Strait region, showing the boundaries between Australian and Papua New Guinean territory 2 Admissions of Papua New Guinea residents to Thursday Island Hospital, Sep 2008 – Sep 20097,15 Reason for admission* No. of patients Tuberculosis (25% had multidrug-resistant tuberculosis) 15 Obstetric case 15 Severe malaria 10 Medical trauma or care (falls, fractures, burns, violent injuries from machetes and spears, snakebite, acute and chronic eye injuries) 52 Total 92 * Only patients with acute, life-threatening conditions were admitted. 3 Overview of agencies operating in the Torres Strait Agency Government Role Torres Strait Regional Authority Australian Participate in health policy coordination, development and planning of initiatives undertaken by state and government agencies Queensland Health (QH) Queensland Manage and fund public health facilities Provide health services to PNG residents on humanitarian and public health grounds* Department of Health and Ageing Australian Provide dedicated funding to QH for Torres Strait services Undertake discrete public health activities in the Torres Strait AusAID Australian Manage Australian Government’s aid program Provide funding to PNG for health systems development in cooperation with the PNG and regional governments Department of Foreign Affairs and Trade Australian Utilise movement monitoring officers to conduct border enforcement measures to prevent breaches of treaty provisions Department of Health PNG Provide health services to PNG residents according to duty of care PNG = Papua New Guinea. * Access to QH facilities is the product of an Australian Government foreign affairs agreement.

Claire E Brolan BA, MA, LLB(Hons) · Susan J Upham BSocWk, GCIPH, PostgradDipHlthPromot · Peter S Hill MB BS, PhD, FAFPHM · Graham Simpson MD, FRCP, FRACP · Stephen D Vincent MB BS(Hons), FRACP

For many decades, Australia has been fortunate to have a low prevalence of tuberculosis (TB).1 This has resulted from a firm commitment to screening for and managing TB since early last century. Because of the low rates of disease, the current population, unfortunately, perceives TB to be a “disease of the past”. Such a perception leads to complacency, even among subgroups of policymakers, who place importance on short-sighted spending cuts over long-term TB control in an era in which drug-resistant TB is an emerging biosecurity threat to Australia. One component of effective TB control is prompt identification and treatment and monitoring of index cases and screening of contacts. In 2001, the Cairns Regional TB Control Unit initiated this response when the first case of multidrug-resistant TB (MDR-TB) was detected in the Torres Strait region.2 The initial and subsequent cases were in people from Western Province in Papua New Guinea (PNG) who resided within the Torres Strait Protected Zone and, by treaty law, are free to travel back and forth from Western Province to the outer islands of Torres Strait for traditional purposes. As new cases emerged from Western Province, the regional control unit established TB outreach services on Saibai and Boigu Islands to treat these patients, both for humanitarian reasons and to reduce the health risk to Australian citizens. The clinics employed medical, nursing and radiographic staff and had access to the Brisbane TB reference laboratory. They carried out ongoing surveillance during a patient’s treatment cycle, to detect any treatment failure or default, and post-treatment follow-up, to ensure the patient was cured. Over the past decade, the number of TB and MDR-TB cases originating from Western Province has increased substantially and the demand on the clinics has been large.2 However, the actions of the clinics have been credited with there being no MDR-TB cases detected in the Australian population in this region. The Australian clinics were set up out of necessity, as Western Province has no established, comprehensive TB service. Further, Western Province has been plagued by long-term political unrest, poverty and lack of transportation, resulting in minimal access for local residents to their regional hospital on Daru Island. The intention of the Saibai and Boigu clinics has always been to hand over care of PNG residents once a clinic and a TB outreach program were established on the PNG side of the border. Over the past few years, there have been regular meetings between Queensland TB control units, the Australian Government, the Western Province local government, the PNG national TB program team and Daru hospital staff. The aim of the meetings has been to facilitate, step by step, the transfer of responsibility for TB management to PNG, including clinical input from both Queensland and PNG health services. As yet, there is no such service within Western Province or through a clinical base at Daru Hospital with an outreach service to Western Province. Unexpectedly, during the first half of 2011, the Queensland Government directed that the TB outreach clinics on Saibai and Boigu Islands be closed in June 2011.3-5 No remedial plan for treatment continuation was included, leaving the 50 patients from PNG who were being treated for TB in a dire situation. Importantly, there was no plan for the ongoing management of patients from Western Province. Through strong pressure from TB clinicians in Australia, operation of the Australian services has been extended, and they will remain open until early 2012 to ensure completion of the treatment cycle for current patients. AusAID is supplying funding to establish TB health services within Western Province,5,6 but the program is in its infancy. There is considerable concern that extensively drug-resistant TB will emerge in the region and eventually infect Australian citizens residing in the outer Torres Strait islands.

Stephen D Vincent MB BS(Hons), FRACP

Setting the global agenda for prevention and control of non-communicable diseases — a report from the recent United Nations General Assembly high-level meeting On 19–20 September 2011, the United Nations (UN) General Assembly convened a High-Level Meeting on Prevention and Control of Non-communicable Diseases (NCDs) in New York. This is only the second time in its 66-year history that the UN General Assembly has gathered to consider a health issue, the previous occasion being for HIV in 2001. NCDs principally comprise cancer, diabetes, cardiovascular disease and chronic respiratory disease, and share four main risk factors — unhealthy diet, physical inactivity, tobacco smoking and harmful consumption of alcohol. The rationale behind the UN high-level meeting is that NCDs currently account for more than all other causes of death combined, and are estimated to have been responsible for 36 million deaths, or 63% of all deaths globally, in 2008.1 NCDs are no longer just problems of old people in wealthy countries. They now disproportionately affect the poor in low- and middle-income countries, where they also kill at a younger age — 29% of NCD deaths in these countries occur among people under the age of 60 years, compared with 13% in high-income countries.1 Two of the most telling statistics highlighted at the UN high-level meeting are the estimate that 366 million people are living with diabetes in 2011,2 and the prediction that an estimated 1 billion people could die from tobacco use this century unless urgent action is taken.3 Estimates from the World Economic Forum are that NCDs will cost more than US$30 trillion (representing 48% of global gross domestic product in 2010) over the next two decades and push millions below the poverty line.4 As Margaret Chan, Director-General of the World Health Organization, pointed out in her address to the General Assembly, NCDs are “a slow-motion disaster” that will “break the bank” unless we act. In an environment where governments and scientists alike call for an evidence base for global investments, these ballooning data are decidedly at odds with the fact that only 3% of development assistance in health is invested in NCDs — the least amount of funding compared with other health focus areas.5 It was largely the Caribbean nations agitating for global action on NCDs that resulted in the convening of the UN high-level meeting. Many lead-up meetings were held in 2011, such as the first Global Ministerial Conference on Healthy Lifestyles and Noncommunicable Disease Control in Moscow,6 in an attempt to move NCDs up the political priority list and to establish global consensus for action. The original UN resolution to convene the high-level meeting, in 2010, called for the adoption of “a concise and action-oriented outcome document”. In the run-up to the meeting, this changed into a “political declaration”. Those charged with writing the declaration had to grapple with contemporary issues that included: reduced donor funding due to the global financial downturn; donor countries wanting to remain focused on AIDS, tuberculosis, malaria, and maternal and child health; the potential for huge spending on new treatments that would be pushed on by “Big Pharma”; corporate harassment by “Big Tobacco”; and pressures from the lobbying of the food and beverage and alcohol industries. The UN is often derided for its slow and ponderous processes, but this criticism fails to appreciate that the UN is a world parliament with 193 highly self-interested and politically diverse members, with an absence of any cohesive political parties familiar to Western democracies. Despite these systemic limitations, a political declaration on NCDs was made,7 and 30 presidents and prime ministers and 100 ministers spoke at the meeting, many probably for the first time, about NCDs. A major positive outcome of the UN high-level meeting process has been the formation of the NCD Alliance, a network of more than 2000 non-governmental organisations in 170 countries, which has been formed by the Union for International Cancer Control, the World Heart Federation, the International Diabetes Federation and the International Union Against Tuberculosis and Lung Disease. Another positive was Australia’s announcement of funding towards implementation of WHO’s 2008–2013 Action plan for the global strategy for the prevention and control of noncommunicable diseases.8 Australia was well represented by Minister for Health and Ageing Nicola Roxon, whose presentation in a number of forums about legislation for plain packaging of tobacco products aroused great interest. Another pleasing feature was the presence of Peter Dutton, Shadow Minister for Health and Ageing, and the support of AusAID and the Department of Foreign Affairs and Trade, emphasising that Australia does have much to contribute in this burgeoning area of health and development. The downsides are, as Her Royal Highness Princess Dina Mired of Jordan pointed out in the opening plenary session, that the political declaration fails to name NCDs as an epidemic, that it lacks clear and measurable targets, and that it is infused with vague language. She, like many others, stressed that what gets measured gets done, and that the declaration should have sent a message to the world to reduce deaths from NCDs by 25% by 2025. It was time to stop numbering deaths and start counting survivors, she said. Another problem was that, apart from Australia and Russia, there were no pledges of funds. In all the discussions leading up to the meeting, there had been a distinct lack of interest in setting up a new agency or fund to drive and underwrite new work in preventing and controlling NCDs. Given the explosion of new health agencies and initiatives in the past decade (UNAIDS, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the GAVI Alliance, the International Health Partnership and related initiatives, and UNITAID, just to mention a few), this lack of interest is understandable — but it throws the weight of expectation back onto WHO, which has few staff working on NCDs in Geneva. Many countries endorsed the role of WHO as the key agency to progress action, but there is little doubt it will need a lot of support. Despite the backing of its Director-General Margaret Chan, it appears that WHO has less than adequate capacity for the tasks it has been given (such as setting global frameworks and indicators, and developing targets). To date, the global effort has been led from WHO’s second level of influence (the Assistant Director-General level), which means it has less than optimal internal and external support, given the many other competing issues for the organisation. WHO will need to leverage expertise and skills from bilateral, philanthropic, multilateral and academic organisations from across the globe. As we learned from HIV, it is vital that action coalesces around an agreed set of data and time-bound goals. The World Bank is starting to seriously engage in NCD prevention and treatment,9 but it will also require the active participation of other multilateral agencies, such as the Food and Agriculture Organization of the UN, the UN Development Programme, UNICEF and the International Labour Organization. Two other groups of major players are yet to get seriously involved. The first is made up of the major donor countries, such as the United States, United Kingdom, European Union and Japan, whose policy capacity, research support and funding will be vital for progress. The second consists of the major international development non-governmental organisations interested in health, such as Médecins sans Frontières, World Vision, Oxfam and CARE International, who will have to engage in NCD prevention and control. After all, evidence now suggests that development is being hampered by the impact of NCDs in low- and middle-income countries in particular.1 These countries must also invest their own resources in NCD prevention and treatment. The role of the multiple and highly diverse industries that have a stake in NCDs is unclear. Tobacco companies are so discredited internationally that they have become corporate pariahs. However, working with food and beverage, alcohol and energy companies, for example, is much more complex. On one hand, we in global health must identify the common ground where we can work together, such as workplace health promotion, food and beverage reformulation, alcohol licensing, and making drinking cultures safer. On the other hand, it is highly unlikely that there will be any accord between these industries and those interested in health over issues such as banning and limiting promotions to children, sponsorships, product warning labelling, and pricing and taxation. These issues will become the battlegrounds for the first half of this century. There are real positives to be drawn from the UN high-level meeting. The fact that NCDs have become an issue of the UN General Assembly and not just the WHO World Health Assembly in Geneva is a major plus. NCDs are now on the political agenda and in the media, and, compared with as recently as 12 months ago, an increase in interest is clearly visible. Whether, and how, this interest will be transformed into preventing premature death and disability, only time will tell.

A Rob Moodie MB BS, MPH

Position statement from the Thoracic Society of Australia and New Zealand, Australian Society for Microbiology, Australasian Society for Infectious Diseases and Public Health Association of Australia Many high-income countries with a low incidence of tuberculosis (TB) are confronting the complicated issue of the cross-border movement of people with TB from neighbouring low-income countries with a high burden of TB. Well documented examples where this is an issue include the United States–Mexico border and Scandinavian countries adjacent to Russia and the Baltic States.1,2 In Australia, we face similar dilemmas, not only with Papua New Guinea (PNG) nationals crossing into the Torres Strait Protected Zone, but also with fisherpersons illegally entering our territory, temporary residents on short-term work visas and students attending tertiary education institutions. Cross-border communicable diseases present a complex mix of clinical, public health, humanitarian, ethical, political and financial issues for governments and health care providers. Fortunately, international organisations have provided guiding principles that should underpin a country’s response to cross-border TB cases. For example, the World Health Organization (WHO) has published ethical guidelines for care of patients with TB and control of the disease.3 This document states that: . . . all governments have a fundamental obligation to provide universal access to high-quality TB diagnosis and treatment . . . universal access to TB care implies a duty to ensure the quality of that care . . . The international community must provide financial and technical assistance to countries that lack the resources to satisfy this obligation on their own. These ethical guidelines are based on numerous values including equity, solidarity, and common good (as providing effective TB treatment prevents ongoing transmission of disease, and thereby benefits everyone). Similar recommendations are made by two complementary documents, The patient’s charter for tuberculosis care (PCTC) and International standards for tuberculosis care (ISTC).4,5 These principles are also embodied in the final draft of the Australian National TB Strategic Plan (2011–2016), which is expected to be published in early 2012. In view of these international ethical guidelines, the Thoracic Society of Australia and New Zealand (TSANZ), the Australian Society for Microbiology (ASM), the Australasian Society for Infectious Diseases (ASID) and the Public Health Association of Australia (PHAA) believe that Australia’s response to any situation involving cross-border TB cases should be based on the following four principles. All patients with TB who present to health care services within Australia’s borders should have free and equal access to TB care from diagnosis to completion of treatment, irrespective of their legal status or other demographic characteristics as outlined in the PCTC.4 Health professionals dealing with these complex issues must have enough support from the relevant Australian state and federal health agencies to enable them to implement best-practice care, and should be closely engaged in the process of consultation about service delivery. Patients should only be transferred to their home country for ongoing care when the TB service in the responsible Australian state is satisfied that the patient’s ongoing care will be of a suitable standard that meets the ISTC.5 Australia should provide financial and technical support to neighbouring countries where TB is endemic, so that they can develop national TB programs meeting the ISTC standards to which Australia’s TB services can confidently return international patients, who are increasingly mobile. The development of these programs may demand an ongoing investment over many years. The complexity and cost of treating multidrug-resistant tuberculosis (MDR-TB) or TB/HIV co-infection compound the dilemmas in providing cross-border TB care. WHO estimates that the cost of treating a patient with MDR-TB is about 100 times greater than for treating a patient with drug-susceptible TB.6 Poor standards of care of patients with cross-border mobility place nations on both sides of the border at risk of dissemination of untreatable drug-resistant disease. Based on the same values of equity, solidarity and common good, the international ethical guidelines argue that the universal right to receive medical advice and treatment must extend to patients with MDR-TB and/or HIV infection.3,4 The TSANZ, ASM, ASID and PHAA therefore recommend that the above four principles should also apply to cross-border patients with MDR-TB or TB with HIV co-infection. Initial substandard care of patients with drug-susceptible TB is the greatest contributing factor to the development of MDR-TB and extensively drug-resistant TB. MDR-TB in expatriates therefore suggests that the national tuberculosis program in their home country is failing. Hence, health care professionals and governments who propose repatriating patients with MDR-TB must be wary of the level of care that will be available when those patients arrive home. The Green Light Committee, an MDR-TB working group that advises WHO and evaluates applications from countries for access to second-line antituberculosis drugs, has developed a set of criteria for assessing nascent MDR-TB treatment programs in low-income countries.7 These criteria include the level of government commitment and funding, the availability of medical personnel trained and experienced in managing MDR-TB, access to supporting laboratory services that are externally quality controlled, the reliability of second-line drug supplies, and existing strategies to assure patient adherence to treatment regimens. Australian governments and state TB services should use the same criteria when determining whether cross-border patients with MDR-TB can be safely returned to their home country for ongoing care. Although they are ethically justified, the above four principles for the care of cross-border patients with TB may appear financially onerous. Interestingly, modelling has found that increasing United States investment in TB programs in Mexico, Haiti and the Dominican Republic could reduce tuberculosis-related morbidity and mortality among migrants, and produce net cost savings for the US.8 The TSANZ, ASM, ASID and PHAA therefore strongly support the four principles described above for the care of cross-border patients with TB on ethical, clinical and public health grounds (including the protection of Australian citizens), and we believe this approach is economically justified. It is critical that all parties involved in providing care of cross-border patients with TB work together to ensure that the necessary outcomes are achieved.

Paul N Reynolds MD, PhD, FRACP · John D Turnidge MB BS, FRACP, FRCPA · Thomas Gottlieb MB BS, FRACP, FRCPA · Michael J Moore BA, DipEd, MPopHealth

Objective: To determine whether premigration screening for tuberculosis is worth undertaking in visa applicants, and whether screening resources are being appropriately directed towards intending migrants at highest risk of tuberculosis.Design, setting and participants: A 12-month survey of all intending migrants with tuberculosis necessitating treatment detected during the premigration health assessment process, whose medical examinations were submitted to the Department of Immigration and Citizenship’s Global Health Branch for assessment by a Medical Officer of the Commonwealth between 1 July 2009 and 30 June 2010.Main outcome measures: Individuals diagnosed with active tuberculosis; proportions diagnosed by sputum smear and culture tests or clinically, and with susceptibility test results; distribution of visa types among people diagnosed.Results: In premigration assessments, 519 people were diagnosed with active tuberculosis (prevalence, 137 per 100 000 in examined population). The top source countries for people with tuberculosis were the Philippines (21.8%), India (16.8%), Vietnam (16.2%) and China (8.3%). Positive sputum smear test results were submitted for 67 cases (12.9%). Positive culture test results were obtained in 230 cases (44.3%), but only 95 of these (41.3%) had susceptibility test results, with 83 fully susceptible. Four people had multidrug-resistant tuberculosis (prevalence, 1.06 per 100 000 population). Five people had both active tuberculosis and HIV infection. Of all those diagnosed with tuberculosis, 162 (31.2%) were intending students, 82 (15.8%) were intending visitors, and 53 (10.2%) were applicants for humanitarian (refugee and Special Humanitarian Program) visas.Conclusions: Premigration health screening of intending migrants is identifying substantial numbers of people who would have required treatment for tuberculosis after arrival in Australia. The high proportion of students, visitors and refugee and humanitarian entrants with tuberculosis validates the current screening program. The screening is of benefit to the applicants, whose tuberculosis is treated earlier than it otherwise would have been, and to the Australian population, by averting exposure to people with active tuberculosis.

Kathleen King BSc(Hons), MB ChB, FRCPath · Paul J Douglas MB BS, MHA, FRACMA · Ken Beath BE, MAppStat, PhD