Speech to AMSA Global Health Conference 2014

Going global

I would like to acknowledge the traditional owners of the land on which we are meeting, and pay my respects to elders past and present.

Global health, and the attitudes of medical students to global health, speak of how different we are as a society compared to even 20 years ago

We are more aware of global issues. We are more interconnected. This is not just because of the internet, but all forms of media.

That interconnectedness has brought us closer as a global community. It makes sense that, compared to my generation of medical students, you are more connected and aware of issues that affect people all over the world.

For my colleagues, we had the same concerns but our knowledge and exposure to global health was different, and more isolated, depending on the media of the day.

When we thought of global health, we immediately thought of famine in Africa and Bob Geldof and friends singing ‘feed the world’.

I have images of Fred Hollows in Nepal and Ethiopia restoring the sight of people with cataracts and trachoma.

So much of our attitude was based on an intervention and a single solution – such as, if we send them lots of rice and tins of food, the problem will be solved.

This is perhaps an oversimplification, and I don’t want to undervalue the fantastic work that they did - it was fantastic, but we have learnt a lot since then.

As I said, the world has changed. It is more interconnected through media and the internet. As they say, the world has become flat.

However, the world has changed in another way – or at least our appreciation of it has. We have recognised that diseases and other factors don’t recognise international borders or sovereignty.

Climate change is a classic example. There is no denying that the ice caps are melting, and that sea levels are rising. With global warming, there will be more extreme weather events and patterns of disease will change. Tropical diseases, particularly those vector- borne diseases, will be distributed further from the equator – in our case, further south.

What someone does in another country affects our health here in this country. Another country’s social policy, its economic policy, its agricultural policy, its health policy – all have real ramifications for everyone else.

So, what we live in is a much more interconnected world, but with such disparate states of health. Addressing these disparate states of health is what global health is about.

Dr Jeffrey Koplan and colleagues from the Consortium of Universities for Global Health offered this definition of global health to The Lancet:

"Global health is an area for study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide.”

The Word Health Organisation says that the term ‘global public health’ recognises that, as a result of globalisation, forces that affect public health can and do come from outside state boundaries, and that responding to public health issues now requires attention to cross-border health risks, including access to dangerous products and environmental change.

You understand the challenges of the social determinants of health. Much of global heath focuses on the dealing with those social determinants.

We know that good housing, an education, a job, an economy, are important to promoting health.

But the reverse is also true. You need health to get an education, to get a job, and work and to develop an economy.

There is no substitute for an educated healthy population.

Global health should be a topic for discussion at the upcoming G20 meeting in Brisbane. We need our political leaders to put health, both locally and globally, as a priority.

Last month, I spent a week in the Northern Territory. I visited the Amoonguna Aboriginal Community just outside Alice Springs, Darwin, and the Tiwi Islands north of Darwin.

The challenges of global health, in particular the problems with social determinants, are on our doorstep. You don’t require a visa or a passport. The problems are here in our backyard, not just in rural or remote Australia, but even in suburbia.

Our ongoing efforts to ‘Close the Gap’ in Indigenous health outcomes must continue. However, we cannot expect to change the rest of the world unless we address our own issues here.

The AMA has a leadership role in global health. The first is in advocating and lobbying to shape policies that support or enhance initiatives for improving global health.

The second is to facilitate opportunities for you, the future of the profession, to gain knowledge and experience, and to contribute to improving the health of all peoples, not just those here in Australia.

I want to talk about some examples of the AMA’s advocacy in relation to global health.

The AMA has been warning of the health issues associated with climate change. As I said, the issues of changing patterns of disease, extreme weather events, the issues of drought, and famine. There are many more.

The AMA has been strong on the issues of non-communicable diseases. The big three – smoking, alcohol and obesity – are all areas where the AMA has been advocating and lobbying for change.

A great example is that of plain packaging for tobacco. An initiative of the previous Government, but something the AMA has supported and more recently staunchly defended.

That may have been a national approach but it is great example of what we do here affects the rest of the world. The tobacco companies know this too. That is why they have been in the courts trying to change the legislation. Australia has led the way and other countries are following.

The AMA has been talking about possible negatives from the Trans-Pacific Partnership (TPP) free trade agreement.

This agreement is the top trade priority for this Government. However, arrangements in these trade agreements, specifically the investor state dispute mechanisms, mean that overseas companies can challenge Australian laws where they may be seen to interfere with trade.

This has implications for Australia to make public health laws. It puts legislation that protects the public, such as the tobacco plain packaging legislation, at risk.

Trade is good, but as doctors, as the AMA who see public health as a priority, we need to be aware of these issues.

We have done much around obesity and alcohol, particularly in terms of marketing and of alcohol to young people, and alcohol-related violence.

The AMA has also been vocal about Australia’s human rights obligations in relation to asylum seekers and refugees.

We have an obligation to ensure that they have access to health care at a minimum. We have called for an independent panel of doctors to inspect detention centres and report to Parliament.

The AMA joins the WMA in condemning human rights abuses around the world, and protesting attacks on doctors and other health personnel in world trouble spots. An example is the current actions against doctors in Turkey who are being pressured not to treat protestors.

You really are not too different to the medical students of previous generations. Like you, they were engaged and concerned for their people right around the world.

For many years, one of the major highlights of medical school has been a student’s elective.

Many medical graduates have worked outside Australia and New Zealand in diverse roles, and many more want to try this experience.

However, what you do have is a much more sophisticated understanding, even at this stage of your career, of the problems, the challenges, but also of the solutions.

Enabling junior doctors to have meaningful and rewarding experiences in developing countries can lead to a lifelong commitment to global health practice and advocacy that benefits both resource-rich and poor partners alike.

Junior doctors and specialty trainees are increasingly looking for global health-related learning and networking opportunities.

There is a growing trend for trainees to undertake a period of work or training overseas, particularly in resource-poor settings.

In recent times, the interest and contribution to global health issues by young graduates and medical students has grown, seemingly exponentially.

This interest has translated into an increasing demand by medical students and junior doctors and trainees for overseas training in developing countries to be recognised and encouraged as part of their training.

Reports suggest that more than 90 per cent of medial students believe that global health should be a component of medical school programs.

However, beyond medical school, options for vocational training in the developing world are limited.

The AMA believes that Australia has a responsibility to produce doctors who are equipped to engage in regional health challenges in a global context, and take on a leadership role.

There are many important health changes that we are likely to see in the future including the rise in chronic disease, change in infectious disease patterns and resistance, and the increasingly migratory health workforce.

We need to be prepared for the future.  Working in poor communities both in Australia and overseas can give trainees crucial experience to help them in their future practice and advocacy – and this is practice and advocacy that will be increasingly valued in a global community.

Placements abroad are not without risk.

Trainees and host communities can potentially be exposed to harms in various forms, including physical, cultural, educational and developmental harms.

The extent to which doctors in training can undertake rotations abroad is limited by a number of factors, including a lack of recognition from education providers, uncertainty about supervision arrangements, lack of adequate cultural competence training, family commitments, cost, loss of income, and security.

Some Colleges have recently adopted a more flexible approach to recognition of overseas rotations.

They allow junior doctors to undertake placements that have furthered their learning and allowed them to make a positive contribution to overseas communities. 

For example, the Australasian College for Emergency Medicine has created a pathway for trainees to undertake up to six months of accredited training in a resource-poor environment via remote supervision arrangements in PNG

Former AMSA President, Dr Rob Mitchell, is currently undertaking this rotation now.

Other Colleges have moved to formally incorporate aspects of global health practice into their curricula.

The Australasian Faculty of Public Health Medicine, within the Royal Australasian College of Physicians, for example, has developed a global health curriculum.

It will form part of its public health training program to help prepare medical specialists and non-specialists for global health practice: through public health training in general and through post-specialist training in global health.

Partnerships are also possible with organisations such as Australian Volunteers International (AVI), who have experience in managing people-centred development projects and programs in a wide range of countries.

This is of real benefit in respect of preparing trainees to work abroad and managing any safety and security concerns while abroad.

This is an area Colleges often struggle with, and organisations like AVI can help Colleges manage this aspect of a placement. These should be longitudinal.

Other medical students and junior doctors are drawn to groups such as Médecins Sans Frontières.

The AMA is keen to support junior doctors and vocational trainees to be able to access rotations and opportunities that align with their learning and career objectives.

What is clear is that doctors working in global health require knowledge and skills beyond those captured in traditional medical curricula.

Although Australian junior doctors are heavily engaged in global health learning and networking activities, there is no defined training pathway for those aspiring to careers in international health and development.

In particular, there are limited opportunities for vocational trainees to undertake accredited rotations in resource-poor environments.

I think that we have a tremendous opportunity in Australia to train doctors who are equipped to engage in regional health challenges in a global context, who can form global health partnerships, and meet our increasingly diverse future health challenges.

We need doctors who can advocate and take on a leadership role on global health issues.

The recent MJA, MDA National, Nossal Global Health competition sought accounts of leadership in global health.

I’d like to close with some words from one such piece, recently published in the MJA.

It is by Kylie Ngu, and titled, Leaders in disguise - the unexpected tomorrows of global health.

“Global health is about the intricate ties in our continually evolving global community, how we affect each other and, more importantly, how we can take this as an opportunity to be a wave committed to the long-term improvement of health outcomes and experiences for our global community.

Leaders in global health are those who can create connections, map roads and build bridges to connect and uplift the lives of others with an embracing vision for their local community that addresses not only the medical needs but the sociocultural barriers to optimal health care.

Such leaders can arise from the most unexpected of individuals, like a 10-year-old Aboriginal girl who teaches her parents to not smoke and to not drink alcohol, and a local ophthalmologist in Ghana who returns to the clinic in the dark to serve more patients after a full day of rural outreaches.

We need to support these local leaders in disguise and help them lead by transfer of knowledge, wisdom and compassion, not just by machines and fly-in fly-out, band-aid approaches to delivering health care. For these leaders of tomorrow, global health starts locally.”

Congratulations to AMSA for putting together a fantastic Conference program, and welcome to a celebration of ideas and ideals.

5 September 2014

CONTACT:        John Flannery                     02 6270 5477 / 0419 494 761

                            Odette Visser                      02 6270 5464 / 0427 209 753

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