The MDGs to SDGs trade off : What has been lost and gained for global equity?

Maja Pleic is a global health and global equity researcher and advocate. She is currently a research collaborator with the Harvard Global Equity Initiative (HGEI), and project coordinator with the Young Professionals Chronic Disease Network, where she leads the Trade and NCDs Working Group. Maja holds an MA in Political Economy of International Development and a BA in International Relations and Economics, from the University of Toronto. Previously, she was Research Coordinator at HGEI before taking time off to focus on independent research in her home country of Croatia. Maja has undertaken research on issues of global equity ranging from: health system financing, universal health coverage, child labour, and employment elasticities in periods of growth. 


The 17 goals. Image credit: United Nations Sustainable Development Knowledge Platform.

Last fortnight, the international community gathered in New York for the 70th session of the United Nations General Assembly and set the post-2015 development agenda in the form of 17 Sustainable Development Goals (SDGs) and 169 associated targets. These targets are successors to the Millennium Development Goals (MDGs) set in 2000: the first global, time-bound and quantified targets for addressing extreme poverty and inequity. The MDGs were composed of eight goals and 21 associated targets to be met by 2015.

While some of the MDGs such as cutting in half the share of people living in abject poverty were reached (largely due to the economic rise of China, and not the MDGs themselves); others such as reducing child and maternal mortality, and achieving universal education, although not met, have nevertheless seen significant progress. It can be argued that the MDGs were instrumental in focusing attention and resources of nations and the international development community on these important goals for improving human and social development and global equity. For more on the achievement of the MDGs, see The Millennium Development Goals Report 2015.

Regardless of the metrics and varied progress towards meeting the MDGs, there is no doubt that their adoption by the UN, and their diffusion to the general public and international development community were successful in raising awareness, catalyzing action, and focusing international cooperation on longstanding, priority areas for global development and equity. This led to rising public awareness of the most heinous forms of global poverty and inequity; a boom in aid money (official development assistance increased by 66% from 2000 to 2014, and official development assistance for health nearly tripled from 2000 to 2012), and the emergence of innovative new actors such as The Global Fund to fight AIDS, Malaria and TB; the GAVI Alliance; and the UN-led platform Every Woman Every Child, which have proven effective in their areas of expertise.

It is important to remember that the resolutions brought by the United Nations are not actually enforceable. The strength of the MDGs lied in their soft power to inspire the public; motivate new and old development actors; and to applaud and shame countries that were or were not on track to meeting the MDGs. The primary reason that the MDGs were so powerful in moving the public, governments and development actors was that they were relatively simple, fundamental goals for global equity that anyone could understand and few could argue with: the eradication of extreme poverty and hunger, the reduction of child and maternal mortality, the achievement of universal primary education and promotion of gender equality, combatting HIV/AIDS, malaria and other diseases, ensuring environmental sustainability, and facilitating global partnerships for development.

These goals have an underlying thread of global equity that almost anyone can relate to. Most ordinary citizens are happy to accept that there are poor and rich economies and poor and rich people in this world; but few are ready to accept that a child born in a low-income country should die for lack of access to such basic necessities as a safe birth, safe drinking water, food, or life-saving essential medicines. Indeed, a quick skim over the MDGs reveals that they are less about economic development in the strict sense of increasing GDP and growing economies, and are more about global equity as it relates to gender, health, access to food and water, education, disease prevention and control, and the social justice of caring for the environment and each other. This was the inspiring, motivating and connecting soft power of the MDGs.

Building on the successes of the MDGs, the Sustainable Development Goals set out an ambitious and admirable set of 17 goals and 169 associated targets to be achieved by 2030, including the end of extreme poverty and hunger everywhere, gender equality, ensuring healthy lives and quality education; and reducing inequality within and among countries, amongst others. The goals and targets have been criticized for being both too broad and un-implementable, and also too bureaucratic. First, the sheer number of goals and targets make them less accessible (and therefore less inspiring) to the general public.

While the list of goals and targets is music to a development student’s ears, the reality is that few outside of the development field will spend the time to read them all, they will most certainly not be able to understand them all, and will therefore be less likely to rally around them in any coherent or meaningful way. This matters. The support of the public is key not only for building global solidarity movements, but also because it is public shaming and pressure that moves unwilling governments to act.

Secondly, in addition to being a long list, many of the goals and targets are simply too broad to be implementable or measurable (e.g. “By 2030, ensure that all men and women, in particular the poor and the vulnerable, have equal rights to economic resources, as well as access to basic services, ownership and control over land and other forms of property, inheritance, natural resources, appropriate new technology and financial services, including microfinance”). This is an admirable goal, but not a realistic one as access to land, technology, and financial services is a function of income in the global economy, and ensuring the right of 7.3 billion people to these assets would require upheaving the entire market-based economy.

Similarly, the goal of “Significantly reducing all forms of violence and related deaths everywhere” would require global powers to drastically alter their foreign policies of military intervention and war – which would be wonderful, but is simply not implementable. The inclusion of such broad-reaching and lofty goals undermines the targets that are realistically measurable and implementable.

Furthermore, no country can reasonably be expected to meet every single one of the 17 goals and 169 targets, hence countries can pick and choose which ones to showcase, and which ones to ignore, and pressuring them or holding them accountable for meeting this many targets will be near impossible. Yet, there are seeds of hope encapsulated in each of the 17 goals and 169 targets as well. First, their number shows that the development community has finally come to understand the complex and interdependent nature of poverty and that there are in fact no ‘magic bullets’ to development.

The SDGs leave no doubt that human and economic development is not as simple as ‘pulling oneself up by the bootstraps’, but require that many things go right in order to lift a population out of impoverishment. While the SDGs are less clear, they are also more nuanced; and even if some of the goals are not realistically attainable, they beg the question: why not? What is wrong with the global legal, economic, and political systems that we consider significantly reducing the level of violence, and affording everyone access to land, health, education, and gainful employment as laughably unrealistic? There are important questions about the global political and economic systems contained within the SDGs – their justness, their legitimacy, consequences for countries and populations at the periphery, and their sustainability in the long run.

With respect to actually achieving the SDGs, some have argued that the money required to finance them would cost an estimated 15% of annual global savings, or 4% of global GDP, and this, in a climate of economic recession and uncertainty, is as unrealistic as the goals themselves.There is certainly the danger that such a long list of goals could bloat development institutions in the West eager to monitor and track the SDGs more than it will bloat the capabilities of low and middle-income countries to actually achieve the targets. Yet, achieving these laudable, although sometimes lofty, goals does not necessarily require the injection of huge sums of money.

In fact, throwing huge sums of money would not in itself solve these huge challenges we face as a global community. Ensuring sustainable global development, in all its facets, requires a complete overhaul of the current modus operandi of international development and relations, global production patterns, natural resource use, and significant changes in the domestic policies of rich and poor countries alike.

Although this presents us with a huge task, it nevertheless also represents the seeds of a global solidarity movement aimed at social justice, equity, equal opportunity and reciprocity, and a respect for your fellow man and the environment. The SDGs, as the MDGs before them, represent a call to global equity, now with all of the multi-faceted and complex components in full bloom.

Equity cannot be achieved through the charity of rich nations to poor nations, nor can it be achieved by choosing. Equity can only be achieved by the recognition of rich nations and populations that some of their government policies, corporations, and national production and consumption patterns inadvertently make the rich rich by making the poor poor – that policies and consumption patterns at home cause real damages abroad; and then taking the necessary steps to remedy those inequities.

Since governments and corporations are not likely to implement such change, the global community must call for, pressure, lobby and shame, and the SDGs are a shopping list of good ideas. If they can be a source of inspiration, and help to educate and engage the public as well as governments and international stakeholders in the complex task that is sustainable development, then maybe by 2030 we will be wishing they had been longer.

In the end, it is not the length, specificity, or implementability of the SDGs that will decide their success, but whether or not they inspire and motivate a global solidarity movement for addressing the inescapable challenges of global development and inequity.

majaMaja Pleic is a global health and global equity researcher and advocate. She is currently a research collaborator with the Harvard Global Equity Initiative (HGEI), and project coordinator with the Young Professionals Chronic Disease Network, where she leads the Trade and NCDs Working Group. Maja holds an MA in Political Economy of International Development and a BA in International Relations and Economics, from the University of Toronto.

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CokeGate – Big Soda’s deep pockets reach further than we think

Alexandra Jones is a lawyer, working on food policy with The George Institute for Global Health. She is interested in how law can be used to create conditions for people to live healthier lives, particularly in the field of non-communicable diseases. Alexandra holds a Master of Laws in Global Health from Georgetown Law, and in 2016 will start a PhD at the University of Sydney exploring nutrition labeling worldwide. 

file000912729856 (1)Coca-Cola’s financial support for the ambiguously named ‘Global Energy Balance Network’ headlined the New York Times in August, prompting global outcry. Citing lessons from Big Tobacco’s similar tactics, the public health world called for greater clarity on exactly what – and whom – Big Soda is funding.

In a public-relations induced ‘commitment to transparency,’ Coke has since released details of US$120 million spent on grants to medical, health and community organizations in the United States alone since 2010. Of this, $21.8 million went to scientific research and $96.8 million to support ‘health and well-being’ partnerships. With good evidence that the source of funding does indeed influence research outcomes and policy processes, the public has a right to be concerned.

The unfolding story of the Global Energy Balance Network highlighted the conflicted nature of Coke-funded research. Money spent has diverted conversation away from ‘calories in’ toward a focus on people not exercising enough. These efforts are a strategic attempt to shift international debate around obesity, and to shift it conveniently away from the side of the equation where Coke’s own products are directly implicated. In a nation where soda is a leading contributor to diet calories, where more than one third of adults are obese, and in the year that the World Health Organization released sugar guidelines clearly recommending reduction of free sugars, Coke continues tout the solution as ‘active living’. These messages deceive consumers and undermine public health. The issue is not only that Coke funds research biased to favour their position that obesity’s solution does not lie in greater regulation of their products, but also that funded scientists and experts become key actors in building and maintaining their corporate legitimacy.

Health and wellbeing?

This month, new information about the extent of Coke’s ‘health and wellbeing’ partnerships is perhaps even more astonishing. These are organizations that have received financial support between 2010 and 2015 in the United States – and the list is extensive. Recipients include influential medical organizations – the American Academy of Family Physicians ($3.5 million), American Colleges of Cardiology ($3.1 million) and Paediatrics ($2.9 million), American Cancer Society ($1.9 million), American Diabetic Association ($1.1 million) and the Academy of Nutrition and Dietetics ($672,000). Hints of these financial ties are seen, for example, in Coke’s ‘gold’ sponsorship of the American Academy of Paediatric’s “” website where it is listed among ‘distinguished’ companies, committed to ‘better the health of children worldwide’.

Diabetes, dentistry, cardiology, cancer, paediatrics and more – the list goes on. And on.

Funding of minority groups like the NAACP and Hispanic Federation in New York may be particularly concerning. Both groups subsequently supported the soda industry’s challenge to then-Mayor Bloomberg’s proposed ban on large sugary drinks – yet both represent the populations most at risk from obesity, diabetes and heart disease; diseases linked to soda consumption.

Aside from medical organizations, Coke spent heavily on athletic groups, parks and community organizations – Scouts, Boys & Girls Clubs – many of them with a focus on (impressionable) youth.


Then come direct payments to individuals – many of whom are leading voices in these very same fields. 115 health experts received payments totalling US$2.1 million. Analysis by Ninjas for Health suggests 57% of these were dietitians, 20% university academics, 7% medical professionals (mostly doctors), 6% fitness experts, and even a few authors, chefs and food representatives.

Among these ‘New Faces of Coke’, dominating social media influence is a common feature. Coke has built a strategic network whose pro-soda influence is profound and wide-reaching, utilising the most effective communications tool to reach young minds today – they’re fully aware, and deeply invested.


In the fallout of this disclosure, the race to create distance has come from both sides of these funding engagements. This week Coke announced ‘budget realities’ will cause it to end contracts with a number of implicated groups at the end of this year. Other partners have been more explicit in their reasons. In the case of the Academy of Paediatrics, this includes announcement that it ‘no longer shares the same values’ as Coca-Cola.

Meanwhile other soda companies are keeping quiet, and this may indeed simply be the tip of an industry-wide funding iceberg.

A New Nanny?

For many, these funding revelations mark a new low in the dubious and underhanded tactics of soda companies to influence the public, their trusted leaders and ultimately – their health. In a time when the industry is happy to call any move by governments to protect citizens from these very behaviours, acts of the “Nanny State”, it is important to see the true powers that be. In a moment when industry is keen to lash out on public health communities for ‘telling people how and what to drink’, it is crucial to reflect. Coca-Cola’s spending on ‘health and wellbeing partnerships’ came over the same period they spent more than US$100 million in America to defeat science-backed public health measures to protect the health of populations.

Finally, all this stands in perspective to the US$3.37 billion Coke spent on advertising globally in 2013 alone – the craft of telling people how and what to drink.

We fear a ‘nanny’ who forces us to make particular beverage choices when in fact she may already be around us – wearing a signature red apron with an iconic white stripe.

Alexandra Jones headshotAlexandra Jones is a lawyer, working on food policy with The George Institute for Global Health. She is interested in how law can be used to create conditions for people to live healthier lives, particularly in the field of non-communicable diseases. Alexandra holds a Master of Laws in Global Health from Georgetown Law, and in 2016 will start a PhD at the University of Sydney exploring nutrition labeling worldwide. 

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Innovation in Neurosurgery

This week we hand over to regular blogger Alex Abel, who has just returned from the Society of British Neurological Surgeons (SBNS) Autumn Meeting in York, UK.

As medical students, we don’t get much intra-curricular exposure to surgery. Then there is the neurophobia, a chronic condition whose main symptom is the inability to apply knowledge of neuroscience to clinical situations. A phenomenon literature suggests is fairly common, and experience tells me is already afflicting my student cohort. As we waited to enter our exams a few months ago, one person voiced what we we’d all been thinking: “I really hope there’s not much brain in this one!” Perhaps as a result of this neurophobia and limited insight into surgical careers, the relatively small specialty of neurosurgery seems to be shrouded in a certain level of mystery for many medical students.

Last week, the SBNS – one of the world’s oldest neurological societies – held their bi-annual meeting in the city of York, hosted by surgeons from my teaching hospital and Neurosurgical Unit (NSU), the Hull Royal Infirmary (HRI). As their first ever ‘press pass’ delegate, I was fortunate to attend SBNS York 2015. I will try to describe my experience and outline some of the main areas of discussion.

Pesky Prions

The conference began by discussing variant Creutzfeldt-Jakob disease (vCJD), occasionally referred to in the media as the human form of mad cow disease due to its link with the consumption of beef infected by Bovine spongiform encephalopathy (BSE). The human prion disease vCJD is an incurable, fatal, neurodegenerative disorder. Fortunately, it is also very rare.

Delegates pass around a Kerrison Punch during the discussion on single-use instruments.

Delegates pass around a Kerrison Punch during the discussion on surgical protocol.

Those born after 1996 in the UK are said to be at ‘near zero risk for vCJD’ thanks to the successful containment of BSE in cattle at that time; but this poses a neurosurgical dilemma. Guidelines recommend separate sets of surgical instruments for post-96 and pre-97 patients, but it can be difficult to assemble a full post-96 set. In these cases, the Chair asked, does duty of candour oblige us to inform patients that we are using pre-97 kit? There was a varied audience response to this ethical question, with one delegate pointing out that he’d probably have bigger things to worry about if he were about to have brain surgery. Are some risks so small that going into them constitutes an unnecessary and potentially damaging disclosure? At my medical school, we call these Theme C questions, which fall under the remit of Health & Society and Professionalism, but we very rarely engage in the kind of spirited debate that was happening here. I think there is a lot of conference behaviour that would be well suited in medical education.

The debate moved on to the paramount issue: how do we minimise the risk of vCJD transmission in neurosurgery? Single-use surgical instruments seemed to be the most sensible option, certainly for procedures in those born after ’96 who have previously had surgery with pre-97 kit. One delegate suggested money might be better spent on developing a suitable detergent, but repeated use might damage reusable instruments, and we would have to be certain that the process could be run safely and effectively across all NSUs. The question that at first seemed so simple was fraught with practical considerations, financial constraints, and concerns over sustainability. It also seemed to be an example of how current guidance does not match up with current practical feasibility.

Innovation in Hull

I was very proud that this conference was being hosted by my teaching hospital, and even more so that their innovative practice featured in many presentations. HRI NSU is the 18th largest in the country, but has become the 3rd busiest for spinal elective cases, primarily through their novel collaboration with physiotherapists.

Sally Fenton, presenting physiotherapy-led services at HRI. Photo Credit: Mr Crispin Wigfield (@CrispinWigfield)

Sally Fenton, talking about HRI’s physiotherapy-led services. Photo Credit: Mr Crispin Wigfield (@CrispinWigfield)

Sally Fenton, Clinical Lead in Physiotherapy, explained how they have streamlined the management of spinal fracture patients using a new model of physiotherapy-led follow-up. Their innovative pathway has been extremely effective, with no adverse clinical outcomes, and a 332% increase in activity over 5 years. Physiotherapist Michelle Naylor went on to outline the success of their physiotherapy-led telephone follow-up service for patients after spinal surgery where an impressive 75% of patients were discharged directly to the GP without further need for consultant follow-up. The benefits of these physiotherapy-led services seem to be in reducing consultant work-load, thereby freeing up more time for clinics and surgeries, reducing waiting lists, and improving patient communication by providing them with a single point of contact within the service. Similarly, the novel nurse-practitioner-led cervical fracture service presented by S. Newton provides an open access service at all times if patients have any problems.

“If you ladies want to come work in Cambridge, you’d be very welcome!” announced a voice from the audience following the presentations. “We’ve already offered them a job in Oxford,” replied another. Fortunately, I think they’ll all still be sticking with us at HRI and continuing their exceptional work.


“I think we need a group of surgeons who are globe trotters, who can practice in different countries without these artificial barriers in place,” said Mr Tom Cadoux-Hudson from the John Radcliffe Royal Infirmary in Oxford, as international neurosurgeons discussed the possibility of a cohesive global process of training and examination. Maybe an SGNS (Society of Global Neurological Surgeons) is some way off, but I particularly enjoyed hearing about how surgeons are collaborating in different countries. Dr Laxminarayan Tripathy, Chief Neurosurgeon and Vice Chairman of the private Medica Superspecialty Hospital, whose passion for teaching was obvious, told us about the training of Nigerian surgeons in Kolkata, India. I was pleasantly surprised to see that his presentation also featured a friend of mine, Tom Robbins, President of our school’s Surgical Society.

Tom’s passion for neurosurgery was inspired by the host of this conference Mr Bruce Mathew, a senior consultant neurosurgeon at HRI, and it was through the help of Mr Mathew that Tom’s elective attachment with Dr Tripathy became a reality. Talking of his time in Kolkata, Tom told me: “Medica Superspecialty hospital was set in the Mukandapur district on the outskirts of Kolkata and was resourced as well as any NHS equivalent hospital. I witnessed the use of brain lab and CUSA for accurate removal and debulking of various brain tumours. There were clean, air-conditioned clinic rooms and swish new wards facilitating excellent pre-surgical and post-surgical care. Such facilities are commonplace back in the UK but what made all of this seem extra special to me was the moment I walked out of the hospital doors. Many of the roads were flooded and crumbling, as it was the height of the monsoon season, the traffic was stationary and there were frequent power outages. Yet despite this seemingly saturated and under-resourced civic infrastructure, Medica Hospital was still flourishing and providing cutting edge care to patients against the odds, much to the credit of Dr Tripathy. My impression of my time spent working in Medica in Kolkata would perhaps be: despite the superficial appearance of disorder there is an underlying thread of intense productivity and so long as you didn’t try to resist this chaos, you could get things done too.”

Reassembled, Slightly Askew

I feel that no scientific conference is complete without an arts contribution. At SBNS York 2015, this contribution came from Shannon Yee with her spectacular immersive audio experience Reassembled, Slightly Askew.

President Richard Kerr and President Elect Paul May try out the immersive audio experience. Photo credit: Shannon Yee (@ReassembledSA)

President Richard Kerr and President Elect Paul May try out the immersive audio experience. Photo credit: Shannon Yee (@ReassembledSA)

Delegates were invited to lie down on patient beds, put on eye masks and headphones, and listen to this incredible piece of theatre, created to depict Shannon’s journey as a patient descending into a coma from a subdural empyema, undergoing surgery, and her subsequent rehabilitation with an acquired brain injury.

“It is normal to feel a bit disoriented, so don’t worry if you need some time to yourself afterwards,” said Shannon as I got ready to put on the headphones. The whole experience was a bit unnerving. It made me feel like I was inside someone else’s head with little control of my surroundings and therefore quite vulnerable – how any patient must feel in a hospital, especially when they can’t comprehend what is happening to them. I think high-quality art projects like this provide an excellent way in to understanding the patient experience. Shannon’s project definitely falls under the heading Innovation in Neurosurgery and was a refreshing addition to the conference.

Feeling introspective, I heeded Shannon’s advice and went outside for a few minutes in the Yorkshire sunshine.

Closing Comments

“I think the success of a meeting can be measured by its delegates’ willingness to provide both positive and negative comment,” said Richard Kerr. By the standard set out in the president’s closing remarks, the meeting was a great success. Throughout the event, people openly questioned each other and weren’t afraid to disagree, but there was a consistently friendly atmosphere in the room. I’d even go as far as to say it was cosy.

Hopefully, fellow medical students will start to see neuro as less of a mystery and more of an exciting field of study and accessible area of surgical practice. I also hope that all students, from their very first day at medical school, will feel able to take the time to go to conferences in any field that interests them. I think it is beneficial to pursue what you are passionate about at an early stage, even if that passion may change or evolve in the future.

The SBNS conference was a pleasure to attend. I met some wonderful people, witnessed the presentation of world-class research, and now know how to correctly pronounce ependymoma. What more could I ask for!

Thank you to Suzanne Murray and Alix Gordon, who were so welcoming and organised such an enjoyable event.

Alexandra Abel is currently a first year medical student at Hull York Medical School. She graduated from Imperial College London with a BSc in Biomedical Science and Global Health, before completing a Master’s in Performance Science at the Royal College of Music, where she looked at the implications of teaching older generations to play a new musical instrument from scratch. Join her on twitter @alexandraabel

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World Suicide Prevention day – reach out and save lives

Jane Brandt Sørensen is a PhD Fellow at the Department of Public Health’s Global Health Section, University of Copenhagen, Denmark. She has studied trauma psychology and international development and has previously worked and studied in Sri Lanka, Ghana, South Africa, and New York.  Recently she co-directed a film in rural Sri Lanka for NCDFREE, focussing on the troubling relationship between chronic kidney disease, alcoholism and suicide. Coinciding with World Suicide Prevention Day she shares key learnings about the growing burden of suicide in low and middle-income settings.

The 2015 World Suicide Prevention Day is today and with this year’s theme Preventing Suicide – Reaching Out and Saving Lives the aim is to encourage everyone to consider how offering support to someone vulnerable may help combat suicide. And it is an important cause. The World Health Organization estimates that more than 800,000 individuals die of suicide globally each year, and for each of these, as many as 20 others attempt. Suicide is the second leading cause of death among 15-29 year olds, and such incidences obviously leave individuals, families, and societies deeply affected.

While we tend to think that suicide is mainly a problem in Western countries, the highest burden of suicide is actually found in low- and middle-income countries with 75% of suicides occurring there. In rural households in Asia and Latin America pesticides are used extensively in agriculture. Take the case of Sri Lanka. After the Green Revolution in the 1960’s, pesticides became easily available across the farming community in the country. This availability has made pesticides the most widely used mean of suicide in Sri Lanka and through-out Asia.


A farmer on his way to spray pesticides in his paddy field.

Most cases of suicide and suicide attempts are not associated with mental illness in Sri Lanka. Here the individuals at stake live under immense pressure linked to socio-economic and health issues, many times exacerbated by problematic alcohol use and social conflicts as a result of this– but rarely with mental illnesses. The suicide attempt is oftentimes a way of responding to these stressors and communicating distress to close relations and local communities. It is rarely done with a wish to die. To an outsider, suicide attempts may seem like an extreme reaction to seemingly trivial social conflicts such as marital disputes or failed love affairs. However these individuals are often caught in a great web of social, financial and emotional problems that cannot be said in words and seem too overwhelming to cope with. Suicide then becomes a solution.


Pesticide-ingestion is the most common means of suicide in Sri Lanka.

I am part of an international team of researchers who explores this topic to better understand and intervene. For this year’s suicide prevention day we teamed up with NCDFREE and created a film showcasing some of the issues at stake in a rural Sri Lankan setting. With the film we have two main aims: First, to showcase how the social determinants of mental health are extremely important when we talk about severe self-harm and suicide – and when interventions and policies are made. You will see how the family we follow is battling a number of difficult issues; chronic diseases, heavy alcohol use, a difficult financial situation and more.

Second, though such situations are complex, solutions do exist. In the film we introduce one of our interventions exploring how storing pesticides in locked boxes, with only one key per family, may deter and prevent the most impulsive suicide attempts and thus deaths. We know that other types of means restriction have proved effective in other settings, for instance with firearms and medicine. This specific type of pesticide intervention has been promoted by the industry and organizations as a solution, and we are with this research testing whether such an approach will prove feasible in this context.

safe storage boxes

Safe Storage boxes ready to be distributed among farmers.

The film further shows the commitment and hard work carried out by local staff members and students at the medical faculty of Rajarata University in the North Central Province of Sri Lanka. By linking medical students with specific families for up to a year, mutual benefits arise. The students are able to build relationships and understand the issues at stake in the family as well as provide mental support and assist the family members to identify solutions. The families we talked to felt acknowledged and many of them improved their life situation, if only just a little bit. At the same time, the medical students get a deep understanding of rural family life conditions and the social determinants of mental health. This equips them with important skills for their future careers as health professionals, showing them how such situations are usually not medical issues, and how crucial it is to keep the social context in mind.

Students involved in the project.

Students involved in the project.

I hope that this film will provide insight into the complexities of mental health in this specific setting, and inspire to action. On this year’s world suicide prevention day I urge you to think about what you can do, wherever in the world you are. Reach out, check in on someone you are concerned about, listen and show kindness and support. It does help!

And then let’s call on our political leaders to get global mental health on the agenda. Suicide and mental health must be prioritized as serious public health problems. And this is not only the health sector’s responsibility to deal with. A multi-sectoral approach is needed and a focus on poverty and equality, to name a few areas, is evident. With mental health now being a suggested topic of the new historic United Nations Sustainable Development Goals, we are at a crucial landmark with the foundation to act and make mental health a priority.



Jane Brandt Sørensen is a PhD Fellow at the Department of Public Health’s Global Health Section, University of Copenhagen, Denmark. She has studied trauma psychology and international development and has previously worked and studied in Sri Lanka, Ghana, South Africa, and New York. Through assignments with the UN (UNICEF, UNDP and WFP), NGOs and Copenhagen University, her focus is on health and development, especially NCDs and mental and social well-being. In her current research she explores alcohol’s role in self-harm and suicide in rural Sri Lanka.

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My journey from civil war to global health

Dr Jibril Handuleh (centre) is physician, researcher and lecturer with dual nationality in Somalia and Djibouti. After training as a general practitioner in his homeland, he overcame multiple challenges to publish 15 papers over the course of two years, in some of the world’s most widely-read medical journals. This is his story.

Somalia’s wars, droughts and famines are well known, but less attention is paid to how these problems undermine the nation’s mental health. Aside from the damage wrought to bodies and property, many Somalian minds bear scars from a two-decade civil war that ended in 1991, and continuing economic precarity. This situation has been exacerbated by the disruption of healthcare services, with hospitals destroyed and doctors fleeing for safer countries.

I was born and grew up in exile in Saudi Arabia, eventually returning to study medicine once stability had returned. During my training, the university in my hometown of Borama had no local teaching staff or exams in psychiatry, despite the fact that two out of every five Somalians are estimated to suffer from mental health problems.

Somalians with psychiatric disorders are often stigmatized, abused and literally imprisoned in their homes. Mentally ill people can become a huge burden, as families don’t know how to deal with severely disturbed or violent relatives. Many are therefore chained up or put into prison in order to control them. Traditional healing methods can be just as repressive, with patients having their heads dunked repeatedly into water almost to the point of drowning, in an attempt to force out harmful jinns (magical spirits).

Moreover, even when they receive medical help, patients are often misdiagnosed with exclusively physical rather than psychiatric conditions. Bipolar and schizophrenic Somalians are commonly presumed to have typhoid fever, and therefore mistakenly prescribed antibiotics that are both expensive and ineffective.

These challenges prompted the Somalian diaspora in Europe to collaborate with the Borama community to establish our first psychiatric unit. Central to the project was the hiring of 10 female healthcare workers, who have run individual and group therapy sessions, and encouraged local community leaders to reduce mental health stigma.

The clinic opened in 2012 – the same year I was introduced to AuthorAID, a website that supports academics in developing countries. Following registration, the platform quickly became part of my daily writing process. It was a key resource in my attempts to communicate the challenges and successes of African healthcare provision. While beginning to publish my first paper, this platform helped me secure access to online literature and research funding – crucial in a country like Somalia where academic infrastructure and the internet itself is weak.

I learnt how to draft and edit a paper, submit it to a journal, and get it published. Within two years, I had papers accepted at three conferences and was able to publish over 15 articles in academic journals, two of which were accepted by leading international mental health journals. The American Journal of Psychiatry published my article on psychiatry hospital practice and The Lancet Psychiatry published my article on mental health services in Somaliland, a territory in Northern Somalia.

Apart from psychiatry, my research has also covered e-health in fragile states, chronic diseases and conflict-health interactions, taking Somalia as a case study. I have worked with researchers from Tulane University, Oxford University, Harvard, the Karolinska Institute and King’s College London. After becoming the first academic to publish from post-conflict Somalia, I was chosen as a Research Fellow at the Centre for Global Health at King’s College London, funded by the King’s THET Somaliland Partnership (KTSP).

In addition to my own research, I have shared my learning experiences with my students and peers. I have run two workshops on research communication for my colleagues, and also set up a newsletter at Amoud University’s College of Health Sciences, where I lecture and practice medicine. The newsletter raises medical students’ awareness of and interest in scientific writing, which helps deepen their training.

Learning from peers in other countries has also been very important for my career development. Through the resources and expertise provided by other Southern academics, I increased my chances of winning a master’s degree scholarship. Motivation letters became easier to write and more compelling and I recently won admission to an MSc in International Health at Germany’s Heidelberg University. My studies will focus on public health training in low- and middle-income countries that receive aid from the German government. Somalia has the world’s highest maternal mortality in the world, and among the highest infant mortality. I hope to use the MSc as a platform for making lasting changes to these inequalities, as Heidelberg is one of the leading centres of global health research.

My plan is to become a researcher, academic and science communication mentor for my students and academics in my country and across Africa. I want to encourage those who come from a similar background to also join the scientific world. By collaborating with peers in African universities, I hope to build the continent’s academic publishing capacity, fighting against academic fraud and raising our reputation in the global publication arena.

Dr Jibril Handuleh is physician, researcher and lecturer with dual nationality in Somalia and Djibouti.

AuthorAID is a free international research network that provides support, mentoring, resources and training for researchers in developing countries. The AuthorAID community, which includes over 10,000 researchers from around the world, helps researchers in developing countries to publish and otherwise communicate their work. It also serves as a wider global forum to discuss and disseminate research. AuthorAID is based at INASP and supported by the UK Department for International Development (DFID) and the Swedish International Development Cooperation Agency (SIDA).

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Healthcare In Danger: what happens when it all goes wrong?

This week on PLOS Translational Global Health, emergency physician and humanitarian & global health doctor, Jenny Jamieson, writes about some of the tacit dangers of delivering healthcare in low-resource settings.

As healthcare workers, some of us travel to resource-limited settings to deliver care where needs are the greatest. Due to various factors, which range from economic inequality among citizens, political instability, natural disasters, conflict or warfare, many of these places are also some of the most dangerous. As a result, healthcare workers can find themselves working side-by-side to crime; and even becoming the target of directed threats or violence. Those who are willing to put themselves on the front line in order to help others, can themselves end up being actively targeted. Aside from a stint in Afghanistan in 2013 and a few fleeting visits to some of the more dangerous regions within the African continent, I never truly considered being at risk from doing my job.

As a doctor I’ve been guilty of feeling like I have immunity. As if there is some fluorescent sign above my head saying “I’m an emergency doctor – don’t harm me. I’m here to help.” Risk perception is entirely subjective, and the degree to which that risk is perceived and then individual decisions are based upon this risk, differ. Familiarity with known risks can, at times, breed complacency.

Any illusions about my “doctor immunity” were recently crushed when I was kidnapped in broad daylight in Dar es Salaam, where I am currently living. While I was held captive for three hours and not physically hurt, critical incidents such as these are rarely factored into plans and preparations for working abroad. Yet violence against health workers is a key and overlooked humanitarian issue in our current global climate. Doctors and health workers may be seen as targets as they treat anyone, regardless of their political affiliation.

An International Committee of the Red Cross (ICRC) study found that there were 1800 incidents involving serious acts or threats of violence to healthcare workers across 23 countries between 2012 – 2013; and it is likely that many more incidents go unreported. In response to growing concerns surrounding the safety of healthworkers,, the ICRC launched the “Health Care in Danger” initiative, which aims “to address the widespread and severe impact of illegal and sometimes violent acts which obstruct the delivery of healthcare.” (Durham). Since then, there has been renewed attention on this issue. During a recent World Health Assembly, WHO Director-General Margaret Chan stated that health workers are under attack like never before. Indeed, health care workers are at greater risk today than than they were when the Geneva Conventions were originally being drawn up. The intensity of threats and attacks to doctors have increased.


Photo v ICRC.

In the last few weeks, we have seen hospitals in Syria being deliberately targeted by violence and crime, reaching the highest levels in a single month since the start of the conflict. A bomb blast on June 10 in Aleppo resulted in damage to medical equipment, pharmacy stores and the post-operative room, resulting in compromised delivery of much-needed health services. A hospital in Busra was hit by 10 barrel bombs on June 15, destroying the only facilty in the province providing dialysis and neonatal care. Médecins Sans Frontières (MSF) have repeatedly called for respect of international humanitarian law and respect for medical staff, medical facilities and civilians accessing these.

It must also be recognised that there is a multiplier force at work here. When violence prevents health care workers from reaching those who are in greatest need of attention, people continue to suffer illness and injury without adequate treatment. This knock-on effect may be in the form of physical injury or a mental health issue, such as post-traumatic stress. Violence may also directly affect the health facilities that are providing treatment; hence violence and crime may undermine the already fragile health infrastructure. Hence a vicious cycle ensues with violence and crime contributing to health care needs being even greater in these settings.

So what can be done to address insecurity in the field? Coupland, who spearheaded the Health Care in Danger project, states that the healthcare community “must recognise this issue and be able to communicate about it.” Proper security training is essential for anyone working in a conflict area and many of the large medical humanitarian organisations will ensure all their employees receive this. Having been a recipient of MSF’s security training, I was able to employ many aspects of this whilst being held captive. Strong government policies to prevent violence and crime, including upholding international humanitarian law and human rights law, is essential, but often difficult in settings where governments may be weakened, destabilised or corrupt. The global health community has taken awhile to recognise that conflict, violence and insecurity are not just constraints to health care delivery – as Coupland states:: “they can be showstoppers.” 

So when it all goes wrong, what do you do?

Despite all this, when things go wrong, humans usually find a way of rebuilding the things that have been stripped away from them. You find a way of rebuilding the bubble of security that was once wrapped around you and has since been brutally torn away. You find a way of restoring your optimism for life and work. You remember why you traveled abroad and the reasons why as a healthcare provider, you are willing to put yourselves at risk in order to help others.

The important thing to remember when embarking on global health work is that things can go wrong. We don’t have absolute immunity. But with adequate training, awareness and precautions, it is possible to make them go right again, too and prevent a dangerous experience from being a showstopper.


AAEAAQAAAAAAAANAAAAAJDJhMDA4NTY1LTg5YzEtNDE5OS1hNTRmLWI1MzRjOTA3ZTY3MQDr Jennifer Jamieson is an emergency doctor from Australia who is currently based in Dar es Salaam, Tanzania. She has previously worked for Médecins Sans Frontières (MSF) in northern Afghanistan. She is a cofounder of the Global Health Gateway, an organisation dedicated to keeping young health professionals engaged in global health activities and work.  



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A Slow Burning Natural Disaster

This week on TGH, Assistant Professor Christopher Tedeschi, MD, MA, FAWM explores heat stroke deaths in India, as they approach record numbers–and as most of the casualties may be avoidable.  

Sometime in the next several days, monsoon rains will begin to sweep across India and gradually move northward, offering drenching relief to thousands caught in this year’s relentless heat wave. Andhra Pradesh, one of the hardest hit states, has reported over 1600 deaths in the past week alone. As of Tuesday morning, more than 2300 people had died nationwide as a direct result of the extreme heat.

flickr / Vinoth ChandarRecent reports describe modest efforts to mitigate this disastrous outcome. The government has encouraged people to stay home and keep hydrated, and established a distribution network for drinking water and buttermilk. Yet many news stories speculate that relief can come only in the form of the coming rains, and imply that other efforts to curb the death toll may be futile.

“These deaths are easily avoidable. All they need to do is follow basic precautions like avoiding working in the sun. Not many listen. What can we do? It’s a problem of poverty,” M. Sudhir Kumar, a civil assistant surgeon at Dakkili Primary Healthcare Centre, told the Times of India.

But local leaders and academics alike need to come up with better ways to reduce the damage rather than throw up their hands.

The heat wave is a slow-burn natural disaster representing the sort of environmental emergency we should expect more frequently in coming years. The UN’s Intergovernmental Panel on Climate Change reports that extreme weather events will likely become more common, and that “it is very likely that heat waves will occur more often and last longer, and that extreme precipitation events will become more intense and frequent in many regions.”

Many of these events will disproportionally affect populations with fewer resources to protect themselves, more to lose when extreme events happen, and longer recovery times.

Flickr / Bryan LedgardHere’s where the global health community, NGOs, and community organizations come in. As we concentrate on the increasing prevalence of non communicable diseases—especially in rapidly developing nations like India—we need to include environmental emergencies and climate driven events in our planning.

Those of us devoted to wilderness and environmental medicine should pay special attention. This ongoing disaster represents an opportunity for the wilderness medicine community to influence public health in remote, austere locations like the ones most affected yearly by blistering heat.

The Wilderness Medical Society guidelines for the treatment of heat-related illness provide an outline for medical care required for different stages of heat illness. With that foundation, local knowledge should take over: what is the best way to alert communities when extreme heat is predicted? Where should towns and villages establish cooling stations?  Can cool mist devices be improvised to serve large numbers of people? 

Heat emergencies are predictable—and amenable to locally devised action plans, which should aim to reduce the morbidity due to heat illness on all levels: by distributing increasingly urgent warnings when high temperatures are predicted, encouraging individuals to change their behavior when temperatures rise (alteration of work hours, frequent breaks for laborers and checks on the elderly), implementing community relief measures like cooling centers and provision of adequate drinking water, and enacting standardized protocols for emergency personnel to treat heat stroke quickly both in the field and at health centers and hospitals.

The Gujarati city of Ahmedabad has had such a system for the past few years. A plan to mitigate heat deaths seems to have paid off—the protocol includes cooling stations, a public health awareness campaign, and social messaging apps to convey updated information. The Ahmedabad Heat Action Plan, an impressive document created by a variety of international organizations including the Natural Resources Defense Council, provides an elaborate blueprint outlining what constitutes a heat emergency and what stepwise responses should be taken. Hopefully the implementation of this plan has already led to measurable decreases in morbidity due to heat stress.

But it’s difficult to tell if similar measures have been enacted in more remote areas, like Andhra Pradesh and neighboring Telangana, which remain perilously exposed. In these primarily rural districts, at-risk groups like laborers and older individuals have little access to cooling measures.

What will it take to implement a campaign like the Ahmedabad plan in the hardest hit regions? In these districts, populations are more spread out and less apt to be the beneficiaries of such a prestigious international academic collaboration. 

Flickr / Dr EG An effective strategy seems to require few resources besides community engagement, the ability to deliver public health messages, and simple technology like electric fans and misted water. Yet despite the escalating—and oftentimes tragically avoidable—death rate, it remains difficult to convince people to comply with solutions offered by the government.

Frustrating, but not hopeless. Academics and local officials like those behind the Ahmedabad plan need to devise more persuasive ways to nudge the population to alter their behavior safely. Rewards for employers to change work requirements? Incentives to persuade people to hydrate appropriately or visit cooling centers? We can probably do better—if experts in public health and environmental medicine effectively join with community innovators with fresh ideas about changing behavior and providing accessible relief.

As the monsoon reaches the south of India in the coming weeks, we’ll likely see a dramatic drop in heat related deaths as the rains provide some much needed cooling, and the specter of heat related deaths will fade from the headlines until next year.

And then the floods will come.

Christopher Tedeschi, MD, MA, FAWM is Assistant Professor of Medicine at Columbia University Medical Center and an emergency physician at NY Presbyterian Hospital. He is a member of the core teaching faculty of the NYP Emergency Medicine Residency and clerkship director of the sub-internship in Emergency Medicine.  Dr. Tedeschi is past-chair of the disaster and humanitarian medicine committee of the Wilderness Medical Society and a Fellow of the Academy of Wilderness Medicine.  He has worked in disaster preparedness and education in India, Sri Lanka, the US and elsewhere with an interest in media coverage and communications during global health emergencies.  His other interests include nonfiction media production, especially as related to medicine.

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Three important things you didn’t know about diabetes

This week, lead blogger Dr Alessandro Demaio of the Harvard Global Equity Initiative returns to lay things straight on a leading cause of global deaths.

When we think of diabetes, we tend to think of rich people with poor lifestyles. A chronic disease linked with obesity, heart disease and worse outcomes for some infectious diseases, diabetes tends to be associated in our minds with wealth, excess and over-consumption.

But it’s not.

Diabetes is a disease that results in higher-than-healthy sugar levels in the blood and can lead to some disastrous outcomes – including blindness, kidney disease and heart disease. In Turkey last week, working with Rotary to deliver workshops on diabetes prevention and care, three important messages emerged that shouldn’t be overlooked when it comes to this massive health challenge.

1. The burden is hitting our poorest, hardest

Globally and locally, the poorest two-thirds are hardest hit, when it comes to the burden of diabetes. To give this concept some shape, in China today, one in two of the population is estimated to be diabetic or at risk – in 1980, one in one hundred had the disease. In fact Latin America, The Middle East and parts of Africa have some of the highest rates of diabetes in the world.

The natural next question, is why – and there’s no simple answer. In part, it is because of the dramatic changes in diet and behaviours observed today across the world – including the globalisation and ‘Westernisation’ of our food and lifestyle patterns. In part, it is because of a lower baseline level of health literacy, as well as under-resourced education and health systems, and prevention mechanisms. In part, it is due to poverty restricting access to increasingly more expensive healthy foods and diabetes medications. And finally, we know that some populations are even at higher biological risk from the disease, developing health problems at an earlier stage and at lower body weights – such as populations from the South Asian continent. Risk that stems from as early as ‘in utero’ conditions and the nutritional status of the mother to those now at risk.

Even within nations like Australia, poorer neighbourhoods and socio-demographic groups are at higher risk from disease, disease progression and poorer outcomes – largely due to the same risks above.

Finally, and sadly, diabetes and poverty is not just a one-way street. With treatment costing as much as 70% of a family income in countries like Malawi and Vietnam, many now see chronic diseases like diabetes, as ‘poverty cycle catalysts – entrenching families in poverty, removing younger generations from work and educational opportunities to care for those affected, and in some cases reversing economic development.

2. It’s not one disease

The second take home from the week just past, is that while diabetes as a single name might seem simple – it’s actually not one disease.

In simplest terms, diabetes can be divided into three main groups based on those it affects. Type 1 Diabetes is a disease where the body attacks its own insulin-producing cells and has an onset earlier in life. Those living with the disease are often young and normal weight when diagnosed – and there is no known prevention method. Nor is it reversible. Type 2 Diabetes (once known as ‘adult onset diabetes’) is associated with overweightedness. The extra weight causes the body to produce more insulin and eventually the organs and cells that produce it, become overwhelmed, exhausted and even fail. It is usually associated with factors like physical inactivity and obesity, but not always. It can be prevented and in the early stages, it can even sometimes be reversed. The third distinct type of diabetes is Gestational Diabetes – which affects women when they are pregnant and usually resolves following birth. It does not often pose the same long-term risks to those affected, but can cause larger babies and problems during birth itself.

There are other types of diabetes, and even some categories and definitions for ‘pre-diabetes’ – those almost, but not quite diabetic. The important message is that all are not the same and the most common type is preventable – so having a conversation with your doctor or nurse can be a wise move, if you’re concerned you’re at risk.

3. Funding is falling between the gap

Crucially for those who work in policy or public health, diabetes at a macro level is being largely forgotten. In short, whether it is at the national or international policy level, or when looking at major donors like Bill Gates and others – diabetes is being left off the map and with serious consequences for those affected. In 2011, the wider group of related NCDs (of which diabetes is one) caused around two in three global deaths yet received only 1.5% of all health aid.

In Australia, it is a similar story. We have an efficient healthcare system, but sadly we spend less than 2% of our health budget on preventing disease – a third of the level spent by Canada and 50% less than the USA. All in a time when we are facing enormous burden of preventable diseases, including diabetes.

Money doesn’t solve everything, but it would go a long way to reducing this burden with many evidence-backed and cost-effective options available.

The final word

Diabetes might cause some confusion, but at the end of an important week of learning and sharing ideas, some things became very clear. Whether to avoid the pain and suffering or the economic fallout, diabetes is truly a global, health issue.

Connect with Sandro on Twitter.

For those on Twitter and interested in Global Health, the Sixty-eighth World Health Assembly of the World Health Organization is happening this week. Follow live via #WHA68.

This article is dedicated to Rotary International, for their efforts in reducing the global burden of diabetes.

The Conversation



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Emerging doctors call for action on global epidemic: non-communicable disease

twentytwelve_bannerThis week, special guest-bloggers and Australian doctors-in-training, Rebecca Kelly and Tim Martin of the Australian Medical Students’ Association, call for greater focus, discussion and action on the world’s leading causes of death.

In March this year, the Australian government released the 2015 Intergenerational report revealing a prediction of the economic and social trends over the next 40 years. There’s some fantastic news; children born in the middle of this century are projected to live greater than 95 years. Importantly, this increase in life expectancy will involve an improved quality of life and Australians will be more prosperous in real terms.

However, the report comes with a warning. Changing economic forecasts flag some potentially tumultuous decades, and an ageing population comes with its own set of challenges. Firstly, there will be a reduction in the number of active participants in the workforce. To make matters worse, Australian government health expenditure per person is expected to more than double, from $2,800 to $6,500 per year in real terms. Finally, with the unavoidable demographic change comes an increase in the rate of non-communicable diseases (NCDs); cardiovascular diseases, cancers, chronic respiratory diseases and diabetes mellitus representing the big four.

Flickr / Brad FlickingerDifficult times lie ahead, and we need to be smart if we want to maintain the health status quo, let alone improve. We already know that the NCD risk factors often start in childhood and adolescence. For instance, greater than 90% of adults who smoke tobacco started in childhood or adolescence and 1 in 4 Australian children are overweight or obese, up from 5% in the 1960s. Subsequently, overweight and obese children are far more likely to be one of the 60% of Australian adults who are overweight or obese. People with risk factors such as obesity, smoking, excessive alcohol consumption, high blood pressure, diabetes, poor diet and sedentary lifestyle are far more likely to develop an NCD.

These figures are striking and extremely worrying. Further, Australian is not immune as NCD rates are skyrocketing around the world. Thus it is timely that the Australian Medical Students’ Association (AMSA), the peak representative body of Australia’s 17,000 medical students, last month passed a policy calling on the Australian Government to prioritise the prevention in NCDs in youth. Medical students are in the unique position of having exposure to the health system whilst also being the targets of youth advertising relating to alcohol and tobacco et cetera. It is an unforgettable experience having a night out with friends, observing binge drinking and smoking, then heading to the Intensive Care Unit the next morning to find a 40 year old, obese man breathing artificially through a tube to his lungs after a lifetime of smoking and drinking. Incidents such as these are all too real and all too common.

Now we are not economists, but it would make sense to think that preventing obesity upstream in children will have a much greater, lifelong impact downstream. If we were policy makers, the question that springs to mind is “what can be done earlier in life to decrease the incidence of NCDs in adulthood?” And if one asks, one finds; there is a rich tapestry of evidence painting the road to NCD prevention.

Flickr / AlessandraWe need to get serious nipping NCD risk factors in the bud with more action and less talk. The McDonalds restaurant on the premises of a children’s hospital in Melbourne is a notable example of nonsensical and counterintuitive policy. Another example is the proposed free trade agreement, the Transpacific Partnership Agreement. Clauses in leaked drafts of the agreement could allow big tobacco, big alcohol or big food to sue sovereign governments over public health legislation. This is no fairy conspiracy; Phillip Morris Asia (the Tobacco company) is suing the Australian Government right now over cigarette plain packaging laws through an existing free trade agreement.

Fortunately, there are (relatively) easy solutions to these problems. The evidence overwhelmingly suggests that the cost of inaction in the prevention sphere is far greater than the cost of action. Earlier intervention equates to better long-term outcomes thus childhood and adolescence are critical points to target. Furthermore, the collective Australian governmental spending on prevention is only around 2%; a pitiful amount. If we spent just that little bit extra on primary prevention rather than expensive new gadgets, and seriously looked at tackling the big tobacco, alcohol and food industries which prioritise profits over wellbeing, Australia might find that we don’t end up with a doubling of health expenditure.

With Government reports such as the Intergenerational report clearly outlining the challenges our health system will face into the future, it is a form of negligence that Australia isn’t doing more to tackle the NCD epidemic. If the Australian Government was fair dinkum about NCD prevention they would be thinking twice about dodgy deals with fast food giants or undercover clauses in secret trade agreements. The medical students of Australia have spoken out in a collective voice; policy settings need to be based in evidence, not ideology. The facts are clear and the yellow brick road has been laid out. We just need to leadership to walk it.

Rebecca is a currently a fourth year medical student at the University of Tasmania. She recently graduated from a Bachelor of Medical Science and her research relates to risk prediction modelling in early life by discovering modifiable risk factors in childhood. Rebecca has become increasingly involved in her local global health network and is also completing a Masters in Public Health. She is looking forward to her a clinical elective at the end of this year in in Cusco, Peru.

Tim Martin is a final year medical student at Monash University with research interests in vaccine safety, hospital acquired infections and healthcare evaluation. He is an aspiring paediatrician passionate about the intersection between health equity and politics. Tim has been involved with various health advocacy organisations such as the Australian Medical Students’ Association and Doctors for the Environment Australia in campaigns, policies and projects involving refugee and asylum seeker health, climate change and health, gender equity, Indigenous health and non-communicable diseases. He is a Diploma of Child Health candidate and is currently studying a Masters of Public Health.

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Hacking human health and behaviour #wiredhealth

This week, we hand over to regular blogger Alex Abel who recently returned from London’s WIRED Health.

The stage is set for the 22 Main Stage talks, hosted by Editor David Rowan

The stage is set at the RCGP for 22 Main Stage talks, hosted by Editor David Rowan

Following last year’s successful inaugural event, WIRED Health returned to the Royal College of General Practitioners (RCGP) in Euston Square, London, on the 24th of April, for a programme of exciting innovations in medicine.

From augmenting our bodies to decoding the brain, the desire to have greater control over human health and behaviour seemed to be the overarching theme at WIRED Health 2015.

Changing the body

One of the most dramatic and noticeable changes to the human body is amputation. The loss of a limb can have a profound effect on individuals, both physically and psychologically, but more than 20 million amputees around the world currently have no access to any sort of prosthetics.

One of my favourite talks of the day came from prosthetics pioneer Nigel Ackland – the man with the bionic hand – who showed us the difference a good prosthetic can make, not only in terms of function, but also self-esteem. People still stare at Nigel in the street, but with his bionic limb, it’s now a look of awe and curiosity.

Modelling bebionic, the world’s most advanced prosthetic, Nigel gave us a demonstration of the different grips his hand can accomplish. He went on to explain that his phantom limb and bionic one seem to be connected in his brain now, because when he is about to move his bionic hand, he feels his phantom limb move first. This must be a very peculiar sensation.

“I’m not The Terminator. I’m just an ordinary bloke who can tie his shoes.” – Nigel Ackland

Having an expert patient tell his story in his own words was a refreshing addition to the WIRED line up, and having met Nigel during the breaks, I don’t think they could have found a nicer man for the job.

Sophie's works of art on display in the WIRED clinic. The crystal leg was worn by Viktoria Modesta at the paralympic closing ceremony.

Sophie’s world: prosthetic creations on display at WIRED. The crystal leg was worn by Viktoria Modesta at the Paralympic closing ceremony.

Prosthetics designer Sophie de Oliveira Barata came to tell the other side of the story. Sophie founded The Alternative Limb Project a few years ago after being inspired by a two-year-old girl who lost her leg and wanted an out-of-the-ordinary replacement. She now makes many of these wonderful bespoke creations, turning replacing limbs into a work of art – something to be worn with pride.

Sophie uses the imagination of her clients to inform her designs. For performer Viktoria Modesta, Sophie made three unique creations: a large spike, a luminous limb, and a Swarovski crystal leg. And for a man who wanted an exact replica of his original limb, she modelled a silicone foot and even used hairs from the back of his neck for the toes.

Changing behaviour

What you call things affects how people behave. This was the conclusion of the thoroughly entertaining talk given by Rory Sutherland.

Using a topical example, Rory explained that if you want A&E to become less crowded, just start referring to it by it’s full name again: Accident and Emergency. The original name implies only the medically vital, whereas “A&E”, he said, sounds like your best friend. Another every day example of choice manipulation is that it’d be perfectly possible to manufacture a fly spray that smells nice; but we wouldn’t believe it. It’d be cognitively confusing!

Rory explained that the way choices are presented to us can also affect outcomes. For example, if you want patients to finish their course of antibiotics, don’t just give them 26 white pills; give them 20 white and 6 red and tell them to take the reds when they’ve finished the white.

“I think if we did have free will, we would have got better at exercising it by now.” – Rory Sutherland, Ogilvy & Mather UK.

Russian roulette: in some parts of the world patients are asked to select a used needle from a lukewarm basin of water

Russian roulette: in some parts of the world, patients are asked to select a used needle from a lukewarm basin of water

Another man who recognises the implications of changing choice structure is Marc Koska, founder of the LifeSaver program. Every year, 1.3M people die from the reuse of syringes by medical professionals around the world – a preventable tragedy. Marc explained that it’s easier to make the wrong choice, so he came up with the K1 syringe that is impossible to reuse – a syringe credited with saving ten million lives to date.

If outside forces such as advertising, availability, and even nomenclature and scent weren’t enough, there is a much more unexpected ‘inside’ influence on human behaviour: Microbes!

John Cryan analogises the microbiome's effect on the brain with the story of Geppetto and Pinocchio

John Cryan analogises the microbiome’s effect on the brain with the relationship between Geppetto and Pinocchio

John Cryan from University College Cork found that changing the microbiome of mice altered their social behaviour and response to stress. So our microbiome actually affects our mental health, and John coined the term ‘psychobiotics’ to describe live organisms that can produce benefits in patients with psychiatric illnesses, IBS, and chronic fatigue.

“In terms of DNA, we are 99% microbial.” – John Cryan, UCC

It is quite unnerving to think that, as John says, if microbes are controlling the brain, then microbes are controlling everything.

The Startup Stage

Running alongside the main event was the Bupa Startup Stage, a Dragon’s Den style contest where 17 keen competitors took to the floor to pitch their ideas in 9 minutes or less; and it wasn’t long before we were talking about the dog’s nose for a second year running. Dogs’ incredible ability to detect minute biochemical change in their human companions is the basis for Medical Detection Dogs, a company that provides trained dogs to help, for example, monitor the blood sugar levels of diabetic patients.

A delegate plays Galvanic PIP, visualising his stress response in the form a soaring dragon

A delegate plays Galvanic PIP, visualising his stress response in the form a soaring dragon

The line up of emerging and established entrepreneurs also included stress control platform Galvanic PIP, which measures electrodermal activity and allows you to monitor your stress on screen in the form of say a flying dragon; and Buddy, a mental health app that texts to ask about your day, and collects responses in the form of an online mood diary to supplement ongoing therapy.

“75% of people with mental health problems don’t get any treatment.” – Kitty Cormack, Buddy

And the winner is…

The Startup Stage winner was Ana Maiques from Neuroelectrics, sporting the wireless electrode cap, named Starstim, which uses transcranial direct stimulation (tDCS) to alter brain activity. Ana told us Starstim has been shown to improve stroke recovery speed by an impressive 20%, and the telemedicine platform may also help treat problems such as chronic pain, depression, and addiction.

Fun fact of the day

During his talk about MinION, Oxford Nanopore’s fun sized DNA sequencer, Clive Brown proclaimed, “we can now pretty much sequence the entire genome of a foetus from the blood of the mother”.

It is quite astonishing to think how far genomics has come in its relatively short study span. According to Bradley Perkins of Human Longevity Inc., genomics has changed every aspect of bacteriology; and us humans are next. Bradley assured us that genomics is going to be the biggest data of big data in Healthcare, opening the door to the next steps in synthetic biology and regenerative medicine.

Most inspiring statement

“Life changing doesn’t have to be life ending.” – Nigel Ackland

Until next year

I think the underlying message of the day can be nicely summed up by a quote from Geoff McGrath during his talk on optimising performance in healthcare.

“Breakthroughs in medicine space will come not just from design and technology, but it’ll definitely need a change of mindset.” – Geoff McGrath, McLaren Applied Technologies

This change of mindset might mean the incorporation of biosensor technology into our daily lives; sharing our biomedical secrets with architects of the ever-expanding universe of big data; or the willingness to make innovations accessible and affordable to the people who need them most. One thing is for sure, science and social science must continue to work hand in hand for the good of the planet and it’s increasingly tech savvy inhabitants.

All of the talks from WIRED Health 2015 are now available to watch via this playlist on the WIRED UK YouTube channel.

Many thanks to João Medeiros for inviting me and curating such a wonderful programme. Congratulations to the entire organising team.

Alexandra Abel is currently a first year medical student at Hull York Medical School. She graduated from Imperial College London with a BSc in Biomedical Science and Global Health, before completing a Master’s in Performance Science at the Royal College of Music, where she looked at the implications of teaching older generations to play a new musical instrument from scratch. In her spare time, Alex is learning to play the ukulele. Join her on twitter @alexandraabel

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