SPEAKER ABSTRACTS

 

Global Public Health: It’s not just a crisis, it’s a scandal of epic proportions

KEY NOTE SPEAKER:

Stephen Lewis

The gutting of the Global Fund to Fight AIDS, Tuberculosis and Malaria  is a scandal of global health funding, governance and accountability .  The Global Fund has been the international financial armada in the battle against the three diseases. The collapse of the next round of Global Fund grants, known as Round 11, is the most serious, catastrophic setback in the Fund’s decade of existence. As things now stand, the Global Fund will not accept proposals for Round 11 until 2013, to take effect from 2014 to 2016. Hiding behind the banner of the financial crisis, the donor countries have clearly decided that if budgetary cuts are to be made, the Global Fund can be among the first to go.

What happened to the Global Fund is the latest episode in the unvarying history of betrayal. In 2005, the G8 Summit in Gleneagles made a commitment to provide an additional $50 billion in aid to the developing world by 2010, $25 billion of which was destined for Africa. By the Summit in 2010, the G8 was between $10 billion and $15 billion short of the target. It’s a scandal of epic proportions

Thirty years into the pandemic, after 30 million deaths, we know how to subdue the virus. We know the treatment and preventive interventions that work. The carnage can cease. Let me simply assert that we have no right, by any measure of human decency, to allow people to die, in huge numbers, unnecessarily. That’s exactly what’s at stake.


 
Physical activity – the neglected risk factor in NCD prevention globally: a saga of denial and politics’

 Adrian Bauman


The issue of physical inactivity has been recognised for six decades, since the seminal work of Jerry Morris in the UK , published in 1953. Evidence is slow to disseminate to health professionals and policymakers, but especially so for physical inactivity, compared to other (clinically treatable) risk factors such as high cholesterol, or hypertension, or even compared to other population-wide problems such as obesity, poor nutrition or tobacco use. The history of physical activity responses from a public health perspective is  a litany of conflict, denial and lack of acceptance, despite physical activity contributing as much as tobacco use to the burden of disease or to global mortality.

One reason for this is that physical activity is not taken seriously enough; how could ‘walking the dog’ or ‘playing with the children’ be as important to one’s health as taking a statin, ACE inhibitor or having major lap-band gastric surgery ? The positioning of inactivity in the media, using bibliometric techniques, confirms this relative lack of position, and that stories either focus on elite sports or on satirising ‘moderate everyday incidental physical activity’.

This neglect of physical activity is expressed at the regional and national level in Australia, with fluctuating  policy positions, lack of coherent responses, and lack of coordination, despite Government rhetoric endorsing ‘physical inactivity’ as a major contributor to chronic disease. At the global level, the 2004 World Health Organisation strategy on diet and physical activity provided a framework for action, but few countries have progressed this work. Relative to the evidence base and numbers of people affected, physical inactivity is the ‘Cinderella’ in the arena of public health action. More sophisticated responses are needed, with better advocacy, communication of the evidence, and professional clinical required to redress this situation 



A Women’s Drug Clinic in Iran:
  Significant improvements in women’s lives

Shabnam Salimi1, Bijan Nassirimanesh2 Setareh Mohsenifar,1 David Allsop3 Azarakhsh Mokri1 and Kate Dolan3
1.Iranian Centre for Addiction Studies 2 Persepolis NGO, Iran 3. National Drug & Alcohol Research Centre UNSW

 Kate Dolan                       


Background -In Iran research has focused on males who dominate drug services. So we established a Women’s Drug Clinic with methadone, sexual and general health care and NSP to improve health and social functioning of female users and to build capacity among drug workers and researchers in Iran.

Participants and design -Women were assessed for MMT, interviewed and bled at baseline and follow up six months later.

Finding -Of 97 clients, we enrolled 65 and F/U 40 women who did not differ from those lost to F/U. On average women had a mean age of 36 and had used drugs for 14 years, usually they smoked heroin (87%) or opium (69%). 25% had injected and 50% had a regular sexual partner. HIV prevalence was 5% and HCV was 24%. Average methadone dose was 67mg (R: 25 to 160 mg).  Most had never been in treatment.

Hepatitis C seroincidence was 7.1 per 100 person years. No one acquired HIV.

Conclusion -This study provides the first picture of Iranian female drug users, their risk behaviours and how well they responded to MMT. More women only drug clinics are required and existing drug services need female only sessions to facilitate treatment entry. These women require intensive help to recover from the harms associated with years of drug use.


 
Responding global Human Resources for Health crisis: Are the current efforts sufficient?

Gülin Gedik

The global health situation and trends are in transition. While the countries are still struggling to achieve MDGs, they are also challenged with the increasing non communicable diseases which are becoming the biggest cause of death worldwide (More than 36 million die annually from NCDs (63% of global deaths)).  The Political Declaration of the High‐level Meeting of the General Assembly on the Prevention and Control of NCDs is also a sign of the acknowledgment of the problem and commitment to address. Furthermore, acceleration of globalization, increasing economic interdependence, and international movements of people and products  have brought new urgency to addressing health on a global scale with the rapid, globalized spread of emerging and re-emerging infectious diseases.

Simultaneously there is a growing consensus that addressing health challenges require well-functioning, effective, high quality and inclusive health systems.Human resources for health (HRH) becomes critical component of health systems in addressing these challenges. However, HRH faces new challenges while still struggling with an unfinished agenda. Deficit of skilled health workforce has been widely acknowledged as a serious obstacle in strengthening health systems.   and some countries are facing a more serious crisis with a critical shortage of health workforce which makes it very difficult to deliver even the basic interventions to achieve MDGs.  Needless to say that shortage is not the only challenge faced, but inequalities, quality, health labour market dynamics, weak evidence based are some of the major challenges.

Global health context and,  therefore,  the global HRH governance is also becoming more and more complex with increasing number and diversity of stakeholders in health, leading to fragmentation in responses. The emerging global initiatives, foundations, partnerships are changing the global heath governance. Though beginning of 21st century has, therefore, witnessed significant increase in resources for global health, yet huge resource gaps, and massive inequities between countries and diseases remain as a challenges and investment in HRH is still insufficient.

Significant efforts have been made not only to draw attention to HRH crisis, but also to address the crisis.  The challenge is ahead requiring to address these issues at country, regional and national level. It implies a shared responsibility for all to work together and collaborate and harmonize better.


 
Closing Health Information Gaps

Judith Healy


Many governments are strengthening their governance in order to become better ‘stewards’ of their health systems. According to the World Health Organisation, this involves three key tasks: setting priorities for improving the health of their populations, assessing progress towards these goals, and ensuring that the relevant actors are held to account. Governments with well-established health care systems are passing legislation and establishing regulatory agencies that require health care organisations and professionals to be more accountable for their performance to the state and to the public.  These new national meta-regulators are experimenting with strategies that include persuasion, standard-setting, financial incentives and enforcement. The traditional strategy of leaving health care regulation solely to the doctors is no longer acceptable. While poorer countries understandably are preoccupied with funding, they should also consider ways to strengthen their regulation of health care quality in order to make better use of scarce resources and to ensure better health care for their populations. 


 
The widening gap in equity of pluralistic health systems in low income and middle income countries in Asia: emerging issues in unregulated health systems.

Rohan Jayasuriya

There is wide recognition that health systems in low income and middle income countries have substantial constraints and that efforts to strengthen them are failing. Evidence shows that in countries with pluralistic ( ie mixed)  systems there is a  widening gap  in universal access  to primary care and  a disproportionate financial burden on the poor.  Historically many countries in Asia took the path to build publicly funded national health systems with a focus to cater for episodic care of acute disease. These investments in secondary and tertiary facilities are now a costly burden in infrastructure and specialised staff. Most countries now face the heaviest burden of disease from chronic disease.    Private health care has over the years lead to a distortion of demand and health seeking behaviour. Countries face policy issues of an unregulated private sector and dual practice of public sector staff. A comparative analysis of selected case studies from Asian countries will be used to illustrate the underlying factors that contributed to this situation and to analyse reform strategies, taken by design and default to respond to the emerging crisis.


 
Powerful determinants of health are deeply embedded in global trade relations; the health sector is woefully unprepared to engage in the field of trade policy

David Legge and Deborah Gleeson



Powerful determinants of health are rooted in international relationships of trade, investment and finance. Examples include: the availability and affordability of medicines, public health regulatory capacity, decent jobs, social infrastructure and food security.  We shall elaborate briefly on these examples.

The challenge for public health is usefully framed by the principles of the Ottawa Charter: create supportive environments; build healthy public policy; and strengthen community action.  We shall explore the implications of these principles at the trade / health interface and draw from this analysis a set of capability statements which specify the kind of capabilities that the public health sector / movement needs (at the national, regional and global levels) if it is to contribute effectively to policy coherence across this interface.

We will evaluate the capacity of public health as reflected in a number of recent debates, negotiations and agreements around trade, investment and finance.  We shall conclude that public health capability in this field is abysmal.

At the global level we shall reflect on the ways in which the funding crisis currently facing WHO has prevented effective action around Resolution WHA59.26 which deals with policy coherence across trade and health. We shall argue that WHO’s funding crisis has been deliberately imposed on the Organisation by the rich countries, led by the US, in order to prevent the majority of member states from committing the Secretariat to engage in ‘political’ matters such as trade.

We shall conclude that global health is indeed in crisis, as measured by its inability to effectively engage in a domain where some of the most critical determinants of health arise. Finally, we shall outline some current initiatives in the trade and health field which illustrate the kinds of strategies needed to build public health capacity to effectively engage in this field.


 
Strengthening public health systems in health sector reform

Vivien Lin

Following a burgeoning of global health funding and orientation towards vertical programming (eg via MDGs, Global Fund and other PPPs), attention has shifted more recently to health system strengthening, as a pre-requisite for successful delivery of program to achieve health outcomes.   The call for renewal of primary health care has become more focused on universal coverage, as health sector reforms sweep across both developed and developing nations.  The emphasis in health sector reform has been on financing of personal health services, and to a lesser extent the organisation of healthcare and the development of health workforce for personal health care.  Despite studies conducted on core public health functions, there has been limited attention on health promotion, disease prevention, and health promotion, ie activities which are at the core of improving population health outcomes.  Where essential public health services have been incorporated into health system reforms, they have also focused largely on personal preventive services.  The basic building blocks of public health systems – workforce, financing, information, leadership, organisation – have not necessarily been considered as a core component of health reforms, although the strengthening of public health systems is also needed.  This presentation will review some experiences with improved financing for public health and approaches to strengthen public health systems, and raise issues about what might a public health system strengthening agenda entail. 


 
Increasing Antimicrobial Resistance – a global crisis

Dilip Matthai


Antimicrobial resistance is a    public health problem of global importance, whether it is to the commonly occurring pathogens which cause widespread infections in the    community like tuberculosis, malaria, salmonella, staphylococci etc. or the infections occurring in    hospitals  to recently introduced antibiotic  classes. The resistance is multi -and pan-drug, complicated   with the emergence of metallo beta- lactamases with no available class to treat such infections.

This resistance is evolving and increasing. The build up is  due to indiscriminate antibiotic use in  humans  and animals ,    exchange of resistant genes  intra- and inter- species and its clonal expansion, spread into the food chain, and rapidly changing ecosystems with poor water hygiene and sewage pollutants . These transmission dynamics ensure spread to and by people to all genre and classes. Spread occurs locally   in the community and into hospitals.  International travel has   made it possible for    intercontinental spread causing further emergence and dissemination of widespread resistance. This is a crisis brewing with explosive implications. It will   undermine advances in global health if left unchecked. This in particular because new drug discovery is increasingly expensive. Costs for development and introduction into clinical use is time consuming and   prohibitively expensive and holds   no promise of financial sustainability and viability. This scenario of rapidly emerging resistance has shortened the life span of drugs which had been effective for long.  

There are several reasons for this unchecked occurrence   usually among enteric pathogens residing in the guts of    over half the world’s human population. In the developing world no antibiotic policy exists:  forcing   its prudent use by practitioners, or placing   limits of over- the- counter sale without prescription, regulations that lack teeth to control sale of inferior quality or prevent spurious or counterfeit products being sold or prescribed, and use of medicine by unqualified quacks and fake doctors. These are issues that occur  because of poverty, lack of access to treatment ,  withdrawal of the welfare state and a high burden of infectious diseases necessitating antibiotic ‘mis-use’ for all ‘fevers’  presumed to be of infectious bacterial origin .Furthermore very limited bacteriological laboratory support is available. These are cascading events which call for a global change in practice.   

There is a national need to amend existing legislation, control antibiotic use in animal husbandry, formulate a drug policy   that assures quality in manufacture, monitor distribution and audit of sales so that it occurs only with bills and with a prescription to general, public and primary care. Doctor- pharmacy synchrony needs to be established. Simultaneously, physicians need to be educated and provided with guidelines or protocols. This way therapy (across all disciplines and specialties) in hospitals is indexed. Feedback that reports appropriateness of use that is supported by microbiology laboratory data would minimize unnecessary use. Establishing good    infection control practices eg hand hygiene using hand rubs ,    monitoring rates of occurrence   of sentinel hospital pathogens audited with stringent regulations that promote hospital accreditation and harmonization with global standards are needed.  In the long term globally orchestrated programs, processes and ideology are required with the introduction of newer and cost effective technologies for antimicrobial resistance containment. Pressure to introduce appropriate policy changes by national health ministries has to be initiated, method of financing and execution of such programs established. Operation, maintenance and management with long term sustainability of this activity is a global challenge. If left unchecked antimicrobial resistance has the potential to negatively impact and reverse the gains in health made so far. Science needs to keep up with the emerging and evolving pathogen to tackle it; with better physician and general public antimicrobial stewardship,, and improved infection control practices, both of which requires awareness. It is a massive educational effort, and behavioral change to win this global battle stalemate it, and possibly reverse the rising tide. A global win appears remote, but a life in harmony with nature appears possible through these various approaches especially during this crisis time.  “Have we won the battle with microbes or have we lost the battle even before waging the global war?”


 
The Role of Myanmar Maternal and Child Health Association (MMCHWA) in improving Maternal and Child Health (MCH) in Myanmar

Thazin Nwe

Myanmar’s Ministry of Health has substantially strengthened its clinical and community maternal and child health care (MCH) sectors in order  to reduce the incidences of infant and maternal mortality and thereby achieving Millennium Development Goals on time. The comprehensiveMCHactivities for safe delivery were enhanced by strengthening adolescent reproductive health, increased male involvement and promoting referral system and community volunteers. The existing capacity of the health system is not enough to implement the said activities in all diversified populations of Myanmar with varying socio-economic strata.

 In order to overcome geographical inaccessibility and staff inadequacy quantitatively and qualitatively, Myanmar Maternal and Child Welfare Association (MMCWA) act as a major stakeholder for the Ministry and had launched rights-based, community sexual and reproductive health (SRH) services and educational activities since 2003. The Association has 13 million volunteer members distributing in all 14 administrative regions of Myanmar and has established maternity homes in 133 Townships. MMCWA provided training of volunteers, provision of medical equipment and commodities to be used for maternity homes (MH) and their SRH services. MH clinics serve as static stations and mobile outreach teams deliver field activities, breaking SES barriers and making SRH services accessible to remote and marginalized populations.

Constraints and challenges are not uncommon in implementing attitudinal / behavioral change programs and developing positive SRH environment in rural communities which are rooted with traditional beliefs and practices. Most challenging issues for MMCWA are 1) advocacy for utilization of skilled birth attendants instead of local traditional ones in rural areas, and 2) developing efficient trainers for SRH education and integrating life skills component into school curriculum. However, MMCWA will put every effort and establish partnerships with related sectors and institutions to achieve the ultimate goal of promoting overall health, education and social standards of the Republic.


 
Primary Healthcare in Vietnam

Tran Thi Mai Oanh

This presentation highlights challenges currently faced by the primary healthcare (PHC) system in Vietnam in the context of renewed interest in primary healthcare initiatives. The presentation also documents some current policies and programs that aim to address these challenges in order to achieve a more equitable and efficient health system including PHC. The delivery of PHC services to the general population has been hindered by a number of constraints: lack investment in facilities and infrastructure, shortage of human resources at the grassroots level, inadequate supply of essential drugs and medical equipment, and low quality and underutilization of primary healthcare services. The shortage of human resources, in particular, is due primarily to the "brain drain" among healthcare professionals working at the grassroots level who often seek employment at higher level health facilities for higher payments and better opportunities in their professional career. In addition, the location of the commune health station – the basic unit of the PHC network, based on the administrative unit rather than the catchment area has created difficulties in providing healthcare to the local residents in areas with low population density. In response to this situation, several program and policy initiatives have been implemented such as increased investment in PHC from the state budget, enhanced human resource development, and expanded procurement of essential drug supply and equipment for primary healthcare facilities based in communes. Notably, policies on training, attraction, and retention of the healthcare workforce in the most disadvantaged areas have achieved some positive outcomes. While the quality of the training though nomination remains to be confirmed, the retention policy via the incentive scheme has resulted in an increased number of healthcare personnel who are willing to work at the commune health station in some remote and mountainous areas. Strengthening the PHC network and improving human resources for PHC continue to be the government priority in Vietnam.


 
Treatment and prevention: human rights and public health, different… but the same?  

Edward Reis

HIV treatment as prevention was lauded as Science magazines ‘Breakthrough of the Year’ (23/12/11). The biological plausibility that ART has a prevention benefit is generally accepted, however the magnitude of that plausibility is unknown, as the evidence is restricted to limited observational studies, randomised control studies and ecological and mathematical modelling. PMTCT is often cited as strong evidence that ART as prevention works, yet the implementation of PMTCT programs, in Asia in particular, has been woefully inadequate. Clearly, structural, social and cultural determinants will affect treatment as prevention, as much as they affect all other HIV interventions and initiatives. Yet,  the ‘treatment as prevention’ juggernaut rolls on and is promoted on the basis that it delivers not only individual health benefits but also public health/ community benefits. At the same time, treatment as prevention is being advocated within the political construction of  a ‘human rights framework’. All of this has profound implications for people infected and affected by HIV who are positioned as the subjects of both public health and human rights discourses. The politics of treatment has always been a feature of HIV programs, but treatment as prevention is radically challenging earlier understandings of the right to health. This presentation will review  the discussion of treatment as prevention at the 2012 IAS Conference in Washington and what the implications of this might be for supporting treatment and prevention in HIV programs in Australia’s regional HIV partnerships.


 

The Framework Convention on Tobacco Control

Robyn Richmond

Tobacco use is an important contributor to premature death and ill-health in the developed and developing world.  Tobacco is the second major cause of death in the world and the fourth most common risk factor for disease worldwide.  Smoking kills almost 5 million people annually, which equates to one in ten adult deaths worldwide.  The diseases caused by tobacco include cancers, respiratory and cardiovascular disease and they are taking an increasing toll in less developed countries and among low-income groups.  The World Bank claims that: “the threat posed by smoking to global health is unprecedented, but so is the potential for reducing smoking-related mortality with cost-effective policies.”  The WHO Framework Convention on Tobacco Control (WHO FCTC) is an important tool to address tobacco control on a global scale.  It is a legally binding instrument negotiated and adopted by World Health Organization Member states.  The objective of the FCTC is “to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke.” The WHO FCTC is a comprehensive multisectoral treaty that includes measures aimed at reducing the heavy toll imposed by tobacco use and production.  The measures are evidence based and effective and include: Increasing the price and tax measures to reduce the demand for tobacco (Article 6); Banning or regulating tobacco advertising, promotion and sponsorship (Article 13); Regulating the contents and disclosure of tobacco products (Articles 9 and 10); Increasing anti-smoking messages on packaging and labeling of tobacco products (Article 11); Protecting from exposure to tobacco smoke (Article 8); Raising public awareness and educating to reduce tobacco use (Article 12); and Encouraging smoking cessation which includes training of doctors and medical students in methods to help patients quit smoking (Article 14).  In this paper, the articles of the FCTC will be discussed.


 

Global health in international context

Richard Taylor                          

This presentation will cover different perspectives on globalisation and health in an international and historical context in order to address the question as to whether ‘Global health is in Crisis”. An introduction will include considerations of changing nomenclature and paradigms from Tropical Medicine, International Health to Global Health, and their similarities and differences, and in the context of vast improvements in health status in human populations over the last 150 years as measured by declines in premature mortality, encompassed by generalisations articulated by the demographic and epidemiological health transitions, albeit with considerable differences between populations, and temporal lags,  such that generalisations need to be tempered with particularities.

Consideration will be given to advantages and disadvantages of health related Millennium development Goals (MDG), both in light of the wider public health context and for countries at different levels of development. Reference will be made to the continuing dialectic between health improvement resulting from broad social and economic development (primarily endogenous), versus specific focussed technical inputs (often from outside) for particular disease conditions.

Finally, there will be mention of the role of rigorous and balanced enquiry versus advocacy in international and global health.


 
Challenges in Universal Health Coverage :
Can Indonesia improve socio-economic and geographic equity together?

Laksono Trisnantoro

In Indonesia the new law on social security agency which targets universal coverage will be effective in 2014. While the main objective is to improve health equity it will pose various challenges to access for health services funded by the social security agency with a real possibility of worsening geographic inequity. The presentation will provide historical facts which have influenced health equity in Indonesia and discuss a possible dilemma in reducing economic and geographical inequity at present and in the future. As  a direct response  to the economic crisis  in late 1990’s, financial protection for health care for the poor was set nationally in 1999.  The protection policy aimed to reduce out of pocket spending by increasing central government funding targeting the poor. A steady growth of central government funding for health social security resulted in a relatively low incidence of catastrophic out of pocket health expenditure, which has declined over time. The financial protection program reduced financial barriers to access for poor households for both hospital and non-hospital services. However, alongside these positive impacts, the regional inequalities in access to services have not improved over time.  There is regional inequity due to shortages in inputs such as health facilities, medical specialist and trained nurses. Historical facts will be used to explain this situation.  Indonesia has taken the route of market –based economies  and is has not been a welfare state since the colonial era.  Hospitals and health service providers are distributed based on market demands and cluster in the cities and regions with good economic development. Therefore, the new Law faces a difficult challenge in terms of geographic inequity. There is a possibility that the improvement of socio-economic equity may worsen the geographic inequity in Indonesia.


 
The Millenium Development Goals, MDG 6 and the Pacific – The Global and Regional Perspectives on Achievement and Value

Stuart Watson

This session will review the official United Nations and actual national status on progress towards achievement of the Millennium Development Goals (MDGs) with specific reference to MDG 6 (HIV) both globally and in the Pacific.  The paper will discuss whether MDG 6 related to HIV is achievable and will also explore whether the MDGs are appropriate as advocacy and programming tools;  appropriate in contributing to the goal of halting and reversing the spread of HIV especially in the Pacific;  whether current HIV response initiatives in the Pacific are adequate; and how effective aspirational initiatives such as the MDGs are in driving or contributing to national HIV responses and social development initiatives



The war on drugs and Australia's response.

Alex Wodak


With its very close ties to the USA, it was inevitable that Australia would become a loyal supporter of global drug prohibition, largely created, expanded and enforced by the USA. Australia’s first drug laws were passed in the colonial period as an expression of anti-Chinese racism. Race continued to be an important factor in Australian drug policy in the early 20th C. Australia was pushed to prohibit heroin in 1953 but her problems with heroin only began after the heroin production and importation was banned. Like almost all countries, Australia signed and ratified the three international drug treaties (1961, 1971, 1988). As in most other democratic countries, Australian politicians observed that Nixon’s 1971 Declaration of a War on Drugs was a very effective political strategy although it slowly became clear that as a policy it was ineffective, often seriously counter-productive and always expensive. At a special meeting of the Prime Minister, all Premiers and the NT Chief Minister on 2 April 1985, Australia adopted harm minimisation as its official national drug policy. This policy has been positively evaluated on several occasions and endorsed each time. In the 1990s, harm minimisation was defined as the combination of supply reduction, demand reduction and harm reduction. Politicians still refer to this as ‘the balanced approach’ although supply reduction receives 75% of government funding, demand reduction (education and drug treatment) 17% and harm reduction only 1%. The adoption of this framework helped the early and vigorous implementation of harm reduction which successfully controlled HIV among and from people who inject drugs. In 1997, after Federal Cabinet had rejected a trial of prescription heroin because ‘it would send the wrong message’, the Howard Government announced a ‘Tough on Drugs’ strategy. This was more about politics than policy as the Howard Government also generously supported harm reduction in Asia (to prevent HIV infection among and from people who inject drugs), diversion of drug offenders from the criminal justice system to drug treatment and allocated additional funds to state and territory needle syringe programmes. Drug policy has received little attention in Australia for the last decade and a half. A country that was not long ago an international pathfinder now lags far behind many other countries in Europe and Latin America attempting to find a drug policy which is better able to protect public health and human rights, based more strongly on evidence and provides a better return on investment. The vigorous, prolonged and largely positive response to a report on drug policy by Australia21 seems to herald a new era in drug policy in Australia.


 
HIV and Development, Dependency and HIV in Small Island States: Pacific case studies

Heather Worth

A range of social and economic factors underpin the direction, extent and character of the HIV epidemic in developing countries Not only are poverty, inequality and power intimately implicated in the course and effects of the epidemic, but HIV both shapes and is affected by the West’s development project. Nowhere is this more sharply brought into focus than in the Pacific, where for a variety of reasons, development is intricately imbricated in the spread of HIV.  

This presentation will focus on the connections between the West’s development project and HIV risk in three Pacific countries: Kiribati, Fiji and Papua New Guinea.  This project challenges the biomedical emphasis on individual actions inherent in risk group positionings, in favour of a political economy of the virus.  Within this more global framework, rather than HIV risk being the domain of the individual, who lacks the tools to practice safe sex, vulnerability to infection must be viewed in relation to unequal trade, international divisions of labour, exercises of global power that promote unequal relationships between the West and Pacific Islands. I will utilise a materialist political economy of development but with a commitment to the challenge involved in grasping, ethnographically, the processes by which these world–historical forces are made meaningful and tractable by Pacific Islands people themselves.



Timor @ 10 – Health system struggles and Development

Anthony Zwi


Timor-Leste this year celebrates 10 years of Independence. The health system has developed remarkably over this period; a tribute to national struggle, pride, innovation and collaboration with others. Presidential and parliamentary elections have recently been held and despite some ‘wobbles’, the country is stable, the policy environment much improved, and the international community are looking to support the ‘New Deal’ and the national development plan

This paper reflects on the achievements and challenges, and highlights the need for interfacing health with development if more sustained gains are to be achieved.  Timor @ 10 presents a valuable opportunity to consider the particular challenges facing countries emerging from periods of conflict and how the international community can most effectively offer support.  It highlights the issues which post-conflict countries are placing on the development agenda and their potential impact for health and the health system.  It argues that global health will be most effectively promoted when the many challenges present are considered within a broader development frame.