Ep67: Boosting Public Health in the Indo-Pacific

Ep67: Boosting Public Health in the Indo-Pacific
31 January 2021

Fellows of the RACP can claim CPD credits via MyCPD for listening to this episode and reading the resources below.

This is the fourth and final part in our series on Global Health Security. Australia’s Indo-Pacific Centre for Health Security was launched in 2017 to provide development assistance to health services as far-flung as Fiji, Cambodia and Timor L’este. Its mission is always tailored to the needs of the partner government. In Indonesia it has provided training to the veterinary sector to foster antimicrobial stewardship. The 2020 COVID-19 pandemic was a sudden shock to the development agenda and has forced a rapid redeployment of resources. Since recording this interview there has been an additional $500 million dollar commitment to fund doses of COVID-19 vaccine and technical assistance to the Pacific and Southeast Asia.



Robin Davies (Head of Centre, Indo-Pacific Centre for Health Security)
Dr Stephanie Williams AFPHM (Australia's Ambassador for Regional Health Security, Indo-Pacific Centre for Health Security)


Written and produced by Mic Cavazzini. Music courtesy of Free Music Archive includes ‘Cast in Wicker’ and ‘the Zepplin’ by Blue Dot Sessions, ‘Linger’ by David Szezstay and ‘Dormir’ by Monplaisir. Photo by Lazslo Mates licenced from Shutterstock.


AFPHM Pacific Health Webinar Series [RACP]
Contain This podcast [DFAT]



MIC CAVAZZINI:                               Welcome to Pomegranate Health. I’m Mic Cavazzini for the Royal Australasian College of Physicians.This is the final part of a series on Global Public Health we started back in episode 63. We already heard how the concept of global health security gained prominence between the HIV/AIDS crisis of the nineties and the 2003 SARS outbreak. The World Health Organisation responded with its International Health Regulations, which spells out several obligations member states are expected to have, to prepare for disease outbreaks and contain the spread.

These obligations include surveillance mechanisms to detect unusual case clusters, as well as minimum requirements for diagnostic labs and public health communication. The list goes on, and it can be very hard for low and middle income countries to meet these standards.

In an effort to bolster these capacities among developing countries in the region, in 2017 Australia launched the Centre for Indo-Pacific Health Security. Most recently the Centre has become responsible for the Regional Vaccine Access and Health Security Initiative. This is a $500 million dollar commitment to fund doses of COVID-19 vaccine and technical assistance to the Pacific and Southeast Asia.

It is early days in this fast-moving space, but to keep up to date you can listen to the Centre’s own podcast called
Contain This. In a November episode an immunisation nurse from Tonga and clinical microbiologist from Indonesia talk about the cultural challenges and local strategies for vaccine uptake in their communities. You’ll find links and more information at the website indopacifichealthsecurity.dfat.gov.au.

This regional vaccination program is just the most recent part to Australia’s wider development agenda. In the last financial year Australia contributed a total of $4 billion dollars in overseas development assistance, and the health component comes after other areas like governance, education, infrastructure and trade.

Prior to COVID-19, Health development received a budget of about $545 million a year of which half goes to global programs like the WHO and UNICEF, GAVI the Vaccine Alliance and the Global Fund. We talked about these in Episode 64.

Today we’ll talk about the other half of that budget. The bilateral, country-specific development programs Australia has. We’ll ask how this money spent and how you decide between different public health goals. And what other local and diplomatic considerations factor into these decisions.

To answer these questions, I went to Canberra to meet with two of the most senior representative of Indo-Pacific Centre for Health Security. Please note that this conversation took place in September before the Regional Vaccine Access and Health Security Initiative had been launched, but unfortunately in the middle of some noisy drilling that interfered with parts of this recording.

STEPHANIE WILLIAMS:  I’m Dr Stephanie Williams, Australia's ambassador for regional health security and principal health advisor at the Department of Foreign Affairs and Trade, and a fellow of the Australian Faculty of public health medicine.

ROBIN DAVIES: And I'm Robin Davies, the head of the Indo Pacific Centre for Health Security in the Department of Foreign Affairs and Trade.

MIC CAVAZZINI: I began by asking Dr Stephanie Williams to outline some of the work that Australian aid has been contributing to. The first example is a long-standing project in sTimor L’Este focused on sexual and reproductive health education. Between 2003-2016 maternal mortality was reduced by a third, and the average birth rate of 8 children per woman was halved.

STEPHANIE WILLIAMS:  So that example in Timor L’este was through a very long-standing contribution to an NGO partner, to enable increased access to family planning service clinics in Timor. Family planning commodities, in particular, are not necessarily available through government-led clinics. That initiative used a range of measures. One quite popular one was a hotline for teenagers to ask questions about sex and family planning and different methods available to them. And that was becoming increasingly popular over time, as more people learned that there was a confidential way to see information that was key to their own health and safety.

And the other measures are really the kind of the foot soldiers of primary health care where you have a visible team turning up every week, you know that they're going to sit at this clinic every Friday, and they're going to talk about this, bring these commodities. And there's a reliability of service provision and visibility of those services in the country, that again, over time, the population warm to and increasingly used.

MIC CAVAZZINI:               One of your interests is the progress of countries as they become more developed and no longer eligible for funding for such specific programs. But that doesn't mean that their problems have ended. You give the example of Cambodia where the main income might be going up, but there are huge chunks of the population still unable to access care. So how does development work in a setting like that take more of a top-down approach?

STEPHANIE WILLIAMS:  So the way in which we work in health is completely dependent on the country context. And the Cambodia example is a good example. There is a public system, but almost everyone their first point of call to the healthcare system is a private provider, a private pharmacist or clinician down the street. So there's a huge out of pocket costs for most Cambodians in health care.

There was a period of time in the late nineties a very vulnerable community in the heart of Phnom Penh. Very small, at the time 3000 people, and where Australia with other development partners with the blessings and in true partnership with the Ministry of Health began a health initiative that said, “What about subsidizing health care for these, the poorest Cambodians, in this particular area? Will that improve the access of this community at public sector facilities where there are occasionally some fees as well?”.

It was successful, and it has in over time grown to subsidise over 3 million Cambodians access to health care through working with the Ministry of Economy and Finance in basically grant provision, so that they can claim back their cost of health care. And it's a relatively complex health system intervention. So I think the opportunities in health system improvement are always context-dependent, partnership-dependent, and timing-dependent.

MIC CAVAZZINI:               Yeah,  I've seen those examples in India, for example, that there might be a public clinic, but the road down the road, there are pharmacists and street vendors selling all the consumables that you might need for your appointment, and you’ve gotta walk in there...

So pandemic preparedness has been at the front and centre of the global health agenda for the last couple of decades. And our region encompasses some of the world's most densely-populated countries, and some of the least developed. So Robin, can give us a couple of examples of how different the needs are, say, Vietnam compared to Tonga?

ROBIN DAVIES: So you said pandemic preparedness had been at the forefront for a couple of decades. That's, I guess, an interesting perspective. It has been at the forefront at certain points in time, after the avian influenza outbreaks around sort of, I guess, 2005-6, and a little earlier than that, after the SARS outbreak. But I have to say that overall investment has really only come back in in the last couple of years. There was, I think, a real trough in the sort of decade from 2010 2011, as people moved on from those concerning outbreaks in the 2000s.

You mentioned two countries, that couldn't be more different Vietnam, Tonga. In the case of Vietnam, that's a country with, as you say, a very densely packed population, particularly dense sort of poultry industry, much intra-country and inter-country trading in livestock and wildlife and therefore facing a lot of risks in terms of zoonotic diseases. Tonga on the other hand, doesn't really have any of that. And it's been, you know, for, for quite some years, much more preoccupied with non-communicable disease issues. So I think in in most of the small island states of the Pacific people were not really thinking about pandemic risks, particularly as global interest in that topic sort of declined.

And even in the countries of the Mekong. I think there was a fading of concern about those issues, people were getting used to occasional avian influenza outbreaks, at least in poultry and the occasional crossover to human beings. So it wasn't really til COVID happened, I think that you suddenly saw governments of very different kinds suddenly focusing on the risks and also on the response measures. For Tonga it's essentially closing borders. For Vietnam, it's incredibly strict isolation and control measures.

MIC CAVAZZINI:               And countries like Vietnam and Tonga might not be able to fund their own pandemic preparedness, some but the Indo Pacific Centre includes a vector-surveillance networks in the Pacific, fellowships to train epidemiologists abroad, resources for diagnostic labs. Are there parts of this program that you can say did improve resilience to the COVID outbreak?

ROBIN DAVIES: I would like to think so but I just want to, I guess, issue, the qualification that this program has existed now for coming up to three years and in the context of international development programs, that makes us very young. Put it this way, I think what we've been able to do is respond by pivoting some existing partnerships that had been formed over the couple of years leading up to COVID. You mentioned vector control, which is less relevant in a COVID context, but we're also working with institutions on the laboratory strengthening, workforce development, surveillance, infection prevention and control, a whole range of relevant areas.

Those partnerships had barely got up and running when COVID hit. So in one sense, we are still constrained because those institutions can't actually do a whole lot on the ground at this point in time. And to some extent, we'll need to wait until particularly travel restrictions ease before they're more able to provide support to their partner institutions in the region. But there are certain areas I think in which we've been able to play a very important role. So to give one example, around COVID testing, we had forged strong relationship with the Papa New Guinea Institute of Medical Research, which is based in Goroka.

And they are playing a very central role in Papua New Guinea’s COVID testing regime, snd in a whole range of ways, we've provided inputs into that, whether it's laboratory experts, whether it's the provision of testing kits, sample collection kits, whether it's gene expert cartridges. We've been able to really support the testing regime in Papua New Guinea, the same is true across other parts of the Pacific. Likewise, the workforce development, particularly for field epidemiologists, as proven very useful in a couple of countries where some of the people that we have helped to train are now being engaged in contact-tracing and other aspects of the country's outbreak responses.

STEPHANIE WILLIAMS:  And I think, you know, the partnerships that Robyn described as being just set up when COVID hit, there have been a handful of those which have both stayed in country, and Timor Leste is a good example of that, but also forged some very proactive remote support, again, back in the area of laboratory diagnostics. So we had already partnered with the Menzies Institute, from Darwin in Timor to improve capacity of surveillance epidemiology—a workforce-based initiative largely. And because that team had been well established with relationships across the Ministry of Health in early this year, we were able to provide extra funding for them to rapidly support the Ministry of Health upgrade their laboratory, and they now have PCR testing for COVID and have been doing that hundreds per week, I think it's from memory, over the last few months. So that's an entirely new capacity delivered and supported by an existing partner of ours.

At the same time, our partnership with the Doherty Institute, again on the laboratory diagnostics have provided material and remote support to Ministry of Health colleagues in the Solomon Islands as they too have installed and now are operating a PCR machine. And that—for a medium and longer term view, the PCR diagnostic capacity that is now in many Pacific Islands has been a real achievement and supported by many of our partners.

MIC CAVAZZINI:               So Papua New Guinea has seen about 500 cases so far. But with one doctor per 16,500 thousand people, one ICU bed per 100,000, and where only two people in 100 can even wash their hands near their home, it's on a bit of a knife edge. And Australia did reallocate $22 million of aid to pandemic support in PNG. How is that being spent?

STEPHANIE WILLIAMS:  So you're right. The challenges in countries like PNG are enormous. And I think your examples about just recognizing not only the interdependencies of a health system, be it the workforce concentration, the access to water within a health system, let alone access to water in a community, there are so many ingredients necessary for a health system and a country able to deal with an infectious disease crisis. And I think, in particular, I think every government realizes for a significant outbreak, how exposed and how much more is involved than just responding to a pathogen.

PNG is Australia's largest developed bilateral development program in the Pacific. So we, as you said, we have pivoted money for the health response and broader in COVID time but it's important to recognize that's on a foundation of several decades of ongoing development support and relationships and programs across multiple sectors in PNG. Just last year, the program identified three priorities for the next five years. There was health security, primary health care in provinces and improved access to sexual reproductive health services and integrated services.

In response to COVID, the health security elements were flexible and adapted to the needs. So some of that expenditure for the 22 million or so on health went directly to provincial health authorities, which are, you know, there’s 22 of them, and they are a bit like Australia, state and territories, increasingly the frontline of the administration and service delivery of health care in provinces. There was some central support as part of that package consumables and material for laboratory specimen collection and testing, a large package of financial support to boost the supplies of PPE at a time where, you know, supplies were short. And there's obviously an ongoing system of procurement of PPE in PNG, and there was extra work in in support for training and infection prevention and control.

They’re some examples, not the full rundown of the $22 million package, of course. And that really continues and you'll know that at this moment, there's the AusMAT team in PNG, from Australia, deployed really in response to their request through the WHO from emergency medical team in late July, as they were diagnosing increased numbers of locally-acquired cases of COVID and around July. And that team is gone straight into work in partnership with leaders in the national Control Centre, and importantly, leaders in Port Moresby General Hospital and the Rita Flynn isolation facility, which are the capital facilities responsible for seeing diagnosing, cohorting, triaging patients, and that teams in week three or four. So we've got sort of a multi-layered, bilateral, regional and external support to PNG in particular during COVID.

MIC CAVAZZINI:               So on top of that, on top of the $22 million, we mentioned, Australia has promised to supply our COVID vaccine to partners in the Indo Pacific, should we get access to one, which will require another $80 million. Are you worried about which long-term projects might have to be put on hold while those more immediate concerns are rolled out?

ROBIN DAVIES: Yeah, and the $80 million you referred to is Australia's contribution to the COVAX Advanced Market commitment for developing countries which has been established by GAVI, the Vaccine Alliance. That's very much an immediate mechanism that will provide for maybe 20% of the vaccine coverage needs of developing countries, the sort of high risk populations. The costs involved in vaccine provision for wider coverage for the populations of developing countries will be extremely high. And a lot of that cost will have to be spread across a whole range of donor institutions, including the multilateral development banks as well as bilateral donors, and then of course, governments themselves.

The Prime Minister has made it clear that Australia is going to play a role in supporting vaccine access for particularly the countries of the Pacific and Southeast Asia. The way in which that might be done is still to be determined. At a time when it's quite difficult to implement programs as originally planned. That's what we saw with the pivot in the previous financial year, something like $280 million in total, was reallocated from programs that essentially could not proceed as planned to COVID preparedness and response activities. So you know, there are a range of ways in which new assistance can be funded and there is, to some extent automatically some flexibility that opens up within the existing aid budget because of the impact of COVID.

MIC CAVAZZINI:                               In episode 63 I talked with Associate Professor Adam Kamradt-Scott about his book ‘Disease Diplomacy’, with co-authors Sara Davies, and Simon Rushton. They describe how the term Global Health Security was first used by the World Health Assembly in May 2001. This language was meant to steer some attention onto the “threat” of infectious disease events, at a period when the world was gripped by geopolitical threats like the Iraq biological weapons program and only months later, the terror attacks on the Twin Towers and then those anthrax letters.

Securitization language has the critics, however, especially from Copenhagen School of Security Studies. They’ve said that it “hyperpoliticizes” issues and distorts their relative importance.
As Adam Kamradt-Scott has written, “Pandemic influenza has become viewed as “the world’s most feared security threat” by the WHO and governments despite its relative infrequency, while malaria on the other hand – which kills an average of 800,000 children under five years of age per year – continues to be treated as a standard public health issue.” Another critique is that such a framing “perpetuates postcolonial … notions of superiority” or a “west versus the rest” mentality. It would be pretty jarring if you heard your country or region described as a ‘hotbed’ of infectious disease, and there’s no doubt that xenophobia has made its way into the social response to COVID-19

Adam-Kamradt Scott has written that Australia’s adoption of health security terminology was initially resisted by regional partners such as India, Thailand and Indonesia, but that over time they all came to see the shared interests in pandemic preparedness. In the 3 years Robin Davies has been leading the Centre for Indo-Pacific Health Security, he says he hasn’t observed any suspicion from development partners about the motivations of the program.

ROBIN DAVIES: I guess the concept of health security has had the advantage of appealing to a number of different policy communities at the same time, but I'm not sure that it amounts to the securitization of health. Well, here's the sort of analogy if you think about the laboratory context, people talk about biosafety and they talk about biosecurity. You know, keeping people within laboratory safe from bad things and stopping the bad things escaping from the laboratory.

And I think the notion of health security is a bit like that. It's not just about people in Australia being protected from threats that might arise in foreign hotbeds, you know. It's really more about the fundamental concept of the International Health Regulations as revised, which was containment at source, which was a shift from the previous approach, which was about how we protect ourselves from something that's coming at us from outside. So that that's how I sort of conceive of health security. But that's not to deny that, you know, there's, I guess there's a convenient aspect to the notion that it does appeal to people who are thinking more in terms of a national defence sort of perspective.

STEPHANIE WILLIAMS:  But I mean, I think it is interesting, I had students ask me the other day, international relations students in a seminar say, “Well, you know, do you think COVID-19 has, given the security and trade framing of international relations, reason to pause and think about investing in the softer side of global health?” It's really, I thought it was a very interesting question about still that, well, “that's just feel good global health investment.

We just do that because it's the right thing to do.” But I hope I was able to convince them that, yes, you can have important health goals such as improving individuals’ access to health care, and improving universal health coverage and improving protection against infectious diseases, that is also a much bigger investment in broader security. If COVID hasn't demonstrated how interrelated these threats are, and then we've kind of missed the point of COVID.

MIC CAVAZZINI:               But there is... One of the criticisms is that the security concept has focused expenditure on pandemics that might threaten the West, and in lower income countries take money away from development goals that they see as more important. That they'd rather spend money on HIV prevention or diabetes care. And indeed, the money that's been reallocated for PNG has been reallocated from other longer-term goals. So does it skew the focus of development spending too far in one direction?

STEPHANIE WILLIAMS:  I think the profile is definitely higher in terms of infectious diseases, but I think we do have to follow the money, not just development assistance for health, but how national governments plan and expend money for health. Because despite increasing attention through the joint external evaluation process of WHO, the core capacities, we actually haven't seen that being skewed. And I think, you know, even in Australia, there's that very stubborn statistic that our health expenditure to public health, which is health protection, promotion and prevention remained around 2% of expenditure. So these are not high, high cost centres in their purest form the functions of surveillance et cetera.

ROBIN DAVIES: Maybe the premise of the question is that, you know, Pacific Island governments might feel that we were coming to them offering to do things that are as much in our own interests as in theirs, and they might not react well to that kind of perspective. But I don't think that's the case. So for example, when the Health Security Initiative was established, we set up two teams to undertake scoping missions to the Pacific and Southeast Asia. And we were very alert to that possibility that, you know, we would walk into a health ministry and say, you know, “Wow, are we here to help you.” And they would say, “Well, hang on, isn't this about Australia's own security? We've got other problems, for example, non-communicable diseases”, or, you know, dengue, or whatever it might be?

Now, that was never the case. I did a lot of these missions myself, Steph did some. For a couple of reasons. For one thing, when we walked into the room, we didn't say we were focused only on threats to Australia, infectious disease threats to Australia. We were as focused on infectious diseases that were quite specific threats to developing countries. But also, all of these countries are, in fact, quite motivated to improve their capacities and better implement the International Health Regulations. They are very open to external support to do that.

MIC CAVAZZINI:               And I think even the fact that the WHO declared both Ebola and Zika as public health emergencies of international concern. They weren't going to affect the health or the economies of the global north, and yet that was still taken seriously. I think that's a good example.

Robin, in writing for the DevPolicy blog, you cited economics professor Inge Kaul from the Hertie School of Governance. And she describes health security, she argues that health security should be described as a global public good, like action against climate change. Can you summarize this argument for us? For listeners who aren't up on Game Theory and philosophy, what is a common good?

ROBIN DAVIES: Well, it's a generalization of the fairly standard economics concept of a public good. So a public good is essentially something that's available to all, nobody can be prevented from accessing it. And when one person accesses it, that that does not reduce the capacity of others to access it. That's essentially the economics concept of a public good. A global public good has those characteristics. Except that, you know, it's more in terms of countries’ access to whatever the good might be. It's something that offers global benefits.

And the paradigm of that would be climate change mitigation. Whenever anyone takes any action to reduce carbon emissions, it benefits everyone. Nobody can miss out on that benefit. So the argument is, often that various forms of assistance should be treated as global public goods. And that they should not be therefore considered as “aid” because it's not just that a developed country is providing a benefit to a developing country, the benefit automatically flows to the entire world. So that's an argument that you can make about health security and that's Inge Kaul's point.

It's a slightly theoretical argument, because of course, many of the things that fall under the health security rubric really are fairly specific benefits for developing countries. Health security in the sense of global pandemic preparedness, that's a different story or health security in the sense of support for research and development for COVID vaccines, that's a different story. Those are those who are genuine global benefits, and you have to find resources for those on top of a budget. But most of what we think of as health security, I think, is legitimately still within the domain of official development assistance.

MIC CAVAZZINI:               And even, I mean, Matthew Bray, writing for Devpolicy, said that when we provide scholarships, well-intentioned scholarships for doctors and nurses from developing countries, Australia becomes a beneficiary of its own aid. I can see what he's saying but the value of the education is much more than the tuition fee that it's that's a long-term investment in those countries.

STEPHANIE WILLIAMS:  Increasingly we fund for health and medical education. And in the Pacific, in particular, fund the development of courses to be developed, implemented and attended in the Pacific. So our support to Fiji National University School of Medicine over decades, and recognising the importance of training in place for workforces suited to the region and context is a core pillar of our support to the Pacific, in particular.

MIC CAVAZZINI: I think it was in your lecture, Stephanie, I've heard you cite that while neonatal mortality, and infectious diseases have declined by 40%, since 1990, the mortality attributed to non-communicable diseases has increased by the same proportion. One astounding figure comes from Fiji where a diabetes-related amputation is done every eight hours, and there's a dialysis list of 200 people. How do those problems need to be sold? I mean, that would more attention to lifestyle diseases also make them more resilient to pandemics, as well.

STEPHANIE WILLIAMS:  I had one public health Professor once say to me that if everybody who was going to die in one year from alcohol, or tobacco or a poor diet, died in a single day, it would change the way we see this, this slowburn pervasive threat. And it's an unfortunate reality, I think of the way in which health conditions or particularly types of conditions are framed, and the ways in which infectious disease can galvanize more urgency and attention and more potentially immediate forms of protection than the more complex space of non communicable diseases. And in the Pacific, we recognize that it is the defining health challenge, in addition to the health impacts of climate change across the Pacific.

In many of the ways in which the development program in health has worked over the years, is really at the core systems of health, supporting planning, budgeting and financing, workforce development, healthcare delivery models, and budget support. So in a place like Solomon Islands over time, Australia has provided money into the operation of the health system and enabled the essential health service coverage to improve. Which in effect targets some of the non-communicable diseases, and we have some specific investments in places like Tonga to improve their detection of hypertension and high cholesterol et cetera,  so risk factor identification through primary health care.

We do support the Secretariat of the Pacific Community to run an NCD multi-sector program from awareness to tobacco industry-monitoring to supporting Pacific Island health ministries to increase attention and awareness and improvements to control of NCDs. I think we do manage to actually strike a balance in many of the ways in which we work in our region that says, here's the everyday here the really big issues and then the surge for the infectious disease response plus that sort of core health security capacity building, but I'm not going to say it's, it's easy.


MIC CAVAZZINI:               If some people read innuendo in the language of Global Health Security there’s nothing subtle about the posture in Australia’s regional diplomacy over the last few years. The so-called “Pacific Step Up” represents a shift away from development partners in Africa and the sub-continent to focus firmly on the Pacific and also South East Asia. 

This shift is emblematic of the absorption of the Department of Australian Aid into Foreign Affairs and Trade back in 2016. It was announced at the time that this would, and I quote, “align… aid more closely with Australia’s foreign and trade policy objectives, while potentially diminishing the relative weight accorded to poverty reduction and sustainable development in considerations of Australia’s ‘national interests’.”

I wondered whether these criteria made it difficult to fund public health projects which didn’t obviously benefit Australia’s strategic objectives. For example was the support for veterinary programs in Indonesia to combat antimicrobial resistance motivated by protection of our $2bn a year cattle export industry?
Robin Davies was quick to dismiss my cynicism, making the case for a long game in regional health security.

ROBIN DAVIES: No, no, no relationship to Australian livestock exports at all. The reason for the focus of that and some other programs on animal health is that our initiative as a whole was set up to incorporate a One Health approach, in other words, an approach that takes into account human health but also relevant aspects of animal health and environmental health. We're interested in animal health from a zoonotic disease perspective and environmental health from an anti-microbial resistance perspective. But overall, the apex is still human health. So that's why we're in that area. And that's an interest that is shared by regional governments that came through our discussions in the scoping stage of the initiative. So, you know, in terms of straightforward diseases of livestock, that's not our business.

MIC CAVAZZINI:               So Stephanie in that presentation to Royal Children's Hospital Melbourne, you referenced the 2017 foreign policy white paper, the premise of which is that trade liberalisation, regional economic health and stability is good for everyone. But free trade also sometimes challenges the self-sufficiency of developing countries. One example was Samoa which for decades had turkey tails dumped on them from the US initially under the guise of foreign aid. These are the fatty rejects that aren't sold in the West, but they've now contributed to a 70 to 80% obesity rate in that country. In 2007, the Samoan government tried to ban these imports, but was told by the World Trade Organization that that was that violated rules about targeted protectionism. So do public health considerations sometimes take second place to trade or other priorities.

STEPHANIE WILLIAMS:  I think there's no secret that the commercial determinants of health drive a huge, like more than say, what we used to talk about the social determinants of health, are really driving the inequitable distribution of risk factors across the world. And you give an example of the turkey flaps per se, and I guess it's one example of many drivers and there's no single cause of NCD and NCD risk. And I would be very outside my lane to be commenting on WTO rules, and in this particular context. But it's something that is talked about and recognized certainly within the Trans Pacific Partnership and ways in which Australia's work in the region does recognize the rights of countries to legislate in favor of their own public health.

I'm not going to say that, you know, the trade system equally protects everyone. And we know that it in many ways, does lead to inequitable risk factors and threats. The World Bank, you know, their work on health financing, and particular assessment of NCD factors in countries like China, they have done a lot of analysis of what are the most appropriate tax measures or incentives or restrictions to put on some imports in that country, potentially, what Samoa was trying to do.

But it's not a simple answer or a system. We do have a role, especially through our partnerships in the health sector and with health ministries in the Pacific to be improving their skills to articulate the health impacts of unhealthy products or the consequences of particular trade agreements and, and movement of goods. And I think that is a role that we do play in the region to support the resilience against potential harmful consequences of trade. 

MIC CAVAZZINI:               You mentioned, maybe you can give the example, you mentioned tobacco monitoring earlier. I mean, that's another example where, not a developing country, but the Australian Government was challenged by Philip Morris on its plain packaging. And Philip Morris found a way to take us before international arbitration on abuse of its trademark. Australia won that but not without spending $50 million in legal costs. And subsequently, I think New Zealand stepped back from plain packaging, because it was seen as too costly to pursue. So again, trade isn't your remit, but what can you do? You gave the example in Fiji? Was it?

STEPHANIE WILLIAMS:  So the example was actually from a non-communicable disease roundtable here at DFAT in middle of 2019, I think it was, with Australian NCD experts. There are bodies and I think in Australia that monitor the kind of nefarious tactics of the tobacco industry through their avenues of influence, and different marketing strategies. And it was a suggestion, not a decision or policy, from one of the contributors at that roundtable, to say that a regional tobacco industry monitoring group, which would collect information around the activities of industry, in certain countries, might be a useful source of intelligence to increase the awareness of the resilience or lack thereof to such tactics across various ministries in the Pacific. And we have a very interesting example of exactly how active some of those tactics were, when the Solomon Islands went in to try and increase the size of the graphic warning on their tobacco package, and how at every step of the way, there was a counter representation in that country from the tobacco industry to eke back, to reduce, to avoid that public health measure being implemented.

MIC CAVAZZINI:               Many thanks to Stephanie Williams and Robin Davies for taking the time to speak to me. Dr Williams now chairs the Expert Advisory Group to the Regional Vaccine Access and Health Security Initiative. This program, conceived during such a challenging period, is a welcome boost to the development assistance budget which reached an all-time low point in 2017.

As a proportion of gross national income, Australia’s aid budget sits at 0.21%, which makes us the 19th most generous out of 37 OECD countries. New Zealand proportionally gives a fraction more, but the target aid to income ratio proposed in the UN Millenium Development Goals is 0.7%. Only Luxembourg, Norway, Sweden, Denmark and the UK meet or exceed that target.

But some support to regional development is also being provided by medical colleges, including the RACP. Our College has in recent years been contributing professional training to aid partners and attending meetings of the Secretariat of the Pacific Community. One particularly strong collaboration is with the Masters of Internal Medicine and Masters of Paediatrics programs at Fiji National University. This support has continued by virtual means in recent months.

I’ll provide a link to the Pacific Webinar series hosted by the Australasian Faculty of Public Health Medicine. In it members of the College and the Pacific Community discuss strategies for a COVID vaccine rollout, and for reopening of borders within the region.

And I also have to recognise the work of Individual Fellows who provide professional support to physicians across the Pacific, not just in public health but also oncology, haematology, infectious disease, gastroenterology and paediatrics. Telehealth has allowed improved care for even the most difficult cases in these remote island nations. You can read some first hand accounts in the RACP’s Quarterly review. In issue two from last year, Dr Dimitra Tzioumis describes her experiences in the highlands of PNG developing HIV-testing capacity, and in the corridors of Fiji’s Health department to establish child protection legislation.

You’ll find links to this and more at our website, racp.edu.au/podcast. I also want to thank Associate Professor Peter Hill who originally conceived of this Global Health Security theme for a lecture at Congress 2020. Instead it turned into these four podcasts, which you can listen to via Apple Podcasts, Spotify, Stitcher, Pocket Casts or any one of the many apps out there. Please tell your friends and colleagues to subscribe if you think they’d like it. Thanks for listening. I’m Mic Cavazzini, for the Royal Australasian College of Physicians.





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21 May 2024
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