Articles Feature Articles

See no evil, hear no evil, speak no evil: Tanzania’s struggles with the HIV epidemic

Nestled on the south-eastern slopes of Mt Kilimanjaro in Northern Tanzania, the sprawling village of Machame emerges from the surrounding rainforest. This village is home to the Machame Hospital, where I was fortunate enough to undertake a month-long elective before commencing my final year of medical school. This elective was a challenging, yet enriching experience, and helped me gain a glimpse into some of the major public health issues affecting the country.

The century-old Machame Hospital is a 120-bed facility that provides essential healthcare to over 150,000 people from the surrounding area. Although severely under-resourced, the hospital was a bustling hive of activity that provided me with a taste of Tanzanian medical, surgical and obstetric services. The locals were exceptionally friendly and welcoming and I was able to get involved in all aspects of hospital functioning including attending clinics, contributing to ward rounds, assisting in surgery and conducting outreach clinics in the community.

Throughout my time there it quickly became apparent that the gravest problem facing the community of Machame, as with much of Tanzania, is that of HIV/AIDS. Indeed, the most recent epidemiological data estimate the national adult prevalence to be 5.7%. [1] This figure, however, is likely to be an underestimation given the prevailing social stigma associated with being HIV-positive and the resultant reluctance of people to come forward for testing.

In Tanzania, HIV is a dirty word. Many of the doctors and health workers were loath to refer to it by name (virusi vya ukimwi or VVU in Swahili), especially around patients. It was often alluded to by euphemisms, becoming the great unspoken problem. Many Tanzanians have a very poor understanding of its natural history or transmission and this engenders great fear, especially as many have witnessed the devastating effects of the disease firsthand. [2,3] When it comes to HIV, unfortunately many Tanzanians really do ‘see no evil, hear no evil, and speak no evil.’

Machame Hospital’s HIV clinic was housed in a little hut ten metres from the main hospital complex itself – an apt demonstration of the social segregation of AIDS sufferers. Accommodating patients with HIV within the main facility may discourage others from presenting for fear of contracting the condition while in hospital. The locals were also worried about being sighted at known HIV treatment or testing locations for fear of social repercussions. The building was instead known as the Centre for Disease Control, a deliberately ambiguous name that enabled patients to attend appointments without fear of being stigmatised as a carrier.

During my elective I also had the opportunity to assist with HIV screening using finger-prick antibody testing. Under the auspices of a general clinic, we would travel to different locations around the village and set up a consulting area. It almost seemed that an unspoken agreement existed between the patients and medical staff to ensure HIV testing was conducted surreptitiously, with the testing area tucked away up the back and never mentioned by name. This made the process all very secretive, ensuring that full, informed consent was often overlooked. Despite this, many seemed to know what was going on and, fortunately, people from the village willingly came forward to be tested.

I met numerous patients during my elective but the most confronting case I saw was that of a two-year-old boy infected with HIV. The child’s mother had already died from complications of AIDS and the grandmother, distraught and surfeited, had brought him in asking for an ‘injection to kill her baby’ because she could no longer bear to see him so sick. He had already lost 30% of his 10kg body weight within the last month and cried throughout the whole consultation. Apart from being deeply tragic on a human level, seeing patients such as this made me frustrated as this situation might have been prevented. Perhaps the greatest tragedy of medicine in the developing world is when medical knowledge exists to provide a solution, but is not implemented due to a lack of financial or educational resources.

Fortunately, there were also many uplifting cases that did highlight the tangible benefits of effective medical therapy. One 38-year-old presented to the hospital with a paltry CD4 count of 1 (the normal adult range being between 500 and 1,300 cells per microlitre [4]). He was commenced on anti-retroviral therapy and is now doing well, able to again provide for his wife and son.

There are certainly many challenges that Tanzanian health authorities continue to face in the fight against HIV/AIDS.

Firstly, the lack of health resources in the country limits the capacity for investigations. For example, in Machame it was not possible to measure HIV viral loads, a test routinely performed in Australia to monitor disease progress. CD4 counts alone stand as the only available measure of treatment efficacy. Secondly, patients perceive little incentive to continue taking anti-retroviral medication if they do not feel that it is improving their well-being, as the notions of prevention and maintenance therapy are generally poorly understood. This generates significant compliance challenges that undermine the delivery of treatment.

For its part, the government provides all HIV medication free of charge. Although this is an excellent initiative, it makes the reluctance of people to get tested and treated harder to fathom, especially considering the effectiveness of pharmacotherapy. For example, the rate of vertical transmission from untreated mother to child is 25-35%, but this can be reduced by up to two-thirds with Highly Active Anti-Retroviral Therapy during pregnancy and six months of breastfeeding. [5]

Thirdly, the considerable social stigma and widespread reluctance to discuss HIV act as a significant barrier to primary and secondary prevention strategies. Public education about HIV/AIDS is severely limited and it is difficult to counsel patients about preventing transmission of the illness when sex remains a taboo subject. Many people are tragically unaware of the role of unprotected heterosexual intercourse in spreading infection, in spite of it being the most common mode of transmission. [1]

There is also an issue of protection for health care workers. I noticed a marked contrast in attitudes towards personal safety and infection control between my time in both the Australian and Tanzanian systems. In Australia, additional precautions are taken for patients with diseases like HIV. Such measures include isolating infectious or immunodeficient patients, collection and incineration of contaminated medical waste, use of personal protective equipment and safe handling of sharps. None of these methods were routinely observed to be practiced during my time in Tanzania and it raised concerns about the rate of potentially preventable transmission amongst hospital staff. Indeed, a recent study of two other Tanzanian hospitals found that nearly half of all healthcare workers experienced at least one occupational injury, such as a needle-stick injury, over a twelve-month period. [6] Clearly, efforts need to be made to improve safety procedures and staff awareness.

Overall, reducing the impact of HIV will depend on multiple approaches with a focus on adherence to treatment, early testing and mitigation of high-risk behaviours. Such improvement can only be achieved through education and good public health initiatives.

My time in Tanzania as an elective medical student proved to be a humbling and eye-opening exposure to global health, with a particular focus on HIV/AIDS. By far the most incredible words I have ever learnt to say are hakuna shida, as this was the Swahili phrase I used to inform patients that their HIV test was negative. People were so pleased to hear this that several patients cried with joy or hugged me upon learning the good news. In a beautiful moment of symmetry to my previous HIV clinic, I saw another lady accompanying her grandchild who had lost his mother to AIDS. This time the boy was negative and, upon hearing this, the grandmother burst into joyous tears. These experiences have helped change my perspective on medicine and what I take for granted in Australia. I look forward to potentially returning in the future and to help get people talking about HIV.


I would like to thank the Insight Global Health Group for providing financial support for this elective through the Insight Development Grant.

Conflict of interest

None declared.

I especially want to acknowledge the significant contribution of colleague Justin Mencel, who undertook the elective with me and helped organise it. Additionally, I would like to recognise the warmth and generosity with which we were welcomed by the whole community, in particular by Hospital Patron Mr Edward Mushi.


M Weightman:


[1] Tanzania Commission for AIDS, Zanzibar AIDS Commission, National Bureau of Statistics (Tanzania), Office of the Chief Government Statistician, Macro International Inc. Tanzania HIV/AIDS and malaria indicator survey 2007-08. Dar es Salaam, Tanzania: Macro International Inc; 2008.

[2] Amuri M, Mitchell S, Cockcroft A, Andersson N. Socio-economic status and HIV/AIDS stigma in Tanzania. AIDS Care 2011;23(3):378-82.

[3] Ostermann J, Reddy E, Shorter M, Muiruri C, Mtalo A, Itemba D et al. Who tests, who doesn’t, and why? Uptake of mobile HIV counseling and testing in the Kilimanjaro Region of Tanzania. PLoS One 2011;6(1):e16488.

[4] Coffey S, editor. Guide for HIV/AIDS Clinical Care. Rockville, MD, USA: US Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau; 2011.

[5] Siegfried N, van der Merwe L, Brocklehurst P, Sint T. Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database Syst Rev 2011;2011(7):1-122.

[6] Mashoto K, Mubyazi G, Mohamed H, Malebo H. Self-reported occupational exposure to HIV and factors influencing its management practice: a study of healthcare workers in Tumbi and Dodoma Hospitals, Tanzania. BMC Health Serv Res 2013;13(1):276.

Feature Articles Articles

The role of Aboriginal Community Controlled Health Services in Indigenous health

“Our right to take back responsibility.” Noel Pearson, 2000 [1]

This emotive aphorism by Pearson embodies the struggle of Australia’s Indigenous people to gain control of their destiny, which for generations has been wrested from them into the power of governments. Although his statement was primarily directed toward welfare, the same right of responsibility can be applied to health, perhaps the gravest challenge facing the Aboriginal population. As Pearson alluded to, the only way to solve the health crisis is by enabling local communities to take charge of their own affairs. This principle of self-determination has led to the creation of Aboriginal Community Controlled Health Services (ACCHS), which has allowed over 150 Aboriginal communities throughout Australia control over their healthcare. [2] This article describes the founding principles behind community controlled health centres in Aboriginal communities through considering several different ACCHS and the unique challenges they face.

The fundamental concept behind each ACCHS – whether metropolitan, rural or remote – is the establishment of a primary healthcare facility that is both built and run by the local Aboriginal people “to deliver holistic, comprehensive, and culturally appropriate health care to the community which controls it.” [2] This is based upon the principle of self-determination and grants local people the power to achieve their own goals. From the beginning ACCHS were always intended to be more than exclusively a healthcare centre and each ACCHS has four key roles: the provision of primary clinical care, community support, special needs programmes, and advocacy.

ACCHS endeavour to provide primary healthcare as enshrined by the World Health Organization in the 1978 Declaration of Alma-Ata. This landmark international conference defined primary healthcare as:

“essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain… in the spirit of self-determination.” [3]

Although conceived subsequent to the advent of the community controlled healthcare movement in Australia, this definition echoes many of the underlying principles upon which ACCHS were founded, including the most important aspect – local control. Indeed, it is widely accepted throughout the literature that the community itself must identify its needs and problems so an effective and appropriate course of action can be undertaken. [4-7]

This principle is espoused in the National Aboriginal Health Strategy’s frequently quoted statement that “Aboriginal health is not just the physical well-being of an individual but the social, emotional and cultural well-being of the whole community in which each individual is able to achieve their full potential thereby bringing about the total well-being of their community.” [8] The notion of ‘community’ is an essential component of the Indigenous view of the self and therefore strongly related to health and well-being. Accordingly, ACCHS have a holistic view of healthcare, recognising that Indigenous healthcare needs to be multi-faceted and focus on cultural complexities that may not be appreciated by mainstream health services. As each Aboriginal community across the country has a distinct culture and language, [9] local control is paramount.

The concept of community control is not new. It can be traced back to early nineteenth-century America, where such services were used with success for improving the health of the poor and recent migrants. [4] The first ACCHS was established in the inner city Sydney suburb of Redfern in 1971. [10] Known as the Aboriginal Medical Service (AMS), it pioneered the concept of community controlled healthcare in Australia and, from modest beginnings, has now expanded into a major, versatile healthcare facility that provides free medical, dental, psychological, antenatal and drug and alcohol services to the large Aboriginal community in Sydney. Redfern’s AMS overcame struggles against an initially distrustful and paternalistic government through the dedication of visionary Indigenous leaders and support of benevolent non-Indigenous Australians. [10,11]

Specialised Indigenous policies are essential, as it is impossible to apply the same approach that is used in health services for non-Indigenous patients. Many Indigenous people are uncomfortable with seeking medical help at hospitals or general practices and therefore are reluctant to obtain essential care. [12] In addition, access to healthcare is often extremely difficult due to either geographical isolation or lack of transportation. Many Indigenous people live below the poverty line, so the services provided by practices that do not bulk bill are unattainable. Mainstream services struggle to provide appropriate healthcare to Aboriginal patients due to significant cultural and language disparities; [5,13] the establishment of ACCHS attempts to overcome such challenges.

For example, the Inala Indigenous Health Service in south-west Brisbane performed extensive market research to determine the factors keeping Aboriginal patients from utilising the mainstream health service. The results showed that several simple measures were highly effective in engaging the local community, such as employing an Indigenous receptionist and making the waiting room more culturally appropriate through local art or broadcasting an Aboriginal radio station. [12] In the five years following implementation of these strategies, the number of Indigenous patients at Inala ballooned from 12 to 899, and an average of four consultations per patient per year was attained, compared to the national Indigenous average of fewer than two. [14] A follow-up survey attributed patient satisfaction to the presence of Indigenous staff and a focus on Indigenous health. [12]

Nevertheless, the consequence of  longstanding obstacles to Indigenous access to mainstream healthcare is manifest in the stark inequity between the health outcomes of Indigenous and non-Indigenous Australians. The most recent data from the Australian Institute of Health and Welfare (AIHW) shows that the discrepancy in life expectancy between Aboriginal Australians and their non-Indigenous counterparts remains unacceptably high, at 11.5 years for males and 9.7 for females. [15] Moreover, studies demonstrate that Aboriginal people have significantly worse outcomes in key health indicators, including infant mortality, diabetes, heart disease, infectious disease and mental illness. [5,12,13,16] Such disparities indicate that a novel, tailored approach to Indigenous health is required.

Cultural understanding is essential, as demonstrated by the example of the Anyinginyi Health Aboriginal Corporation in the Northern Territory. Anyinginyi serves the twelve remote Aboriginal communities within a 100km radius of Tennant Creek and its name comes from the local Warumungu language, meaning ‘belonging to us’ [17] emphasising the community’s control of, and pride in, this service. Anyinginyi has always strived to be more than just a health service and has evolved to deliver many other community programmes. This is embodied by Anyinginyi’s insistence on ‘culturally appropriate’ healthcare for Aboriginal people. In addition to medical advice, the local Aboriginal community is offered support through various programmes that range from employment services to cultural and spiritual activities promoting Indigenous language and culture. One such social service is the ‘Piliyintinji-Ki Stronger Families’ initiative, which assists community members through access to support services relating to issues such as family violence and the Stolen Generations. [17] Indeed, ACCHS such as Anyinginyi have the additional benefit of providing employment opportunities for community members, as the vast majority of the employees are Indigenous. All new staff members participate in a Cross Cultural Workshop, as one of Anyinginyi’s goals is to ensure that the local Aboriginal cultures are respected and continue to thrive.

The other important arm of healthcare in ACCHS relates to population health, with initiatives ranging from education campaigns to immunisations and screening for diseases. [2] One of the first large-scale community health promotion campaigns run specifically for Aboriginal people was conducted by the Redfern AMS between 1983-1984 to encourage breast-feeding among the local Koori mothers. [11] It achieved such stunning success that it set a precedent for all future ACCHS to continue in the important area of preventative medicine, with similar campaigns for sexual health and safe alcohol consumption having been undertaken subsequently.

Moreover, each ACCHS runs special services that are dictated by local needs and priorities. In some instances, there is a specific health problem that needs to be addressed, such as poor nutrition or substance abuse. Other programmes are directed at specific groups, such as young mothers or the elderly. The flexibility of these special services allows each ACCHS to identify and address the most significant problems within its area – problems that can only be identified by the community itself. For example, the Danila Dilba Health Service in Darwin runs a programme called ‘Dare to Dream’ that provides support and counselling for young Indigenous people suffering from mental illness. [18] It is an early intervention programme that intends to identify and support adolescents exhibiting early signs of both behavioural and mental health problems. To this end, school visits are undertaken to promote awareness of mental health issues to students and staff, as well as the services that Danila Dilba has to offer. A ‘chillout’ centre has been set up in Darwin as a safe place for young people to come and allows the community workers to refer those who present to appropriate counselling services. As such, Danila Dilba is empowered to proactively address an important local issue in the most culturally-appropriate way.

ACCHS are also active in the area of advocacy. This involves providing a voice for the community so that their needs can be expressed. Although each ACCHS operates autonomously, they form a national network with their collective interests represented both on a state/territory level and also nationally. Each of the eight states and territories has a peak representative body that acts on behalf of all ACCHS within that jurisdiction. [2] Examples of these organisations include the Aboriginal Health & Medical Research Council of New South Wales and the Aboriginal Medical Services Alliance Northern Territory. At the national level the umbrella body overseeing all the different stakeholders across the country is the National Aboriginal Community Controlled Health Organisation (NACCHO). [2] Individual ACCHS, as well as NACCHO and the affiliated state or territory peak bodies, lobby all levels of government for increased funding and greater recognition of the issues facing Aboriginal communities. The collective weight of NACCHO as a national advocate allows each community’s needs to be heard.

Inevitably, the scope of the services each ACCHS can provide is restricted by funding, most of which comes from the Commonwealth or State and Territory Governments. [2] More money continues to be spent per capita on mainstream health services than on Aboriginal health, despite the great dichotomy in health outcomes. Indeed, the 2012 Indigenous Expenditure Report published figures showing that for every dollar spent on healthcare subsidies for non-Indigenous health, only $0.66 is spent on Aboriginal health. [19] This statistic covers all the key areas of healthcare expenditure, such as Medicare rebates, the pharmaceutical benefits scheme (PBS) and private health insurance rebates. Therefore, Indigenous patients are not receiving the same level of health service delivery, including clinical consultations and treatment, compared to their non-Indigenous counterparts. However, it is propitious to note that the funding bodies have recognised the value of the public health efforts of ACCHS, as the spending in this area is a $4.89 to $1.00 ratio in favour of Indigenous health. [19] Nevertheless, the priority needs to be placed on ensuring that sufficient funding exists to allow Indigenous patients to access health care subsidies as required.

In addition to inadequate funding, another major obstacle that ACCHS face is the difficulty in attracting and retaining doctors and allied health professionals. According to the AIHW’s most recent report, only 63% of Indigenous health services currently employ a doctor. [20] Consequently, a significant increase in the number of general practitioners working with Indigenous patients is required simply to provide adequate services. There is additionally a severe lack of Aboriginal medical students and general practitioners, which limits the opportunities for Indigenous professionals to provide culturally-appropriate care to their own communities. Census data from 2006 found that there were 106 Indigenous doctors nationally, accounting for only 0.19% of all medical practitioners. [21] These shortages are compounded further for ACCHS in rural and remote areas. By 2011, further data from Medical Deans demonstrated that the numbers had increased to 153 Indigenous medical practitioners nationally, along with 218 enrolled Indigenous medical students. Although promising, these numbers remain grossly inadequate to fulfil workforce demand. [22]

Services become stretched due to perpetual resource inadequacies. Understandably, the remoteness of some communities makes service delivery challenging, yet even major metropolitan areas with large Indigenous populations can struggle to adequately provide for those in their catchment area. Under-resourcing places major constraints on service delivery and different ACCHS throughout the country exhibit significant variation in the level of services offered. Some are large, employ several doctors and provide a wide range of services; others are much smaller and operate without doctors. [20] These rely on Aboriginal health workers and nurses to provide the bulk of primary healthcare.

As such, the success of the ACCHS concept would not have been possible without the contribution of Aboriginal health workers. The role of Aboriginal health workers, who are often sourced from the local community, is to provide the primary healthcare that ACCHS offer. [23] This involves assessing patients and then coordinating or providing the medical attention required. Health workers are able to treat certain conditions with the help of standard treatment guidelines and provide a selection of important medications to patients. Importantly, Aboriginal health workers have a liaison role between medical professionals and Aboriginal patients. They are often required to act as an interpreter between the patient and health professional, thus providing an intermediary for cross-cultural interactions, and therefore improving the quality of healthcare provided to the local community.

Due to the often quite remote locations of ACCHS and the scarcity of doctors and nurses, Aboriginal health workers perform many clinical tasks that would be provided by a medical professional in mainstream health services. Aboriginal health workers bear much greater responsibility than their colleagues in the public sector and often learn a wide range of procedural skills including how to perform standard health checks, vaccinations and venepuncture. [23] Indeed, some choose to specialise in a specific area (such as diabetes, pregnancy or infant care) thus gaining additional skills and responsibilities. Still others take on managerial responsibilities. This is in contrast to the public sector, where health workers are often fixed to one routine area or even to non-clinical work such as transportation or social assistance. [23] Without Aboriginal health workers performing these additional tasks, ACCHS would not be able to provide a sufficient level of service for the community. For this reason, Aboriginal health workers are rightly considered the backbone of community controlled health services.

As one example, the Pika Wiya Health Service in the South Australian town of Port Augusta runs two outreach clinics for communities in Copely and Nepabunna. Due to the shortage of doctors, these clinics are staffed entirely by Aboriginal health workers. Their invaluable contribution is evident, with 695 clinical encounters performed by health workers during 2008, [24] ensuring that the absence of doctors did not deny the local people the chance to receive healthcare. Whilst the major health issues faced by Indigenous people are broadly similar between urban and remote communities, these problems are often compounded by the remoteness of the location. Although these are challenges that Copely and Nepabunna will continue to have to face, the empowerment of Aboriginal health workers has helped redefine the direction of Pika Wiya’s outreach health services.

Aboriginal health workers face many difficulties. Perhaps the most significant is that, until recently, there had been no national qualifications or recognition of the skills they developed. [23] The introduction of national registration for Aboriginal health workers (from July 1 2012) and the new qualification of Certificate IV in Aboriginal and Torres Strait Islander Primary Health Care (Practice) have revolutionised the industry. [25] This has had the benefit of standardising the quality and safety of the Aboriginal health worker labour force. However, as the changes will increase the required length and standard of training, there is the potential for current or prospective health workers to be deterred by the prospect of undertaking study at a tertiary level, particularly if they have had limited previous education. Nevertheless, national registration is a positive step for recognising the important work done by Aboriginal health workers, and in providing them with the training to continue serving their communities.

In addition to doctors, nurses and health workers, medical students are also important stakeholders in Indigenous health. First, much has been done in recent years to increase the numbers of Indigenous medical students. For example, the University of Newcastle has been the first medical school to make a dedicated attempt at training Indigenous doctors and has produced approximately 60% of Australia’s Indigenous medical practitioners. [26] This achievement has been based on a “strong focus on community, equity and engagement by the medical profession.” [26] Encouraging community members to enter the profession can be an important way of addressing both the lack of doctors in Indigenous communities and paucity of doctors of Indigenous background. The benefits are broader than this, as Indigenous doctors provide strong role models for young Indigenous people and also have the opportunity to contribute with advocacy and leadership within Indigenous health.

Secondly, the medical student population as a whole is exposed to increasingly more Indigenous health as part of the core curriculum at university following adoption of the updated Australian Medical Council accreditation standards from 2007. [27] Additionally, some students even have the opportunity to spend time in an ACCHS and experience first-hand how the system works. There has been some criticism of these ‘fly in, fly out’ medical electives, where students are sent to ACCHS for short periods and then leave. [28] Whilst this model may be beneficial for the student, it fails to engage the local community as they are unable to build meaningful or lasting relationships with the student.

Better models allow for a longer-term placement and immersion in the community. These include the John Flynn Placement Programme where some students are able to spend a fortnight annually in an ACCHS in the Northern Territory over a period of four years. [29] Another example is the Northern Territory Clinical School, which allows third-year medical students from Flinders University to spend a whole year of study in Darwin, providing the opportunity for increased contact with local Indigenous communities. [30] Initiatives such as these help to build a relationship with the community, and allows for increased acceptance of the medical student. Additionally, the student is able to make a more meaningful contribution to various client’s healthcare. Prolonged or longitudinal attachments have also been shown to increase the likelihood of students returning as a doctor. [31] Certainly, there is much scope for the contribution of medical students to be harnessed more effectively.

It is abundantly apparent that any solution to address the health inequalities of Aboriginal people will only be effective if it recognises that the local Aboriginal communities must control the process of healthcare delivery. This is the principle upon which ACCHS were founded and can be attributed to their many successes, as demonstrated through the examples of Redfern’s AMS, Inala, Anyinginyi, Danila Dilba and Pika Wiya. In spite of the challenges posed by inadequate funding, under-staffing and often remote locations, these organisations strive to uphold the ideals of self-determination and community control. It is hoped that wider adoption of these principles by national governing bodies together with improved financial support will enable Indigenous Australians control over their lives and destinies, leading to better health outcomes.

Conflict of interest

None declared.


The author would like to thank the Australasian Faculty of Public Health Medicine for their generous support of this research through awarding the 2011 John Snow Scholarship for South Australia. Additionally, the author wishes to acknowledge the guidance of Dr Doug Shaw when preparing this work for presentation at the 2012 Population Health Congress.


M Weightman:


[1] Pearson N. Our right to take responsibility. Cairns, Queensland:  Noel Pearson and Associates; 2000.

[2] National Aboriginal Community Controlled Health Organisation. 2010-2011 Annual Report. Canberra, ACT: NACCHO; 2011.

[3] World Health Organisation. Declaration of Alma-Ata. Alma-Ata, USSR: WHO; 1978.

[4] Minkler M, Wallerstein N. Improving health through community organisation and community building: a health education perspective. In Minkler M, editor. Community organizing and community building for health. New Brunswick, USA: Rutgers University Press; 1998, 26-50.

[5] Stephens C, Nettleton C, Porter J, Willis R, Clark S. Indigenous peoples’ health – why are they behind everyone, everywhere? Lancet. 2005; 366(9479): 10-13.

[6] Horton R. Indigenous peoples: time to act now for equity and health. Lancet. 2006; 367(9524): 1705-1707.

[7] King M, Smith A, Gracey M. Indigenous health part 2: the underlying causes of the health gap. Lancet. 2009; 374(9683): 76-85.

[8] National Aboriginal Health Strategy Working Party. A national Aboriginal health strategy. Canberra, ACT: National Aboriginal Health Strategy Working Party; 1989.

[9] Burgess CP, Johnston FH, Berry HL, McDonnell J, Yibarbuk D, Gunabarra C, et al. Healthy country, healthy people: the relationship between Indigenous health status and ‘caring for country.’ Med J Aust. 2009; 190(10): 567-572.

[10] Marles E, Frame C, Royce M. The Aboriginal Medical Service Redfern: improving access to primary care for over 40 years. Aust Fam Physician. 2012; 41(6): 433-436.

[11] Foley G. Redfern Aboriginal Medical Service: 20 years on. Aborig Isl Health Work J. 1991; 15(4): 4-8.

[12] Hayman NE, White NE, Spurling GK. Improving Indigenous patients’ access to mainstream health services: the Inala experience. Med J Aust. 2009; 190 (10): 604-606.

[13] Zhao Y, Dempsey K. Causes of inequality in life expectancy between Indigenous and non-Indigenous people in the Northern Territory, 1981-2000: a decomposition analysis. Med J Aust. 2006; 184(10): 490-494.

[14] Deeble J. Expenditure on health services for Aboriginal and Torres Strait Islander People. Canberra, ACT: Department of Health and Family Services; 1998.

[15] Australian Institute of Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander people: an overview 2011. Canberra, ACT: Australian Institute of Health and Welfare; 2011.

[16] Anderson I, Crengle S, Kamaka ML, Chen T-H, Palafox N, Jackson-Pulver L. Indigenous health in Australia, New Zealand, and the Pacific. Lancet. 2006; 367(9524): 1775-1785.

[17] Anyinginyi Health Aboriginal Corporation. 10/11 Annual Report. Tennant Creek, NT: Anyinginyi Health Aboriginal Corporation; 2011.

[18] Danila Dilba Biluru Butji Binnilutlum Health Service Aboriginal Corporation. Annual Report 2010. Darwim, NT: Danila Dilba Biluru Butji Binnilutlum Health Service Aboriginal Corporation; 2010.

[19] Steering Committee for the Review of Government Service Provision. 2012 Indigenous expenditure report: overview. Canberra, ACT: Productivity Commission; 2012.

[20] Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander health services report, 2010-11: OATSIH services reporting – key results. Canberra, ACT: Australian Institute of Health and Welfare; 2012.

[21] Australian Bureau of Statistics. Population distribution, Aboriginal and Torres Strait Islander Australians, cat. no. 4705.0. Canberra, ACT: Australian Bureau of Statistics; 2007.

[22] Cavanagh J. Medical Deans – AIDA: national medical education review. Canberra, ACT: Medical Deans Australia and New Zealand, Australian Indigenous Doctors’ Association; 2012.

[23] Mitchell M, Hussey LM. The Aboriginal health worker. Med J Aust. 2006; 184(10): 529-530.

[24] Pika Wiya Health Service Inc. Annual Report for Year 2007-2008. Port Augusta, SA: Pika Wiya Health Service Inc; 2008.

[25] Health Workforce Australia. Growing our future: the Aboriginal and Torres Strait Islander Health Worker project final report. Adelaide, South Australia: Health Workforce Australia; 2011.

[26] Lawson KA, Armstrong RM, Van Der Weyden MB. Training Indigenous doctors for Australia: shooting for goal. Med J Aust. 2007; 186(10): 547-550.

[27] Australian Medical Council. Assessment and accreditation of medical schools: standards and procedures. Part 2. Educational standards. Canberra, ACT: Australian Medical Council; 2006.

[28] Crump JA, Sugarman J. Ethical considerations for short-term experiences by trainees in global health. JAMA. 2008; 300(12): 1456-1458.

[29] Young L, Kent L, Walters L. The John Flynn Placement Program: evidence for repeated rural exposure for medical students. Aust J Rural Health. 2011; 19(3): 147–153.

[30] McDonnel Smedts A, Lowe MP. Efficiency of clinical training at the Northern Territory Clinical School: placement length and rate of return for internship. Med J Aust. 2008; 189(3): 166-168.

[31] Denz-Penhey H, Shannon S, Murdoch JC, Newbury J. Do benefits accrue from longer rotations for students in rural clinical schools? Rural Remote Health. 2005; 5(2): 414.

Book Reviews

A neuroanatomical comparison: Blumenfeld’s Neuroanatomy through Clinical Cases vs. Snell’s Clinical Neuroanatomy

Blumenfeld H. Neuroanatomy through Clinical Cases, Second Edition. Sunderland: Sinauer Associates; 2010.

RRP: AU$119.95

Snell, RS. Clinical Neuroanatomy, Seventh Edition. Baltimore: Lippincott Williams & Wilkins; 2009.

RRP: AU$107.80

As stated by Sparks and colleagues [1] in their comparison of Clinically Oriented Anatomy and Gray’s Anatomy for Students, studying anatomy can be a challenging endeavour. This is true even more so for the study of neuroanatomy, which many students find particularly overwhelming. In the neuroanatomy textbook arena stand two ‘gold standard’ textbooks: Neuroanatomy through Clinical Cases, by Hal Blumenfeld, and Clinical Neuroanatomy, by Richard Snell. Inspired by the aforementioned comparative anatomy textbook review in the previous issue of the journal, I ponder the question: Which neuroanatomy textbook is superior, the more established Snell or the newer Blumenfeld?

I begin my comparison with a consideration of their similarities…


Gifts between pharmaceutical companies and medical students: Benefits and/or bribes?

It was with some interest that I read the Review Article ‘What do medical students think about pharmaceutical promotion?’ by Carmody and Mansfield, published in AMSJ Volume 1, Issue 1. [1]

As the article reports, there is a conspicuous lack of solid data investigating the relationship between pharmaceutical companies and medical students, particularly in Australia. Clearly there are both positive and negative aspects to this relationship, and I think the main concern many students hold is, at its roots, an ethical one. Can these companies exert an influence over our opinions about drugs, and subsequently affect our future prescribing practices? More importantly, does this have any relationship at all to accepting free gifts which might benefit our education?

The ethics regarding this issue is a veritable maze of should, should-sometimes and should-nots, and as with many issues, ethics often takes a second place to convenience, and sometimes even third place behind convenience and greed. Naturally, this is not to say that medical students are either indolent or opportunistic, but the importance of this issue is undeniable, with many Australian medical students uncertain about how to deal with pharmaceutical gifts and promotions.

From ethical principles, all moral individuals are bound by the Law of Reciprocity, which unequivocally states that we are disposed, as a matter of moral obligation, “to return good in proportion to the good we receive” – but how does this fit into the situation today? [2] Can a moral person, regardless of whether they are a medical student, accept a gift, be it a pen, mug, lanyard or free sandwich, and not feel a sense of ethical obligation towards the giver?

Carmody and Mansfield report that both doctors and students believe they possess a certain ‘invulnerability’ to any such nefarious ploys of inducing a reciprocal obligation, and as such feel free to accept small gifts without fear. Yet this is acting in direct opposition to the moral law of reciprocity, and consequently, does this mean we are acting unethically?

While medical students may think that getting something for free is an obvious win-win situation, in reality nothing could be further from the truth. If anything, it’s one of those infuriating lose-lose situations. Accepting a gift means the beneficiary takes on a debt which may lead to a conflict of interest in the future, and in doing so acts unethically, something which is frowned upon quite seriously within the medical profession.

Some might argue that medical principlist ethics is not dictated by the moral law of reciprocity, but we all know that few things in this world come free, and in all seriousness, what are the odds that pharmaceutical companies are spending money on gifts for purely altruistic reasons? The Review Article mentions that each doctor in Australia is subjected to an estimated $21,000 worth of pharmaceutical company promotion each year. [1] Certainly, this is a pittance when compared to the US $11 billion that are spent on pharmaceutical marketing and promotions each year in the United States; yet the implications remain clear. [3]

With that said, there are positive sides to an early association between those studying medicine and the pharmaceutical industry. Disregarding the free pens, free food and other little (or not so little) gifts, pharmaceutical companies sponsor educational seminars, social outings and even travel costs to conferences. Surely this can only have a beneficial effect on our medical education. Or, should these too be considered ‘gifts’ of a different kind – gifts that will enrich us intellectually rather than materialistically? If nothing else, such an early relationship will help to prepare medical students for how to deal with the pharmaceutical industry after they graduate.

The path ahead is not clear, for the relationship between pharmaceutical companies and medical students has both positive and negative effects. Barack Obama is reputed to have said that “If you’re walking down the right path and you’re willing to keep walking, eventually you’ll make progress”; yet how can we know where to place our feet if the ‘right’ path is hidden from us within a murky quagmire of ethical principles? Carmody and Mansfield suggest more research studies on this issue regarding Australian medical schools, and while I am not convinced this will make a pronounced change in clearing the fog obscuring the way forward, surely it cannot be a bad place to start.


[1] Carmody D, Mansfield P. What do medical students think about pharmaceutical promotion? Australian Medical Student Journal 2010;1(1):54-7.

[2] Becker L. Reciprocity. 2nd ed. Chicago: Routledge & Kegan Paul; 1990.

[3] Wolfe S. Why do American drug companies spend more than $12 billion a year pushing drugs? Is it education or promotion? Characteristics of materials distributed by drug companies: four points of view. JGI Med 1996;11:637-9.

Review Articles

Minimally invasive mitral valve repair: A new surgical option for mitral insufficiency

Long-shafted instruments in use during mitral valve repair


Minimally invasive mitral valve repair (MIMVR) is a relatively new alternative to median sternotomy for valvular heart surgery, and has become increasingly appealing due to its improved cosmetic results and more rapid recovery time. Patients suffering mitral valve disease are increasingly turning to their medical practitioners for advice regarding this procedure. It is the aim of this article to provide a review of MIMVR to allow students and doctors to better understand this recent development in cardiac surgical therapy.


An evidence-based approach to representation

Ross Roberts-Thomson

Research is an important part of a medical education and to be able to accurately interpret, contribute to and even publish research is something all medical students should be able to do.

Thus, it is a pleasure to be able to welcome you to the first edition of the Australian Medical Student Journal.

Medical students have made some significant discoveries over time, including heparin, insulin, Ether anesthesia and even the sinoatrial node. Furthermore, a significant proportion of medical students would like to have research as part of their future career. Thus it makes sense for medical students to have and run a journal to showcase their work.

Over the past number of years, AMSA has conducted the AMSA Medical Education Survey. This survey looks at what medical students think about medical education in Australia and what their future intentions are. Governments, non-government organisations, lobby groups, universities and researchers around the world have used these data for various purposes and they are, of course, infinitely useful for AMSA itself.

In the current paradigms of science, politics, and education, being merely a representative body is no longer sufficient. Representation must be backed by robust evidence and thus AMSA must be the true authority on medical students if it is to be successful into the future. It is in this light that AMSA is pursuing a more evidence-based approach to medical student advocacy, something we like to call Evidence-Based AMSA.

As part of this initiative we are looking to collect qualitative as well as quantitative and anecdotal evidence to help further our advocacy and shed light on issues affecting medical students. Evidence-Based AMSA will be conducted in consultation with epidemiologists and education experts. It will allow us to better direct our arguments on issues affecting medical students, and subsequently enhance AMSA’s influence over Governments, university institutions and non-government organisations.

AMSA will also be forming ties with one of the world’s biggest pools of data on medical students – the Medical Deans of Australia and New Zealand Medical Student Outcomes Database (MSOD). The MSOD collects a variety of data including where medical students come from, what rotations they do and their respective career intentions. The Medical Deans Longitudinal Tracking Project even follows these students beyond university to see where they actually end up practicing.

Linking the AMSA Medical Education Surveys with the MSOD and Longitudinal Tracking Project provides a more solid foundation upon which to base our conclusions and recommendations, and this partnership is one AMSA is extremely excited about.

Finally, to give students the opportunity to publish and be involved in the running of a journal such as this is a great initiative and I very much look forward to future editions of the Australian Medical Student Journal.