GHMP 2016

Global HealthMentoring Program

Introducing the 2015 Global Health Mentoring Program

Foreword: It has been a pleasure to Chair this year’s mentoring program with these inspirational mentors, enthusiastic student mentees & hard-working committee. This magazine represents a culmination of the knowledge, insights,

ideas and interests of our mentoring partnerships in 2015. Congratulations to the student mentees for successfully completing the program,

and a big thankyou to our committee members and brilliant mentors for their time and effort. ~ Emily Nixon (GHMP Chair 2015)

The Global Health Mentoring Program matches Monash medical students from all year levels with experienced global health

professionals, for a year-long mentoring partnership.

Interested in becoming a student mentee? Keep an eye out for applications on our website and the Ignite Facebook page in the latter half of the year.

http://www.ignitehealth.org.au/index.php/about1/global-health-mentoring-program

MentorsDr Fiona Lander

Dr Suman MajumdarDr Chris Morgan

Dr Lloyd NashDr Elissa Kennedy

MenteesJoan WangJesse SchnallAndrew WangZachary O’BrienNeda So

With thanks to Louise Nixon for editing the magazine

Last but not least, as a subcommittee of Ignite Global Health, GHMP would like to acknowledge the tremendous and ongoing support that we receive

from the Ignite Committee.

Team GHMPChair

Publications Coordinator Mentor Coordinator Student Coordinator Events Coordinator

Academic Coordinator

- Emily Nixon- Laval TM Chu- Kurvi Patwala- Semonti Modak- Lauren Healy- Divya Raghavan

Staying Connected: The Role of Mobile Phone in Global Health By Andrew Wang

1| The global perspectiveThe role of the mobile phone in the healthcare setting is becoming increasingly prominent. Industry figures estimate that at least half of all some 3.4 billion plus smartphone and tablet users will be using a health care application in 2018.1

Developing countries face increased rates of both communicable and non-communicable diseases. Lack of proper infrastructure and education and a scarcity of human resources make the provision of adequate healthcare a challenge. Many look to mobile phones as the solution to such a problem. Mobile healthcare, known as mHealth, is defined as "the delivery of healthcare services via mobile communication devices”.2

The burgeoning rates of mobile phone ownership in resource-poor countries mean that there is the opportunity for increased access to health-care to many in resource scare communities. In 1999, 10% of the African population had mobile phone coverage. In little more than a decade, this percentage increased to 84%.3 The year 2012 saw nearly three quarters of mobile subscriptions occurring in developing nations.4

The technology, too, is there. Phones with limited capabilities are now being superseded. Feature phones - basic level smart phones - allow the installation of applications and the recording of video. Smart phones, too, are becoming increasingly affordable and accessible. The A50S, a smartphone manufactured by Karbonn, was launched in 2014. It costs little more than $50 AUD and is an example of the increasing availability of technology to a low-income market.5

In summary, the increasing prevalence and decreasing cost of the mobile phone offers many advantages and challenges for health in the 21st century. This piece will explore some of these.

2| Potential uses of mHealthThe World Health Organisation lists several methods through which technology can aid healthcare in countries where there is a mismatch in the supply and the demand for health services. mHealth has the potential to play an integral role in each of these areas.

Extending geographic accessMany developing nations do not have adequate numbers of physicians to meet the needs of the population. A developed country such as Australia has around three physicians per 1000 patients. In many countries in Africa and South East Asia, there is less than half a physician per patient.6

The scarcity of medical professionals results in large swathes of resource poor nations in need of health care workers. Mobile health is currently instrumental in dealing with such an issue. In the developing world, SMS is the third most common method of technology usage in healthcare.7 The use of mobile communication mitigates the long distances and difficulties in accessing a health centre for many, collapsing the long distances often involved in doing so.

Recent technology by Peekvision has seen a smartphone camera replace the ophthalmoscopes for eye examinations, allowing assessment of eye health to reach more people in more remote areas.

With the app, healthcare workers need only point the camera into the patient’s eye. Technology then does the rest - an abnormality is automatically focused upon, an image is taken and sent to medical professionals for further analysis.8

Improving diagnosis and treatmentThere are myriad applications to aid in the diagnosis of a disease. Australia has been instrumental in developing a number of these. A recent application delivered by the Nossal Institute aims to lower the death rates from a disease both treatable and preventable in the young - pneumonia. An infection of the lung, it is a disease that annually kills between 1 million to 1.5 million children.

Designed in Melbourne for feature phones, the application offers a simple solution. In countries where a limited number health workers face a limited amount of resources and limited time, a consultation can last little more than two minutes. On average, two questions decide whether a child has a cold or pneumonia. The application allows non-health workers to measure the respiratory rate of a child, making sure a crucial diagnosis of pneumonia is not missed.9

Facilitating patient communications Mobile health allows remote communication between doctors and patients. SMS can be a crucial aid in communication between doctor and patient as well as promoting adherence to medications.

A device named the SIMpill, which is attached to a monitor on a pill bottle, sends a reminder message to the patient. A trial documented in a Lancet report shows treatment through such technology garnered a success rate of 94%, as compared to a 71% direct observation success rate for tuberculosis treatment in South Africa.10

Most importantly, mHealth has the potential to promote health awareness in developing countries. The Mobile Alliance for Maternal Action (MAMA) sends expecting and new mothers messages of advice appropriate for that point in pregnancy and the age of their child. The service now spans 35 countries to prevent maternal mortality and prenatal complications. To circumvent linguistic barriers, messages can be delivered as an audio recording, and can be re-recorded to account for strong dialects.4

Improve data managementThe mobile phone can also act as a tool to track disease epidemics in real time, allowing researchers to better evaluate and analyse data on disease incidence. Inadequate reporting in regards to the extent and severity of diseases has been an issue that has long plagued epidemiologists in the third world.

Well-known epidemiologist Dr Seth Berkley argues that “a more accurate headcount” can be obtained through mHealth. Infants can sadly pass away without being registered as existing. A better measure of infant mortality can be gauged and better interventions can be staged through the use of mobiles for register the birth and death of a child.11

3| Issues to tackleYet there is a long way to go in developing effective, essential and clear communication with patients. In a comment published in the Lancet in 2015, it was found that of the 1700 mHealth projects they surveyed, none provided “essential, actionable, offline guidance for direct use by citizens by addressing the range of acute health are situations … encountered in low resource settings…”.12 There are a number of issues which mHealth must face to allow it to become truly established in countries where resources are scarce.

Firstly is the issue of getting the applications onto the phones themselves. In areas where Internet connection is hard to come by, the process of downloading of relevant applications becomes difficult. The solution - having preloaded health content onto mobile phones - is limited by both the capacity of the basic phones themselves as well as by the need for selectivity of the audience using the application. The challenge lies, therefore, in finding a way to provide the right app to the right individual.10

Secondly, whilst mHealth is making successful inroads into tacking difficult diagnoses and raising awareness in low to middle income countries, there has been little high quality research to support its implementation. A 2014 review of the impact of mHealth interventions13 of the available evidence has been anecdotal. Consequently, the need to over come poor data collection in low-income countries and the need for high quality assessments of trials are of vital importance in gaining funding and attaining sustainability.

Lastly is the issue of the fragmented nature of mHealth. There is no united front representing the multitude of applications, services and programs; no set of standards or frameworks unites each of the initiatives. Collaboration between programs can result in patients reaping greater benefits. Developers and entrepreneurs can benefit from the sharing of ideas. Merging of applications makes the process of diagnosis more streamlined and efficient. An program which combines assessments for a number of significant pediatric diseases - gastroenteritis, pneumonia, dehydration - can significantly reduce the number of applications needed and improve decision making for health workers.

Mobile health is a field of great potential. In a world where access to a good standard of healthcare is a priority, mobile phones have the capacity to dramatically alter lives. More funding and collaboration and integration into national policies will see further development of this field into a sustainable industry.

Air Pollution and Health by Jesse Schnall

As western societies continue to strive towards economic prosperity, technological and economic growth are providing innovative, effective methods of raising global health standards. Yet while this rapid industrialization may be improving standards of living in the developed world, it poses an equally deleterious threat to the most fundamental of our biological needs: access to clean, breathable air. In burgeoning powerhouses like China and India, dramatic increases in populations, transportation usage and factory production continue to cloud many cities in a perpetual haze of particulate matter and respiratory illness. And while images of the smog-laden streets of Beijing may not seem like our concern, we should be wary of ignoring the reality of our planet. A recent WHO report confirmed that as the cause of roughly one eighth of global deaths in 2012, “air pollution is now the world’s largest single environmental health risk.” 1

Air pollution today is typically equated to scenes of smoke, fog and a rising usage of facemasks. It is within the fog and under the microscope however that the pathogens exist, in the form of PM10, or particulate matter of 10 microns or less in diameter. These microscopic particles, which include sulfur dioxide, ozone, nitrous oxide and other harmful agents, occur both naturally and as the result of manmade processes such as the burning of fossil fuels and biomass. So how is it that these miniscule molecules come to be a crucial factor in the development not only of respiratory disease, but also cardiovascular issues and cancer? 2

The answer lies in the most innocuous and undetectable of acts: breathing. When we breathe, PM10 particles enter our respiratory system, becoming embedded in our lungs and airways. Our lungs recognize these foreign bodies, producing mucous to trap particulate matter in preparation for expulsion by cilia. If, as is the case with PM10 and the even more concerning PM2.5, these particles get deep enough into the lungs, they become trapped. It is once lodged in our respiratory system that these toxic bodies can cause health effects ranging from coughing and asthma to lung disease, emphysema and lung cancer.3 The smaller the molecules, the farther they can travel in the atmosphere, and into our lungs. And with the rising industrialization and populations in urban centres, particulate matter is fast becoming a silent killer.

Globally, the toll has already begun to climb. ‘Ambient,’ or outdoor, air pollution in both rural areas and city centres caused approximately 3.7 million premature deaths worldwide in 2012 (WHO website as above). This steep rise in mortality was primarily due to ischemic heart disease and strokes (80%), as well as chronic obstructive pulmonary disease or lower acute respiratory infection and lung cancer (14% and 6% respectively) (WHO). Yet it is not only the modernized and industrialised citizens of the western world that are feeling the suffocating effects of this epidemic. Indoor air pollution, that is the rise in particulate matter within our homes, represents a serious health risk to the roughly three billion people who use biomass to cook and heat their homes. (WHO). The combustion of biomass fuels, which are derived from organic materials such as wood, manure or crops, emits a hazardous smoke that causes almost 50 000 deaths annuals, and is responsible for almost 5% of the burden of disease in nations like Ethiopia.4 This harsh reality verifies that air pollution does not exist in a social or geographical vacuum; it pervades all societies, especially those who lack access to vital healthcare treatment.

Perhaps no country has been more gravely impacted by air pollution than China, a nation whose capital city has been afforded the undesirable moniker of “Greyjing.” Home to the world’s largest population, and a rapidly growing economy, the global powerhouse is feeling the side effects of a bustling industrial sector. Declining air quality has not only resulted from an increase in motor vehicles and factory production lines, but also form incomplete combustion of solid fuels in household stoves. 5

Unsurprisingly, this insidious decay is having far reaching consequences in multiple facets of Chinese society. The economic impact of air pollution alone has grown to a significant expense, rising from $22 billion in 1975 to $112 billion in 2005.6 Yet despite, or perhaps because of these damning statistics, the nation renowned for its efficiency and growth has adopted a similarly rigorous campaign to reduce its air pollution burden. Recent reports confirm that “Chinese households are… undergoing a massive transition to cleaner household fuels” 5 in an attempt to cleanse household air standards. The culture is changing, and the numbers confirm it: population weighted exposure for Chinese citizens underwent a reduction of (36-70) μg/m3 PM2.5 in the last decade.5 On a policy level, the government has introduced its ‘Action Plan on Prevention and Control of Air Pollution,’ detailing a 10% reduction of inhalable particulate matter in cities by the year 2017.7 If this manuscript is even half as impactful as the reduction in household air pollution, which has saved an estimated $31 billion USD for the Chinese health system, the nation may well be a model worth emulating in the battle against particulate matter.5

Despite these latent improvements, the gravity of our situation should not be underestimated. The WHO’s most recent report into global air standards has dauntingly warned that of those who live in cities that report their air quality levels, only 12% of people are breathing air that meets WHO standards.1 These standards, which demarcate acceptable 24 hour and annual mean levels of airborne particulate matter, are part of the WHO Air Quality Guidelines. Along with these benchmarks, the WHO has backed the Pan European Programme on Transport Health and Environment to promote the mitigation of transport-related air pollution through member state and multi-sectorial cooperation. And while industry, transport, urban planning, waste management and power generation have been earmarked as key areas for improvement, we as individuals can adopt smaller measures in our day-to-day lives. Opting for walking or our cars, cycling instead of our motorbikes, and of course, shedding our dependence on coal energy, are all ways we can limit particulate matter emissions and reduce a its growing burden of illness.

Climate Change and the Role of StakeholdersBy Joan Wang

There are many reasons to think about climate change, from extreme weather events to endangerment of species, yet health is often not one of them. Paradoxically, it is a far more tangible and prioritised concept to the public than abstract figures of however many tonnes of emissions produced or changes in annual precipitation levels. Health effects of climate change can be direct (e.g. death or injury from droughts, floods, fires) or indirect through damage to infrastructure (e.g. water supply and sewerage), ecosystems (e.g. food scarcity and disease vectors), economies and social structure, as mass migration and civil unrest develop over strains on resources.1 With the upcoming Conference of the Parties 21 (COP21) to be held in Dec 2015, it is time we examined the vital role that the health community can play in achieving climate change goals.

Does health have a place in climate change campaigns currently?Health as a marketing strategy for climate policy change is limited, with international NGOs such as Oxfam,2 NSF3 and Save the Children4 making little mention of it in their impact sheets or action statements, often focussing more on emergency humanitarian support for natural disasters. Even Greenpeace, an organisation with divisions dedicated to climate change as part of its mission to ‘expose global environmental problems, and to force … solutions’ 5 only directly references health in one line of its impacts information webpage – ‘Dengue fever will threaten millions of Australians and thousands more will die from temperature-related deaths’.6

What about the impact of health bodies?Bodies such as the AMA, AMSA, Doctors for the Environment Australia (DEA) and certain medical royal colleges (e.g. Royal Australasian College of Physicians) seem to have embraced climate change advocacy. The AMA not only submits press releases and ratifies reports such as the Australian Academy of Science Report ‘Climate change challenges to health: Risks and opportunities’,7 but also puts forward policy submissions. This includes the proposal of a National Strategy for Health and Climate Change which incorporates local disaster management plans, addressing disaster-related mental health issues, increasing education for health professionals, and improving communication between hospitals, major emergency centres and weather forecasters.8 Despite appropriate media coverage and an analogous campaign by the Climate and Health Alliance pushing for a National Strategy,9 this has yet to occur. Additionally, the AMA’s position statement delineates no other specific targets or how to attain them – as an example, they ambiguously advocate for ‘adopt[ing] mitigation strategies that reflect a precautionary approach’ without outlining said strategies.8

AMSA has a policy statement that can be better assessed for advocacy effectiveness, as it calls on the Federal and State government to place health at the centre of UNFCCC (United Nations Framework Convention on Climate Change), a clear ‘reduction in greenhouse gas emissions at 25-40% of 1990 levels by 2020’, for climate change to be incorporated into the curricula of Australian medical schools and it exhibits a firm support for the concept of divestment.10 Whilst the emissions data cannot yet be evaluated, unfortunately targets such as centralising health into the UNFCCC have not been achieved, and medical students are still not taught climate change. Divestment, essentially the opposite of investment, refers to the act of withdrawing investments from companies that generate a profit from unethical industries or behaviours, and thus can be used for the social goal of reducing fossil fuels.11

In a landmark move, the British Medical Association voted to end investments in the fossil fuel industry in June 2014,12 an outcome that such advocacy may have had a role in. However, despite a call for medical students, practitioners and the wider public to divest from the top 200 fossil fuel companies and divest personal funds from banks loaning to such institutions, top 200 companies such as Rio Tinto have seen an increase in share prices and net earnings over the past financial year.13

Thus, lack of impact from health stakeholders thus far may be due to a lack of clear, concrete policies and lack of intention for advocacy, poor dissemination of information, a poor response from the public, government and other institutions, or a likely combination of several factors.

So why should we care? What can health stakeholders do? The aforementioned health organisations are powerful unions, not just for their membership base or scientific influence, but because doctors are often seen in a position of trust and confidence in the community. Generally, they are highly regarded and their opinions often carry weight, both with patients and parliament. Thus, because of this privileged position in health, not only is there an opportunity to influence public discourse, there may be a moral obligation to do so. Ultimately, doctors represent the interests of the patient and should be able to advocate on their behalf to the government about an issue that inevitably affects their health. We need only look to the example of the Latrobe Valley in Victoria, whose fossil fuel industry has been allowed to escalate as a result of poor government policy, leading to increased respiratory morbidity.14 Clearly, local doctors see the direct impacts of even low air pollution levels, and hence there is a need for the medical profession to advocate for change. Furthermore, doctors are in the privileged position of being able to access and understand scientific reports and new evidence, and so can be the bridge between that data and patients.

AMA president Brian Owler describes our actions as ‘intergenerational theft’ if we do not act on climate change, and indeed it is imperative that health stakeholders do more as advocates, as current methods have led to a situation where ‘tackling climate change could be the greatest global health opportunity of the 21st century’.1

The Adverse Effects of Donated DrugsBy Zachary O’Brien

“This year alone, there will be over 40 million deaths in developing countries, one-third among children under age five. Ten million will be due to acute respiratory infections, diarrhoeal diseases, tuberculosis, and malaria – all conditions for which safe, inexpensive, essential drugs can be life-saving.” 1

Access to medicines in developing countries is a frustrating challenge. It is an issue with a seemingly simple solution, but sending the required drugs to those needing them proves to be surprisingly complicated. Though with a recent audit showing that over 600 tonnes of medications are disposed of in Australia each year, there doesn’t seem to be a physical shortage of drugs.2 Of these, some of the most commonly disposed medications are antibiotics that would be invaluable in low-income countries. Given this situation, an offer from pharmaceutical companies to donate medications seems like a proposal too good to be true. Maybe that’s because it is.

The field of global health is one fraught with paternalistic good intentions, where appearing to provide foreign aid can be more gratifying to some than improving the actual wellbeing of its recipients. More commonly however; the general public choose to trust organisations that assure stakeholders they are working tirelessly against an apparently insurmountable problem. While this may be true of many not-for-profit initiatives, perhaps commercial corporations with a poor altruistic track-record should be investigated with greater scepticism. With the global pharmaceuticals market being valued at US$300 billion a year and expected to continue growing,3 this is an industry that operates on a scale with tangible global effects. To put this sum into perspective, economist Jeffrey Sachs estimates that the cost to eradicate extreme poverty in the world would be less, at approximately US$250 billion a year.4

In view of these figures, donating medications seems like a good start for a sector that has the potential to do considerably more. The concept initially seems to be purely philanthropic but there are some known issues that tarnish the idea and call the motives of donors into question. The first of these regards the question do donated drugs actually help?

While the benefits of having access to medicines are obvious, there are many problems that may begin to outweigh the net good they can do. These tend to be exaggerated in emergency response situations when poor planning amplifies the negatives effects. The World Health Organisation recognises these, explaining that the drugs donated are not always relevant, known by local staff or within their expiry dates. In other cases, medicines may be labelled in languages not understood by staff, or be of a quality below acceptable standards in the donor country.5 In these scenarios the donations may not only be unhelpful but could prove to be dangerous to the patients requiring them.

The logistics surrounding inappropriate drug donations prove to be quite a burden on their recipients. Sorting, storage and distribution can consume limited resources and often transportation costs are higher than the value of the pharmaceuticals.6 This barrier is one that also applies to the donation of appropriate drugs but in a cumbersome quantity. A World Bank analysis indicated that following an earthquake in India in 2001, 95% of drug donations were appropriate, but exceeded the required amount by 1178 tonnes.7

Following the recognition of these problems, the WHO issued guidelines for drug donations in 1996 that were then revised in 1999. These guidelines were based on four “Core Principles” being:

“ 1. Maximum benefit to the recipient2. Respect for wishes and authority of the recipient3. No double standards in quality4. Effective communication between donor and recipient” 5

The effect that these guidelines have had on resolving the issues outlined is unclear, as little research has been conducted following their publication. With these guidelines clearly outlining ways in which donors can maximise the benefits of their contribution, is it not immediately apparent why inappropriate donations continue to occur. It can be assumed that companies are not simply ignorant or naïve to the problems they are perpetuating, which suggests there must be an incentive for continuing to donate in this manner. The most obvious reason to both the general public and pharmaceutical companies is that helping those in need creates good publicity. Improving the social reputation and image of an industry that is generally seen to be selfish has clear benefits, making the donations mutually beneficial to some degree. This however, is not where the benefit to donors ends.

The benefit that pharmaceutical companies do not advertise as widely, stems from the shear volume of drugs disposed of each year as previously mentioned. This should ideally be completed by incinerating the medicines at high temperatures, which proves to be a costly process. A WHO publication from 1999 provides example quotations for the cost of this service at US$2.2/kg to US$4.1/kg.8 This can make it significantly cheaper for pharmaceutical companies to donate their stock that is soon to expire, rather than pay to have it incinerated. Consequently, they are not only giving away drugs to developing countries, but also all the costs that are attached.

Companies are further enticed by another lesser-known perk. By donating medicines, these companies can become eligible for tax breaks that reduce their costs yet again.9 Suddenly, it is becoming increasingly apparent that donating inappropriate drugs would be quite a savvy business decision. This is recognised by pharmaceutical companies, who subsequently try and acknowledge but dismiss the benefit. Pharmaceutical giant GlaxoSmithKline very briefly mentions the point in a 2014 Public Policy release, admitting that “deductibility of a donation may be conducive to any decision to donate” and also that “The majority of GSK donations originate from the US and are, therefore, eligible for tax relief.” They continue to explain that “...while tax relief is obviously welcome, it is not the motivating factor behind our donations.” 10

The donation of medicines, and foreign aid interventions as a whole, are incredibly difficult tasks. They involve a delicate balancing act between issues of ethics, morality, economics and sustainability - through which efficacy can be forgotten. The motives of donors may be questionable, but many would argue are irrelevant providing they still donate. Whether the donation of drugs to the developing world ultimately serves its recipients is unclear, though we are not currently in a position to decline such offers. Particularly when, this year alone, at least 10 million deaths will occur from conditions “for which safe, inexpensive, essential drugs can be life-saving.” 1

Bibliography

Staying Connected: The Role of Mobile Phone in Global Health 1. Jahns, Ralf-Gordon. '500M People Will Be Using Healthcare Mobile Appli-cations In 2015'.Research2guidance 2010: 1. Web. 18 July 2015.2. Togan, Carol. 'The Mhealth Summit: Local & Global Converge'. Kinetics 2015. Web. 18 July 2015.3. Royston, Geoff. Ensuring That Mhealth Applications Provide Essential Healthcare Information For Citizens In Low Resource Settings. 1st ed. 2015. Web. 22 July 2015.4. Mechael, P. Struble, S. 2013. Wellness by Number: How Cellphones Save Lives. Solutions. Vol 3, No. 6. Pp1-2 http://thesolutionsjournal.com/node/22915. Nick, Fadge. 'One In The I For Apple: Smartphone That Costs Just £26 Set To Rival The Iphone And Samsung Galaxy At A Fraction Of The Cost” http://Www.Dailymail.Co.Uk/News/Article-2707480/One-Apple-Smartphone-Costs-Just-26-Set-Rival-Iphone-Samsung-Galaxy-Fraction-Cost.Html#Ix-zz3givtomrp Follow Us: @Mailonline On Twitter | Dailymail On Facebook'. Daily Mail 2014: 1. Web. 18 July 2015.6. Gamapserver.who.int,. 'WHO | World Health Organization'. N.p., 2015. Web. 17 July 2015.7. Lewis, Trevor et al. E-Health In Low- And Middle-Income Countries: Findings From The Center For Health Market Innovations. Washington: Development Institute World Health organisatioin, 2012. Web. 17 July 2015. Bulletin Of The World Health Organization.8. Braw, Elizabeth. 'Technology-Based Mobile Health Takes Off In Developing Countries'. The Guargian2014. Web. 17 July 2015.9. Milland, Julie. 'Made In Melbourne: Phone App For Detecting Pneumonia Set To Save Thousands Of Lives'. The Citizen 2015. Web. 17 July 2015.10. Barclay, Eliza. 'Text Messages Could Hasten Tuberculosis Drug Compli-ance'. The Lancet 373.9657 (2009): 15-16. Web.11. Berkley, Seth. 'How Cell Phones Are Transforming Health Care In Africa'. MIT Technology Review2013. Web. 17 July 2015.12. Royston, Geoff et al. 'Mobile Health-Care Information For All: A Global Challenge'. The Lancet Global Health 3.7 (2015): e356-e357. Web13. Hall, Charles S. et al. 'Assessing The Impact Of Mhealth Interventions In Low- And Middle-Income Countries – What Has Been Shown To Work?'. Global Health Action 7.0 (2014): n. pag. Web.

Air Pollution and Health 1.WHO. (2014). 7 million premature deaths annually linked to air pollution. Available from: http://www.who.int/mediacentre/news/releases/2014/air-pollution/en/ (Accessed March 25, 2014).2.WHO. (2014). Ambient (outdoor) air quality and health. Available from: http://www.who.int/mediacentre/factsheets/fs313/en/ (Accessed May 15, 2014).3. PIMA county department of environmental quality. What is particular matter? Available from: http://www.airinfonow.org/html/ed_particulate.html (Accessed May 15, 2014).4. Sanbata, H., Asfaw, A., and Kumie, A. (2014). Indoor air pollution in slum neighbourhoods of Addis Ababa, Ethiopia. Atmospheric environment, 89:230-234.5. Aunan, K. and Wang, S. (2014). Internal migration and urbanization in Chi-na: Impacts on population exposure to household air pollution (2000-2010). Science of the total environment, 481:186-195.6. Matus, K., K.-M. Nam, N.E. Selin, L.N. Lamsal, J.M. Reilly and S. Paltsev. (2011). Health damages from air pollution in China. Joint program report series, Available from: http:// globalchange.mit.edu/research/publica-tions/2142 (Accessed May 20, 2014).7.Ministry of environmental protection of the PROC. (2013). The State Coun-cil Issues Action Plan on Prevention and Control of Air Pollution Introducing Ten Measures to Improve Air Quality. Available from: http://english.mep.gov.cn/News_service/infocus/201309/t20130924_260707.htm (Accessed May 14, 2014).

Climate Change and the Role of Health Stakholders1. Watts N, Adjer WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health and climate change: policy responses to protect public health. The Lancet Commissions [Internet]. 2015 June 23 [cited 2015 July 16];373(9676), 4-14 2. Oxfam Australia. Climate Change [Internet]. Melbourne VIC: Oxfam Aus-tralia, [cited 2015 July 16]. Available from https://www.oxfam.org.au/contact-us/ 3. NSF International [Internet]. Ann Arbor MI:NSF, 2015 [cited 2015 July 16]. Available from http://www.nsf.org/

4. Save the Children Australia. Climate Change Adaption [Internet]. East Mel-bourne VIC: Save the Children Australia, [cited 2015 July 16]. Available from http://www.savethechildren.org.au/our-work/the-issues/climate-change-ad-aptation 5. Greenpeace International. Our Core Values [Internet]. Amsterdam Neth-erlands: Greenpeace International, 2015 [cited 2015 July 16]. Available from http://www.greenpeace.org/international/en/about/our-core-values/ 6. Greenpeace Australia Pacific. Local Impacts [Internet]. NSW: Greenpeace Australia Pacific, 2012 [cited 2015 July 16]. Available from http://www.greenpeace.org/australia/en/what-we-do/climate/Polluting-our-future/Local-impacts/ 7. Flannery J, Visser O. Launch of Australian Academy of Science Report – Cli-mate change challenges to health: Risks and Opportunities. AMA. [Internet]. 2015 April 30 [cited 2015 July 17]. Available from https://ama.com.au/media/new-report-highlights-risks-human-health-climate-change 8. AMA. Climate Change and Human Health – 2004. Revised 2008 [Internet]. ACT: AMA, 2008 Nov 8 [cited 2015 July 17]. Available from https://ama.com.au/position-state-ment/climate-change-and-human-health-2004-revised-2008 9. CAHA. National Strategy for Climate and Health [Internet]. VIC:CAHA, 2014 [cited 2015 July 17]. Available from http://caha.org.au/campaigns/national-strategy/ 10. AMSA. Policy Document – Climate Change and Health Policy. ACT, 2014 11. Fossil Free. What is Fossil Fuel Divestment? [Internet]. Fossil Free, 2015 [cited 2015 July 17]. Available from http://gofossilfree.org/what-is-fossil-fu-el-divestment/ 12. Medact. UK Doctors Vote to End Investments in the Fossil Fuel Industry [Internet]. London UK:Medact , 2014 June 25 [cited 2015 July 17]. Available from http://www.medact.org/news/uk-doctors-vote-end-investments-fos-sil-fuel-industry/ 13. Rio Tinto. Performance Highlights [Internet]. London UK:Rio Tinto, 2015 [cited 2015 July 17]. Available from http://www.riotinto.com/ar2014/pdfs/performance-highlights.pdf 14. Voigt T, Bailey M, Abramson M. Air pollution in the Latrobe Valley and its impact upon respiratory morbidity. Aust NZ J Public Health. 1998 Aug; 22(5):556-61

The Adverse Effects of Donated Drugs1. World Health Organisation – Essential Medicines and Health Products. Essential Medicines [Internet]. Geneva: World Health Organisation. 2015 [cited 12/7/15]. Available from: http://www.who.int/medicines/services/essmedicines_def/en/2. Bergen PJ, Hussainy SY et al, Safe Disposal of Prescribed Medicines [Inter-net]. Melbourne: Australian Prescriber; June 2015 [cited; 12/7/15]. Available from: http://www.australianprescriber.com/magazine/38/3/90/23. World Health Organisation – Trade, Foreign Policy, Diplomacy and Health. Pharmaceutical Industry [Internet]. Geneva: World Health Organisation. 2015 [cited 12/7/15]. Available from: http://www.who.int/trade/glossary/story073/en/4. Munk N. The Idealist. New York: Doubleday; 2013. Pg 325. World Health Organisation – Department of Essential Drugs and Other Medicines. Guidelines for Drug Donations [Internet]. Geneva: World Health Organisation. 1999 [cited 12/7/15]. Available from: http://www.who.int/hac/techguidance/guidelines_for_drug_donations.pdf6. Management Sciences for Health. 2012. MDS-3: Managing Access to Med-icines and Health Technologies. Chapter 15.3. Arlington, VA: Management Sciences for Health7. Autier, P., R. Govindaraj, R. Gray, R. lakshminarayanan, H. G. nassery, and G. Schmets. 2002. Drug Donations in Post-Emergency Situations. Washing-ton, D.C.: World Bank8. Grayling T. Guidelines for Safe Disposal of Unwanted Pharmaceuticals in and after Emergencies [Internet]. Geneva: World Health Organisation. 1999 [cited 12/7/15]. Available from: http://apps.who.int/medicinedocs/en/d/Jwhozip51e/1.html9. Pinheiro CP. Drug Donations: What Lies Beneath [Internet]. Geneva: World Health Organisation, August 2008 [cited 12/7/15]. Available from: http://www.who.int/bulletin/volumes/86/8/07-048546/en/10. GlaxoSmithKline Communications and Government Affairs. GSK Public Policy Positions – Product Donations [Internet]. April 2014 [cited 12/7/15]. Available from: https://www.gsk.com/media/280890/product-dona-tions-policy.pdf