Essay : Public Health Policy

New Years Eve 2030

Dear Reader,

These letters were found in the hands of the last known "Goodwill Islander", Ms Harriet Mari when she passed away earlier today in a field hospital outside Port Moresby. Ironically you may be aware that Harriet was a second cousin to Matricia Mari¹ a former dedicated participant of the National AIDS Council of Papua New Guinea (PNG).

These letters chronicle a tale of a pacific island nation truly obliterated by HIV/AIDS and the impact of neighbouring foreign policy on the outcome of the HIV/AIDS epidemic in the region. Mr Alexander Downer the former Australian Federal Minister for Foreign Affairs could not be reached for comment today and so I will let you the reader draw your own conclusions from the subtle analysis presented in these letters of a piece of foreign policy that effectively started in July 2004 with "Meeting the challenge: Australia's international HIV/AIDS strategy".

As we mourn the irrevocable loss of the Goodwill Islands people please ponder the constructs of the afore-mentioned document. The letters you are about to read will expose the arguments, expose the politics in and outside the document and may provide a sense of 'what actions' or 'lack of actions' lead to the devastating loss of a nation of peoples, that prior to the 21st Century had existed in good health, peace and harmony for over 50,000 years.

Nagrom Nasus
Concerned citizen of the region

New Years Day 2006

Dear Mr Downer,

I am writing to you on behalf of the nation of the Goodwill Islands. You may remember that we met at the APEC summit in 2004. In 1996 my people built our wonderful international airport and since then have experienced a regular influx of visitors. Primarily these have been workers for our 'lime mining' operations. We are performing strongly in the international lime export market and enjoy our trade agreement with your country.

Most of the workers come through to us from Papua New Guinea and New Caledonia. Early 2000 we began to notice a sickness amongst some of our women. We had not seen such an illness before. We then began to notice our babies also becoming sick and soon more and more people were no longer with us. We have come to know that this illness is HIV/AIDS and we are appealing to Australia for help.

I would like to take this opportunity to refresh your knowledge of our humble nation and to present some data on the impact of this HIV/AIDS illness:

The Independent Nation of the Goodwill Islands is located approximately 8,000kms north north-east of Sydney. Our Queen has ruled for the last 30 years and we have a stable political system. Our country's demographics can be summarised as follows:

This (fictitious - not referenced) census data is presented by the UN population division database and also WHO (WHR2005)/UNICEF.

From this data you can see that this illness is having alarming effects on our population. It is affecting our workforce and we need to employ more and more workers from PNG. This in turn reduces our gross national income and our gross domestic product (GDP) is also weakening in World Bank rankings.

We have an immediate crisis in dealing with the sick and dying. Traditional cultural practices and lack of infrastructure are making it difficult to provide good care. We also need help to isolate the source of the illness and to stop it killing any more of our people. Our government is finding it difficult to comprehend the size of this epidemic and our 10 doctors of western medicine do not have the ability to cope.

Recently we have seen the arrival of 3 non-government organisations, Oxfam, Medecins Sans Frontieres (MSF) and World Vision. Their initial message has been that this illness is often caused by intravenous drug use and promiscuity. My people are both honourable and moral. We predominantly follow the Catholic faith and the Goodwill Islands do not have a drug problem.

We also have had a visit from a UNAIDS envoy and have been told we are able to access the Global Fund (GFATM) for the treatment and prevention of HIV/AIDS. However due to the size of the problem globally and more specifically in Sub-Saharan Africa, our call on these resources will likely be inadequate to address our problem. This fund is in urgent need of more donations. Further more the United Nations Development Program (UNDP) predicts that our economic growth could drop by 40% in 2015 due to this epidemic. (fictitious - based on similar statistics projected by UNDP for PNG 2004) We appeal to Australia for urgent help.

Mr George Morte
Prime Minister of Goodwill Islands

March 2006

Dear Mr Morte,

Australia is committed to continuing its leadership role in the Asia-Pacific region as well as providing support to leadership of our neighbours. The World Health Organisation (WHO) provided a report in 2004, which stated that 7.4 million people in the Asia-Pacific region were living with HIV/AIDS. The WHO asserted that sexual transmission remains the major cause of spread of the epidemic in the Pacific and that young adults (primary workforce) are the demographic group most affected. Australia realises the devastating effects this has on both the health of a nation, its economic performance and hence its ability to participate in regional trade.

Australia advocates that during this time of crisis, leadership and political commitment are fundamental to responding effectively to the HIV/AIDS crisis. With due respect precedence has been set that "Every country has engaged in denial; leaders typically assert that moral values of their society would not permit transmission of an agent such as HIV that is associated with risky sexual behaviours, homosexuality, or injecting drug use. But behaviours that spread HIV exist in every country. Denial merely delays the response and worsens the epidemic" (Ainsworth & Teokul 2000)

Australia "...depends on others having, for example, the capacity to formulate, implement and sustain policies that detect and disrupt terrorists, liberalise trade and investment, protect the environment in ways that do not distort trade, and respect human rights". (Australia's Foreign and Trade Policy White Paper, 2003). Australia does enjoy a good trading relationship with the Goodwill Islands and hopes for this to continue into the future. Australia is committed to stability in the region and therefore is prepared to deliver a supportive response.

This response will be consistent with our current policy on foreign aid in the region. - "Meeting the challenge: Australia's international HIV/AIDS strategy". (July 2004)

This document outlines 5 Priority Action Areas:

1. Strengthening leadership and advocacy
   • Advocate for the recognition of Asia-Pacific region as a global priority
   • Increase the role of Overseas mission in promoting political leadership on HIV/AIDS
   • Advocate for HIV/AIDS on agenda of key international meetings
   • Advocate for protective leadership frameworks
2. Building Capacity
   • Governance programs
   • Support for national AIDS authorities
   • Build Health system capacity
   • Support for community organisations
3. Changing Attitudes and Behaviours
   • Social Marketing of Condoms
   • Encourage active participation of people living with HIV/AIDS
   • Targeting needs of Vulnerable groups
4. Addressing HIV transmission associated with injecting drug use
   • Inclusion of prisons
5. Supporting treatment and care
   • Services to manage the treatment and transmission of STI's, including STI surveillance
   • Support for continuum of care
   • Support for international trade agreements that increase access to antiretroviral drugs
   • Strengthen engagement with key multi-national organisations, UN agencies, WHO and GFTAM
   • Develop partnerships with peak professional organisations in Australia

Australia produced this document based on reflection of key evidence from successful interventions in HIV/AIDS epidemics in Senegal and Uganda. "High-level political commitment, coupled with prompt action in Uganda and Senegal, has shown that the AIDS epidemic can be contained and even reversed. Uganda has cut HIV/AIDS prevalence from double-digit figures to around 9 per cent (and in some age groups by half), while Senegal has stopped infection rates at between 1 and 2 per cent." (Mwaura 1999)

Furthermore Australia is a signatory to the 8 United Nations (UN) Millennium Development Goals, significantly number 6 which states, "halt and begin to reverse the spread of HIV/AIDS by 2015". (UN 2001) The UN also has developed a 'three ones policy'. Australia also supports the United Nations ' three ones' principles.

UNAID'S three ones Principles

1. One agreed HIV/AIDS Action Framework that drives alignment of all partners
2. One national AIDS authority, with a broad-based multi-sectoral mandate
3. One agreed country-level monitoring and evaluation system,

Australia's domestic response has been characterised by a partnership involving government, affected communities, researchers, educators and health professionals. (Aust. Gov. Dept of Health & Aging website, 2005) Australia urges your country and government to adopt a similar strategy. AusAID will immediately call for expressions of interest in providing an appropriate Aid response to your requests.

The Hon Alexander Downer MP
Minister of Foreign Affairs (Australia)

September 2009

Dear Mr Downer

I applaud the Australian Government for supporting HIV/AIDS projects in the Goodwill Islands. However I would like to stress the urgency and the key challenges that need to be addressed by this AusAID project.

I draw your attention to a statement made by Dr Walter Malu Goodwill Islands Minister for Health (ABC radio December 2006 - fictitious but based on actual statement by Dr Clement Malou, PNG National AIDS Council 2000 ABC)

"We in the Goodwill Islands have a most difficult place to work in HIV/AIDS in the world. We've got a very diverse society. We have isolated communities, 50 different languages and people have maybe the similar number of thoughts and ways of thinking about general issues in life, and sex is one of those issues. There are issues of development, accountability of leaders,...the cash economy...people putting themselves at risk in trying to have a decent way of life" Dr Walter Malu Health Minister 2006

I also draw your attention to the fact that HIV/AIDS is under reported in the Pacific. The South Pacific Commission in 1997 released a strategy for the prevention of AIDS/STD and it has been stated that the epidemic is considerably more serious than available data details. (SPC 1997)

"Women in particular are vulnerable. Issues such as economic dependence on men, domestic violence, and double standards of sexuality, illustrate the lack of control women have in their sexual relationships. Simply being married is a major risk factor for women" (Moodie & Fry 2000)

I also suggest that politically for the Goodwill Islanders this problem will be hugely challenging as a dramatic cultural shift and challenges of long standing taboos must be faced.

Finally I urge the Australian Government to immediately ensure our Aid package to the Goodwill Islands aims to have effective programs for the following key issues:

• To address domestic economic challenges within the Goodwill Islands. This epidemic is more than a health and humanitarian concern. Economic breakdown due to loss of healthy productive workforce has dire consequences. Australia's traditional mode of Aid programs has been to use Australian companies. The time has come to empower 'local' companies and hence supporting the local economy and build local infrastructure and capacity.
• Ensure that Australian aid assistance is well integrated into the broader social, economic and health care needs of the Goodwill Islanders. As their economy experiences negative growth, more of the population will need help with food, shelter and security. Practicing safe sex will seem a low priority if food and shelter are not adequate.
• Focus on supporting high-level political and bureaucratic mobilisation as per the success in Uganda.

(Moodie & Fry 2000)

As supported by the severe drop in population and economic performance of the Goodwill Islands, I stress again the importance of a timely and effective response.

Rob Moodie
CEO VicHealth and International Health Promotion Expert

December 2010

Dear Mr Moodie

The Australian Government appreciates your expert suggestions. You will be aware that over the last 10 years the Australian Government has been reorienting the focus of foreign aid dollars away from pure education and health to an overall governance approach.

Over the last 25 years the Pacific region has received substantial Aid dollars. "Between 1995 and 1999 average per capita aid to Melanesia was US$73, 3 times that to Sub-Saharan Africa and 35 times aid to India". (Brown 2005) Professor Helen Hughes (2003) from the 'Centre for Independent Studies' in Sydney produced a report outlining the harm that unlimited and un-restricted aid has on recipient economies. "Pacific states regard aid as part of their government revenues. They spend aid on consumption. That is why roads, electric power, communications, schools and health centres are deteriorating." The Australian Government recognises the continual deterioration of infrastructure in this region, despite large injections of funding and has therefore to demonstrate compassion has shifted its focus to ensuring responsible governance within the region which will then create measurable economic improvements.

"The ODA budget for 200405 is significant on two counts. First, some 33 per cent of the ODA is allocated for projects related to governance, up from 15 per cent in 19992000. On the other hand, expenditure in support of education and health programs has declined from 27 per cent and 14 per cent respectively in 19992000(2) to 14 per cent and 12 per cent in 200405. Second, it emphasises the Governments enhanced whole-of-government approach to ODA." (Tomar 2004)

Australia is committed to the stance that HIV/AIDS should be addressed using a 'whole of government approach' and that we are dedicated to keeping law and order within the Goodwill Islands such that normal economic activity can continue to occur. Further more this will allow the Government of The Goodwill Island to implement their national HIV/AIDS response.

Australia is supporting the Goodwill Islands with the running of their Lime Mining operations, which are fundamental to stabilising their economy.

The Hon Alexander Downer MP
Minister of Foreign Affairs (Australia)

July 2012

Dear Mr Downer,

I bring your attention to the dire situation caused by the HIV/AIDS epidemic within the Goodwill Islands. Oxfam has been present in a NGO capacity since mid 2005. In this time, despite partnerships between NGO's, local communities, there has been no stemming of the tide of new HIV/AIDS infections.

Surveillance programs initiated by AusAID demonstrate dramatic increases in HIV cases, especially among young women between ages of 15-24. The virus is concentrated among the heterosexual community (practising high risk behaviour), followed by vertical transmission from mother to child. Infection rates are now nearing 30%. Furthermore due to heavy loss of productive workforce the Goodwill Islanders are facing dire consequential health and economic conditions.

Sending more Australian police and military is shifting the focus from health and poverty alleviation towards security and governance. The current Australian Aid program running in the Goodwill Islands has little to no cultural sensitivities and therefore is ineffective in addressing behaviour changes that can lead to halting the spread of HIV/AIDS. Health Infrastructures to support provision of antiretroviral therapy to prevent the emergence of drug-resistant strains of HIV are essential.

The Goodwill Islands government is on the verge of losing the economic capacity and trading capability to negotiate effectively TRIPS agreements for the affordable purchasing of antiretroviral drugs. We acknowledge that Australia sees this role primarily as the responsibility of the Goodwill Islands government, but due to the increasing loss of effective workforce and the 'chimney effect' on the population, they soon will have lost the capacity to do so.

"The population structure for developing countries can be represented by the pyramid - a wide base because of high birth rates that narrows with increasing age caused by high death rates. HIV/AIDS is causing the production of a completely new shape called a "population chimney". The most obvious structural change is a radical shrink in the population aged between 20 and 40. There is also a reduction in number of children because of the increased death rate of women of reproductive age and because of transmission of HIV from mother to infant." (UNAIDS 2001)

Australia is a signatory to UNAID and hence has an ethical obligation to continue its agenda of HIV/AIDS effected populations in developing countries accessing antiretroviral medicines. Brazil provides a positive example of how these drugs can be effectively managed through a public health system.

"The potential global impact of scaled-up treatment access is apparent from experience in Brazil, which began providing Anit-retroviral treatment (ART) through its public health service in 1996. ...... the country currently provides ART to 119,500 patients. Since initiation of its ART treatment programme, Brazil has seen AIDS-related mortality decline by 50%, averting an estimated 90,962 deaths." (UNAIDS website)

Australia is urged to increase its funding to support more research, especially in the area of ARV's to prevent vertical transmission between mother and child.

Australia, as one of the most developed nations in the region has an ethical responsibility to help its neighbours in a timely and selfless manner. Oxfam, MSF and World Vision ask Australia to refocus its Aid initiatives into health care, infrastructure, condoms and ARV's. The extent of the problem in the Goodwill Islands is almost to the point of no return. Australia is a signatory to the UN and must act now.

Dr Jones, Dr Smith and Dr Hill
Oxfam, MSF, World Vision

December 2012

Dear Doctors,

The Australian government stresses that we are committed to helping address the HIV/AIDS crisis within the Pacific region, and we advocate responsible aid delivery. Furthermore we support NGO's performing humanitarian roles and are aware of the growing challenge in the Goodwill Islands. Australia is committed to supporting the initiatives of the Goodwill Island government in regards to improving infrastructure and development.

"While the humanitarian role of NGOs is unquestionably important in the many disaster (although mainly man-made) situations that afflict developing countries, the role of NGOs in development is more open to debate. The multinational NGOs of which the main Australian NGOs are subsidiaries strongly support the welfare and statist policies that have been abandoned by Australia and that are a major cause of the Pacific's difficulties." (Hughes 2003)

In 2003 - 4, AusAID spent 21% of its budget on controlling STD infection, including the spread of HIV. Australia then implemented a $A 200 million, six-year HIV/AIDS initiative in the Asia-Pacific region. In Bangkok in 2004, I announced a significant funding boost of $A350 million over six-years to combat the disease - more than doubling our commitment to a total of $A600 million by 2010. (AVERT website June 2005). The US and various charities have also supported the region with sizable donations. The answer is not to continue to send money but to focus on initiatives that strengthen governance. Australia can only help the Goodwill Islands by standing firm with its current Aid policy.

The Hon Alexander Downer MP
Minister of Foreign Affairs (Australia)

August 2015

Dear Cousin,

I have managed to secure passage on a small fishing vessel across to Port Morseby. I should arrive in approximately 3 weeks. Life in our islands has become unbearable and everyone around me is sick. Since the lime mine closed corruption and violence has been rife and there are severe food shortages.

Sadly I fear that I too have become infected with this killer disease. I am truly grateful that you are able to provide me shelter. I hope to see you soon.

Harriet Mari