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Lifting the baseline: Tackling healthcare challenges in developing economies

Paediatrician and public health researcher Dr David Hipgrave discusses the challenges to the provision of healthcare in developing economies. He also takes a close look at infant mortality and child health in these countries. Presented by Dr Dyani Lewis.

"The really strong marketisation of the health sector in China had a pretty adverse impact on accessibility and affordability of health care for poor people" -- Dr David Hipgrave




Dr David Hipgrave
Dr David Hipgrave

Dr David Hipgrave, Associate at the Nossal Institute for Global Health, is is an Australian paediatrician with extensive country-level experience on child health in Africa, Southeast and East Asia. He worked for two years as a clinician in Malawi, and for seven years in public health in Vietnam, Cambodia, Laos and Myanmar, focusing on vaccination, malaria, intestinal parasites and tuberculosis. He completed his PhD on the introduction of hepatitis B vaccine in Vietnam. From 2004 – 2011, David managed a diverse array of health and nutrition interventions for UNICEF in Indonesia and China. In Indonesia, he was closely involved in the response to the Asian tsunami, a polio outbreak, the avian influenza response and many field initiatives in maternal and child health and nutrition. In China, in addition to similar programs as those he managed in Indonesia, he and his team worked closely with the government on evaluation of its current health system reforms. David is currently on leave from UNICEF, undertaking collaborative academic writing in several areas.

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VOICEOVER 
Welcome to Up Close, the research talk show from the University of Melbourne, Australia. 

DYANI LEWIS
I'm Dyani Lewis. Thanks for joining us. When it comes to public health, there are seemingly endless ways in which health might be improved given the right amount of funding. Campaigns to reduce smoking, vaccinate against disease or improve organ donation rates all cost money and deciding how to use the public health purse to get the biggest bang for your buck is a challenge that all governments face. In the context of developing countries, the challenges can be even greater and access to the most basic health services is beyond the reach of many.To discuss some of the challenges faced by developing nations, we are joined on Up Close by Dr David Hipgrave, a paediatrician and currently an Associate at the Nossal Institute for Global Health at the University of Melbourne. For seven years, until late 2011, David worked for the United Nations Children's Fund, better known as UNICEF, first in Indonesia and then in China as chief of UNICEF's health and nutrition programs in those counties. Welcome to Up Close, David.

DAVID HIPGRAVE
Thanks very much Dyani.

DYANI LEWIS
David could you start by giving us a brief overview of some of the main health challenges facing communities in developing countries?

DAVID HIPGRAVE
Sure, that's a broad question and I'll try and be as brief as possible. It really depends on what you're referring to by developing countries, because developing countries is a term which covers a wide range from very low income countries with a gross national income per capita of less than $1000 up to upper middle income countries where the GNI per capita is actually $12,500 according to the World Bank figures.

DYANI LEWIS
That's US dollars is it?

DAVID HIPGRAVE
That's US dollars, yes. So you really do get a broad range of countries that still fit into their broad category of countries which are referred to as developing countries. But assuming that you're asking about countries which are more in need of, for example, development assistance or where the issues of development are still very relevant, particularly to the poorer parts of those countries' societies, the health issues really still relate to maternal and child health, sanitation, nutrition, communicable diseases, health systems issues such as quality, access, equity and efficiency of the use of health resources, human resources for health, health financing. There's a lot of focus now globally on universal coverage of basic health care, regulation of health systems, the growth of the private sector as economies improve, the issue of payment of health workers.I've left out when I was talking about diseases specifically, the growing incidence of non-communicable diseases, not only in developed countries, we know a lot about that in Australia, talking about heart disease or hypertension or diabetes or overweight, but these issues are also increasingly affecting developing countries as well.

DYANI LEWIS
So a lot of these sound  like very systemic or system-wide challenges that developing countries are facing and from a research perspective, how is something like a health system assessed? What outcomes can be measured?

DAVID HIPGRAVE
There's a wide range of indicators which are used to measure health and health systems function. In child health or maternal and child health, we commonly look at maternal and child mortality. Maternal and child health indicators like antenatal care uptake and quality of antenatal care, postnatal care, development screening of children, disease specific indicators like the incidence of neonatal tetanus or measles or management of common childhood illnesses like antibiotic treatments or pneumonia or oral rehydration salts for treatment of child diarrhoea, vitamin A distribution, et cetera.

DYANI LEWIS
Why is there such a focus on child mortality as a measure of health system function?

DAVID HIPGRAVE
Yes, you're right. Child mortality is a major global health indicator and it was selected as one of the targets or one of the Millennium Development Goals. You've probably heard of those. Millennium goal four is reduction of the rate of child mortality per 1000 live births from 1990 to 2015 and the target is a 66 per cent reduction in that rate. I think child mortality is probably used as a comparator between countries, because it's relatively easy to measure. Early childhood is a high risk period of life and is an indicator of many aspects of health system functioning like access, affordability, uptake, quality of care, et cetera.Child mortality is also very closely linked to and influenced by issues like female education and literacy. I think probably overall it's just considered an indicator which is relatively easier to measure than things like life expectancy or disease incidence among adults where the population that you're trying to measure is much less clear.

DYANI LEWIS
Now you mentioned that it's relatively easy to measure. Is this from the perspective of a researcher going in and measuring that off the ground, or are you relying on reported data for that measure?

DAVID HIPGRAVE
That's a great question, because unfortunately where child mortality is highest, the data is often the weakest and relies on systems of measurement which are quite difficult to implement. So for example, the measurement of child mortality relies a lot on vital registration systems which are often not functioning very effectively in all countries.Vital registration is a system where the key life events are measured either on a subset of the population or all members of the population and it's things like births, deaths, age of mortality; in more advanced systems they might have cause of death, et cetera. If those systems are not functioning well, then you rely more on sampling, such as during surveys which are conducted at varying levels of frequency and with varying sample sizes and therefore varying levels of representation of different groups within the population, whether it be a geographic area or socioeconomic echelon or religious group or ethnic group or even gender. Mortality across genders is often not very clear.Child mortality is also often measured using verbal autopsy which is where once a death has been reported, then further investigation is done by ideally a person with expertise in clarifying the cause of death through interviews with family members or hospital staff or investigations around the circumstances of death. Interestingly, verbal autopsy is now being expounded to include social autopsy where they're looking more at the clinical antecedents of death and also at the more social and economic and community antecedents or context for the death.

DYANI LEWIS
David what are some of the causes for child mortality?

DAVID HIPGRAVE
Normally the under-five mortality is divided into newborn deaths, infant deaths and young child deaths are deaths between the ages of one and five. Newborn deaths refer to deaths in the first month of life and are predominantly due to pre-term birth complications, birth asphyxia, infections, et cetera and they make up about 40 per cent of all under five deaths. General under five mortality we're looking at communicable diseases predominantly, such as pneumonia, respiratory infections, diarrhoeal disease, measles, meningitis, HIV, malaria, et cetera. As the number of deaths fall over all and the rate of mortality is falling, non-communicable diseases including accidents and injury, particularly drowning, are also becoming a bigger proportion of under five deaths and other things like congenital abnormalities are increasingly a proportion of under five deaths too.

DYANI LEWIS
Now David you mentioned earlier that reducing child mortality is one of the UN's eight millennium development goals. How are we progressing towards meeting that goal?

DAVID HIPGRAVE
Pretty well, but not well enough. There's been some improvements in the last 10 years or so. As I mentioned earlier, the target for the millennium development goal four is a 66 per cent reduction on the 1990 rate and for that to be achieved, it requires a 4.4 per cent reduction per year over the 25 years between 1990 and 2015. So for that 4.4 per cent reduction to be achieved, obviously quite a significant input into child health has to be undertaken. Globally, from 1990 to 2000, the reduction in under five mortality was only 1.9 per cent per year. But between 2000 and 2010, it increased and it's now up to 2.2 per cent per year. But obviously if the reduction has to be 4.4 per cent per year over the full 25 years, then there's an incredible amount of work still to be done.I started off this answer by sounding positive, in fact it's not very positive but over the last 10 years there have been positive signs of improvement in RIM -- reduction in mortality. Just to put some numbers on that, in 1990 there were an estimated 12 million deaths among kids under five globally. Figures just released in September show that for 2011 that number is now down to about 6.9 million, so it's a very significant reduction given that populations have obviously increased during that time. But as I mentioned earlier, the overall rate of under-five mortality has not declined nearly enough for us to be confident that the MDG target will be achieved.

DYANI LEWIS
That needs to be achieved by when?

DAVID HIPGRAVE
2015. For something as difficult to make a big impact on as under five mortality, we've only got a three year window to really save a lot of kids' lives. So it's touch and go as to whether that target will be achieved.

DYANI LEWIS
This is Up Close. I'm Dyani Lewis and in this episode, we're talking about measures to improve public health in developing countries with Dr David Hipgrave.So David what are some of the measure that can be taken to reduce child mortality?

DAVID HIPGRAVE
There's a broad range of things. Obviously some of them are systems related and some of them are very specific to child health. Globally it's more recognised that there have been some fantastic initiatives in the last 10 or 15 years which have made major impacts and a lot of that reduction in mortality that I referred to earlier has been because of large scale programs and I'm referring to vaccination, the introduction of bed nets. I should say with respect to vaccination, there have been campaigns of vaccination against diseases like measles and as well as introduction of new vaccines including vaccines against bacterial meningitis in countries where that disease is common.As I said, bed net distribution has made a major impact on malaria deaths, particularly in African countries, but also in other places. Improvements in sanitation and hygiene in many countries has also reduced the number of diarrhoeal deaths. Issues such as the treatment of children with antibiotics for pneumonia at community level and increased recognition of the effectiveness of that has been responsible for the saving of a lot of lives; but there's still a great need for improving the management of pneumonia at a community level globally.Then there's systems issues such as improved newborn care, improved delivery care, increases in the number of women who are delivering with a skilled birth attendant; those things have a major impact on newborn deaths. Newborn deaths are approximately 40 per cent of all under five deaths, so anything that impacts on newborn mortality is going to have a big impact on under five mortality overall.Increased awareness of child nutrition is another issues which has improved in the last 15 or 20 years. There's been a lot of focus on breastfeeding, on hygienic preparation of food, on the quality and content of child nutrition, particularly during the first two years of life. Those things, I think, have shown some improvement.

DYANI LEWIS
So why is breastfeeding so important?

DAVID HIPGRAVE
Breastfeeding is particularly important, in fact there was a Lancet series in 2003 where they estimated the impact of certain interventions on child mortality and I think breastfeeding came out as the number one intervention which could save children's lives. I think a 13 per cent proportion of child deaths could be prevented if early and exclusive breastfeeding for the first six months of life were implemented.Breastfeeding is extremely effective in preventing newborn and early child mortality by reducing the risk of infection. It has long term impacts on child nutrition. It's thought possibly to have impacts on long term disease incidents, diseases such as atopic illness such as asthma and eczema and well as possibly on the incidence of non-communicable diseases such as overweight, heart disease, diabetes. I think the jury is still out on those details, but there are signs that the length and quality of breastfeeding or amount of breastfeeding has an impact on non-communicable diseases in the long term.

DYANI LEWIS
David, you mentioned that the Lancet series in 2003 described breastfeeding intervention as having an impact, but is breastfeeding something that needs to be encouraged?

DAVID HIPGRAVE
It varies from country to country, but there have been, you could say, scandals where poor women in developing countries who can not only ill afford to purchase formula for their infants, but the hygienic preparation of breast milk substitutes like infant formula is actually quite difficult. So yes, breast milk is extremely important for women in those countries and its promotion and its recognition as a major child survival intervention was, I guess, lost for a few years in the '80s and '90s and its promotion has really been quite a focus of child health specialists globally in the last few years.

DYANI LEWIS
So that's just a bit of a lack of knowledge at the community level that breast milk is valuable. Has that knowledge been lost?

DAVID HIPGRAVE
Well it's not only lack of knowledge, it's also because of promotion of breast milk substitutes by formula companies which have, in some cases, misled people into thinking that the outcomes for their baby will be better if they use infant formula. So there's been a strong campaign by global health authorities, WHO, UNICEF, the American Academy of Paediatrics, to make sure that people are aware that there is no truth in the claims that infant formula produces a better outcome for the baby and that breast milk is most definitely the best food for newborns and infants.

DYANI LEWIS
David you specifically looked at breastfeeding in Indonesia after the 2006 Jogjakarta earthquake. What did you look at there and what did you find?

DAVID HIPGRAVE
We looked at the exposure of infants to breast milk substitutes, specifically infant formula in the aftermath of the earthquake. So we looked at the proportion of infants who had ever consumed infant formula before the earthquake as compared to after the earthquake. We looked at the number of households who had received donations of breast milk substitutes and we looked at the incidence of diarrhoea among children according to receipt of those breast milk substitutes. We found that there was a very high rate of receipt of breast milk substitutes. It was I think 80 per cent of all households and 75 per cent of households that had an infant as a member of the household. We found that consumption of breast mild substitutes increased from roughly 32 or so per cent to above I think 43 per cent after the earthquake among infants and we found that within the previous seven days, the incidence of diarrhoea had increased from 11 per cent to 25 per cent among infants in households that had received breast milk substitutes. So it was a pretty strong association with the receipt of breast milk substitutes and a change in infant feeding patterns and also in a health indicator, that is, the incidence of diarrhoea.

DYANI LEWIS
So this really raises the question then of how aid organisations who are presumably there to provide assistance in the time of need, how they can ensure they are helping rather than hindering a population.

DAVID HIPGRAVE
Yes and I'm not pointing the finger necessarily at aid organisations. People are very well meaning and the amount of assistance which was provided to the people who were suffering after the earthquake was really fantastic to see. The assistance came from all sorts of groups who maybe can't be expected to be familiar with the kinds of risks that I was talking about earlier that come with using breast milk substitutes in conditions where there's poor hygiene and also poor knowledge on the part of the mothers. So I'm not suggesting that aid organisations were doing anything malicious or with bad intent, but it's very important to have very strong and good quality information available for groups that are providing assistance in situations of natural or complex emergencies and one of those things should be that infant formula should not be part of the supplies that are distributed to families in distress.

DYANI LEWIS
I'm Dyani Lewis and my guest today is paediatrician and public health researcher, Dr David Hipgrave. We're talking about public health in developing countries, here on Up Close.David I'd like to take a closer look at China. You have quite a bit of experience in China and China is a country that has seen some very large and often rapid change to its economy over the past few decades. So how has China's health system changed with these economic changes?

DAVID HIPGRAVE
That's a great question and something I like talking about, but it's something that's difficult to answer in a short period of time. I think people forget that China's situation at the time that the Communists took over in 1949 was really among the worst in the world in terms of life health indicators. The life expectancy was in the 30s, the vast majority of deaths were due to communicable diseases, there was very little access to health care in the rural areas which housed the vast majority of the population.So when the Communists took over, they focused very quickly and they set to work very quickly about improving the situation of rural populations and that involved the introduction of many things that they learnt from the Soviets. So they established communicable disease control stations around the country as well as maternity units around the country and those two things alone were probably responsible for very rapid and very large improvements in life expectancy and in deaths due to common communicable diseases and also newborn deaths and also deaths due to things like newborn tetanus.China led the world in smallpox eradication. They had smallpox campaigns in the '50s. I believe they vaccinated as many as 550 million of a population of 600 million up to about 1955. I can't remember the exact year, but that disease disappeared from China 20 years before it was eradicated globally. So they made some really remarkable achievements.But one thing that was still missing was access to good quality clinical care and that was missing all the way up to the mid '60s when the introduction of the barefoot doctors commenced. They were promoted by Mao and there's lots of political and economic reasons why he might have done that, but that was really the first access that most rural Chinese had to some form of clinical care and particularly to Western style medicine. Of course they were hailed at the conference in Almaty or Alma-Ata in Kazakhstan in 1978 as the foundation of the primary healthcare movement. The village doctors were at their peak from the late '60s and through the '70s and then with the introduction of the market economy in the late '70s and early '80s, they really declined both in number and in the quality of service they were providing.

DYANI LEWIS
So what sort of services was a barefoot doctor able to provide?

DAVID HIPGRAVE
They were really the community based provider and communicator of both public health messages and a very basic degree of clinical care. So they might have been involved in sanitation campaigns, in health education, in referring pregnant women to appropriate antenatal and delivery care, as I mentioned, sanitation campaigns related to disposal of faeces, using clean water sources. Those are the kinds of public health initiatives that village doctors were involved in. But they were also probably involved in - or they were involved in distributing basic medicines like antibiotics, vitamins, anti-malarials, et cetera.

DYANI LEWIS
But they certainly weren't a doctor in the sense of the amount of training that we would assume goes into becoming a doctor now.

DAVID HIPGRAVE
Very basic training, very basic training; these people had a maximum usually of about six months as a kind of apprentice and often that was on the top of an education that only went to probably middle school level or maybe even junior primary level. So these people were very low functioning in terms of their technical capacity, but they, I guess, implemented the kind of basic care that was common in many developing countries where there's pattern recognition and the availability of a small supply of different drugs and they were able to do quite a lot of good.

DYANI LEWIS
Still, just getting that information out to the populace.

DAVID HIPGRAVE
Yes. Unfortunately the village doctor scheme, as I said, wound down in the 1980s and they've evolved into - so the barefoot doctor scheme wound down, so they've evolved into what's called village doctors who are now much better qualified, but until recently were functioning pretty much as private entrepreneurs in their delivery of health care and that meant fee for service which often meant profiteering and drugs and where the quality of care may have been more related to the sale of medicines, rather than actual need in terms of the patients' needs.In fact that's a kind of example of what happened to China's health system in the 1980s and 1990s and even up to the last 10 years or so where there was just a heavy marketisation of health sector and a reduction in public spending, government spending on health and expectation that health was a private matter between providers and individuals. So there's been a lot of recognition of that in the last five or 10 years, both public recognition as well as government recognition.In the last 10 years China has initiated a number of very high profile and very large scale initiatives to improve public access to care, things like reintroducing a national health insurance scheme, a rural health insurance scheme, which now has coverage well above 90 per cent. Basically the insurance coverage of individuals in rural China has grown from something like 15 per cent to the level of above 90 per cent; 800-odd million people who are now covered by that scheme.

DYANI LEWIS
So with that kind of scheme, what does that mean for access to health services for Chinese people today?

DAVID HIPGRAVE
In 2000 the World Health Organisation released a world health report that rated countries on a measure of equity and China was really towards the bottom of the list of 190-odd countries. Wasn't at the very bottom, was really down low, around about 160, 170 and that really referred to the fact that poor people simply could not afford health care. So the insurance scheme, particularly for inpatient care, has enabled people to be able to afford inpatient services and to, in many cases, avoid catastrophic health expenditure which bankrupted poor households around the country at an alarming rate and also resulted in high rates of people who were discharging themselves, against medical advice, because they simply couldn't afford to be in hospital anymore.The scheme has, as I said, focused on inpatient care, but is increasingly now focusing on outpatient care as well. They're also aiming to increase the benefit of the scheme, that is, the level of reimbursement that people can get for either hospitalisation or for outpatient care.

DYANI LEWIS
So you talked a bit about the disparities between wealthy and poor Chinese. What about the differences between rural and city dwelling communities?

DAVID HIPGRAVE
The differences are still quite great, not only in very core indicators like maternal and child mortality - actually maternal mortality is theoretically no different now, but certainly child mortality, there's still great regional differences in child mortality across China and differences between urban and rural areas. If you're thinking of a city like Shanghai or Beijing, you can get care that's the equivalent of almost anywhere in the world. I believe Shanghai's under five mortality rate is not very different to Australia's. Certainly the quality of all sorts of medical care and the availability of even advanced care, transplantation, medicine, fertility treatment, those kinds of things are very much available in wealthier urban areas of China, but most definitely not available in many rural areas.So I'm not saying that rural healthcare in China is bad, it's actually improved dramatically in the last 10 or 15 years, or even over a longer period than that. But there are great disparities both in the quality of care, the availability of different sorts of care and also in the uptake of care and as a result, the health indicators that we were talking about are earlier.

DYANI LEWIS
The high level of care in cities, is that also true for migrant workers who have come from the countryside?

DAVID HIPGRAVE
The access of migrant workers to healthcare is a very fraught issue in China and I think it's something I think they're having to deal with at a very rapid rate because urbanisation is proceeding very quickly in China. It's also tied in with political issues such as the official recognition of migrant workers or people who migrate from rural areas to urban areas as having what's called hukou or the official permit that enables them to live in and also benefit from the services that are operated or provided for residents of the city.So there's a lot of debate and concern about the fact that migrant workers are legally only able to access certain benefits in their place of origin and not in urban areas that might also apply to the availability of health insurance for them. So it's not just for the workers, but also for the families that migrate with them, so there are definitely differences in both the access to care and also the health outcomes for migrant workers in urban areas of China, rural migrants.I would imagine that the next five years in China will see major changes in some of these very basic issues that affect individuals. Another one is potentially the one child policy which there might also be some announcements on.
DYANI LEWISYes, I was going to ask you about the one child policy. Could you just give us an explanation of what it is and what impact it has had on health in China?
DAVID HIPGRAVEThe one child policy was introduced in the last 1970s in response to high fertility rates amongst Chinese women. I think the fertility rates were as high as five or six. But there had already, even before the policy was formalised, there had already been major reductions as the economy was progressing and also the rates of child mortality were decreasing. It applies to approximately two-thirds of married couples and of course as the name implies, they are only allowed to have one child. The exceptions to the rule are couples who are the only children of both of their parents, so they are allowed to have two children. It's also not applied as strictly to ethnic minority groups in China, which makes up about eight per cent of the population, there's 53 or so ethnic minority groups in China. There are exceptions for couples who have a child that is severely disabled or some other kind of tragedy affects the child.Having said all that, it's been extremely effective. There's no doubt that the number of children born in China has been reduced dramatically through implementation of the policy. You're probably aware that there have been lots of controversies about how strongly and how strictly the policy has been implemented. It's been the subject of a lot of controversy and adverse reporting. But more recently the real adverse reporting about the one child policy is the demography of China and the impact it's had on the ageing of the population where by 2050 I think almost 20 per cent of China's population will be above 65, maybe even more than 20 per cent.The number of young people who are in the labour force and who are paying taxes and producing goods and driving the economy will actually be a considerably smaller proportion of the overall population than in other countries. I think there are many people who are starting to acknowledge that this is something that needs to be acted upon very quickly to avoid a situation where you've got a very old and not very productive society overall.
DYANI LEWISThat would have huge impacts then on health program delivery.
DAVID HIPGRAVEAbsolutely and epidemiology of disease and illness in the country and the affordability of health programs, et cetera.
DYANI LEWISOne final question, what lessons can really be learnt from China and the way it has developed its health system over the years and applied to other developing nations?
DAVID HIPGRAVEI think the lesson, it's kind of a negative lesson unfortunately, is the really strong marketisation of the health sector in China had a pretty adverse impact on accessibility and affordability of health care for poor people. China's done extremely well on lifting people out of poverty, but when it comes to healthcare access, it was not nearly as effective. Their strategy was not nearly as effective. So that's one issue I think is a good lesson for countries whose economies are improving and whose ability to regulate the health sector and regulate the private sector in particular may not be very strong. That's really a big proportion of developing countries, particularly in this region where economies are still continuing to grow, but the involvement of government, particularly in societies or governments where there's a lot of decentralisation, so the involvement in government and regulation of the health sector are maybe quite weak. That's one lesson that I think countries could look to China for.Of course there are positives. China's been very effective at control of vaccine preventable diseases, for example. Very effective at reducing maternal mortality and unusually effective at reducing newborn mortality, probably through the same mechanism that they have been effective in reducing maternal mortality and that's going very strongly with a strategy of hospital delivery for newborns. In many countries they are focusing more on community based skilled birth attendants, but China's policy was very strongly to encourage women to deliver in a hospital or in a health facility and the hospital delivery rate has increased from the mid-60s, so roughly 65 per cent in about 2000 to now well above 95 per cent and that's had a major impact on maternal mortality and also newborn mortality. It's a great lesson for other countries to learn.I think the other area that China's done very well in is child nutrition. There's a millennium development goal target to halve between 1990 and 2015 the proportion of people who suffer from hunger and one of the indicators is the prevalence of underweight among children under five years of age. They achieved that target well ahead of schedule and the numbers of kids who are underweight in China is really a small fraction of what it was in 1990. I'm not saying it's zero; there's still, I think, 12 per cent of kids in poor rural areas who are underweight, but it's significantly less than it was 20 or 25 years ago.

DYANI LEWIS
So certainly some lessons to be taken away then?

DAVID HIPGRAVE
Sure.

DYANI LEWIS
David thank you for being our guest today on Up Close and talking with us about public health in developing countries.

DAVID HIPGRAVE
Pleasure, thank you.

DYANI LEWIS
Dr David Hipgrave is an associate at the Nossal Institute for Global Health at the University of Melbourne. Relevant links, a full transcript and more info on this episode can be found at our website at upclose.unimelb.edu.au. Up Close is a production of the University of Melbourne, Australia. This episode was recorded on 18 October 2012. The producer for this episode was Kelvin Param, the associate producer was myself, Dyani Lewis, with audio engineering by Gavin Nebauer. Up Close is created by Eric van Bemmel and Kelvin Param. Until next time, good bye.

VOICEOVER
You've been listening to Up Close. We're also on Twitter and Facebook. For more info, visit upclose.unimelb.edu.au. Copyright 2012, the University of Melbourne.


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