Environmental health

To the Editor: In 2009, we calculated that an estimated 50 405 prison inmate separations occurred in Australia in the 2007–08 financial year,1 and argued that the significant mortality risks associated with release from custody necessitated accurate and routine dissemination of such information. We believe this is still required, and that reporting the most current estimate of inmate separations may help facilitate better through-care and post-release health service provision. Our previous estimates have been used to contextualise discussions of prisoner health,2 estimate the number of post-release deaths,3 and advocate for needle and syringe programs in Australian prisons.4 Consistent with the approach detailed elsewhere,5 we estimated the number of inmate separation episodes occurring in Australia for the financial year 2008–09, using benchmark data from public documents on the website of each state and territory government department responsible for prisons. We attempted to obtain the total (ie, sentenced and on remand) number of inmates released from prison in 2008–09. This figure was available for Victoria (5458), South Australia (4489) and the Northern Territory (3078). For New South Wales, data could only be obtained for separations of sentenced prisoners (8941). To adjust for separations of prisoners on remand in NSW, we assumed that separations of sentenced prisoners comprised 38% of all separations, reflecting the ratios of separations in other jurisdictions. Hence, the total estimated number of separations in NSW was 21 468. Adding this to the other three figures gave a total of 34 493 separations in four jurisdictions that collectively hold 63% of the national prisoner population. A multiplier of 1.59 (1/0.63) was applied to this figure to produce a national estimate of 54 751 prison separations in 2008–09, each of which is associated with a significant increase in risk of death. Our estimate represents an 8.6% increase on the estimate from the previous financial year. This substantial increase suggests that routine reporting of actual incidents of separation, as well as numbers of unique individuals released from prison, remains vital to the provision of adequately scoped and resourced post-release health and welfare services in Australia.

Kristy A Martire · Sarah Larney

To the Editor: Significant mortality and morbidity occur among pedestrians involved in road traffic incidents.1 The National Road Safety Strategy 2001–20102 aimed to achieve a 40% decrease in pedestrian fatalities in Australia through road safety measures, including urban speed limit reductions. To assess the impact of such measures, we examined the long-term mortality trend in pedestrians presenting to an inner Sydney major trauma centre and determined whether incident location was a predictor of major trauma (defined as in-hospital mortality, intensive care unit admission and/or Injury Severity Score > 15). We identified 1944 trauma registry records of adult patients admitted to Royal Prince Alfred Hospital between 1992 and 2010 as the result of a pedestrian incident within the hospital’s catchment area, excluding transfers from other facilities (Box 1). Incident locations noted on clinical and ambulance records were classified as city or suburban according to current City of Sydney local government area boundaries. Population data were obtained from the Australian Bureau of Statistics. From 1992–1994 to 2007–2009 (population data for 2010 were unavailable at time of analysis), the age-adjusted mortality rate fell from 6.25 to 2.31 per 100 000 population (Box 2), a relative decrease of 63% (incidence rate ratio [IRR], 0.94; 95% CI, 0.91–0.98; P = 0.003). Negative binomial regression analysis showed that the reduction in mortality was statistically significant for incidents in the city (IRR, 0.91; 95% CI, 0.86–0.96; P = 0.01) but not suburban areas (IRR, 0.96; 95% CI, 0.92–1.00; P = 0.09). Multivariable logistic regression showed the odds of major trauma were 70% higher for suburban incidents than city incidents after adjusting for age, sex and time of presentation (after hours and weekends) (adjusted odds ratio, 1.7; 95% CI, 1.1–2.6; P = 0.02). The decrease in pedestrian mortality appeared most prominent after 2003, around the time the urban speed limit was reduced from 60 km/h to 50 km/h, and to 30–40 km/h in areas with high pedestrian activity.3 The 10 km/h speed limit reduction alone is estimated to have resulted in a 6% decrease in pedestrian fatalities.4 However, the trend appears to be limited to city incidents, with an annual reduction of 10% in the city versus 3% in suburban areas (Box 1). The observed improvement in outcomes, particularly in the City of Sydney, is likely a result of speed-limit reductions, drink-driving laws and improvements in clinical care. However, more needs to be done to protect pedestrians in suburban areas. 1 Baseline characteristics and outcomes of pedestrian incidents City (n = 883) Suburban (n = 1061) P Male 561 (47%) 625 (53%) 0.04 Median age (IQR) 34 (24–53) 46 (29–67) < 0.001 Median ISS (IQR) 4 (2–9) 5 (4–17) < 0.001 ICU admission 124 (11%) 241 (19%) < 0.001 Median hospital length of stay, days (IQR) 3 (1–9) 5 (1–13) < 0.001 Major trauma* 175 (20%) 336 (32%) < 0.001 Deaths 32 (4%) 76 (7%) 0.001 Crude mortality rate (95% CI)† 1992–1994 2.1 (− 0.4, 4.7) 1.5 (− 0.03, 3.0) 1995–1997 1.2 (− 0.6, 3.0) 2.3 (0.4, 4.4) 1998–2000 0.9 (− 0.6, 2.4) 2.0 (0.2, 3.8) 2001–2003 1.6 (− 0.3, 3.6) 1.5 (− 0.03, 2.9) 2004–2006 0.3 (− 0.5, 1.2) 1.3 (− 0.09, 2.7) 2007–2009 0.3 (− 0.5, 1.2) 0.9 (− 0.2, 2.0) Annual change over 18 years‡ − 10% − 3% IQR = interquartile range. ISS = Injury Severity Score. ICU = intensive care unit. * ISS > 15, requiring ICU admission, and/or death. † Rate per 100 000 population among adult pedestrians averaged over 3-year periods. ‡ Calculated using the formula: change (%) = (P1/P01/n − 1) × 100 where n is number of years observed − 1, P1 is the final average rate and P0 is the initial average rate. 2 Age-adjusted mortality rate per 100 000 population for adult pedestrians, 1992–2009* * Age standardised to Australian Bureau of Statistics 2006 census data (bars represent 95% confidence intervals).

Matthew Oliver · Michael M Dinh · Susan Roncal · Soufiane Boufous · Bernardino Branco · Christopher M Byrne

Health professionals should educate families about risk factors for accidental asphyxiation in shared-sleeping arrangements Over the past two decades, great advances have been made in identification of hazardous sleeping environments for infants and young children, with significant reductions in numbers of deaths.1 However, one issue that continues to incite heated debate is whether adult caregivers should sleep on the same surface as infants,2 referred to as “shared sleeping”. It is recognised that infants who sleep in the same room as their carers have a reduced risk of sudden infant death syndrome (SIDS),3 possibly due to an increased level of direct supervision.4 However, what of infants who sleep in the same bed as their parents or carers? First, it is important to clarify terminology. Although it is claimed that shared sleeping increases the risk of SIDS, it is perhaps more accurate to state that it is associated with an increased risk of infant death generally. An indication that shared-sleeping deaths may be different to “classical” SIDS deaths that occur among infants sleeping on their own is a finding of an almost equal sex ratio in shared-sleeping deaths, compared with the 2 : 1 male–female ratio among infants who died of SIDS.5 If some of the risk factors for shared-sleeping death (eg, parental obesity, fatigue, soft sleeping surfaces) are examined in isolation, accidental suffocation appears to be a more likely mechanism of death than subtle processes leading to SIDS.5 These apply to any shared-sleeping surface, not just to beds. It is difficult to formulate absolute recommendations on shared sleeping, as the current incidence in most communities is unknown, and the form that it takes varies greatly between families. There are also cultural issues to take into consideration — for example, shared sleeping is very common in South-East Asian communities, but with low incidences of unexpected infant deaths.6 However, a study from Avon, United Kingdom, found a disturbing percentage increase in shared-sleeping deaths among two cohorts of infants who died of “SIDS”, from 12% (17/147 in 1984–1988) to 50% (18/36 in 1999–2003) (P < 0.001).7 The authors noted that although the number of shared-sleeping deaths that were not on sofas dropped (from 16 to 14), the decrease was not as great as that among infants who were sleeping on their own, perhaps explaining the increased proportion of unexplained infant deaths found in shared-sleeping situations. This difference may be due to mechanisms of death being different in the two circumstances. A similar effect was noted in South Australia, where the proportion of shared-sleeping deaths increased from 7.5% of “SIDS” deaths (23/306 in 1983–1990) to 32.3% (21/65 in 1991–1993).8 The percentage of deaths in shared-sleeping situations in the early part of the study also showed an overrepresentation compared with the shared-sleeping rate of 1.5% in the general community in 1988.8 As some infants are particularly vulnerable to the effects of airway occlusion,9 and as there is often no clinical predictor of this vulnerability, all that can be stated is that certain infants may be inherently at increased risk in a shared-sleeping situation. It is generally agreed that in Western cultures, the safest place for an infant is in a cot that meets recommended safety features and is positioned beside the caregiver’s bed.1,2 Supporters of shared sleeping cite advantages that include an increased incidence and longer duration of breastfeeding, enhanced maternal–infant bonding and improved settling.1 However, it has been reported that 50% or more of infants who are found unexpectedly dead are sleeping with an adult.10 The suggestion of possible accidental asphyxia by a parent “overlaying” a shared-sleeping child has been criticised, because it has been assumed that a parent would always arouse. However, parents can fail to wake if they are sedated or overly fatigued. There is an increased risk of infant death when caregivers have taken illicit drugs, smoked, or consumed more than two units of alcohol.10 In addition, it is not necessary for an adult to be lying over an infant completely for respiration to be compromised, as an infant who has rolled into a trough between a parent’s much larger body and a soft mattress may also be at risk.11 This is exemplified by the dangers of shared sleeping on a sofa.7 On occasion, parents state that they successfully slept in the same bed as all of their children without any deaths occurring. While such anecdotes are undoubtedly true, few risks are absolute and so it cannot be used as definitive evidence that shared sleeping is always a safe practice. The key to assisting with this issue lies in adequately informing caregivers of potential risks. Clinicians should discuss with caregivers the risk factors for accidental asphyxiation in shared-sleeping arrangements, such as sedation, excessive fatigue and hazards predisposing to suffocation. This may help prevent infant deaths in the future.

Roger W Byard MB BS, MD

Ray Moynihan explores the push for new powers and strong opposition to it If there was ever a case of market forces running ahead of regulators, it is corporatised medicine in Australia. Driven by medical entrepreneurs and merchant banks, the creation of giant health care empires has taken place with little public debate or political interest. While a new private industry is now successfully profiting from publicly funded Medicare, health authorities have so far found no meaningful mechanism to police the sector. “The business of medicine has been altered forever”, argues the former head of Medicare’s watchdog unit, “by the entry of corporatised medicine”.1 Testifying to a recent senate inquiry, Tony Webber, former Director of the Professional Services Review (PSR), said he’d like to see a revamped PSR scheme within Medicare given the power to “investigate scams and unacceptable corporate behaviour, of which I have seen significant examples”. Asked if any executive had been prosecuted, Webber told senators: “Sadly, no, because the legislation makes it very difficult to do so”.1 Responding to his concerns, the committee recommended strengthening the watchdog’s powers and government is currently considering its response. Evidence of corporate “scams”, says Webber, remains largely anecdotal and based on tip-offs which, while appearing credible, are currently unable to be followed-up. According to Webber, the problem is while companies are geared to make money, Medicare was never designed to pay the doctor and a nice corporate dividend as well — a theme he expands on elsewhere.2 One of the industry’s giants is Sonic Healthcare, owner of the Independent Practitioner Network with 140 medical centres and around 1000 GPs who produced “strong revenue growth” last year, contributing to Sonic’s overall profit of $295 million.3 The other giant is Primary Health Care Limited, running almost 90 centres, also contracting 1000 doctors, worth around $1.5 billion, and with profits of $80 million.4 Another player is Healthscope, bought recently by a consortium of global private equity firms. All three are “vertically integrated”, with medical centres, pathology laboratories and imaging facilities. There is no suggestion that these, or other particular corporations, or people associated with them, engage in or encourage any form of inappropriate behaviour. The man known for pioneering corporatisation of health care in Australia is Edmund Bateman, managing director of Primary Health Care Limited. The company describes itself as the “most profitable in this field” with a “formula” offering value to doctors and patients.4 In an extended interview with me recently, Bateman strongly rejected the need for enhanced watchdog powers, saying it was “based on the assumption that the corporation is responsible for the behaviour of the doctor”, which was “out of touch” with the reality. He said there’s also an assumption of “improper pressure” on doctors, but it doesn’t exist. “I can’t tell them what to do”, he told me, “if there is any pressure, it’s to practise better medicine”. While stressing that doctors signing contracts with Primary Health Care Limited retained clinical autonomy, in general, they also “undertake to support our services, where clinically appropriate” he said, adding doctors “tend to support the pathology in the building, out of convenience”. The idea of forcing corporations to contribute to paying the fines of doctors found to have practised inappropriately is also opposed by Bateman: “it’s human nature for people to try and blame other parties”, he says, “professionals in particular are responsible for their own behaviour”. Arguing it’s not “proper process”, he suggests that the entire PSR Scheme should be abandoned and any action against doctors happen via “normal legal process”. Asked about his own use of courts to take action against doctors contracted to his companies, and a newspaper report that there had been dozens of cases against practitioners in the past decade,5 Bateman declined to confirm a figure, saying that of the 1000 contracts with doctors only a “very small minority” ended in litigation, and that he is suing the newspaper involved. Questioned about suggestions that his centres had created and billed for “care plans” for patients who regularly saw doctors outside, he said that “sounds like sour grapes from someone who should have provided one before this”. Other corporate chiefs contacted declined to comment. In my view, one way to independently assess competing claims about corporate medicine might be to compare profiles of doctors working inside and outside corporate structures. While complex, with confounding factors, a sophisticated analysis could cast much-needed light here and build academic expertise in the field. As to recommendations for new powers to “pursue abuse” of the system,1 the government’s response is pending. Perhaps it may also be timely to reassess just how well the private-for-profit corporate structure sits with the spirit of a publicly funded universal health insurance scheme.

Ray Moynihan BA

Yes. Public health adviser David Roder and Cancer Council Australia CEO Ian Olver believe the reduction in breast cancer mortality in Australia reflects both treatment and screening effects All screening programs should be assessed for their benefits and risks, including the extent of overdiagnosis. Recently, Burton and colleagues concluded that almost 60% of the Australian decline in breast cancer mortality since 1991 could not be due to BreastScreen Australia (the free national mammographic program), attributing most of the decline to adjuvant hormonal and chemotherapy.1 Questions around attribution are not new. There has been no formal modelling in Australia, but modelling funded by the National Cancer Institute in the United States suggested that about half the US breast cancer mortality reduction may be due to adjuvant therapy and about half to screening.2 Age-standardised breast cancer mortality rates have decreased by about 29% among Australian women since the 1989–1991 period, when organised mammography screening (now known as BreastScreen) began.3 Compared with a linear projection of mortality increases in the 1980s, the observed rate in 2007 was about 38% lower.3 Observations on women outside the screening age range show that factors other than screening would have contributed to this decline, but there is also evidence for an important BreastScreen effect.3 Three evaluations of mammography screening of Australian women aged 50–69 years, including the formal BreastScreen Australia Evaluation Plan, indicated reductions in breast cancer mortality of between 30% and 47% from screening.3 This range is broadly consistent with trial evidence where a reduction of around 35% was estimated by an expert working group of the International Agency for Research on Cancer (IARC).4 A 25% reduction in breast cancer was estimated by Australian researchers from a meta-analysis of trial data for all ages.5 Collective results of 35 studies in other countries are similar to the IARC’s 35% reduction estimate,3,4 although individual study results varied from little or no benefit to reductions of up to 76%.3 With present participation rates in Australia’s BreastScreen program, a 35% reduction in breast cancer mortality in participants would correspond with an estimated 270 fewer breast cancer deaths a year in all Australian women aged 55–74 years. (Note that this allows for a time lag of 5 years in deaths.) Breast cancer incidence rates rose in Australia following the introduction of BreastScreen.3 The extent to which this reflected lead-time effects of screening, changes in pathology and other diagnostic practices, overdiagnosis, and real increases due to changes in underlying risk factors (eg, reproductive behaviour, body weight, alcohol consumption and use of hormone replacement therapy) is unknown. Increases in incidence were already occurring in the 1980s before BreastScreen introduction,3 but the contributions of increased use of private mammography and changes in risk factors during that period are not known. The increase in breast cancer mortality rates in the 1980s is suggestive of real increases in underlying incidence.3 There is concern that screening may result in detection of cancers that would never have caused symptoms or death in a woman’s lifetime (ie, overdiagnosis).3 There is no consensus on levels of overdiagnosis, with estimates worldwide varying from close to zero to over 30% of diagnosed cancers, irrespective of whether in-situ lesions were included.3 The estimates vary so widely that interpretation is difficult. Research is needed to better define levels of overdiagnosis and, ideally, to develop more effective means of determining at diagnosis the potential for screen-detected and other breast cancers to progress. In summary, it is likely that the reduction in breast cancer mortality in Australia reflects both treatment and screening effects. The relative contribution of each to the overall reduction is not clear, although there is evidence that both would be contributing substantially. Women should be informed of both the risks and the benefits of screening, including the uncertainty around overdiagnosis. However, present screening participation levels of 50–69-year-olds in BreastScreen would be consistent with a significant annual reduction in breast cancer mortality. Levels of overdiagnosis are uncertain and require better definition. Means of better predicting the likelihood of progression of untreated in-situ lesions and early invasive breast cancers to advanced disease are needed, and this need is likely to increase as more sensitive screening and diagnostic technologies are developed.

David M Roder PhD · Ian N Olver MD, PhD, FRACP

No. Breast cancer researchers Robin Bell and Robert Burton believe that screening can result in overdiagnosis Screening mammography undoubtedly saves lives. Since 1991, when Australia’s free national mammographic screening program (BreastScreen Australia) began, there has been a 29% reduction in breast cancer-specific mortality. However, our analysis of age-stratified data indicates that BreastScreen does not account for most of this mortality reduction.1 Furthermore, it is now recognised that the balance between the benefits and harms of screening has become increasingly unfavourable. Women should be given a balanced explanation of what BreastScreen offers them. Our study analysed age-specific trends in breast cancer incidence, mortality and BreastScreen participation by Australian women aged 40–79 years since 1991.1 We found that the participation rates and relative mortality declines were the opposite of what the randomised controlled trials (RCTs) of mammographic screening had predicted. Women aged 40–49 years, who had the lowest BreastScreen participation (about 20%), had the largest mortality reduction (43.6%; 95% CI, 34.8%–51.2%). Women aged 60–69 years, who had the highest BreastScreen participation (about 60%), had the smallest mortality reduction (19.1%; 95% CI, 10.5%–26.9%). We also analysed the proportions of the declines in absolute breast cancer-specific mortality from 1991 to 2007 in two parts (before and after 1999–2000), to identify periods before and after any effect of BreastScreen on mortality might have been expected. We found that only about a third of the reduction in mortality in the age group invited for screening (50–69 years) occurred after 1999–2000.1 We have calculated the contribution that adjuvant endocrine therapy and chemotherapy could have made to the reduction in breast cancer mortality in Australia since 1991. Australia is unique in having six datasets from population-based breast cancer treatment surveys between 1986 and 1999. These document the stage at diagnosis and adjuvant treatment received for early breast cancer for different samples of Australian women. Based on a 10–15-year follow-up of their overviews of RCTs of adjuvant therapy in early breast cancer between 1985 and 2000, the Early Breast Cancer Trialists Collaborative Group (EBCTCG) concluded that appropriate use of anthracycline-based chemotherapy followed by tamoxifen for oestrogen-receptor-positive disease would result in annual breast cancer mortality reductions of 57% for oestrogen-receptor-positive women < 50 years of age and 45% for those aged 50–69 years.2 Our analysis, using 1999 Victorian survey results and the EBCTCG overview, found that breast cancer mortality reductions in Australian women in 1999 from adjuvant endocrine therapy and chemotherapy could have been up to 38% for women aged 40–49 years, and up to 24% for women aged ≥ 50 years.1 Therefore, adjuvant therapy had the potential to produce most of the 29% reduction in breast cancer mortality in Australia since 1991. In theory, screening for an asymptomatic earlier stage of a disease that is more effectively treated with available therapies than symptomatic disease will produce less morbidity and mortality, but screening can result in overdiagnosis. Overdiagnosed breast cancers are those detected by screening mammography that would not have become symptomatic in the woman’s lifetime. Overdiagnosis by mammographic screening is most accurately estimated from the RCTs by comparing the increased numbers of breast cancers diagnosed in women invited to undergo screening compared with those not invited. A recent Cochrane systematic review of the RCTs puts the estimate at 30%.3 An estimate from incidence trends in New South Wales indicated that 30%–40% of invasive breast cancers were overdiagnosed in 1999–2001.4 The benefits and harms of mammographic screening are measured in terms of the ratio of lives saved to cases overdiagnosed. Using the RCT data, the 2011 Cochrane review determined that, with 30% overdiagnosis and a relative mortality reduction of 15%, “for every 2000 women invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy women, who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer patients and treated unnecessarily”.3 As the outcome of treatment for both symptomatic and asymptomatic disease improves, the impact of screening diminishes and the balance of benefits to harms will become less favourable. This has serious implications for health policymakers. We believe it is time for women to be presented with a more balanced view about the benefits and harms of breast screening. Screening programs are currently undergoing review in the United Kingdom, and one of the first commitments is to a new process of developing written information for the public that will synthesise information on benefits and harms. There has been an assurance that the leaflet about breast cancer screening will be among the first to be revised.5

Robin J Bell PhD, MPH, FAFPHM · Robert C Burton MD, PhD, FRACS

Objective: To compare three cystic fibrosis (CF) newborn screening strategies used in Victoria since 1989.Design, setting and participants: Retrospective review of newborn screening and clinical records for people with CF born in Victoria between 1989 and 2008 to compare screening strategies: repeat immunoreactive trypsinogen (IRT) testing (IRT/IRT, 1989–1990), IRT and p.F508del mutation analysis (IRT/p.F508del, 1991–2006) and IRT with analysis of 12 CFTR mutations (IRT/12 mutations, 2007–2008).Main outcome measures: Total number of infants screened, people identified with CF (by screening or clinical diagnosis), number of CF-affected terminations of pregnancy, and number of carriers detected.Results: There were 420 people born with CF (live-birth prevalence, 1/3139; 95% CI, 1/2853–1/3462) and 78 CF-affected pregnancy terminations (overall prevalence, 1/2647; 95% CI, 1/2425–1/2896). Of the babies born with CF, 283 (67.4%) were detected by newborn screening alone, 61 (14.5%) had meconium ileus, 33 (7.9%) had a family history of CF, nine (2.1%) were diagnosed antenatally, and 34 (8.1%) were missed by screening (17 missed because IRT level was < 99th percentile, two with repeat IRT level not elevated, 14 without a screened CFTR mutation, and one with missing data). The sensitivities of the protocols were 86.6% for IRT/IRT, 89.9% for IRT/p.F508del, and 95.8% for IRT/12 mutations. Including 12 mutations in the analysis detected one patient who would otherwise have been missed and, had this protocol been implemented from 1989, it would have detected four others.Conclusion: Most babies with CF without meconium ileus, a family history or antenatal diagnosis are detected by newborn screening. Despite improved sensitivity with the 12-mutation analysis, most infants detected would have been diagnosed using the IRT/p.F508del protocol.

R John H Massie MB BS, PhD, FRACP · Lisette Curnow BSc · Judith Glazner RN · David S Armstrong MB ChB, FRACP, MD · Ivan Francis BSc, GradDipCompSc

More comprehensive investment is needed to abate the extreme disadvantage experienced in some Aboriginal communities Poor housing, inadequate hygiene practices and household overcrowding directly or indirectly underlie many of the health and social problems present in most remote Aboriginal communities in the Northern Territory. Improving housing and hygiene and reducing household overcrowding are fundamental developmental steps to reduce the extreme disadvantage experienced in remote Aboriginal communities.1-2 These improvements are not only essential to improve health outcomes, but are also a prerequisite for the success of current government efforts to increase participation in the workforce, improve school attendance rates and develop safe communities.3 In this article, I discuss Australian and NT Government policies and programs aimed at Closing the Gap on Indigenous disadvantage in remote Aboriginal community contexts.4 Current initiativesThe Australian Government’s agenda to close the gap on Indigenous disadvantage is driven by three imperatives: to overcome decades of underinvestment in services and infrastructure; to encourage and support personal responsibility as the foundation for healthy, functional families and communities; and to build new understanding and respect between Indigenous and non-Indigenous Australians.4 The policy approach includes the identification of seven key “building blocks” to address specific areas of Indigenous disadvantage — early childhood, schooling, healthy homes, safe communities, economic participation, and governance and leadership. Through the National Partnership Agreement on Remote Indigenous Housing, the Australian Government is investing $5.5 billion nationally over 10 years “to tackle the housing backlog across remote Australia and to help reduce overcrowding in Indigenous communities”.4 Under the Strategic Indigenous Housing and Infrastructure Program (SIHIP), at a cost of $672 million, the Australian and NT governments will build 750 new homes, rebuild 230 existing houses and refurbish 2500 houses across 73 remote Indigenous communities and several community living areas (town camps) in the NT by 2013.5 A new system to manage public housing in remote communities has been introduced. This system includes introduction of tenancy agreements, payment of fair rent, an improved process for repairs and maintenance to homes, and improved tenant support services.6 Influences on the household mixDespite these initiatives, it appears that governments still do not recognise the complex social and cultural issues that underlie housing, health and social issues present in many remote Aboriginal communities in the NT.7,8 Non-Indigenous health workers in remote communities learn about some local practices because they need to be accommodated in the workplace — for example, avoidance relationships that exist between individuals (in some communities, between brother and sister) and protocols concerning “men’s business” or “women’s business”. However, little or nothing is known about how cultural observances shape householders’ day-to-day living practices, especially hygiene behaviour, and how housing infrastructure is perceived and used. Household overcrowding is more complex than a couple and their children living in a house too small for their needs.9 Rather, household membership comprises extended family members, and frequently includes one or more individuals with special needs (eg, frail older people, or people with psychiatric disorders and/or in poor health from chronic diseases). Households experience higher levels of stress when the behaviour of one or more family members is affected by misuse of alcohol, drugs, kava or petrol, or if problem gambling is an issue. More stress is added when a family member is in the court system, imprisoned or in juvenile detention. This household mix presents challenges for those caring for children, and those who wish to maintain good personal and domestic hygiene, and keep their house in a good condition. No quick fixWithout more extensive initiatives, providing a limited number of new, renovated and refurbished houses (compared with the size of the need) will not directly increase employment, improve school attendance, or make remote communities safer. That housing is seen as a quick fix is reflected in three case studies in the Closing the Gap — Prime Minister’s report 2011.4 In these case studies, it is inferred that new housing will enable one tenant to become employed; children will now attend school; and one tenant will now teach his children to keep the house clean. Research has shown that providing infrastructure alone will not resolve the social and cultural factors that shape people’s attitudes and behaviours.10,11 A need for supportIn late January 2011, the Australian Government reported the completion of 179 new houses and 1036 rebuilds or refurbishments in the NT.5 These additional and improved houses meet an urgent need, but it is of concern that very little has occurred to provide tenant support programs, such as life skills or homemaker programs, and improved repairs and maintenance services. Without these programs, any health or social gains as a result of the additional or improved housing are likely to be minimal.10,12 Communities’ desire for such support is evident from a perusal of Local Implementation Plans (plans developed through close consultation between governments and local reference groups that set out the priorities for each community as part of the Working Future program in the NT).13 Of the 11 NT Plans publicly available at the time of writing, eight indicate a desire for programs (eg, life skills and/or improved repairs and maintenance programs) to achieve healthy housing. Addressing key factorsThe size of the housing backlog, the poor state of many existing houses and the level of overcrowding suggest that four key factors need to be addressed in unison to achieve healthy housing in the remote Aboriginal community context: all existing housing stock be maintained in good condition; overcrowding be incrementally reduced by continuing to provide additional housing; appropriate, acceptable programs that are intensive and ongoing be provided to help improve standards of personal, domestic and environmental hygiene; and multifactorial tenant support programs be set up to deal with underlying social and other issues.10,14 Regrettably, there is little or no good-quality evidence available to know what interventions might work in this context. In the past, health promotion and life skill programs have either not been evaluated, or the evaluations have lacked rigour; as a result, the strength of any available evidence is poor.15 Past housing construction and repairs and maintenance programs in remote Aboriginal communities are contentious and generally viewed as failed or failing.16,17 Political imperatives driving the Indigenous health and housing agenda have resulted in a failure to accumulate a knowledge base in these areas. Reviews are conducted to monitor the management of SIHIP,16 but no mechanisms appear to be in place to prevent the unintended negative consequences of past housing policies being repeated. There is a danger that if Closing the Gap programs do not demonstrate progress (especially as this concerns housing), the commitment by governments to deal with the wider social determinants of health will lessen. Instead, narrow lifestyle interventions focusing on personal responsibility and individual behaviours will be introduced. There are examples of this happening already (introduction of tenancy agreements as the primary means to modify tenants’ behaviour;18 income management and the introduction of the BasicsCard;19 withholding the welfare payments to parents whose children do not attend school;20 and fining parents for children’s non-attendance at school21). These measures all reflect a simplified approach to deal with complex problems, and in most cases are not likely to be successful.22,23 More must be doneA recent strategic review of health inequalities in England recommended that to reduce the steepness of the social gradient in health, actions need to be universal, “but with a scale and intensity that is proportionate to the level of disadvantage”.3 The current approach to housing in remote communities falls short both in scale and intensity when compared with the extreme disadvantage experienced in these communities. To achieve major improvements in overall living conditions, and other Closing the Gap programs (especially education, employment and making communities safer), greater investment in a range of social and public health programs needs to accompany the current investment in infrastructure.

Elizabeth L McDonald PhD, MTH, BSc(Nurs)

Preparing for a future in humanitarian medicine Many young doctors are becoming aware that their careers will be spent in an increasingly globalised society — one in which major challenges will be managed by global initiatives and not by individual nation states alone. The concept of “global health” transcending geographical borders and requiring cooperative solutions between governments, organisations and individuals is becoming widely accepted in developing and developed countries.1 Over the past decade alone, the number of individuals who identify themselves as humanitarian and global health professionals has doubled, at least in the Western world.2 It is therefore no surprise that in recent years Australian medical students have been keen to join this growing movement.3 The Australian medical education system appears to be offering more opportunities to meet these interests. Recent initiatives range from academic and education options to policy development and grassroots conferences. To some people, working for global health means serving a humanitarian organisation, so some medical students and junior doctors make it a priority to get involved with humanitarian organisations locally and abroad. However, humanitarian aid is just one subset of the global health area and requires a specific skill set. A big picture understanding of all areas of global health allows for a balanced and solid foundation.1 Those who have an appreciation of the nuances of culture, poverty, gender inequities, corporate and social governance, health diplomacy, public health, and ethnic and religious factors will make better health care providers in emergency aid and other settings. For a young medical student or junior doctor, the plethora of global health opportunities can be overwhelming. We present a list of suggestions to help medical students and junior doctors prepare for a career in global health, with some pointers for faculty members. Tips for medical students and faculty membersGet involved as early as possibleDuring our medical training, we were privileged to be involved in global health projects as junior students. These experiences reaffirmed and strengthened our interest in the global health movement by exposing us to complex issues and needs in unfamiliar environments. The Australian Medical Students’ Association (AMSA) has restructured all Australian university global health groups so they are now in the AMSA Global Health Network.4 Being an active part of a global health group at our university helped us to better understand and appreciate the challenges that pioneers working for global health face. It also allowed us time to bond and network with like-minded colleagues around the country, to exchange ideas and discuss projects, and to fundraise and initiate practical help to communities in developing regions. Attend global health meetingsThe annual AMSA Global Health Conference is a 4-day intensive program. Renowned speakers educate delegates and raise awareness of current global health issues, and students are able to interact with like-minded students and faculty members. Notable presenters with interests in global health are often invited to conduct plenary sessions, deliver a keynote speech or train students in a workshop setting. For other meetings, check the Global Health Gateway website (http://www.globalhealthgateway.org.au/), which is updated frequently to reflect new global health-related events in Australia. Arrange a global health electiveOnce armed with knowledge of the conceptual framework of the global health sector, students are strongly encouraged to spend time in a national or international location during their elective or in vacation time. This allows an invaluable opportunity to transfer principles into practical experience.5 Overseas elective opportunities can be identified using well researched books, journals and media resources. It is important to be thorough in choosing an appropriate elective. Seeking references from others who have served with the organisation or agency can be helpful. One suggestion is to approach a host hospital directly, but remember to allow enough time for applications to be processed. This year, the Australian Medical Association Council of Doctors-in-Training and AMSA have jointly authored a Medical Journal of Australia supplement, A guide to working abroad, a resource for medical students and junior doctors who want to work and/or study abroad.6 Curriculum developmentRegular dialogue between students and faculty members should be facilitated to increase interest in and commitment to global health. At the least, faculty members should be encouraged to support students who are interested in this area.7 Most other specialty and subspecialty areas are well addressed within the undergraduate medical curriculum; there should be little reason why global health should not be given some attention. Take classes focusing on global healthSome medical schools have responded to the growing interest in global health and are now offering optional classes or modules focusing on global health issues. Teaching about global health issues, addressing access and availability of health care, inequities in health services and outcome-based evaluations provide the theoretical framework in which students can structure and make sense of future or previous global health experiences.7 Ideally, the expanding role of global health education in undergraduate medical curricula will lead to a proportionate increase in the number of practical international opportunities available to students.8,9 Some medical student societies run their own short courses on global health, with different weekly lecture topics. If there are no such modules or courses available, it may be worthwhile inviting noteworthy speakers for guest lectures, symposia or workshops. A monthly journal club or meeting can also help students stay abreast of global health developments and share ideas with colleagues. Develop links with facilities in developing countriesMedical faculties and student clubs involved in the global health area should also strive to develop links with countries and health services in national or international regions. With the support of faculty members, exchanges, learning opportunities, practical placements and research openings are more likely to be sustainable and hence beneficial to communities in the resource-poor settings they intend to serve. Tips for junior doctorsDo subspecialty training in your area of interestThe value of attaining subspecialty training is rarely disputed in today’s era of specialised medical care. In resource-limited settings, this holds true as well. Groups such as Médecins sans Frontières and the International Committee of the Red Cross provide emergency and trauma surgical care in places of conflict and disaster, as well as establishing their own hospitals or working closely with local health officials to improve health infrastructure. Extra training for surgeons and anaesthetists in obstetrics and gynaecology, orthopaedics and trauma care is invaluable. Recognising that the highest mortality and morbidity arise from a lack of basic public health resources (eg, water, sanitation, food and shelter), physicians trained in paediatrics, public health, primary health care and infectious diseases (especially HIV, AIDS and tuberculosis) are urgently needed in many areas. Repay student loans as early as possibleThe reality is that most positions in humanitarian medicine are voluntary or only pay small stipends, so the earlier a student loan is repaid, the sooner there is unrestricted flexibility to work in the global health sector. It is not uncommon for hospital medical officers (HMOs) in Australia to use their salaries from locum work to fund their overseas travel and global health projects. Tips for medical students and junior doctorsLearn a foreign languageSpeaking the local language is a vital asset when practising in the field. Short courses are available, and some programs allow cultural immersion in the country while allowing day classes to learn the basics of a language within 6 weeks. Combining a medical school elective with a language course can be a viable and attractive option. Find a faculty mentor with global health interestsIt is highly beneficial to identify a mentor with interests in the global health area. Someone experienced in the field who is willing to motivate, empower, encourage, teach by example and provide advice and guidance will prove invaluable.10 A global health mentor for a medical student or junior doctor could assist in many areas ranging from research topics or collaborators to options for working in the field. The importance of working with like-minded faculty should not be underestimated. The combination of the youthful passion and enthusiasm of students and the wisdom and experience of interested and dedicated faculty members is synergistic. Choose an employer supportive of global health activitiesSome employers are more flexible and supportive of global health activities. The capability and support of a director of clinical training and the HMO roster coordinator can be deciding factors for being able to undertake an international elective or sabbatical leave from training. Elective rotations are not readily available during junior doctor residencies. HMOs may take time off or take unpaid leave to pursue their interest in the global health area. Once in a specialty training program, it can be difficult to balance training requirements with global health initiatives. A fully trained medical specialist is likely to make more complete contributions in the field. Get an additional degree in the global health areaGlobal public health is primarily population-based care, not individual-based care. The benefits of dedicating time for further study of global health include: development of theoretical and practical skills in core competencies of global public health for future practice; and opportunities for networking and setting up global public health projects, which may culminate in further research or service opportunities. Ideally, areas of global health research should be matched to a future specialty of choice. In the surgical arena, for example, future research could focus on the increasing burden of surgical disease in an area, safety of surgical care in resource-limited settings and developing long-term sustainable academic and service partnerships.11 Community health projects are also very useful for those interested in pursuing a career in family medicine, obstetrics or paediatrics. A masters qualification in international health, public health or global health science can be obtained from one of the many Australian or international schools of public health. These institutions offer degrees varying in duration, structure and online capacity, and the different courses focus on different aspects of global health. With current global initiatives calling for a blueprint for professionalising humanitarian assistance, to ensure accountability and accreditation, our suggestions become even more crucial.12,13 ConclusionAlthough by no means comprehensive, our snapshot of suggestions aims to provide medical students and junior doctors a platform to explore the myriad opportunities in the global health sector. Most importantly, we believe that students and doctors alike should continue to read extensively, ask critical questions, appreciate the global health context and become passionate about this exciting area of medicine.

Jeffrey J Leow MB BS · Daryl R Cheng MB BS · Frederick M Burkle Jr MD, MPH, DTM

Objective: To determine whether sleep duration of Australian adults has declined over recent years.Design: Analysis of nationally representative data from repeated cross-sectional time-use surveys conducted in 1992, 1997 and 2006.Setting: Private households in Australia.Participants: Respondents aged 15 years and over (N = 21 195) who completed time-use diaries over two consecutive days.Main outcome measure: Change in sleep duration by sociodemographic group.Results: Mean sleep duration was 8 h 20 min in 1992, 8 h 33 min in 1997, and 8 h 30 min in 2006 (SEM for all years, 1 min). After adjustment for sampling during weekends and different seasons, there was no significant change in sleep duration from 1992 to 2006 (adjusted difference, 2 min; 95% CI, − 2 to 5 min; P = 0.33). The only significant decreases in sleep duration were observed in people aged 65 years and over (adjusted difference, 12 min; 95% CI, 4–19 min; P < 0.001), people with no income (adjusted difference, 17 min; 95% CI, 7–27 min; P = 0.001) and male carers (adjusted difference, 31 min; 95% CI, 9–53 min; P = 0.002), although people in these groups reported over 8 h sleep on average.Conclusions: Most Australian adults were not sleeping less in 2006 than they did in 1992. Public health concerns over declining sleep duration do not appear to be warranted. Investigation of possible changes in quality of sleep is required.

Yu Sun Bin BSc(Hons) · Nathaniel S Marshall PhD · Nicholas S Glozier MB BS, MRCPsych, PhD

Objective: To determine whether emergency department (ED) patients’ self-rated levels of anxiety are affected by exposure to purpose-designed music or sound compositions with and without the audio frequencies of embedded binaural beat.Design, setting and participants: Randomised controlled trial in an ED between 1 February 2010 and 14 April 2010 among a convenience sample of adult patients who were rated as category 3 on the Australasian Triage Scale.Interventions: All interventions involved listening to soundtracks of 20 minutes’ duration that were purpose-designed by composers and sound-recording artists. Participants were allocated at random to one of five groups: headphones and iPod only, no soundtrack (control group); reconstructed ambient noise simulating an ED but free of clear verbalisations; electroacoustic musical composition; composed non-musical soundtracks derived from audio field recordings obtained from natural and constructed settings; sound composition of audio field recordings with embedded binaural beat. All soundtracks were presented on an iPod through headphones. Patients and researchers were blinded to allocation until interventions were administered. State–trait anxiety was self-assessed before the intervention and state anxiety was self-assessed again 20 minutes after the provision of the soundtrack.Main outcome measure: Spielberger State–Trait Anxiety Inventory.Results: Of 291 patients assessed for eligibility, 170 patients completed the pre-intervention anxiety self-assessment and 169 completed the post-intervention assessment. Significant decreases (all P < 0.001) in anxiety level were observed among patients exposed to the electroacoustic musical composition (pre-intervention mean, 39; post-intervention mean, 34), audio field recordings (42; 35) or audio field recordings with embedded bianaural beats (43; 37) when compared with those allocated to receive simulated ED ambient noise (40; 41) or headphones only (44; 44).Conclusion: In moderately anxious ED patients, state anxiety was reduced by 10%–15% following exposure to purpose-designed sound interventions.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN 12608000444381.

Tracey J Weiland BBSc(Hons), PhD/MPsych · George A Jelinek MB BS, MD, FACEM · Keely E Macarow BA, MA, PhD · Philip Samartzis GradDipArt · David M Brown DipArt, MA · Elizabeth M Grierson LicDip, MA, PhD · Craig Winter MB BS, MBA, FACEM

This is the first published case series of patients with injuries from watercraft propellers and jet skis. Five patients presented to the level-one trauma centre of Western Australia with such injuries over 10 days during the 2010–2011 Christmas holidays; all required surgery, and all but one sustained multiple, severe injuries. (MJA 2011; 195: 000-000) Clinical recordsPatient 1A 61-year-old man was pushing his boat into the water when he lost his footing and struck the propeller, sustaining a laceration to the lateral aspect of his left ankle. He presented to the emergency department (ED) of a peripheral hospital where his wound was irrigated and sutured. The patient presented to a general practitioner four days later with a painful and erythematous ankle. Erythromycin was commenced and sutures were removed. Four days later, he presented to our ED with worsening pain and spreading erythema and feeling generally unwell. At this time, his wound was intact. He was diagnosed with cellulitis and commenced on doxycycline and cephazolin. The infection abated marginally on the antibiotic therapy, with a decrease in inflammatory markers (the C-reactive protein level and white cell count), but the infection failed to resolve completely. Subsequent intraoperative wound exploration revealed several pockets of debris or soil contamination, and after washout, the wound was closed. The patient subsequently recovered well. Patient 2 A 28-year-old man was riding his jet ski at high speed when he lost control, hit some rocks and was thrown, landing on his right side. He sustained an open fracture of the middle third of the right ulna, fractures of the right distal radius and ulnar styloid, an extra-articular comminuted fracture of the right scapula, right-sided posterior fractures of ribs 9–12 and a dislocation of the right patella with rupture of the anterior and posterior cruciate and medial collateral ligaments. Reduction of the dislocated patella was performed in the ED before the patient was transferred to theatre. Debridement, washout and open reduction with internal fixation of the ulnar shaft and distal radius fractures were performed. The cruciate and medial collateral ligaments were reconstructed 2 weeks later. Antibiotic therapy with cephazolin, metronidazole and ciprofloxacin was provided for 6 days, as advised by an infectious diseases specialist. The patient was discharged from hospital with plans for ongoing physiotherapy and rehabilitation for his knee. Patient 3A 23-year-old man was injured while he and his colleagues were riding jet skis after a Christmas party. A colleague collided with him at high speed, crushing his left leg between their jet skis and causing a subtotal amputation just below the knee; only a small bridge of skin remained. The leg was deemed unsalvageable and the amputation was completed in theatre (Box). Several debridements and washouts were performed before the stump was covered with a latissimus dorsi flap. Antibiotic therapy with intravenous meropenem and ciprofloxacin was given for 22 days on the advice of a clinical microbiologist. The patient will require extensive physiotherapy and occupational therapy during his rehabilitation. He will also need a prosthesis, which will be challenging to develop because of the fastidious nature of the flap and the very short stump (Box). Patient 4A 35-year-old man’s left leg was caught by the propeller of his newly acquired speedboat as he attempted to connect its anchor. He bled profusely and the earliest recorded systolic blood pressure at the scene was 60 mmHg. In the ED, the primary threat to his life was severe hypovolaemic shock from exsanguination, and aggressive fluid resuscitation was instituted, involving multiple units of packed red blood cells. A comminuted fracture of the inferior pole of the left patella and extensive soft tissue injury to the posteromedial aspect of the left thigh were noted before the patient was transferred urgently to theatre. Surgical exploration showed division of the patellar tendon and medial quadriceps tendon as well as transection of the left superficial femoral artery, which was on view. Saphenous vein graft repair was performed, and coverage was achieved with the viable proximal two-thirds of the adductor longus muscle. Intraosseous repairs of the patellar and quadriceps tendons were also performed. After repeated debridement and washout, the large soft tissue defect was covered with a flap. Patient 5A 21-year-old woman was riding in a large rubber tube being towed by a powerboat when she fell out of the tube. When she attempted to climb into the boat, both her legs made contact with the propeller. She sustained limb-threatening soft-tissue damage to both proximal thighs including bilateral sciatic nerve transection, left superficial and profunda femoris artery transections and incomplete left femoral nerve disruption. A displaced open comminuted fracture of the proximal right femur further complicated her injuries. Left superficial femoral artery saphenous vein graft and left leg fasciotomy were performed. Her femur fracture was controlled with an external fixator. Multiple debridements, washouts and vacuum-assisted wound closure dressing changes were undertaken on both legs for wound management. One week later, when the wounds were clean, bilateral sciatic nerve repairs were performed using sural and common peroneal nerve grafts. The patient has been without any lower limb function since arrival at the hospital and the success of her bilateral sciatic nerve repair remains to be seen over the coming months to years. DiscussionThis cluster of incidents occurred over a short period of time in a city whose population has ready access to a range of recreational activities involving watercraft. Western Australia has seen a trend in recent years towards smaller, propeller-driven boats, possibly as a result of the global financial crisis. The number of newly registered large cabin-cruiser boats in WA dropped steadily from 572 in 2006 to 332 in 2010. During the same period, the number of new jet and racing boat purchases remained largely unchanged (17 in 2006 and 18 in 2010, with moderate fluctuations in between these years).1 Furthermore, in the period from December 2006 to March 2011, there were 72 boat and watercraft accidents in WA, seven of which were caused by the propeller (unpublished WA watercraft injury statistics for 2006–2010 held by the Royal Perth Hospital trauma registry). This occurred despite appropriate legislation for licensing, speed restrictions and operating watercraft under the influence of alcohol. Watercraft and propeller injuries are often characterised by severe initial injury and physiological insult, including severe haemorrhage. The cutting nature and high speed of propellers results in repeated wounding of the body at multiple levels, greatly multiplying the risk of irreparable damage to deep neurovascular structures. Also, serious complications can ensue after the initial damage control period, particularly uncontrollable wound infection, often with unusual bacteria which may not be detected by routine culture methods.2,3 This may necessitate amputation, even if a limb may initially appear to have been saved. There has been little progress in the design of safety features for power boats in recent years, with the primary focus on fire management and warning signage around the hull. One maker of jet skis has developed promising features, including a “learner key” which limits speed and a “braking” system. Such innovations may reduce injuries, but the problem of the exposed propeller remains. A concept worth mentioning is that of a propeller guard.4 The guard provides a barrier to the cutting edge of the blades and eliminates the risk of a person making contact with a running propeller. We believe that this is still a relatively unknown idea in Australia, and some retailers suggest that uptake may not be universal among new boat owners. Staff at a major Perth boating retailer believe that people purchasing a boat for speed or associated recreational activities like skiing may be deterred by the potential loss of speed. This case series highlights the issue of injury from boating and small watercraft activities, as well as the need for increased public awareness of these risks. Currently, there is little coverage of this issue in the Australian literature. We believe that the medical community should provide accurate and relevant data, and embrace our role as leaders and health advocates by working with government and other non-governmental organisations to build effective public awareness campaigns and to drive manufacturers and retailers to produce and sell safer products. Injury to Patient 3 and surgical amputation of the leg A. Surgical amputation just below the level of the tibial tubercle (insertion of the patellar ligament). B. X-ray showing postoperative anteroposterior view. C. X-ray showing postoperative lateral view.

Hemant Garg MB BS · Reto Twerenbold MD · Rene Zellweger MB BS, MD, FRACS

During a time of war, the federal government passed the National Fitness Act 1941 to improve the fitness of the youth of Australia and better prepare them for roles in the armed services and industry. Implementation of the National Fitness Act made federal funds available at a local level through state-based national fitness councils, which coordinated promotional campaigns, programs, education and infrastructure for physical fitness, with volunteers undertaking most of the work. Specifically focused on children and youth, national fitness councils supported the provision of children’s playgrounds, youth clubs and school camping programs, as well as the development of physical education in schools and its teaching and research in universities. By the time the Act was repealed in 1994, fitness had become associated with leisure and recreation rather than being seen as equipping people for everyday life and work. The emergence of the Australian National Preventive Health Agency Act 2010 offers the opportunity to reflect on synergies with its historic precedent.

Julie A Collins BArch, PhD · Peter Lekkas BPty, MPty

“Sometimes you go looking for one thing and you find another” — Sancho Panza, in Cervantes’ Don Quixote1 The Arab Spring had been followed by the autumn of the euro. In Lombardy, Italy, at the Rockefeller Foundation Bellagio Center, the season of mists and the gilding of leaves had begun. There I met Paul Pholeros, as he arrived from the celebration of the United Nations World Habitat Day on 3 October this year (Box 1 and Box 2). Pholeros is Managing Director of Healthabitat (http://www.healthabitat.com), working with Dr Paul Torzillo (Medical Director) and Stephan Rainow (Community Director). This private Australian company has won the Building and Social Housing Foundation World Habitat Award for 2011. Established in 1985 as part of the United Nations International Year of Shelter for the Homeless, the World Habitat Awards recognise practical innovations for current housing needs and problems. The citation describes Healthabitat’s Housing for Health program as an initiative to improve the health of Indigenous people in Australia, by ensuring they have access to safe and well functioning housing and an improved living environment. Many Aboriginal and Torres Strait Islander people cannot take safe, functional housing for granted. That inconvenient truth holds now, even though many public health texts, assuming the obvious connection between housing and health, simply focus on emergency shelter.2 What was it about the Healthabitat approach that appealed to the judges ahead of many other projects that might have seemed more exciting? There were about 250 entries from 82 countries, as varied as the GLOBE Community Champions program, from Canada, and a post-earthquake reconstruction and rehabilitation program, from China. The safety and health principles of Healthabitat’s method were first developed in 1985 when a group of Indigenous Australians attempted to improve the health of their communities in a remote desert region of South Australia.2 Housing and the living environment were linked directly to health outcomes. The first priority of the Housing for Health program is safety from electrocution, gas explosion, fire and structural collapse, and the second is the capacity for people to wash. The program systematically works through priorities, house by house, resulting in well documented health improvements.3 “No survey without service” is the starting point, in the tradition of Cochrane and Hollows.4 Instead of vague policy promises on the never-never, Healthabitat’s work in a remote community housing project means immediate, tangible improvements. On the first morning at any house, testing of around 250 aspects of house function begins, with some fixing starting that same day, so that people can live more comfortably. Healthabitat has shown that positive change is possible and sustainable. According to Pholeros, demonstrable health improvement is the essential justification to fix housing problems; building standards alone do not motivate people. The medical and other professions could, similarly, emphasise more often the bottom line of human health in debates about social, environmental or economic improvement. Like the aims of Healthabitat, the Rockefeller Foundation seems to take a long-term view. The Foundation supported the work of Jane Jacobs about what cities should be, half a century ago. Her writing is still much celebrated, as should be the results of Healthabitat projects in coming years. Jacobs talked of urban peace ... kept primarily ... by an intricate, almost unconscious network of voluntary controls and standards among the people themselves, and enforced by the people themselves.5 The Christmas story was set in a “low-rent” district and describes shelter that was apparently adequate for childbirth. Healthabitat represents more good news that all Australians can celebrate, about health and housing, particularly for Indigenous Australians, and shows that change is not too hard or hopeless, and is possible. Before All Souls’ Day, my wife, Hilary, and I visited the Church of San Giacomo in Bellagio, Italy. The Italians proceeded with their religious observances, oblivious to tourists. Hilary lit a candle for my late brother while I searched for the ancient symbols of the evangelists. Luke, patron saint of physicians and artists, is represented by an ox in marble carvings, lost behind plaster for centuries, then found in 1907, and now rightly famous (Box 3). Christian ritual may leave you cold, but the pursuit of peace and shelter as prerequisites for health should at least appeal to those mindful of the Ottawa Charter for Health Promotion.6 The secular stories of Healthabitat remind us how vital these determinants are for improvements in Aboriginal health. 1 Paul Pholeros, Healthabitat Managing Director, with the World Habitat Award 2 Autumn in Bellagio, Italy 3 Ox carving, Church of San Giacomo, Bellagio, Italy

Charles S Guest PhD, FAFPHM

To the Editor: Health data can have an important role in alerting product safety regulators to consumer product-related injuries. Such injuries are a significant public health concern, with an estimated 173 000 incidents occurring each year in Australia, many of which require medical treatment.1 The new Australian Consumer Law (ACL; http://www.consumerlaw. gov.au), enacted in January 2011, increases safety requirements and recognises that industry members have an important injury prevention role. The ACL requires suppliers to report to the Australian Government when they become aware of serious injuries, illnesses or deaths associated with products they supply.2,3 Monitoring product safety issues under the ACL therefore relies on systematic reporting of injuries by consumers to suppliers, and by suppliers to safety regulators, although the extent of compliance is unknown. Given that medical treatment is an indicator of injuries serious enough to warrant mandatory reporting, monitoring of products involved in injuries that require treatment in hospital emergency departments is a logical place to focus initial attention. Australia currently has an array of injury data, such as emergency department data, morbidity and mortality data and specialised injury surveillance collections, that could be used for this purpose, without the need for new, expensive data collections. We conducted a pilot study of product-related injuries in children in Queensland, which identified significant potential for using existing injury data more effectively in product safety surveillance.4 A comprehensive national evaluation of routinely collected health data would enable product safety regulators to better understand and use these data. With a lack of exposure to the ACL in the health sector, clinical staff and injured parties may not be aware of reasons for and mechanisms of reporting product-related injuries. It is important that medical professionals are made aware of the law and informed about actions they can take to support this system. Engaging emergency department staff could be a first step for product safety regulators. This could be as simple as a well publicised free-call number or a dedicated email address that clinicians can use to access information or report injuries quickly, without the need to complete large amounts of paperwork. There are substantial opportunities for strengthening product safety surveillance in Australia using existing routine health information systems and timely reporting of clinically significant incidents. This is critical for ensuring a more strategic approach to emerging product safety issues, prioritising efforts and evaluating the efficacy of product safety initiatives, to reduce preventable injuries and deaths related to unsafe consumer products.

Kirsten McKenzie · Ruth A Barker · Deborah A Scott · Dave A Strachan

To the Editor: Faunce and colleagues wisely called for the introduction of legislation modelled on the United States False Claims Act (FCA) in the Australian health care setting.1 Indeed, whistleblowers require protection and reward.2 The authors stated that the “key strengths of the US qui tam anti-fraud regime ... lie in its recovery of large amounts of public monies, its encouragement of good corporate practice” and noted that it is “largely compensatory or remedial rather than punitive”.2 However, the non-punitive nature of the regime is problematic. Settlements in the US may appear substantial. In 2009, Pfizer paid US$2.3 billion to settle a false claims action against their marketing of Bextra (valdecoxib).1 However, this sum represents only a small proportion of Pfizer’s overall profits, given that Bextra was marketed from 2001 to 2005 and the company’s profit for the first quarter of 2011 was US$2.2 billion.3 Clearly, pharmaceutical companies in the US cope with the FCA — their huge profits largely compensate for the settlements. “While the defense industry used to be the biggest defrauder of the federal government under the FCA ... the pharmaceutical industry has greatly overtaken the defense industry in recent years.”4 Between 1991 and 2010, settlements for criminal and civil monetary penalties reached a total of US$20 billion. Three-quarters of these occurred between 2006 and 2010.4 The message from the US experience is that non-punitive anti-fraud laws do not stop pharmaceutical companies from engaging in fraudulent activities.

Alain Braillon

Objectives: To describe the prevalence of lifetime and 12-month stimulant use disorders in the Australian population, and to compare the prevalence estimates from a population survey with prevalence estimates derived using indirect methods.Design and setting: Data were drawn from the 2007 National Survey of Mental Health and Wellbeing, which sampled 8841 residents of private dwellings in Australia in 2007. Interviews were conducted by lay interviewers using the Composite International Diagnostic Interview.Main outcome measures: Lifetime and 12-month rates of stimulant use and stimulant use disorders (abuse, dependence) diagnosed according to the Diagnostic and statistical manual of mental disorders, 4th edition.Results: Lifetime prevalence of stimulant use disorders was 3.3%, and 12-month prevalence was 0.6%, equating to more than 97 000 Australians. Nearly half of those who had used stimulants on more than five occasions met criteria for a lifetime disorder. More than 8% of men aged 16–29 years met criteria for a lifetime stimulant use disorder. Prevalence estimates were consistent with recent estimates using indirect methods.Conclusions: Stimulant use disorders affect a significant number of Australians, and are most common in the age groups at greatest risk for development of psychosis.

Grant E Sara MM, MM(Psychother), FRANZCP · Philip M Burgess MA, PhD · Meredith G Harris BA(Hons), MPASR, MPH · Gin S Malhi MD, FRCPsych, FRANZCP · Harvey A Whiteford MB BS, MPH, FRANZCP

Take another look at the cover of this issue of the MJA and you will see just how close Papua New Guinea (PNG) is to Australia’s Boigu Island. In 2004, Queensland Health established tuberculosis (TB) clinics on Boigu and Saibai islands in the Torres Strait to provide medical care for PNG residents with multidrug-resistant TB (MDR-TB) (Queensland Health spokesman, personal communication, Oct 2011). The strategy has been extremely effective in treating these difficult cases and has, as Vincent states, been credited with “there being no MDR-TB cases detected in the Australian population in this region”. It is not surprising, then, that TB experts are working to lobby the government to reconsider its decision to close these clinics by February 2012 and hand over care of these patients to services provided by PNG. PNG is a desperately poor country, ranked 137 out of 169 countries in the United Nations Human Development Index (http://hdr.undp.org/en/statistics). Its health services are largely in disarray. The position statement in this issue of the Journal (Reynolds et al) invokes the World Health Organization ethical guidelines for care of patients with TB to call for free, equal and comprehensive care for patients with TB who present within our borders. It insists that transfer to the home country for ongoing care should only be contemplated when it is known that adequate care will be available. It recommends that Australia provide financial and technical support to neighbouring countries with endemic TB. The authors of the position statement cite sound economic and scientific reasons, as well as the obvious humanitarian arguments, for their stand. For example, the WHO estimates that the cost of treating a patient with MDR-TB is about 100 times greater than that of treating a patient with drug-susceptible TB. According to the authors, substandard care of patients with TB is “the greatest contributing factor to the development of MDR-TB”. Brolan and colleagues examine the Torres Strait treaty as it affects the provision of health care by Australian clinics to residents of PNG. They point out that, while providing such care is not strictly allowed, the practice meets our humanitarian obligations while offering protection to vulnerable Aboriginal communities in north Queensland. While the Australian Government has pledged a large slab of financial support to improve PNG-based health services, and particularly to assist with providing TB treatment facilities in PNG’s Western Province (http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr11-nr-nr175.htm), more time is needed. As Vincent says, effective TB control requires prompt identification and treatment as well as monitoring and contact screening. Only when PNG clinics can provide all this should care be transferred. It seems extremely unlikely that this will occur by the planned date of February 2012. Australia enjoys one of the lowest rates of TB in the world. King and colleagues, also in this issue, argue that this can in part be attributed to premigration screening, which they say benefits applicants, by earlier detection of their disease, and the Australian population, by avoiding exposure to people with active TB. Their argument of substantial cost savings with this approach is compelling. While it is impossible to completely protect Australia from TB coming to our shores, the two strategies of continuing to treat PNG residents and conducting premigration screening appear to be effective at reducing this risk and should be supported.

Annette Katelaris

Public health expert, Simon Chapman points to activists with hidden agendas Wind farms are a main component of efforts to harness renewable energy and reduce greenhouse gas emissions. Globally, there are an estimated 120 000 wind turbines, and this number is increasing rapidly, with China, the United States, Germany, Spain and India being the largest wind energy producers. Commercial wind farms began operating more than 20 years ago, but claims that they directly cause illness (often rapid, acute effects from even single exposures) are far more recent. Together, these observations indicate sociogenic dimensions to this latest example of anxieties about modern technology. Anti-wind-farm websites reveal an ever-expanding and often bizarre array of self-reported symptoms — tellingly never raised by landowners who earn income by hosting turbines, but rather by neighbours with land unsuitable for hosting turbines and by people with prior histories of opposition to wind farms. It has long been observed that envy of neighbours’ turbine-hosting incomes, beliefs that turbines are ugly with no local community benefit, preference for pristine bucolic environments and NIMBYism (not-in-my-backyard-ism) all predict complaints.1,2 These diverse symptoms are lumped together as “wind turbine syndrome”, a popularised catch-all term that yields zero returns from searches of the research literature in PubMed or Web of Science. The most recent review of published evidence concluded (consistent with four previous reviews) that health effects among some living near wind turbines “are more likely attributed to physical manifestation from an annoyed state than from wind turbines themselves”.3 In other words, anger about or fear of turbines can make people sick. Another review of health effects of inaudible low frequency infrasound, regularly demonised by anti-wind-farm activists as silently noxious, concluded “There is no consistent evidence of any physiological or behavioural effect of acute exposure to infrasound in humans”.4 The psychogenic and sociogenic nature of this phenomenon appears to parallel recent findings about complaints and “illness” said to be generated by exposure to mobile phone base stations and powerlines.5 The recent rise of complaints appears to be closely associated with advocacy from anti-wind-farm interest groups, such as the Waubra Foundation. Future research will need to test for temporal associations between this Foundation’s publicity and its movement through rural communities, and case reports of health effects. The Waubra Foundation’s chairman is Peter Mitchell, who has major interests in uranium and coal seam gas and, at least until February 2011, was also chairman of the Science and Economics Committee of the Australian Landscape Guardians. Like the United Kingdom-based Coastal Guardians, the Landscape Guardians have links to those who oppose wind farms but are silent on “guarding” Australian rural landscapes from mining.6 The Waubra Foundation, the Landscape Guardians and the Mitchell family’s investment company Lowell Capital all have the same post office box, yet Sarah Laurie from the Foundation wrote recently “The Waubra Foundation is not a front for the Landscape Guardians . . . Peter Mitchell . . . has kindly made his mailbox available for the use of the Foundation, as we have extremely limited financial resources”.7 The Victorian Government’s recent decision (August 2011) to allow landowners to veto turbines within 2 km of houses8 and hostile comments from the New South Wales Premier9 threaten to severely limit wind farm development in Australia. Spurious health claims fanned by anti-wind-farm activists, often with vested interests, are a key component influencing these politics. The National Health and Medical Research Council is working on an update of its 2010 review.10 That agency’s fundamental commitment to the importance of evidence-based policy will oblige it to highlight both the sociogenic aspects of this phenomenon and the competing interests of many of those standing behind the amplification of this latest textbook example of suggestion and mass hysteria.11

Simon Chapman PhD, FASSA

Position statement from the Thoracic Society of Australia and New Zealand, Australian Society for Microbiology, Australasian Society for Infectious Diseases and Public Health Association of Australia Many high-income countries with a low incidence of tuberculosis (TB) are confronting the complicated issue of the cross-border movement of people with TB from neighbouring low-income countries with a high burden of TB. Well documented examples where this is an issue include the United States–Mexico border and Scandinavian countries adjacent to Russia and the Baltic States.1,2 In Australia, we face similar dilemmas, not only with Papua New Guinea (PNG) nationals crossing into the Torres Strait Protected Zone, but also with fisherpersons illegally entering our territory, temporary residents on short-term work visas and students attending tertiary education institutions. Cross-border communicable diseases present a complex mix of clinical, public health, humanitarian, ethical, political and financial issues for governments and health care providers. Fortunately, international organisations have provided guiding principles that should underpin a country’s response to cross-border TB cases. For example, the World Health Organization (WHO) has published ethical guidelines for care of patients with TB and control of the disease.3 This document states that: . . . all governments have a fundamental obligation to provide universal access to high-quality TB diagnosis and treatment . . . universal access to TB care implies a duty to ensure the quality of that care . . . The international community must provide financial and technical assistance to countries that lack the resources to satisfy this obligation on their own. These ethical guidelines are based on numerous values including equity, solidarity, and common good (as providing effective TB treatment prevents ongoing transmission of disease, and thereby benefits everyone). Similar recommendations are made by two complementary documents, The patient’s charter for tuberculosis care (PCTC) and International standards for tuberculosis care (ISTC).4,5 These principles are also embodied in the final draft of the Australian National TB Strategic Plan (2011–2016), which is expected to be published in early 2012. In view of these international ethical guidelines, the Thoracic Society of Australia and New Zealand (TSANZ), the Australian Society for Microbiology (ASM), the Australasian Society for Infectious Diseases (ASID) and the Public Health Association of Australia (PHAA) believe that Australia’s response to any situation involving cross-border TB cases should be based on the following four principles. All patients with TB who present to health care services within Australia’s borders should have free and equal access to TB care from diagnosis to completion of treatment, irrespective of their legal status or other demographic characteristics as outlined in the PCTC.4 Health professionals dealing with these complex issues must have enough support from the relevant Australian state and federal health agencies to enable them to implement best-practice care, and should be closely engaged in the process of consultation about service delivery. Patients should only be transferred to their home country for ongoing care when the TB service in the responsible Australian state is satisfied that the patient’s ongoing care will be of a suitable standard that meets the ISTC.5 Australia should provide financial and technical support to neighbouring countries where TB is endemic, so that they can develop national TB programs meeting the ISTC standards to which Australia’s TB services can confidently return international patients, who are increasingly mobile. The development of these programs may demand an ongoing investment over many years. The complexity and cost of treating multidrug-resistant tuberculosis (MDR-TB) or TB/HIV co-infection compound the dilemmas in providing cross-border TB care. WHO estimates that the cost of treating a patient with MDR-TB is about 100 times greater than for treating a patient with drug-susceptible TB.6 Poor standards of care of patients with cross-border mobility place nations on both sides of the border at risk of dissemination of untreatable drug-resistant disease. Based on the same values of equity, solidarity and common good, the international ethical guidelines argue that the universal right to receive medical advice and treatment must extend to patients with MDR-TB and/or HIV infection.3,4 The TSANZ, ASM, ASID and PHAA therefore recommend that the above four principles should also apply to cross-border patients with MDR-TB or TB with HIV co-infection. Initial substandard care of patients with drug-susceptible TB is the greatest contributing factor to the development of MDR-TB and extensively drug-resistant TB. MDR-TB in expatriates therefore suggests that the national tuberculosis program in their home country is failing. Hence, health care professionals and governments who propose repatriating patients with MDR-TB must be wary of the level of care that will be available when those patients arrive home. The Green Light Committee, an MDR-TB working group that advises WHO and evaluates applications from countries for access to second-line antituberculosis drugs, has developed a set of criteria for assessing nascent MDR-TB treatment programs in low-income countries.7 These criteria include the level of government commitment and funding, the availability of medical personnel trained and experienced in managing MDR-TB, access to supporting laboratory services that are externally quality controlled, the reliability of second-line drug supplies, and existing strategies to assure patient adherence to treatment regimens. Australian governments and state TB services should use the same criteria when determining whether cross-border patients with MDR-TB can be safely returned to their home country for ongoing care. Although they are ethically justified, the above four principles for the care of cross-border patients with TB may appear financially onerous. Interestingly, modelling has found that increasing United States investment in TB programs in Mexico, Haiti and the Dominican Republic could reduce tuberculosis-related morbidity and mortality among migrants, and produce net cost savings for the US.8 The TSANZ, ASM, ASID and PHAA therefore strongly support the four principles described above for the care of cross-border patients with TB on ethical, clinical and public health grounds (including the protection of Australian citizens), and we believe this approach is economically justified. It is critical that all parties involved in providing care of cross-border patients with TB work together to ensure that the necessary outcomes are achieved.

Paul N Reynolds MD, PhD, FRACP · John D Turnidge MB BS, FRACP, FRCPA · Thomas Gottlieb MB BS, FRACP, FRCPA · Michael J Moore BA, DipEd, MPopHealth

Objective: To evaluate mammography screening outcomes in women with a personal history of breast cancer (PHBC), who have an increased risk of recurrent or new breast cancer, relative to women without PHBC.Design, setting and participants: Retrospective study of 713 191 screening mammograms from two groups of women — those with versus those without PHBC — who participated in the BreastScreen WA program in Western Australia between 1997 and 2006.Main outcome measures: Cancer detection rate (CDR), recall to assessment rate, recall positive predictive value (PPV) for cancer, and distribution of cancer characteristics within and between the two groups.Results: Screening detected 4125 breast cancers: CDR per 10 000 screens was significantly higher in women with PHBC (95.5; 95% CI, 78.3–112.7) than in women without PHBC (57.2; 95% CI, 55.4–58.9). Recall to assessment rate per 10 000 screens was lower in women with PHBC (385.2; 95% CI, 350.6–419.8) than in women without PHBC (504.9; 95% CI, 499.7–510.2). Recall PPV was higher for women with PHBC (24.8%; 95% CI, 21.0%–28.9%) than those without PHBC (11.2%; 95% CI, 10.9%–11.6%). Cancer characteristics were consistent with early detection (most were smaller than 2 cm and node-negative) and were similarly distributed in both groups, except for tumour grade, with PHBC women having fewer low-grade cancers and slightly more high-grade cancers than women without PHBC.Conclusions: The relative rate of cancer detection between women with PHBC and women without PHBC who attended an Australian population-based breast screening program was similar to estimates from international studies. Recall rates were within national standards. Screen-detected cancers had similar characteristics in both groups, except for tumour grade. These data support national integration of mammography screening for women with PHBC into BreastScreen, although evaluation of interval cancers will be necessary.

Nehmat Houssami MB BS, FAFPHM, PhD · Janette J Tresham BSc(Agric) · Lin Fritschi MB BS, FAFPHM, PhD · Liz E Wylie MB BS, FRANZCR

Objective: To use population-level data to monitor the impact on smoking cessation activity of the April 2010 Australian tobacco tax increase.Design and setting: The Cancer Institute NSW [New South Wales] Tobacco Tracking Survey (CITTS) is a continuous tracking telephone survey conducting about 50 interviews per week. Data from February to September in 2009 and 2010 were analysed (ie, data on people who quit smoking in the 3 months before and 5 months after the tax increase in 2010 were compared, and quitting activity over the same period in 2009 was also analysed).Participants: Adult smokers and smokers who had stopped smoking in the previous 12 months; 2009 (n = 1604); 2010 (n = 1699).Main outcome measure: Recent quitting (defined as stopping smoking or trying to quit within a 1-month period).Results: 22% of the sample reported that they had quit smoking in May 2010, compared with 13% in April 2010 and 12% in May 2009. Respondents interviewed in the 3 months after the tax increase (May–July) were significantly more likely to report quitting than those interviewed in the 3 months before the tax increase (odds ratio, 1.84; 95% CI, 1.26–2.69; P < 0.01). This increase in quitting activity was not sustained in the subsequent months (August–September).Conclusions: The tobacco tax increase was associated with a short-term increase in the rate of smoking cessation among NSW adult smokers and recent quitters, suggesting that regular increases in tobacco tax may further encourage quitting activity.

Sally M Dunlop PhD · Trish F Cotter BSc, MPH · Donna A Perez BSc

Health promotion expert Garry Egger argues that obesity is a sentinel of broader environmental causes of chronic disease Any important disease whose causality is murky, and for which treatment is ineffectual, tends to be awash in significance. Susan Sontag, Illness as metaphor1 Evidence in science requires time, but when that evidence arrives, it may suggest that we need to think about things differently. In the case of research into the relationship of obesity to chronic disease, the accumulating weight of evidence has meant a rethink of what obesity means, and what we are trying to achieve in “treating” obesity. After three decades of rapid increases in mean national bodyweight, we now seem to accept that we have a problem. Around one in two Australians are overweight (body mass index [BMI] > 25 kg/m2), and more than one in three are obese (BMI > 30 kg/m2).2 However, now that the message has hit home, the evidence relating obesity to chronic disease has started to shift. Some question whether obesity really is the issue. Should we be focusing instead on those factors (such as lifestyle, environment and social factors) that may (or may not) cause obesity? Why the change of heart? There is little doubt that obesity is linked with the dysmetabolism associated with much chronic disease, and particularly type 2 diabetes. But there are also more distal drivers, which may or may not require obesity in the causal pathway for chronic disease to occur, and these may not be considered if the focus is purely on obesity. This has become clear with the concept of “metaflammation”3 — a form of low-grade, persistent systemic and chronic inflammation, which is associated with much, and perhaps most, chronic disease. While the classical form of inflammation has a healing role in acute disease, metaflammation, because of its persistence, may have a causal role in aggravating and perpetuating chronic disease. Linked not just to obesity, it is also associated with a range of “inducers”, some of which directly cause obesity (overnutrition, inactivity, stress), but also many that are not direct causes.4 These include environmental factors like pollution and passive smoking, a newly identified group of endocrine-disrupting chemicals, and social and occupational factors such as inequality, perceived injustice and even shift work. Together, these make up a group of inducers of chronic disease that could be called “anthropogens” — human-made environments, their by-products, and associated lifestyles. Some of these may be detrimental to human health; all have arisen since the industrial revolution and seem to be foreign to our ancient physiology. These anthropogens may be considered to be the “germs” behind many chronic diseases. A focus just on the proximal causes of obesity and associated individual behaviours could have the adverse impact of blaming individuals for the environment that surrounds them. It deflects criticism from more distal social and environmental causes, where the recognition of an anthropogen-based causality would get to the heart of chronic disease causation. Given this, what would be the point of targeting the “fit fat” — the 35% of obese individuals who have no obvious health risk (apart from mechanical and possibly psychological issues) — and ignoring the approximately 25% of lean people who fit the “lean unhealthy” phenotype and have all the risks expected of the obese?5 The current focus is on visceral fat, which gets close to the issue, but we need to think about what is causing visceral adiposity in the first place. All this points to obesity as an intermediary as much as an offender in chronic disease — it is a sentinel of problems in the broader environment. This is not to suggest that weight loss is not a justifiable goal; of course it is. But to do the job properly, it should be accompanied by broader initiatives aimed at targeting the anthropogens that are using obesity as their cover.

Garry Egger MPH, PhD

To the Editor: In a recent article that appeared in newspapers such as Melbourne’s The Age and Sydney Morning Herald on 19 Jan 2011,1 one of us (P Z) argued that it is both ineffective and inaccurate to blame those who are overweight and obese for their health problems. It was highlighted that our social, economic, cultural and physical environments are all “obesogenic”,2 acting as barriers to achieving a healthy lifestyle. The article by Proietto in the August 2011 issue of the Journal similarly argued that the obesogenic environment, and its interaction with a person’s genetic make-up, is to blame for the increasing prevalence of overweight and obesity.3 Neglecting to address the role of environmental factors in lifestyle disease may lead to a number of unintended negative consequences. First, healthy eating and being physically active are not easy choices. If attempts are not as successful as first hoped, and if the response from health professionals is simply “try harder”, feelings of guilt and despair can result, which then make it even harder to engage in healthy behaviours. Second, a sole emphasis on individuals’ responsibility for their own health has led governments at all levels in Australia to be passive on this issue. Governments seek to protect us in other ways (eg, legislation to restrict the use and advertising of tobacco), so they now need to be encouraged to take steps towards reducing the obesogenic nature of our environment (eg, introducing policy that ensures affordable and sustainable fruit and vegetable production).4 Finally, focusing on individual health behaviours alone may create or reinforce a social stigma around obesity and related chronic conditions, such as type 2 diabetes.5 When individual behaviour change is the sole focus of prevention and management efforts, the subtext is that the individual is to blame if he or she develops the condition. The astonishing and immediate public response to the aforementioned newspaper article — almost 300 comments were posted online on The Age and Sydney Morning Herald websites alone within hours — reflected an entrenched attitude of blame towards people who are overweight or obese. Given that type 2 diabetes can only be prevented in about 60% of cases,6 these comments reveal and perpetuate a limited understanding of the multiple causes of lifestyle diseases. It remains critical to encourage people to pursue healthy lifestyle choices. However, addressing the obesogenic elements of our environment is just as important. Encouraging patients to become involved in organisations such as The Parents’ Jury, an online network dedicated to improving children’s food and physical activity environments (www.parentsjury.org.au), or to become familiar with community-based initiatives such as Victoria Walks (www.victoriawalks.org.au) may be beneficial. More broadly, it is important for health professionals and their professional bodies to make known to governments their support of policy and other initiatives that make our environ-ment conducive to healthy choices.

Jessica L Browne · Paul Zimmet · Jane Speight