Environmental health

Kari A J Jarvinen,* Bradley J McCall,† Clare B Nourse,‡ Joe G McCormack,§ Martyn H Tilse¶ * Senior Public Health Registrar, † Public Health Medical Officer, Communicable Disease Control, Brisbane Southside Public Health Unit, 39 Kessels Road, Coopers Plains, QLD 4108; ‡ Paediatric Infectious Diseases Physician, § Director of Infectious Diseases, ¶ Director of Microbiology, Mater Health Services, South Brisbane, QLD. kari_jarvinenAThealth.qld.gov.au To the Editor: Pertussis continues to be a significant public health problem in Australia. Children aged under 1 year are most at risk from severe, life-threatening complications from the disease.1 Traditionally, erythromycin has been the drug of choice for treatment of cases and prophylaxis in selected contacts. However, its use in neonates is known to carry a risk of infantile hypertrophic pyloric stenosis.1,2 Its propensity to cause QT prolongation and ventricular arrhythmias is also well described.2,3 Both azithromycin and clarithromycin have been recently recommended as suitable alternatives for management of pertussis.2,4 The US Centres for Disease Control now regard azithromycin as the agent of choice for neonates less than 1 month of age.1 There is evidence suggesting azithromycin has less pro-arrhythmic potential than erythromycin or clarithromycin.5,6 Azithromycin does not interact significantly with the hepatic cytochrome P450 system and has less potential for significant drug interactions than other macrolide antibiotics.3,5,6 Azithromycin and clarithromycin also require less frequent administration (1–2 doses per day) and shorter treatment regimens (5–7 days) than erythromycin. In Australia, roxithromycin is the most widely prescribed macrolide antibiotic. However, there are no clinical studies on its effectiveness in pertussis, and in-vitro sensitivity studies suggest it may be inferior to erythromycin. Thus, roxithromycin cannot be recommended in pertussis.4 Updated versions of Australian antibiotic guidelines to be released later this year will recommend azithromycin for pertussis treatment and prophylaxis. However, access to azithromycin for this purpose in Australia is currently limited by the restrictions placed on prescribing through the Pharmaceutical Benefits Scheme (PBS). Azithromycin is currently approved for Chlamydia trachomatis urethritis, cervicitis and trachoma. Pertussis is an approved indication only for the use of 500 mg tablets under the Repatriation PBS. This restriction has important implications for the effective and safe management of pertussis in Australia. Widespread use of newer macrolides in the community is not advisable because of the propensity of macrolides to induce antibiotic resistance, and their greater cost. However, for pertussis infection, Australians need to be able to access agents such as azithromycin. PBS restrictions for this indication need to be revised, for both tablet and liquid formulations.

Kari A J Jarvinen · Bradley J McCall · Clare B Nourse · Joe G McCormack · Martyn H Tilse

Objectives: To examine changes in asthma prevalence in the context of other population changes between 1990 and 2003, for specific age and sex groups.Design: Cross-sectional survey based on household interviews, repeated annually.Setting and participants: Representative samples of the South Australian population between 1990 and 2003 (around 3000 people per year).Main outcome measures: Current prevalence of doctor-diagnosed asthma and other health and demographic variables potentially associated with asthma, and asthma management.Results: Response rate was over 71%. Between 1990 and 2003, asthma prevalence increased significantly, doubling in females (from 7.3% in 1990 to 14.6% in 2003), with a smaller increase in males (from 7.8% to 9.4%). Asthma also increased in all age groups, but the largest relative increases occurred in people aged 55 years and older. Logistic regression analyses showed that obesity was a major predictive variable for every age group studied. The prevalence of asthma morbidity (waking at night and days lost from usual activities because of asthma) among those with asthma showed no significant changes between 1990 and 2003. Asthma action plans (introduced on a population basis in 1992) peaked in their distribution at 42% in 1994, and then declined to half that percentage in 2003. The increase in asthma prevalence occurred at the same time as increases in population prevalence of obesity (10.3% to 18.7%) and diabetes (3.1% to 6.9%), and decline in recent vigorous exercise (42.4% to 32.7%).Conclusions: The increase in asthma prevalence over a decade was large, but concentrated among specific sex and age groups. The increase accompanied population increases in obesity and diabetes and a decline in vigorous exercise.

David H Wilson PhD, MPH, BEd, AdvDipEd · Robert J Adams MD · Richard E Ruffin MD · Graeme Tucker BSc · Anne W Taylor MPH · Sarah Appleton BA

Australia’s effective monitoring system shows that serious reactions are rare Australia has achieved very high levels of vaccination coverage in the past 10 years, with 91% of children fully vaccinated at 12 months of age and 92.1% at 2 years.1 Consequently, rates of vaccine-preventable diseases are very low. As the incidence of vaccine-preventable diseases declines, the safety and side effects of vaccines gain prominence, and an increasingly important role of health care professionals is to communicate the benefits and risks of vaccination to parents.2 Worries about vaccines date back more than 200 years, when Jenner’s introduction of cowpox vaccine prompted cartoons in the satirical magazine Punch depicting vaccine recipients turning into cows. More recently, unproven and unjustified concerns about pertussis vaccine3 and measles–mumps–rubella vaccine4 have resulted in falls in vaccination uptake in the United Kingdom, and the needless deaths of children.3,4 Vaccine constituents, such as preservatives, stabilisers, adjuvants and biological growth media used in vaccine production, are necessary to ensure the efficacy, stability and safety of vaccines, but can also contribute to consumer concerns.5 A recent review concluded that the amounts of aluminium, formaldehyde, antibiotics and yeast proteins in vaccines have not been found to be harmful to humans and animals in exposure studies.5 Currently, if providers have concerns about constituents of vaccines, they can consult the excellent booklet Myths and realities.6 In addition, the National Centre for Immunisation Research and Surveillance (NCIRS) website (<http://www.ncirs. usyd.edu.au>) has a fact sheet relating to thiomersal: <http://www.ncirs.usyd.edu.au/facts/f-thiomersal.html>. The US Centers for Disease Control and Prevention have fact sheets on vaccine components at <http://www.cdc.gov/node.do/id/0900f3ec8006587f>. The article by Eldred et al7 in this issue of the Journal is an important overview of vaccine components and constituents of vaccines in use in Australia, and is an important reference for vaccine providers to answer consumer concerns and questions. Serious adverse events following vaccination are rare, and the risk of morbidity associated with these adverse events is generally far less than the risk from catching a vaccine-preventable disease. Nevertheless, it is extremely important to have in place adequate surveillance for adverse events associated with vaccines. Both the public and health care professionals need to feel confident of vaccine safety. Australia has had local reporting mechanisms for many years, but only since 2000 has there been a national reporting system.8 Under the current system, which was driven by the dynamism of John McEwen, former Principal Medical Adviser of the Therapeutic Goods Administration (TGA), all adverse reports are coordinated by the Australian Adverse Drug Reactions Unit (ADRU) of the TGA. Adverse events associated with vaccines can be reported to ADRU by health care professionals or the public by telephone (02 6232 8386) or by prepaid reporting form (“blue card”) or online at <http://tga.gov.au/adr/bluecard.htm>. The data are further analysed by NCIRS and regularly reported in Communicable diseases intelligence.9-11 The data are extremely reassuring: serious adverse events are rare. Between 2000 and 2004, only seven of 5128 adverse events reported following vaccination were reported as having persisted and resulted in sequelae.9-11 Furthermore, the reporting of an adverse event following vaccination implies an association in timing with vaccine administration, but does not necessarily mean the vaccine caused the reported adverse event. Australia has an effective system for monitoring vaccine safety. In future, privacy laws permitting, it is hoped to link Australia’s database of immunisations, the Australian Childhood Immunisation Register, with hospital admissions to be able to look actively at questions regarding the safety of specific vaccines. It is vital that parents and providers are fully informed about the risk of vaccines and of the diseases they prevent. Australia’s monitoring system will continue to gather the data for informed decision-making.

Nicholas Wood MB BS, DCH, FRACP · David Isaacs MB BChir, MD, MRCP, FRACP, FRCPCH

Objective: To describe the epidemiology of invasive pneumococcal disease (IPD), and the impact of pneumococcal vaccines on IPD, in Indigenous people in north Queensland.Setting: North Queensland, 1999–2004; there are about 53 750 Indigenous people in the region, including nearly 6900 children < 5 years and nearly 5650 adults ≥ 50 years.Main outcome measures: Incidences of IPD in Indigenous children and in Indigenous adults compared between the 3 years before and after the introduction of a 7-valent pneumococcal conjugate vaccine (7vPCV) (1999–2001 versus 2002–2004).Results: Estimated annual incidence of IPD in Indigenous children < 5 years of age declined from 170 to 78 cases per 100 000 in the 3 years following the introduction of 7vPCV in 2001. The annual incidence of vaccine-preventable IPD in Indigenous adults had declined by 86% since a 23-valent pneumococcal polysaccharide vaccine (23vPPV) was introduced to the region in 1996, to 15 cases per 100 000 (95% CI, 8–25) in 2002–2004.Conclusion: Although there was a rapid decline in IPD in young Indigenous children, it is unlikely that the incidence will fall much further with the current 7-valent vaccine. There was a suggestion that vaccinating Indigenous children indirectly protected those aged 5–14 years and Indigenous adults ≥15 years of age. Incidence of IPD in Indigenous adults in 2002–2004 was the lowest on record in the region.

Jeffrey N Hanna MPH, FAFPHM · Jan L Humphreys · Denise M Murphy DipMedTech

Dorothy L Robinson Senior Statistician, Armidale Air Quality Group, Building W46, University of New England, Armidale, NSW 2351. drobinsoATmendel.une.edu.au To the Editor: There should be no contradiction in recommending that people enjoy recreational exercise when air pollution is low but nonetheless walk/cycle for transport.1 I cycle home after 5 pm, when pollution increases to health-hazardous levels (Box), but it is astounding to see people out jogging in such unhealthy air. Cycling for transport is undoubtedly better than driving. Despite dangers from pollution and busy roads, commuter-cyclists have 40% lower mortality than drivers.2 Nonetheless, cycling in diesel fumes at concentrations typically present on busy roads causes significant damage to blood vessels,3 and should be avoided if there is a choice. This concept is no harder to understand than the concept that moderate intake of mono- and polyunsaturated fats is beneficial but excessive saturated fat intake is bad. Regrettably, this distinction was once considered so complicated that people were told simply to reduce all fat consumption. Until people understand the hazards of air pollution, controls will remain inadequate. In Sydney, Melbourne, Brisbane and Perth, air pollution causes an estimated 1611 premature deaths every year, with more than 3000 estimated for Australia as a whole. The most serious health problems relate to fine particles (PM2.5), emitted predominantly by diesel-powered vehicles and woodheaters.4 Winter measurements in Liverpool, Sydney, follow a similar temporal distribution to those in Armidale, in regional New South Wales (Box), suggesting that both regional and metropolitan residents should jog at lunchtime in winter, rather than after work. A recent review estimated that health costs of PM2.5 emissions in urban Australia range from $100 to $300 per kilogram of particles. A typical woodheater (emitting 20 kg of these particles every winter) therefore generates $2000–$6000 in health costs — considerably more than switching to non-polluting heating.4 Older (pre-1990) diesel cars and utilities emit about 0.75 g PM2.5 particles per kilometre (13.8 kg per 20 000 km), generating estimated annual health costs of $1380–$4140. This exceeds the cost of converting to liquid petroleum gas or retrofitting a particle trap/oxidation catalyst. When PM2.5 pollution was reduced in Dublin by banning non-smokeless coal in 1990, there were 2154 fewer deaths in the first 6 years of the ban than the previous 6 years (15.5% fewer respiratory and 10.3% fewer cardiovascular deaths/year).1 Euro II emission limits for new diesel-powered vehicles became mandatory in 1996/97 in Europe (and in 2002/03 in Australia). Simple, cost-effective measures for reducing the major sources of urban PM2.5 pollution — including converting or retrofitting diesel-powered vehicles that exceed Euro II limits, phasing out woodheaters and strongly discouraging stubble-burning in areas where it increases smoke pollution in rural towns1 — would significantly reduce pollution-related illness. It would also allow cyclists, pedestrians and joggers to exercise whenever desired, with fewer worries about air quality. Hourly concentrations of fine particle pollution (PM2.5 measured by nephelometer scattering coefficient) in Armidale (regional NSW) and Liverpool (Sydney) on the first occasion (11 June 1997) that Sydney residents were asked to reduce pollution by not using woodheaters. (Data sources: Sydney, NSW EPA; East Armidale, Armidale Air Quality Group, with assistance from CSIRO Department of Atmospheric Resources.)

Dorothy L Robinson

Objectives: To examine whether children’s television viewing may be a useful indicator of risk of obesity-promoting versus healthy eating behaviours, low-level physical activity (PA) and overweight or obesity among children of primary school entry and exit ages.Design: Cross-sectional study, stratified by area-level socioeconomic status.Participants and setting: 1560 children (613 aged 5–6 years [50% boys], and 947 aged 10–12 years [46% boys]) from 24 primary schools in Melbourne, Australia, randomly selected proportionate to school size between 1 November 2002 and 30 December 2003 .Main outcome measures: Parents’ reports of the time their child spends watching television, their participation in organised physical activities (PA), and their food intake; each child’s measured height and weight and their PA levels as assessed by accelerometry for one week.Results: After adjusting for the age and sex of child, the parents’ level of education, clustering by school, and all other health behaviour variables, children who watched television for > 2 h/day were significantly more likely than children who watched television for ≤ 2 h/day to: to have one or more serves/day of high energy drinks (adjusted odds ratio [AOR], 2.31; 95% CI, 1.61–3.32), and to have one or more serves/day of savoury snacks (AOR, 1.50; 95% CI, 1.04–2.17). They were also less likely to have two or more serves/day of fruit (AOR, 0.58; 95% CI, 0.46–0.74), or to participate in any organised PA (AOR, 0.52; 95% CI, 0.34–0.80).Conclusions: Health practitioners in the primary care setting may find that asking whether a child watches television for more than 2 hours daily can be a useful indicator of a child’s risk of poor diet and low physical activity level.

Jo Salmon PhD · Karen J Campbell MPH, PhD · David A Crawford PhD

Many claims about nutrition and weight loss stem from small, short-term studies, incorrect interpretations or distortions of evidence. Our knowledge of what people eat is poor; difficulties include accurate assessment of consumption, the complex composition of foods and individual variations in nutrient bioavailability. When advice appears to be ineffective, poor compliance is a likely explanation. There is no simple solution to obesity, and no fast way to create the energy deficit required for sustainable loss of fat — weight loss requires long-term commitment to permanently change eating and exercise habits. Valid advice is to reduce overall energy intake, include more vegetables, fruits and wholegrain products and fewer foods high in saturated fat, sugar and salt. While mindful of the need to encourage individuals to make changes, the medical profession needs to lead the charge to advocate for changes to our obesogenic environment.

Rosemary A Stanton OAM, PhD

Research shows that a large proportion of shade structures provide insufficient protection against the sun’s ultraviolet light. Shade creation guidelines need to be updated. Community organisations such as child care centres and schools that need to provide effective shade are hindered by cost and building regulations. The protective function of shade structures is more important than their aesthetic appeal.

David J Turnbull PhD · Alfio V Parisi PhD

In view of the possibility of a human pandemic of avian influenza, a first-line strategy for many countries is stockpiling of antiviral neuraminidase inhibitors (oseltamivir [Tamiflu] and zanamivir [Relenza]), which can reduce mortality, morbidity and influenza transmission. However, global supply of the antivirals is controlled by the European-based patent owners, Roche and GlaxoSmithKline. This prevents competition in the manufacturing and distribution of antivirals and has reduced global supply capacity and affordability. The Australian Government has acknowledged that, in the event of a pandemic, its own stockpile of antivirals will be limited and reserved for those on a confidential rationing list. Pharmacies are running out of stocks, limiting opportunities for individuals to secure supplies privately. Compulsory licensing provisions, permitted under domestic patent law, would allow Australian generic manufacturers to start producing antivirals locally or import them from generic producers at affordable prices. Australia also has an opportunity and a responsibility to promote compulsory licensing and generic antiviral production in the Asian region, to ensure our neighbours can establish pandemic stockpiles in a timely and affordable manner.

Buddhima Lokuge MB BS, MPH · Peter Drahos GDLP, LLM, PhD · Warwick Neville BA, LLB, STD

Tolkien II — a needs-based, costed stepped-care model for mental health services. Gavin Andrews and the Tolkien II Team, University of New South Wales at St Vincent’s Hospital. Sydney: World Health Organization Collaborating Centre for Classification in Mental Health, 2006 (vi + 376 pp). ISBN 0 9578073 4 1 Rarely does a book grab you by the shirt front and shake you in the way that this one does. It is an in-your-face call for reform in the way mental health services are configured and delivered, claiming “a plan in which a 30% increase in budget could treat 50% more people and produce a 90% increase in health gain”. Mental illness is one of the key contributors to burden of disease. Burden of disease studies, though, don’t give any indication of marginal benefits that would accrue from additional investment and so do not per se provide useful information for an investment strategy. This book does. It starts with an analysis of the cost-effectiveness of the contemporary allocation of resources for the various classes of mental illness, suggesting, for example, that the cost-effectiveness ratio for affective disorders is $20 for each year of disability averted, compared with schizophrenia at $196 for each year of disability averted. It proposes a new configuration of investments, with greater reliance on community-based accommodation, for instance, and estimates that its proposals would lead to improved cost-effectiveness across all of the major illness subgroups. In format, it has a very brief introduction followed by proposed treatment recommendations or intervention models for each of the main classes of psychiatric illness. The “stepped-care model” in the title is reflected throughout the book in investments in front-end primary care and community interventions, designed to filter patients so that the use of the high-cost inpatient end of the treatment continuum is minimised. These plans are designed from a societal point of view, with implementation impacting on both Commonwealth and state responsibilities. I am not a psychiatrist, so I cannot make any assessment of the validity of the proposed treatment plans, but an impressive range of expert consultants has been used in the development of the plans. The weakness of an expert-panel approach is acknowledged, and the lack of approaches based on higher levels of evidence is claimed to be because of the lack of such evidence. There are nine people in Australia who, without a doubt, must read this book, or at least the first few pages: the Directors-General/Secretaries of the state, territory and Commonwealth Health Departments. They should then request their Directors of Mental Health to evaluate the book and the recommendations therein, and to advise on why this should not be the approach adopted for future investments in mental health funding. Stephen J DuckettExecutive Director, Reform and Development Division, Queensland Health, Brisbane, QLD

Stephen J Duckett

An urgent alternative watershed management strategy is needed The world has vast natural reservoirs of geological arsenic. The ubiquitous nature of this element means that in some countries arsenic contaminates drinking water, enters the food chain and imposes significant human health risks. Globally, up to 100 million people are at risk of exposure to excessive levels of naturally occurring arsenic in well water or groundwater.1 The countries where arsenic levels in drinking water supplies exceed acceptable levels include Argentina, Bangladesh, Bolivia, Chile, China, Hungary, India, Mexico, Nepal, Peru, Romania, Taiwan, the United States and Vietnam.1,2 A young girl drinking water from a tube-well. (Reproduced with permission: PE-12G-003/Shehzad Noorani/UNICEF Bangladesh.) In Bangladesh, the problem is particularly widespread. Many of the tube-wells in Bangladesh, which supply 95% of the water to 138 million people,3 are contaminated with arsenic at concentrations much higher than the current recommended levels.4,5 If no action is taken now, it is likely that within 20 years a substantial proportion of the Bangladeshi population will develop arsenic-related disease, including cancer. Here, we describe the magnitude and the consequences of the problem, and consider what actions are being pursued and what more needs to be done to prevent this potential public health catastrophe from becoming a reality. Arsenic is a human carcinogen.6 Chronic arsenicosis is characterised by hyperpigmentation and hyperkeratosis of the skin and cancers of the skin, lungs and bladder. Other adverse health effects include hypertension, cardiovascular disease (ischaemic heart disease), cerebrovascular disease, diabetes and reproductive effects including low birthweight, higher occurrence of spontaneous abortions and stillbirths, and congenital malformations in the offspring.7 The World Health Organization’s Guidelines for drinking-water quality8 set a provisional level for arsenic in drinking water of 10 μg/L (or 10 ppb [parts per billion]). In Australia, the guideline value set by the National Health and Medical Research Council and the Agricultural and Resource Management Council of Australia and New Zealand is 7 μg/L.9 However, in many developing countries, including Bangladesh, 50 μ g/L is commonly adopted as the guideline value, often for economic reasons, thus exposing the population to long-term risks.10 In Bangladesh, since the 1970s, in an effort to curb water-borne diseases from pathogen-contaminated surface water sources, over 10 million tube-wells have been installed by aid agencies and non-government organisations as sources of clean drinking water. Unfortunately, arsenic was not measured in tube-well water until the 1990s, and it is now known that 30%–90% of the wells in many of the villages tested contain levels in excess of the national standard of 50 μg/L — placing tens of millions of Bangladeshis at even higher risk.4,11 Arsenic-related skin lesions and the other non-cancerous conditions caused by arsenic contamination have a latency period of about 5–10 years, whereas the latency period for arsenic-related cancers is about 20–30 years. A full survey of contaminated wells in Bangladesh has yet to be completed, but initial estimates predict the cancer burden on the health system will be substantial. Lifetime excess mortality risks (per 100 000 persons) from liver, bladder and lung cancer attributable to arsenic in drinking water have been reported as 0.9, 21.5, and 175.9 in males, and 3.4, 2.1, and 48.3 in females, respectively.12 In countries such as Bangladesh whose gross domestic product or gross national income is dwarfed by those of developed nations (Bangladesh is rated 54th of 60 countries),13 the burden of arsenicosis will have a significant impact on the economy, health system and social structure. Construction of a dug-well in Bangladesh which uses a shallower aquifer to provide “arsenic free” water. An urgent alternative watershed management strategy is needed to prevent further arsenic poisoning, and several options are currently being investigated. Bangladesh’s high annual rainfall means that a key option is large catchments and dams with proper disinfection facilities to treat pathogens from surface water supply. But this is considered a long-term solution, requiring large capital investments beyond the resources of Bangladesh. For an immediate solution, relatively inexpensive interventions are being trialled at the family or village levels. These include the use of alternative water sources with low arsenic concentrations, such as dug-wells, deep tube-wells and rainwater storage. Other strategies have included the use of slow sand-filtration systems with or without chlorination and low-cost domestic filtration and/or precipitation systems using iron compounds, alum, or coal fly ash. Ultimately, it is likely there will be more than one solution. The advantages and disadvantages of these strategies have been discussed.5 Cost and compliance will be the governing factors — but we can be certain that action must be taken now. Since the problem was discovered, international aid agencies have been working with the government of Bangladesh and non-government organisations in an attempt to test every tube-well in Bangladesh to identify which wells have arsenic-free drinking water. They are also implementing many small to medium sized water treatment technologies to reduce arsenic contamination, as discussed above. However, future priorities should focus on large-scale nationally managed watershed programs and better utilisation of the vast surface water source that exists in Bangladesh. In addition, international effort is needed to find effective therapies for the people who have developed arsenicosis. Some view this as a problem that only concerns the developing world. However, continuing pressures on water resources in many developed countries, coupled with the presence of geological arsenic and acid sulfate soils, indicate that the events now occurring in Bangladesh could be repeated elsewhere. For example, in mineral-rich countries, where acid sulfate soil is prevalent in many areas, the acid-generating potential of the soil will mobilise arsenic present in ore bodies resulting in arsenic contamination in the groundwater. Recently, we have focused on the effect of the catastrophic tsunami in Asia, hurricanes in the United States, and the earthquake in Pakistan and Kashmir — natural disasters that have claimed many lives. Generally, acute disasters get a lot more media and political attention and international aid. But we also need to look to the horizon to reduce the arsenic-induced casualty that is happening in Bangladesh where tens of millions of people’s lives are potentially at risk.

Jack C Ng PhD, DABT · Michael R Moore PhD, DSc

The longest life might not be the best life An articulate 52-year-old woman recently telephoned me. “Give the ‘smoking kills’ line a rest”, she urged. “I’ve smoked for 30 years. I have emphysema. I am virtually housebound. I get exhausted walking more than a few metres. I have urinary incontinence, and because I can’t move quickly to the toilet, I wet myself and smell. I can’t bear the embarrassment, so I stay isolated at home. Smoking has ruined my life. You should start telling people about the living hell smoking causes while you’re still alive, not just that it kills you.” The call crystallised for me some diffuse unease I have long felt about some underexamined fundamentals in the entire public health enterprise. Here is how I see it. We are all going to die. Advanced age is easily the strongest predictor of death. Nearly half of all deaths in Australia occur in a hospital.1 These three truisms have acquired profane, almost unutterable status in contemporary health care debate. Each is banal in isolation, and they remain banished from polite discussion as indecent reminders of the pathos of the human dust-to-dust destiny, occasionally insisting to be heard amid the unbridled optimism of the scientific legacy. Huge energy is invested in avoiding their mention. Perhaps the most unabashed manifestation of this denial is the spamming American Academy of Anti-Aging Medicine which boasts 11 500 members in 65 nations,2 and unblinkingly speculates about the virtues of people living to the age of 120 and possibly as long as 170.3 The decadence of such a first-world cosseted vision, in times when more than a billion people live on less than $1 a day and another 1–1.5 billion live on $1–$2 a day,4 37.8 million mostly young people are infected with HIV,5 and one million still die of malaria each year, would be remarkable were it not for the values it shares with mainstream health politics and the media-fuelled public expectations which sustain it. Today, anyone bold enough to suggest pausing to question the unrequited battle and conquest metaphors which dominate the politics of health, risks being branded a medical heretic or even an apologist for involuntary euthanasia of the aged. The dominant medical motto for our age might well be “never say die”. Recently, following on from Richard Nixon’s declaration of war on cancer in 1971, the current head of the United States National Cancer Institute, Andrew von Eschenbach, caught the spirit of George Bush Junior’s all-conquering Zeitgeist, and challenged America to “eliminate suffering and death from cancer” by 2015.6 In Sweden, it is government policy that the road toll should strive to reach zero,7 not merely to fall. If you scratch the surface of the human genome project, unstated assumptions about eternal life are not hard to find in the pitch to the often elderly biotech investors. Single-issue health organisations often talk of research that might one day eliminate their diseases. The recent announcement of an imminent vaccine for cervical cancer8 is self-evidently a wonderful thing. Here is a near-to-fully translated research advance that promises to end the collected misery, pain and indignity that millions of women would otherwise suffer over the years. The eradication of smallpox and the predicted departure of wild polio from the planet are astonishing achievements. So why not conquer everything else? In wealthy nations today, there are few causes of death that cannot boast a non-government agency and a research focus dedicated to eradicating the offending disease. Health agencies’ mission statements are purged of anything that even hints that a point might be reached when an organisation might be content with a certain incidence of deaths from their cause. Defeat is anathema to medical progress when it comes to death. Plainly, there is much to admire in all this. If the go-for-gold death eradication scenarios played out for each preventable cause, a huge number of young and middle-aged lives would be saved. But if no one died from cancer, was ever killed on the roads, or died from any given cause now subject to ever-onward mortality reduction targets, what would take their place? If the death toll from late-age cancer plummeted, if heart disease became something permanently able to be postponed, would this be progress? Which causes of death would increase when others declined? What would we die from? Isolated from the wider “if not death from X, then what?” question, advances against deaths from particular diseases may be pyrrhic victories if all it means is that cause-of-death deckchairs are being shuffled on life’s Titanic, only to sink around the same time. In at least six of the cases investigated in which patients died after being admitted to Sydney’s Camden and Campbelltown hospitals in 2001, the patients were aged over 80. Several others had serious diseases likely to cause their deaths, sooner rather than later.9 Yet, an unexamined assumption in much of the outcry was that something was inherently wrong in very old or very sick people dying in hospital this month rather than in the next 6.10 The discourses of shameful government neglect, of un-Australian inequitable health service provision in low socio-economic areas have steamrollered the now endangered discourse of the innate decency of the “good innings”. The “rule of rescue”11 — the imperative people feel to rescue identifiable individuals facing avoidable death — similarly permeates health policy and resource allocation. Tucked deep away in the Productivity Commission’s 2005 report on the Economic implications of an ageing Australia,12 are examples of a very different kind from today’s never-say-die epic, hinting at a lament among experienced doctors for times when: . . . pneumonia, the old man’s friend, came to visit, that was regarded as quite a good outcome. That is not acceptable to the community anymore. There is a great tendency to do significant interventions in the very old . . .; Older people are able to undergo operations and procedures that previously were denied to them. For example, 10 years ago, 75-year-old people often were not dialysised if they had chronic renal failure, but this would be a common occurrence now.12 While there are ideological imperatives stoking apocalyptic visions of unsustainable ageing populations,13 it is true that the elderly consume hugely disproportionate health care resources, particularly in the last years of life where up to 40% of health care expenditure can occur.14 If the health care costs for 25–29-year-olds are indexed at 100, those expended on the 65–69 years age group are 387.6, and those aged 85–89, 614.2.12 Moreover, hospital separations in those aged 65 and over grew from 26% to 33% between 1991 and 2001, with the growth being only minimally explained by the growing number of aged people in the population.12 The director of the US Hastings Center, Daniel Callahan, has written of the deeply ingrained “pathology of hope”, and its beneficiaries in the pharmaceutical, diagnostic and medical industries.15 Together, these fuel exponential health care expenditure in ageing populations. Callahan’s heretical proposal is that civil society should supplant medicine’s present open-ended goal of prolonging life at all costs with a radical refocusing on quality of life and the compression of morbidity during a decent life span. He writes: The average person in good health in the developed countries of the world . . . already lives long enough to accomplish most reasonable human ends. A medical policy that could assure those now being born that they could live as long . . . and healthy lives as their parents, should be perfectly acceptable . . . This ideal of steady-state life expectancy at its present level would establish, happily, a finite and attainable goal: Enough, already. Average life expectancy in Australia has risen from 51 for men and 57 for women at the beginning of Federation, to 78 and 83, respectively, today.16 Australia’s non-Indigenous population has the world’s fourth highest life expectancy after Japan, France and Switzerland. As a nation, we are near to being the healthiest in the world, with the exception of the national shame of the poor health status of our Indigenous population. Increasing longevity in the last 30 years reflects success in many areas, but particularly in preventing and treating heart disease, declining disease caused by reduced smoking in men and big reductions in motor vehicle and child injury deaths. These and other major preventable causes of death kill Australians early, often well before their retirement, still causing tens of thousands of person-years of life lost (PYLL) before age 75. Indeed, the PYLL concept enshrines the idea that years of life lost after 75 do not “count”, not entering into national calculations of the national state of health. A hallmark of a civilized society is valuing life at all stages, and not simply when its citizens are in the peak of their economically productive powers. The revulsion that many expressed at news of the study sponsored by Philip Morris (which advised the Czech Government that early deaths of smokers each saved $1227 on health care, pensions and housing17) is an index of these values. However, the corollary is not to hold the door of life open unquestioningly and indefinitely, regardless of the quality of such life or the costs of doing so. A recent systematic review of the rate of functional decline in older people in the US has shown a significant reduction in this decline in the past 3 decades, suggesting some success in compressing morbidity (ie, delaying the onset of illness) through both disease prevention and medical care.18 However, the demographic wave of people entering old age will mean that the number of people who are disabled, dependent and living with reduced functionality through multiple chronic conditions will grow to be larger than ever before.19 With this trend compounded by the rapidly growing obesity epidemic,20 we seem likely to see an unprecedented prevalence of disability in ways that may have not been previously anticipated in modelling. The number of people with Alzheimer’s disease in Australia (presently around 200 000) is expected to reach 580 000 by 2050.21 Death, and particularly early death, is typically privileged above suffering in the formulae used by health planners to set priorities. Health ministers boast about disease survival rates all going in the right direction, but spare relatively little thought about how to reduce the burden of chronic disability in the living. A reorientation that saw improvements in quality-of-life indices like chronic pain, immobility, isolation, sensory impairment and depression as being just as, if not more, important than the slavish pursuit of prolonging lives, would see a major rechannelling of research and expenditure. National audits of the morbidity arising from such quality-of-life-eroding variables deserve more attention and public policy discussion. The medical specialties that would benefit from such a reorientation would include pain management, public health efforts dedicated to keeping people physically and mentally active, and efforts at improving the much-discussed Bhutanese-inspired concept of “gross national happiness”.22 More importantly, considerations of such qualities of life would force the health and medical enterprise to engage more with others sectors like financial and residential planning and ergonomic design to facilitate greater independence for the aged, rather than focusing so much on simply keeping people alive in old age. And we need to embrace “Enough already”.

Simon Chapman PhD

Taking a risk and embracing opportunities may yield unexpected benefits I didn’t really know back then why I had to go, but something within me was pushing, and so, I went. I grew up in the United Kingdom and trained there in medicine. During my internship, I realised that I wanted to go to Africa for what were, then, a variety of ill-formed reasons. They included travel, adventure and an attraction to the notion of mission doctoring — doing “everything” while working in an underserved community. Without doubt I was, in part, naïve, but in 1987, straight after internship, I was on my way to Jane Furse Hospital in the black South African “homeland” of Lebowa, 3 hours’ drive north of Johannesburg. It was only later that I learned I had been employed after the other hospital doctors had left because of local violence. Vignette 1: the changing colours of Africa Awake. My first morning in Africa. The night before, my journey from the airport to the hospital had been a nightmare. In a decrepit truck, with companions who spoke no English. On rough roads, in a dense darkness the like of which I had never experienced before. It had taken hours and I had never felt more alien in my life. The scene that next morning, as I wandered across the mission hospital campus, is etched in my mind. The very light itself was different. A cloudless blue sky. Deep red earth carpeted with purple flowers that had fallen from the jacaranda trees. The pinks, purples and reds of the bougainvillea. And, of course, the smiling black faces of the nurses contrasting with their radiantly white uniforms. Yes, this was where I needed to be. I recall having said at my medical school interview that I wanted to do medicine because it offered me the opportunity to help people less fortunate than myself. I’m still not sure who cringed more — me, or the interviewer — but I did mean it. I enjoyed medical school and my internship in a district hospital in northern England, and had been accepted into a general practitioner training program in the Midlands. But first of all I was going to do a year in Africa. Vignette 2: on practising “grass roots” medicine Vusi was 22 years old and had been caught stealing. He was brought into our rural district hospital in poor shape, with a spear through his abdomen and lower chest — some punishment. However green I may have been, I was the only doctor available and so, with help from the nurses, I stabilised him in the emergency room before moving him, as quickly as possible, into theatre. I knew there were only two units of blood in the hospital that weekend. I intubated and anaesthetised him and handed over his care to the student nurse on duty. Then, scrubbed up and with a theatre nurse assisting, I opened his abdomen and repaired multiple small and large bowel lacerations and a liver tear. Vusi left hospital a week later and, in subsequent years, I was often greeted cheerfully by him as I moved around the village. Members of a local church celebrate the opening of a new clinic I had gone to Africa against the advice most teachers and mentors provided — “too risky”, “bad for your career” and “go later, do your training first”. But I went, and after a year I knew that if I wanted to make a real difference, to do something meaningful, to give, then I needed to stay. It seemed to me that those who only stayed for a year or two took more than they gave. I stayed for 12 years and regret not a moment. I gained extraordinary clinical experience, as the workload was so high and we had so few doctors. Within 18 months of arriving, I recall noting that I had seen almost every fracture covered by my orthopaedics textbook — and had become adept at their conservative management. I gave of my limited clinical training and skills, and I received more in return by way of experience. By staying on, as I learned more and more I was able to give more. Always, I received yet more in return. Vignette 3: from patients to protocols and programs Mhlambe watched me, disinterested, with a dull, glassy stare. Eighteen months old but very underweight, he had all the stigma of kwashiorkor — peeling skin, oedema, and thinned red hair. He had the worst type of malnutrition, kwashiorkor plus marasmus. Malnutrition was our second most common paediatric problem (gastroenteritis was the most common). Mhlambe prompted me to develop an evidence-based protocol for the management of malnutrition in place of the previous ad hoc approach, and mortality rates fell as a result.1 A few weeks later, Mhlambe was discharged well and went on to be treated for tuberculosis through another newly developed community program. He finished treatment successfully and his mother became involved in a women’s group developing a vegetable garden and making crafts, helping to address the underlying cause of Mhlambe’s admission — poverty. I spent most of my time at Hlabisa Hospital in KwaZulu-Natal, perched on top of a ridge looking down across the plains to massive forested sand dunes and the Indian Ocean coast. It was a 450-bed hospital with 10 000 annual admissions, serving a population of around 250 000. Usually we had about five doctors, sometimes up to around 10. At times, I was the only doctor available. Vignette 4: evolving research A lazy Saturday morning spent mulling over the events of the week. Obstetrics had been busy that week — I had done 15 caesarean sections, two vaginal breach deliveries and had successfully managed a shoulder dystocia. But I had also signed six stillbirth certificates on Friday. None of the bereaved mothers had been seen antemortem by a doctor and I could still hear their wailing. Something was not right. I wandered over to the obstetrics ward and made a list, from the maternity register, of all the perinatal deaths I could find in the previous 3 months. Then, on to the medical records office where I could obtain and examine the records of these deaths. I estimated the perinatal mortality rate to be about 60 per 1000 (about 10 times higher than the best in the UK at that time). Most of the cases had never been seen by a doctor and it was obvious that at least a third were associated with an error or omission in care. Without knowing it, and with no training, I was doing some health systems research. In response to my findings, I wrote some simple protocols, developed a training program for midwives and doctors in the hospital and village clinics, and visited all clinics monthly to implement the protocols and support the staff. I was doing public health medicine. Within a few months, perinatal mortality was significantly down and hardly any deaths were classed as avoidable. Most importantly, we embedded the changes into routine practice, disseminated our results through publication, and helped others implement similar programs.2,3 Completing one of the 2000 caesaean sections I did during my 12 years in Africa. It soon became obvious to me that clinical services, although very necessary in this environment, were insufficient if the goal was improved population health outcomes. Organisation, systems, processes, an evidence-based and protocol-driven approach to care — all within a population health ethos — are crucial too. In reality, there is no divide and distinction between clinical medicine and public health; each feeds off and complements the other. As we organised and strengthened the clinical service, so we organised and strengthened the community services. We worked hard to integrate the hospital with the clinics, and so to develop a truly engaged service. We also worked hard on priority, high burden diseases such as tuberculosis,4-6 sexually transmitted infections and HIV/AIDS. Vignette 5: engaging the community Petros, thin as a rake, was coughing, bent over, almost retching with the effort. We saw hundreds of cases of tuberculosis each year; the incidence had risen dramatically as the prevalence of HIV increased. A simple audit showed that only about 20% of diagnosed TB cases could be shown to have completed the prescribed 8 months’ course of treatment. Clearly, the practice of 4 months’ hospital admission followed by 4 months’ treatment through the village clinics was not working. First, we adopted a shorter and simpler 6-month drug regimen with admission for only 2 weeks. Then we developed community-based, directly observed treatment using village clinics, with community health workers and a wide range of lay people as supervisors. Documented treatment completion rates rose to over 80%.4 The benefits of community participation included managing an ever-increased disease burden, at lower cost, and with much improved outcomes.6 I went to Africa on an impulse and against all advice. In all honesty, I considered that I was a risk and had very little to give. But I gave what I could — myself, my time, and my commitment. I received so much more in return — extraordinary clinical experience and skills, a deep appreciation of the importance of public health medicine, a range of opportunities to develop clinical, research, and leadership skills, and the privilege of meeting a wide range of fascinating people. Research based on my observations blossomed and, over time, I published more than 100 papers. Seven years ago, I came to Australia as new opportunities and challenges presented themselves. Aspects of the transition were hard, while others were easy. My African experience certainly eased meeting the responsibilities of my appointment as Foundation Chair in Rural Health at the University of Adelaide, where I was instrumental in establishing the Department of Rural Health and the Rural Clinical School. There followed a stint in senior university management, and I am now preparing to take over as Head of the School of Medicine at the University of Queensland at the end of 2006. However, every 6 months I return to Africa to foster my ongoing research there, and for some reason it always feels like going home.

David Wilkinson MB ChB, PhD, DSc

Jesia G Berry,* James E Harrison,† Raymond A Cripps,‡ Ruth Marshall§ * Research Officer, † Director and Associate Professor, ‡ Research Associate, National Injury Surveillance Unit, Flinders University, GPO Box 2100, Adelaide, SA; § Director, South Australian Spinal Cord Injury Service, Royal Adelaide Hospital, SA. Jesia. BerryATflinders.edu.au To the Editor: The authors of a recent article on football spinal injuries1 restate the case made in 1987 “for an independent registry of football-related ASCIs [acute spinal cord injuries]”2 and conclude that “the games must be made safer than they presently are, and a national registry is the first step in this direction”.1 The Australian Spinal Cord Injury Register (ASCIR) was established in 1995 by the National Injury Surveillance Unit of the Australian Institute of Health and Welfare and the directors of all six Australian spinal units. The ASCIR collects data from these units on persisting ASCI from all causes. Published reports are available at <http://www.nisu.flinders.edu.au/publications. php#hdr16>. We think that this existing register provides the basis for the function advocated by Carmody et al.1 The ASCIR can be used to identify particular types of ASCI cases, such as those due to football, and can provide basic demographic and clinical information. Indeed, The ASCIR was used to identify relevant cases when Carmody and colleagues1 asked spinal units for this information. Ideally, data for a sports injury register are obtained from injured players, witnesses and clinicians to enable detailed analysis of mechanisms and circumstances. A good example is a register of catastrophic head and neck injuries in American football which has, since 1977, collected data from each injured player’s coach, physician and athletic director, prompting rule changes and equipment improvements.3 As a register of ASCI generally, the ASCIR does not normally obtain such detailed information about cases occurring during football. There is no obvious reason why football-related cases ascertained by the ASCIR should not be flagged for supplementary information collection, perhaps by or in collaboration with interested researchers such as Carmody and colleagues.1 In addition to case data, participation numbers over time are necessary for trend analysis. The Australian Rugby Union has published comprehensive annual participation data since 1996, but the Australian Rugby League has not. The American football register is supplied with participation figures by national school and collegiate associations,3 and similar information from Australian sports-governing bodies would be beneficial. The brief statement of methods and the omission of year-specific case numbers by Carmody et al1 left us unsure how trends had been modelled (eg, Were trends based on annual rates? Were annual exposure data interpolated from their Box 1 figures?) We note that their figure of 68 179 registered rugby union players in 1996 is more than 20 000 lower than the figure published by the Australian Rugby Union.4

Jesia G Berry · James E Harrison · Raymond A Cripps · Ruth Marshall

Thomas K F Taylor,* David J Carmody,† David A Parker,‡ Myles R J Coolican,‡ Robert G Cumming§ * Emeritus Professor, † Registrar, ‡ Surgeon, Department of Orthopaedics and Traumatic Surgery, Royal North Shore Hospital, Pacific Highway, St Leonards, NSW 2065; § Professor, Centre for Education and Research on Ageing, Concord Hospital, Concord, NSW. tktaylorATmed.usyd.edu.au In reply: We welcome the opportunity to comment briefly on what we consider a registry for spinal injuries in football should actually be. The raw data collected by the Australian Spinal Cord Injury Register is valuable for governments and other statutory bodies — for example, to plan for the enormous costs of acute spinal cord injuries (ASCIs), irrespective of their causation. However, a proper registry for spinal injuries from football (all codes) is a far cry from this. In particular, hospital records are notoriously inaccurate as to the way in which injuries sustained are documented, and to rely on them ensures misleading, if not spurious, data. We established long ago that interviewing players was the only accurate way to identify the mechanisms of injury, which are the keys to possible preventive measures.1 It is entirely relevant that ASCIs are at one end of a spectrum of vertebral column injuries (eg, fractures, dislocations) sustained in all football codes. Between 1986 and 2002, 65 footballers were admitted to the Royal North Shore Hospital with vertebral column injuries but no spinal cord damage. These injuries were sustained by the same mechanisms as their more serious counterparts and differed from them in degree rather than absolute kind. We contend there should be mandatory reporting of all spinal injuries to an independent registry and that football club registration should depend upon compliance with this requirement.

Thomas K F Taylor · David J Carmody · David A Parker · Myles R J Coolican · Robert G Cumming

With the demise of the Aboriginal and Torres Strait Islander Commission in 2004 after a long and painful 8-year illness, a new council to represent the views of Indigenous people, the National Indigenous Council, has been chosen for us. One of the first viewpoints expressed by one of the new council members concerned the “Sorry” debate.1 The council member stated that an apology for past injustice was important, “but does not address domestic violence in our homes”, and went on to say that the need to address poverty, poor health and lack of education were a higher priority than statements of regret. In my view, this comment was a disappointment, not only because of the leverage this kind of statement gives to the “anti-bleeding heart” brigade, but also because a true apology — and, more importantly, the actions that go with it — would address exactly these conditions in our communities. Genuine measures would go some way towards making holistic health gains and dealing with health inequities experienced by Aboriginal and Torres Strait Islander people. To be truly effective, any actions taken should be based on the existing framework of the recommendations of the Human Rights and Equal Opportunity Commission’s report, Bringing them home.2 A little background: the Bringing them home inquiry traced the history of the forcible removal of Aboriginal and Torres Strait Islander children from their families from the earliest days of colonisation to contemporary removals that took place in the 1990s. In New South Wales, the Aborigines Protection Act 1909 allowed the Aboriginal Protection Board (APB) to “assume full custody and control of the child of any Aborigine”. Intimidation and influence hadn’t been effective in getting families to hand their kids over, so the law was brought in. The justifications for removal included claims that children would receive a better education or that it would help them gain good employment (the reality was that education was often discouraged and adolescents were sent off to do menial domestic and farm or labouring jobs). However, what isn’t so well known is the reasoning at the time, which was simple, and may explain why many who were connected personally and professionally with the issue called the policies and practices “genocide”. The architects of the Aborigines Protection Act had an aim of making the Aboriginal race cease to be a problem to settlers and townspeople: In the course of a few years there will be no need for the camps and stations; the old people will have passed away, and their progeny will be absorbed in the industrial classes of the country.3 An amendment to the Act came into force when the APB desired the power to remove children without having to go through a court and without having to establish neglect (Aborigines Protection Amending Act 1915). Reasons for removal found on files in the NSW state archives include “to send to service”, “at risk of immorality”, “to get her away from surroundings of Aboriginal station/removal from idle reserve life” and “being Aboriginal”.2 Mostly, children were sent to institutions such as the Bomaderry Childrens Home, Cootamundra Girls Home or Kinchela Boys Home. The experiences of these children were often brutal, with assimilation into white society the main aim. Experiences such as that recounted below are detailed in the Bringing them home report. Most of us girls were thinking white in the head but were feeling black inside. We weren’t black or white. We were a very lonely, lost and sad displaced group of people . . . We didn’t know anything about our culture. We were completely brainwashed to think only like a white person. When they went to mix in white society, they found they were not accepted [because] they were Aboriginal. When they went and mixed with Aborigines, some found they couldn’t identify with them either, because they had too much white ways in them. So that they were neither black nor white. They were simply a lost generation of children. I know. I was one of them.”2 The APB evolved into the Aboriginal Welfare Board, and the amended Act became the Child Welfare Act 1939 (NSW), which had one system of regulation for Aboriginal children and another for non-Aboriginal children. While the Child Welfare Act returned removal matters to the court system, most parents were excluded from procedures because of physical isolation from the towns where children’s courts were located and a lack of money to pay for legal representation. Added to the legislation at this stage were the terms “neglected” and “uncontrollable”, with all the race and class subjectivity that goes along with interpreting the definitions. The Aboriginal Welfare Board finally ceased to exist in NSW in 1969, but not before the institutionalisation of removed children had been slowly phased out over the years in favour of adoption and fostering into non-Aboriginal family homes. By this time, the fine art of coercion by Welfare staff had been honed — much more “civilised” than driving in and rounding up kids with a truck while their parents tried to hide them in flour bags. This trend, reinforced by adoption laws, gave children little chance of finding out who they were and where they were from or even that they were Aboriginal, unless they were fortunate enough to be told by caring adoptive families. Even today, Aboriginal children are placed in out-of-home care at rates up to 13 times greater than those for non-Aboriginal children.4 Contrary to recent claims made in public discourse and media reports, Aboriginal children, unlike other children, are removed for neglect more often than they are for abuse.4 The well publicised high rates of incarceration also bear witness to the continued institutionalisation of Aboriginal and Torres Strait Islander people, well after the shift away from assimilationist policies. If the seeds of future ill health are indeed present before birth,5 what could be the cumulative consequences of several generations’ worth of control by the government? I would suggest you need look only as far as your Aboriginal patients who present for treatment. The likelihood is that these policies, or their equivalents in other states, have affected them in some way. The Bringing them home inquiry estimated there would barely have been a family untouched by these practices. If your patient was not taken, he or she may have parents, siblings, aunts, uncles, cousins, grandparents or great grandparents who were taken. The patient’s own children may have been removed or temporarily separated. Or the patient’s family may have lived in fear after witnessing friends’ children being taken and grown up denying their own Aboriginality to avoid the same fate. How could these removal policies have had such an effect on such a great number of individuals across Australia, and could that explain the poor health, educational and socioeconomic status and the social problems of Indigenous people so visible today? The effects of the policies are numerous and include: The grief of parents and family for the child or children removed; The interruption to family and community structure when children have been taken; The loss of identity, of rightful place in family, of ties with family, community and culture of the children removed; The anxiety of the search for family and identity; The turmoil, for all, of trying to fit each other back in each other’s lives; and The pain and anger when this doesn’t happen as it was hoped, or if it can’t happen at all. Each of these effects manifests itself in various ways, leaving its impact on relationships, physical and mental health, family structure, parenting skills and social and criminal behaviour. Perhaps here it’s best to let one of the many hundreds of people who submitted evidence to the Bringing them home report tell you her story in her own words: After the kids had gone to the home Mum and Dad hit the grog hard as they had done everything in their power and in their hearts to keep us away from . . . the Welfare. But they sniffed us out of the bush like dogs. My parents couldn’t handle the trauma of not having the closest warmth loving caring family we were. They separated. My Mum went one way; my Dad went his way . . . Eventually I got married when I was 21 years old. I thought maybe I could get my brothers and sisters and give them the home that the Welfare said my parents had to do . . . After about 14 years my [eldest] brother came to live with us. One sister found us through the Salvation Army about 16 years later. Then my brother [the baby] who died last year, who was caught up in the System was like a lost street kid and was bashed by the police in Melbourne a couple of years ago, ended up with a tumour on the brain and was never the same again. My second sister who I or my family didn’t see for 27 years. What could anyone do now to make up for those 27 years of not having their sister a part of their life? A terrible big hole in my heart that will never be filled. We all are in contact with each other now and we try to make up for all those lost years. But something’s missing. Could you put yourself in the situation that we were put through?2 The view that an apology for past injustice is important “but does not address domestic violence in our homes” is mistaken. The impact of removal policies goes on down the line and will continue to do so for as long as child welfare policies are directed at removal rather than prevention, with Indigenous families bearing the brunt. Professor Beverly Raphael spoke to the Inquiry of the reaction people had to the kind of trauma described above. She described it as: . . . a high level of arousal . . . that heightened arousal can stay on a heightened level with physiological responsiveness for the rest of one’s life . . . And one reason they take alcohol and other substances is often to dampen this down and they don’t know its cause.2 The Bringing them home report also discussed research into the effects of adoption on relinquishing parents and the impact of bereavement on mortality and morbidity. The researchers stated that there were a number of matters affecting recovery: Perceived social support facilitates adjustment; The opportunity for free expression of feelings facilitates adjustment; The ability to find meaning in the outcome facilitates adjustment; and The presence of other life stressors impedes adjustment.6 If this is a framework upon which to base the healing of those affected, it surely can be seen how genuine apology and practical support (or lack thereof) for survivors could have an impact on health and wellbeing. When families have been torn apart and parenting and familial roles undermined, damage is done and lives continue to be interrupted. Aboriginal people can grow up with emotional scars and cultural identity issues, leading to deep and highly visible “practical” problems such as family violence, social and emotional wellbeing issues, and substance and alcohol abuse problems. Many people affected have shown great resilience to overcome such problems and emerge with their families safe and intact, but many more have not and are still trying. There are services to help, such as Link-Up7 and the many “Bringing Them Home” counsellors, Aboriginal social and emotional wellbeing workers, Aboriginal health workers and many other concerned professionals. These positions, their integrity, and the existence of these organisations must be assured. * While state governments around the country made apologies around the time of the release of the report, the federal government has failed to do so. Furthermore, if the cycle of trauma that the “Stolen Generations” has created is to be halted, there are numerous recommendations from the Bringing them home report that must be put into action. The proposals range from acknowledgement and apology* to guarantees against repetition, implementation in federal legislation of the Genocide Convention,8 restitution and rehabilitation (including medical and psychological care, legal and social services), to parenting skills training and health professional training regarding the effects of removal. Unfortunately, until the underlying problems are appropriately addressed, existing services guaranteed and the required new services implemented, the cycle will continue and we’ll struggle to deal with the important issues such as poverty, poor health and lack of education that this new National Indigenous Council member rightly spoke of.

Wendy A Hermeston BA(Psych)

Perceptions of young people’s health and wellbeing vary greatly, reflecting differences between disciplines, ideologies and generations. Young people are resilient, adaptable and doing well but, at the same time, are experiencing increased rates of important mental and physical health problems. While some of the contradictions in the evidence can be explained — for example, between measures of life satisfaction and happiness and indicators of psychosocial health — tensions between perspectives remain. We describe briefly a project involving cross-disciplinary synthesis that sought to gain a better understanding of the points of convergence and divergence in the commentaries and evidence on young people’s wellbeing in Australia. The project suggests that, if young people’s situation is to be optimised, there needs to be greater focus in both research and policy on: the “big picture” of the social changes reshaping life today; total health and wellbeing, not just ill health; the “mainstream” of youth, not only those young people who are marginalised and at-risk; and social and cultural resources that are as important to wellbeing as material and economic resources.

Richard M Eckersley BSc(Hons), MScSoc · Ani Wierenga BA(Hons), PhD · Johanna Wyn BA, MA, PhD

Paediatricians could raise parents’ awareness of potential problems with media exposure by asking a few simple questions during consultations “This instrument can teach, it can illuminate; yes, and it can even inspire. But it can do so only to the extent that humans are determined to use it to those ends. Otherwise, it is merely wires and lights in a box.”1 The media cut across virtually every major area of concern that parents and paediatricians have about adolescents — aggressive behaviour and violence, suicide, sex, drugs, obesity and eating disorders, and learning problems.2 Yet, both parents and paediatricians seem to show little understanding of the media’s impact on young people, and to take little time to try to consider the current situation — in which teenagers are inundated with messages in the media that are potentially harmful to their health. Why? My own theory is that parents and paediatricians are just too busy raising and caring for children and adolescents to have much time to watch, listen to, or read much media themselves. Furthermore, on the list of “important things” for parents to fight with teenagers about, their media use ranks near the bottom for most. Parents may also buy into the Hollywood myth that television and movies are merely fantasy entertainment. For paediatricians, it is difficult to have time to talk about the media in a busy office visit when there are so many other, “more important” topics to cover — vaccinations, seat belts, bicycle helmets, proper nutrition. However, the media should rank at the top of all concerns because they can have an impact on so many crucial areas of a teenager’s life, and paediatricians and parents need to realise that the media’s influence begins at a very young age. According to the first wave of the long-term Growing Up in Australia study, infants are already spending nearly 1.5 hours a day watching television, and 4–5-year-olds are spending about a third of their total play time (2.1 hours) watching television.3 In 2002, a study of more than 1000 Australians aged 10–13 years found that median screen time for this age group was up to nearly 4 hours per day (Tim Olds, Associate Professor, School of Health Sciences, University of South Australia, personal communication), and more than half of all Australian children aged 8–18 years have a television set in their own bedroom.4 The latest Kaiser Foundation study found that older children and teenagers spend more than 6 hours a day multi-tasking with a dizzying array of media, ranging from television and video games to the Internet, mobile phones and instant messaging, and iPods.5 What we knowMedia violence: There are more than 1000 studies linking exposure to media violence to real-life aggressive behaviour.6-8 Media violence also leads to desensitisation and to the belief that violence is an acceptable solution to everyday problems. A recent study found an association between viewing media violence at a young age and bullying.9 In fact, the connection between media violence and real-life aggression is nearly as strong as the link between smoking and lung cancer, and stronger than the connections between lead and IQ, homework and achievement, calcium and bone mass, and exposure to asbestos and cancer.2,6 Although much of the research has been done in the United States, an Australian Psychological Association position paper in 200010 and the Royal Australasian College of Physicians in 20044 acknow-ledged the significance of media violence. Teen suicide: Numerous studies in the US and Europe have shown a link between media coverage of suicide and subsequent increases in suicides among teens.11 Sex: Only a handful of studies have examined sexual content in the media and its impact on teenagers, but they all show that there is an impact.12 In the absence of effective sex education, the media have become one of the leading sex educators of children and teens today.12 In the most recent study of nearly 1800 teenagers, teens’ viewing of sexual content led to a doubled risk of earlier sexual initiation.13 In addition, most teenagers have been exposed to pornography online, whether intentionally or inadvertently.14,15 Drugs: Young people view as many as 2000 advertisements annually for beer on television alone in the US, and such ads do have an impact.16,17 Children and teens who view R-rated movies (designated suitable for ages 17 years and older in the US) are three times more likely to begin smoking.18 Obesity and eating disorders: Overweight and obesity are increasing at alarming rates in Australia, with a 2.5-fold rise over the past 20 years.19 Australia now has one of the highest rates of type 2 diabetes in the developed world.20 Numerous studies show that there is probably a causal connection between TV viewing and obesity,2 although the exact reasons remain unclear — might the constant barrage of junk food advertisements21 be contributing? A recent study from the Australian Divisions of General Practice found that there is an average of one junk food advertisement per commercial break in children’s television programming, and that 99% of all food advertisements during children’s TV was for junk food.22 Watching TV also correlates with unhealthy body self-image among young girls and teen girls.12,23 A recent study found a cause-and-effect relationship between the introduction of American TV programs into Fiji and the development of new eating disorders and abnormal body self-image among adolescents there.24 Learning problems: In the first study of its kind to examine this concern, researchers found that hours of television viewed per day at both ages 1 and 2 is associated with attentional problems at age 7.25 What we don’t knowWe don’t know why parents and paediatricians don’t pay more attention to the media’s influence on children and adolescents. During an office visit, how long would it take to ask two simple questions of parents? How much TV (and other media) does your child view each day? Is there a TV set in your child’s bedroom? For children and teens who are aggressive, obese, or who are doing poorly in school, perhaps a more detailed media history could be obtained. The recent report from the Royal Australasian College of Physicians outlines a variety of ways that paediatricians can be more attuned to this issue.4 For example, they can be far more assertive in providing counselling to parents about the impact of media on children, and encourage household rules about media use. They should avoid placing TV sets in their waiting rooms. Paediatricians should also be at the forefront of discussions with filmmakers about depicting cigarette smoking in mainstream movies. Finally, both parents and paediatricians need to lobby governments for more funding for research into the crucial areas of how the media affect children and teens, what can be done to maximise pro-social media and protect against harmful media’s influence, better programming for young people, and more funding for media education campaigns and media education programs in schools. TV, movies, and video games may seem like “harmless entertainment” to adults and to Hollywood, but they exert a potent influence on young people. The question is not whether children and teenagers are learning from the media; it is how much and what are they learning.

Victor C Strasburger MD

Objective: To determine immunity to tetanus and diphtheria in the Australian population.Design and setting: Analysis, using double antigen enzyme immunoassays, of a representative sample of sera (1950 samples tested for diphtheria and 2884 for tetanus) collected opportunistically from Australian laboratories between July 1996 and May 1999.Main outcome measure: Immunity to diphtheria and tetanus, defined as negative (susceptible) when the antitoxin level was < 0.01 IU/mL, positive (immune) when it was ≥ 0.1 IU/mL, and low positive (partially immune) when it was in the range 0.01–< 0.1 IU/mL.Results: About 99% of children aged 5–9 years had diphtheria and tetanus antitoxin levels ≥ 0.01 IU/mL (immune or partially immune). Antitoxin levels declined with age and generally more markedly for diphtheria than tetanus. For subjects aged 50 years and over, less than 60% were immune or partially immune to diphtheria and less than 75% to tetanus. Men and women had similar diphtheria antitoxin levels, while women had lower levels of tetanus antitoxin compared with men of the same age, with the difference being most marked in the age group ≥ 70 years (37% v 60%; P < 0.001).Conclusions: Immunity in children appears to be good, but adults, especially older people, may not be adequately protected. Recent changes to the Australian Standard Vaccination Schedule should improve immunity in cohorts now aged < 50 years. However, additional efforts are required to protect those over 50 years (especially travellers), who are most susceptible.

Heather F Gidding BAppSci, GradDipEpidBiostats, MAppEpid · Josephine L Backhouse BRurSc · Gwendolyn L Gilbert MD, FRACP, FRCPA · Margaret A Burgess MD, FRACP

Preeti Sachdev,* Simon Chapman† * Postgraduate Honours Student, † Professor, School of Public Health, University of Sydney, NSW 2006. simonchapmanAThealth.usyd.edu.au To the Editor: Smokeless tobacco products (with the possible exception of Swedish “snus”1) are carcinogenic.2 They cause oral cancer, sometimes rapidly (within 7 years of use).3 A pinch of smokeless tobacco held in the mouth for 30 minutes delivers as much nicotine as 3–4 cigarettes.4 Sachet of smokeless tobacco In Australia, the sale of smokeless tobacco was first banned in 1986, in South Australia.5 Thereafter, all states enacted legislation outlawing its sale, and, in 1991, an amendment to the federal Trade Practices Act 1974 banned the manufacture, importation and commercial supply of the products.6 Nevertheless, permits to import smokeless tobacco for personal use were issued on application, and, in March 2002, an amendment to the federal Customs (Prohibited Imports) Regulations 1956 allowed importation without a permit of amounts up to 1.5 kg for personal use.7 Between September 2000 and March 2002 (when permits were still required for all importations), 2270 permits were issued, while between March 2002 and December 2004, a further 88 permits were issued for amounts exceeding 1.5 kg (Mr Tim Pulford, Australian Competition and Consumer Commission, Canberra [which administers permits], personal communication). Following observations of smokeless tobacco being sold in south Asian shops in Sydney, New South Wales, we sought to assess its availability. We selected 14 Sydney suburbs with large populations of residents from south Asia (defined as the Indian subcontinent), and surveyed all south Asian mixed businesses in the shopping precincts of these suburbs in March 2005. If no smokeless tobacco products were displayed, the person serving was asked if they had any “paan masala or guthka” (Hindi expressions for smokeless tobacco) for sale. Fifty of the 53 shops surveyed (94%) sold smokeless tobacco: 31 (62%) of these kept it under the counter, 14 (28%) on display behind the counter, and five (10%) on shelves accessible to consumers. No shopkeeper advised that sale of the products was illegal. The prevalence of “under the counter” storage suggests widespread awareness that it is illegal to sell the products. The federal Customs (Prohibited Imports) Regulations do not restrict the number of times a person may import up to 1.5 kg of smokeless tobacco for personal use without a permit. A typical sachet of guthka (Box) weighs 4.6 g, meaning that around 320 sachets could be legally imported for personal use. It would be entirely legal for a shopkeeper and each family member to import up to 1.5 kg on a daily basis if it was intended for personal use. Diversion of this into retail trade appears easy. The ease with which we were able to obtain smokeless tobacco suggests that the law prohibiting sale is not being enforced. The New South Wales Public Health Act 1991 empowers officers, such as environmental health officers, to investigate breaches of the Act. These officers should undertake surveillance of the readily identifiable shops in the manner that we did, confiscate the products being sold and warn that future sales will result in prosecution.

Preeti Sachdev · Simon Chapman

Chris E Rissel Clinical Associate Professor, School of Public Health, University of Sydney, Level 9, King George V Building, Missenden Road, Camperdown, NSW 2050. crissATemail.cs.nsw.gov.au To the Editor: The editorial by Sharman about exercise and air pollution1 makes the point that cars contribute substantially to air pollution, and air pollution is known to have adverse health effects. Therefore, Sharman posits that exercise, which is unequivocally good for human health, is best done away from sources of air pollution. This “common-sense” maxim to avoid air pollution when exercising is superficially reasonable as far as it goes, but is a very weak response to the health and social problems generated by motor vehicles or the need for increased levels of physical activity in the population. With only half the Australian population achieving adequate levels of physical activity,2 recommendations to patients to be more physically active are essential. To simultaneously promote exercise and then put a health warning on this physical activity effectively undermines the recommendation. Part of the difficulty in judging the actual risks from air pollution and benefits of physical activity is that the science of pollutant exposure is not well understood at the individual level. It is not currently possible to say that exercising in a particular environment will have a net negative effect. Thinking laterally, perhaps physical activity even boosts the immune response in a way that helps the body resist adverse effects of air pollution? Perhaps only under more extreme conditions would outdoor activities need to be curtailed. One body of relevant research that Sharman did not consider is the research on pollutant exposure by travel mode, which clearly indicates that car drivers and passengers have pollutant exposures at least twice that of pedestrians walking on the same street.3,4 The longer people sit in cars, the greater their exposure to air pollutants, not to mention the increased risk of obesity.5 Therefore, a highly sensible approach is to recommend to patients that they avoid travelling in cars, particularly if the patient is sensitive to air pollutants or if traffic is congested. The most obvious common-sense solution to reduce air pollution and increase individual and population levels of physical activity is to recommend to patients that they replace short car trips with walking or cycling. As little as two 15-minute active transport trips per day can achieve recommended levels of physical activity to maintain health. It is possible to change travel behaviour, and this is a far better recommendation for all patients than telling them not to exercise near traffic.

Chris E Rissel

Louis A du Plessis Former Senior Lecturer, School of Applied Science, Riverina–Murray Institute of Higher Education, Wagga Wagga, NSW (retired). eldupeATbigpond.com To the Editor: Health professionals in the Sydney Greater Metropolitan Region have been found to be less aware of air pollution and its health effects than are patients susceptible to such effects.1 Therefore Sharman’s brief review of the harmful effects of air pollution is welcome.2 In offering advice on how to minimise the exacerbation of pollution-induced harm by exercise, Sharman concentrates on the spatial distribution and temporal variation of traffic. The advice is sound for the metropolitan population, but incomplete for non-metropolitan residents exposed to smoke from burning biomass. Australia’s National Environment Protection Measure defines limits for inhalable particulate matter suspended in ambient air (PM10). The NSW Department of Environment and Conservation operates a network of monitoring stations to measure PM10 and other pollutants, and posts the results daily on its Internet site <www.epa.nsw.gov.au/index.htm>. The National Environment Protection Measure requires environmental authorities to work towards reducing the number of days on which PM10 exceeds the daily limit to no more than 5 days per year. This goal is far from being realised in some places. One such place is Wagga Wagga, NSW, where monitoring of PM10 started on 11 April 2001. From that date up to 6 July 2005, the city experienced 118 days on which PM10 exceeded the limit, as well as many days of pollution near but below the limit. In the same period, monitoring stations in the Sydney Greater Metropolitan Region registered between 11 and 33 days of excess PM10. Of the 118 days of above-limit PM10 in Wagga Wagga, 30 occurred in the period from 30 October 2002 to 26 January 2003, when there were severe bushfires in south-eastern Australia. Most of the rest had a cause that is very evident in the surrounding countryside in autumn — the burning of paddocks to prepare them for sowing. Rural residents’ health is worse than urban residents’ health for many reasons, but biomass burning is not widely recognised as one of them. The Australian Medical Association’s Rural Reference Group, which is being convened to improve rural health,3 may wish to add environmental health to its agenda. There are two steps that the Group could take to lessen the effects of smoke from burning biomass. The first is to acquaint rural doctors with information such as that presented by Sharman. The second is to persuade the Department of Environment and Conservation and NSW Health to issue rural health warnings based on the continuous, real-time output of PM10 monitors in regional centres.

Louis A du Plessis

James E Sharman Postdoctoral Research Fellow in Cardiovascular Physiology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD 4102. jsharmanATsoms.uq.edu.au In reply: As emphasised in my editorial, regular aerobic exercise is to be encouraged, as it is of undeniable benefit to health.1 The crux of the intended message was for people to undertake an exercise program, but not near busy roads. There was no suggestion to curtail outdoor activities. Although the effect of traffic pollution on an individual is not well understood, there are many hundreds of scientific papers consistently finding that whole automotive pollution, or components thereof, damage biological tissue and promote disease.2 The World Health Organization recognises urban air pollution as a major risk to human health, with exposure to particulate matter alone accounting for an estimated 800 000 deaths a year globally.3 Would it be ethical to confine this information to the annals of scientific literature, or should some attempt be made to inform those who may be unknowingly and unnecessarily exposing themselves to veritable risk? People should have access to all the available information so that they can make an informed decision on where to exercise. Not only is it common sense, but it is entirely reasonable to suggest that people would be better off avoiding exercise alongside roadways congested with traffic. Quite separate to the question of exercising beside busy roads, but equally important from a health perspective, is the issue of persistently high ambient levels of particulate air pollution in certain regions. The air quality problem encountered in Wagga Wagga is exacerbated by geographical and climatic factors that encourage entrapment of air pollution, owing to a temperature inversion layer that is particularly apparent during winter. Other cities, such as Launceston, Tasmania, suffer the same fate and, in both cases, smoke from domestic wood-heaters is thought to be the biggest contributor to poor air quality. What are people to be told regarding exercise in these regions? It may be reasonably argued that habitual exercise in such environments would be detrimental to health, but it would be a very poor public health outcome if people were advised to stop exercising. In the affected areas mentioned, community education programs have been in existence for years, but these appear to be of limited value, as daily air pollution limits are regularly exceeded,4 as highlighted by du Plessis. Although unpopular, the answer lies in stricter regulations to clean the air, such as banning wood-heaters and tighter monitoring of rural burning.

James E Sharman

The obesity epidemic has been described as a catastrophic failure of government and public health authorities to devise and implement concerted, effective evidence-based action. To respond effectively to major public health challenges such as this, Australia needs a Ministry for the Public’s Health, with a budget and accountability to parliament separate from the Health Minister. This Ministry would be better able than current health departments to develop and implement health — rather than health care — policy, to build partnerships across tiers of government, and to present the health and economic arguments for disease prevention to state and federal treasuries. Such a Ministry has international precedents, with dedicated public health agencies created in Canada, Sweden and the United Kingdom, although it is, as yet, too early to gauge their effectiveness. The Ministry would be best placed within state and territory governments, as it is at this level that partnership building and whole-of-government cooperation would have the greatest impact.

Stephen J Corbett MPH, FAFPHM

Grant A Mackenzie Paediatrician and Postgraduate Student, Ear Health and Education Unit, Menzies School of Health Research, PO Box 41096, Darwin, NT 0811. grantmacATmenzies.edu.au To the Editor: Funding of universal varicella zoster vaccine (VZV) at ages 18 months and 10–13 years was recently announced in Australia. Health professionals should be aware of a number of related issues. Varicella vaccination was recommended in the United States from 1996 for all children aged 12–18 months, with catch-up vaccination to age 13 years. US surveillance shows: Decreased varicella mortality in all age groups except those aged ≥ 50 years (average varicella deaths per year: 145 in 1990–1994 versus 66 in 1999–2001).1 Decreased varicella cases in all age groups, with a non-significant reduction in hospitalisations (average annual hospitalisations in three surveillance regions: 40 before vaccination versus 14 after vaccination).2 US data on herpes zoster have not yet been published. There are concerns that, in the longer term, universal varicella vaccination may increase the incidence of adult varicella and herpes zoster, similar to the effect of pertussis vaccination on adult pertussis. Modelling in the United Kingdom predicted that universal infant vaccination would initially reduce varicella, but would result in increases in herpes zoster 5–10 years later and adult varicella 20–40 years later.3 In contrast, modelling of adolescent vaccination predicted a small decrease in varicella, but no increase in later adult varicella.3 Varicella is generally perceived as a mild illness, while vaccination is largely valued for preventing serious, life-threatening conditions. Anecdotal reports of low levels of private purchase of VZV in Australia suggest it may not be a priority for some families. With 36% of general practitioners concerned about unknown side effects of VZV,4 and public concern about vaccine adverse events in the face of low disease rates, the level of acceptance of universal varicella vaccination by providers and consumers is uncertain. Alternatives to universal varicella vaccination were a high-risk strategy (vaccination of children with chronic illness and family members of high-risk individuals) or waiting until US disease patterns were established. These were real options as: A high-risk strategy may prevent up to 45% of paediatric hospitalisations.5 Hospitalisation and herpes zoster contribute more to health costs than treatment in the community or acute varicella.5 Natural infection, at the cost of disease, immunises most of the population. Any increase in adult varicella and herpes zoster caused by varicella vaccination may be alleviated by booster doses, but the added cost, difficulty in reaching the target population, and potential impact on community confidence in vaccination may be significant problems. The universal varicella vaccination program will test providers’ and consumers’ acceptance of vaccination against what is perceived as a mild illness.

Grant A Mackenzie