Social determinants of health

The postwar arrival of refugee doctors heralded changes to the Australian health workforce that we are still adjusting to todayInternational medical graduates (IMGs) are an important part of Australia’s health workforce, accounting for about 23.5% (n = 16 186) of all doctors in Australia today.1 The recruitment and placement of IMGs in rural areas is particularly vital to the provision of health services in rural Australia, where there ...

Daniel R Terry BNurs, MInternatHlth · Jessica J Woodroffe BA(Hons), PhD · Quynh Le PhD, MAppComp, MEdStud · Kathryn J Ogden MB BS(Hons), MPH, FRACGP

Dennis McDermott argues that educating doctors about the health consequences of everyday racism towards Indigenous Australians challenges all involvedAgenuine engagement with Indigenous health issues challenges medical students and doctors alike. When participants in medical education analyse racism as a social determinant of health, the challenge deepens. The experience can range from disquieting to profoundly disturbing. For educators, the experience can be stressful, even daunting. Analysing racism ...

Dennis R McDermott BEc, BA(Hons)(Psych), MA

To the Editor: Your focus on obesity in the 20 February 2012 issue of the Journal expresses the frustration of many of us working in this area. After 25 years, it is clear that we have achieved little in reducing the problem at the population level and that the existing model for dealing with obesity, based on personal ...

Garry J Egger

To the Editor: From 2007 to 2009 in Australia, a three-dose course of quadrivalent human papillomavirus (HPV) vaccine was offered to all females aged 12–26 years through school and primary health care settings, with coverage recorded on the ...

Bianca Barbaro · Julia M L Brotherton · Dorota M Gertig

Staff safety is improved by clear procedures for managing abuse and assault. Hopper and colleagues describe a scenario familiar to many hospital clinicians and managers: staff reports of verbal abuse and physical assaults from patients.This is often in an organisational context of scarce reliable data about the phenomenon, an ad-hoc management response and no specific training of staff to manage aggression....

Brett McDermott MD, FRANZCP, CertCAPsy

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

Kristy A Martire · Sarah Larney

Major reform plus targeted strategies have the potential to provide relief Underpinning recent global health initiatives, including the Millennium Development Goals and the United Nations’ High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases, has been recognition of the links between illness, disability, poverty and economic development. In Australia, the economic effects of illness, particularly long-term illness and disability, are often overlooked or examined exclusively in terms of the consequences for government budgets and the economy. While such analyses may be effective in alerting policymakers to the scale of particular epidemics, they provide little indication of the direct impact of illness on the wellbeing of those in the community. To do this, the unit of analysis needs to be shifted from the macro economy to individuals and households. The existence of universal publicly funded health care and social security arrangements has possibly encouraged complacency among researchers and policymakers about tackling this issue. However, there is emerging evidence in Australia that chronic illness and disability are associated with serious levels of economic hardship and that such hardship affects health behaviour1-3 — thereby completing a cycle in which poor health leads to poverty, which then leads to poor health. The economic consequences in question include not only the out-of-pocket costs of medical treatment, but also the costs of self-management (eg, home modifications, transport and paid care) and loss of income for patients and carers.1,3,4 As a result, those of low socioeconomic status are at greater risk of experiencing illness and disability and are more vulnerable to the consequences. Out-of-pocket costsThe most direct manner in which the economic impact of illness is felt is through the out-of-pocket costs of care. In Australia, despite a free public hospital system and universal social health insurance coverage through Medicare, levels of out-of-pocket payments are high by international, high-income country standards. In a recent Commonwealth Fund survey of 11 high-income countries, the incidence of out-of-pocket spending exceeding US$1000 in the previous year among individual respondents was 21% in Australia — behind only the United States (35%) and Switzerland (25%), and well above countries such as the United Kingdom (1%), France (4%) and New Zealand (7%).5 In 2009, out-of-pocket spending as a proportion of total health expenditure was 18.2% in Australia — above the Organisation for Economic Cooperation and Development (OECD) median of 15.8% (Box 1).6 This proportion has remained steady in Australia, not varying much from the 1999 value of 19.9%, and seems unlikely to change given one of the recommendations of the National Health and Hospitals Reform Commission: “We want to see the overall balance of spending through taxation, private health insurance, and out-of-pocket contribution maintained over the next decade.”7 It is hard to see any compelling fiscal justification for such a policy when a comparison across OECD countries indicates that public spending on health in Australia in 2009 (5.8% of gross domestic product) was well below the OECD median (6.9%).6 What are the implications of these costs?The picture emerging from recent studies in Australia is that major burdens are being imposed on particular patient populations by high out-of-pocket costs.1-4 For example, in a study of patients with chronic obstructive pulmonary disease (COPD), 46% of patients experienced an incidence of catastrophic health care spending — defined as out-of-pocket costs exceeding 10% of income for the period studied.1 The main out-of-pocket costs incurred by these patients are shown in Box 2. In general, evidence suggests that the high burden of out-of-pocket costs tends to be skewed toward those with comorbidity1 and those with more severe illness.8,9 However, the hardship related to such burden tends to be most pronounced in people who have retired1 and those of low socioeconomic status,1 and there is little evidence of concession or insurance status providing significant protection.1,10 In addition, substantial costs incurred by patients are often not for health care but for home modifications, social support and transport.1,3,4,10 Significantly, increasing levels of out-of-pocket costs associated with copayments for PBS-listed medications have been found to be associated with reduced rates of prescriptions being filled.2 Such findings are supported by evidence from a qualitative study of patients with chronic illness in western Sydney and the Australian Capital Territory; lack of affordability of medical treatment, and thus impaired ability to self-manage, was a major aspect of economic hardship for these patients.3 Putting these findings into context, over the past 10 years the out-of-pocket burden associated with both MBS-listed medical services and PBS-listed medications has increased substantially (by 4.2% and 6.7% per year respectively).6 The concern is that these rising levels of copayment will adversely affect compliance, particularly in patients who require long-term treatment. Indirect costsIllness and disability also affect household economic circumstances through their effect on employment. In 2006, 33% of 18–64-year-olds who reported specific limitations or restrictions lived in households in the lowest income quintile, compared with 10% of those without such impairment.11 This pattern is further pronounced in individuals with intellectual disability and severe or profound disability, with 40% and 36% of people in these groups, respectively, living in the lowest income quintile households.11 This impact extends to informal carers, who often leave paid employment to care for a sick family member. While there are income support programs in place to assist those with long-term illness and their carers, often these barely cover living and medical expenses.3 Nevertheless, the prospect of losing income support payments and concessional status as a result of resuming employment can create a welfare trap for patients and carers, particularly those in low-income occupational groups. Financial stress and illness-related povertyIn Australia in 2009, 28 665 individuals became bankrupt, of whom 11% cited ill health or absence of health insurance as the primary reason.12 While illness-induced bankruptcy is not as large a problem in Australia as it is elsewhere (such as the US, where it caused 62% of bankruptcies in 200713), significant numbers of Australians are catastrophically affected by illness. In addition, disability has been found to be associated with more acute measures of economic hardship, such as financial stress based on an individual’s ability to raise a sum of money for something important. The Australian Institute of Health and Welfare (AIHW) has found that individuals with specific limitations or restrictions, when compared with those without impairment, report over double the rate of being unable to raise $2000 (26% v 11%).11 Another criterion for assessing financial stress is the inability to make necessary household payments. According to the AIHW, 34% of 18–64-year-olds with specific limitations or restrictions reported at least one such incident in the previous 12 months, compared with 18% of those without impairment.11 One study which adopted this broader perspective of examining the economic impact of illness and disability on households found that, in patients with COPD in western Sydney, 78% reported at least one instance of being unable to make necessary payments in the previous 12 months or, to do so, needed help, sold assets, moved house or borrowed money.1 Similarly, in individuals participating in the Household, Income and Labour Dynamics in Australia (HILDA) Survey, a population-based longitudinal survey, such incidences of financial stress were found to be strongly associated with disability, poor physical function and poor mental health.14 What can be done?The studies conducted in Australia indicate that health-related economic hardship tends to disproportionately affect specific patient populations, largely due to costs that are conventionally treated as being unrelated to the health sector. In the absence of comprehensive evidence, it is only possible to gather findings from a patchwork of unrelated studies. Priority should therefore be given to developing a consistent approach that records the specific costs to individuals and their households associated with illness and identifies the impact of these costs on health behaviour and wellbeing. The available evidence indicates that the out-of-pocket costs of treatment and self-management and loss of income from chronic illness and disability are associated with economic hardship, catastrophic health care spending and non-compliance with medical treatment. Major reform, such as the recently proposed National Disability Insurance Scheme (NDIS), has the potential to address hardship associated with illness and injury. However, meaningful improvement is also possible through small-scale targeted strategies. As household economic burden is skewed toward specific patient groups, effective remedies could include focused interventions such as income support and subsidies. These measures would identify and catch those individuals and households that currently fall through the cracks. They would also be unlikely to involve changes that distort current health care priorities or restructure the responsibilities of different government sectors. Furthermore, they could be implemented quickly. Ultimately, both broad-brush policies such as the NDIS and targeted support measures are needed to provide direct relief to individuals and households most at risk of illness- and disability-related economic hardship. 1 Out-of-pocket costs as a share of total health expenditure in OECD countries, 2009* OECD = Organisation for Economic Cooperation and Development. * Reproduced with permission from the Australian Institute of Health and Welfare.6 2 Main out-of-pocket costs associated with managing chronic obstructive pulmonary disease1 Home oxygen and medications Transport Medical consultations and tests Home care Medical equipment

Stephen Jan BEc, MEc, PhD · Beverley M Essue MPH · Stephen R Leeder BSc(Med), MD, PhD

Objectives: To identify patterns of khat use among Somali-Australians in Australia and to explore their views about the links between khat use and personal health.Design, setting and participants: Qualitative study using semistructured focus groups among adult members of Somali communities in Brisbane, Sydney, Melbourne and Perth who volunteered to attend focus groups in January and December 2010.Main outcome measures: Emergent themes related to Somali-Australians’ understanding of the links between khat use and personal health.Results: Nineteen focus groups included 114 participants. Khat use was reported to be common among the Somali community, and more common among men than women. Khat was usually chewed in prolonged sessions, producing mild psychostimulant effects such as increased energy, enhanced mood, reduced appetite and reduced sleep. Khat was widely perceived to be a food, not a drug, and as harmless, or even beneficial, to the user’s health. Many users reported discontinuation effects such as lethargy, sleep disturbances and mood problems after sessions of heavy khat use, and some reported self-medicating with alcohol to cope with such problems. Problems of addiction to khat were identified by some participants, but not all believed it is addictive. Many khat users reported visiting their health professionals for treatment of adverse effects and failing to disclose their khat use.Conclusions: Health professionals require greater awareness of khat use and related health problems. Health promotion activities targeting communities with high levels of khat use are required to increase understanding of the potential risks of regular khat use, to promote harm-reduction strategies, and to increase awareness of services available for those experiencing harm. Health professionals should consider targeted screening for khat use among individuals from Horn of Africa communities who present to health services.

Heather Douglas LLB, LLM, PhD · Merali Boyle LLB(Hons), BSc · Nicholas Lintzeris MB BS, PhD, FAChAM

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

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

To the Editor: The editorial by Newman and colleagues on suicide and self-harm in immigration detention1 was a timely reminder of a contemporary issue that has aroused clinical, sociological and political debate. However, in providing a list of dot points for investigation, there was one curious omission. Although perhaps not politically correct or indeed comfortable for the authors, the well recognised possibility that suicide and self-harming behaviour could be politically motivated2 should also be addressed. This is important, not only because we as health professionals could be seen to be naive to ignore this, but, more specifically, so that inappropriate medicalisation of readily understandable distress does not occur.

Robert D Goldney

In reply: We thank Goldney for his thought-provoking response. We recognise that self-harm has multiple determinants, including mental disorders, but that it also attempts to influence or communicate. Acknowledging the political context that has created and sustains this issue, we also note long traditions of politically motivated self-harm and suicide, for example, by self-immolation or hunger strike; and that political protests using these methods — lip-sewing, cutting and self-burial — have occurred in Australian immigration settings. Our belief, based on extensive clinical engagement, is that the motivation for most self-harm and suicide in Australian immigration detention is not primarily political, but anchored in detainees’ deep despair. Many say that by killing themselves, they will end their pain and no longer be a problem to themselves, the government or their loved ones. As clinicians, we experience a tension — we acknowledge, with Goldney, the importance of not medicalising an area where the environmental and contextual influences so overtly create and maintain distress, yet we have a duty of care to reduce the risk associated with such behaviour and distress, irrespective of their origins. A pre-eminent challenge for professionals working in such stressful environments is to remain open to these multiple influences. We remain open to what the data will tell us about political and other contributing factors.

Michael J Dudley · Nicholas G Procter · Louise K Newman

Self-interest and global responsibility create a public health balancing act The treaty between Australia and Papua New Guinea (PNG) referred to as the “Torres Strait treaty” entered into force in February 1985.1 The treaty’s purpose is to provide certainty of the sovereignty and maritime boundaries between the two countries, including in the Torres Strait, where there are over 200 islands. The three major inhabited Australian islands of Boigu, Dauan and Saibai are situated several kilometres off the coast of the South Fly District of PNG’s Western Province (Box 1).2 In September 2009, the Australian Senate requested that the Foreign Affairs, Defence and Trade References Committee inquire into and report on matters related to the region and the treaty,3 including the administration and management of public health in and around the Torres Strait. Although the treaty excludes health access as a justification for travel, its free-movement provisions have contributed to a situation where access to Australian health services by people from PNG and public health issues — particularly those related to tuberculosis (TB), HIV/AIDS, cholera, dengue and malaria — have become major concerns. We present our analysis of the committee’s November 2010 report and highlight the increasing immigration, health, socioeconomic, cultural and human complexities that exist in the region. Such complexities require collaborative commitment between state and national governments from both sides of the border in formulating policy and providing resources. The Torres Strait treatyThe Torres Strait treaty established a Torres Strait Protected Zone. Within the protected zone, people who live in the coastal areas of PNG and Australians who are Torres Strait Islanders are permitted to travel across the border in accordance with their way of life as the traditional inhabitants of the region. Australia and PNG are divergent in wealth and development, and this divide has grown in the past 20 years. PNG has one of the poorest health records in the Pacific region and is unlikely to meet any of its health-related Millennium Development Goals.4 Communicable diseases are the major cause of death and illness across all age groups; life expectancy is 57 years;5 and 30% of children in PNG are considered to be moderately to severely malnourished.6 The health system in the remote Western Province is particularly poor.7 This area’s main health facility is Daru Island Hospital, which operates with poor infrastructure as well as ongoing staff and clinical supply shortages.8 The hospital lacks capacity to support rural areas in clinical outreach services.9 Western Province has been described as the “most economically depressed region of PNG”.10,11 Poor sanitation and water quality and limited disease-control activities result in outbreaks of infectious diseases such as malaria, HIV/AIDS and other sexually transmissible infections, TB and multidrug-resistant TB (MDR-TB).8 Unsurprisingly, the international border provides a bridge for emerging infectious diseases.9,12,13 To counter this, the treaty allows for border integrity as a public health priority — under its provisions, Australian or PNG authorities can close the border to limit or prevent free movement.14 All cross-border travel was restricted in 2009 because of the H1N1 influenza epidemic,15 and again in 2010 because of a cholera outbreak in Daru that killed 30 people.16 There is increasing alarm over the potential for a major public health crisis on Australian shores, such as MDR-TB spreading into vulnerable Aboriginal communities in north Queensland.9,12 Main committee findings related to health servicesTraditional inhabitants were exempt from usual immigration health checks at the Australian border in the Torres Strait: This exemption, under the treaty’s freedom of movement provisions, aroused locals’ “fear of likely transmission of serious diseases”. The committee highlighted that Unauthorised visitors who manage to land on the islands undetected . . . increase the risk of diseases being transmitted to people on the islands.17 PNG residents traversed the border for Australian health care services: Although access to health services is not classified as a traditional activity pursuant to the treaty, the reality was that people from PNG frequently travelled into Australia to receive treatment at Queensland Health clinics, particularly those located on the islands of Saibai and Boigu.17 Demand for Queensland Health services was increasing: Although data on the number of people from PNG who sought medical assistance in the Torres Strait were incomplete, there were “significant” and rising numbers receiving Queensland Health services. This caused a strain on Queensland Health services and subsequent access difficulties for Australian Torres Strait residents that contributed to local unease and tension.17 The committee found that the situation was complex, with “very strong push and pull factors” driving the trend for PNG residents to seek Queensland Health services.17 The factors included: A lack of health care services and resources in Western Province, and particular paucity in the South Fly District adjacent to Torres Strait. The proximity of Australian medical facilities for South Fly District residents. Queensland Health clinics on Saibai and Boigu islands are a 15–30-minute boat trip, costing about A$60 return for fuel, which was subsidised by the clinics.9 Daru hospital is a 2-hour boat ride, for which the cost of the fuel ranged from $180 to $240. Provision of health care by Queensland Health, with the support of the Australian federal government, to PNG residents who required urgent medical attention. This occurred on humanitarian and public health grounds, especially to prevent the spread of infectious diseases into Australia and throughout Western Province. Australia’s “level of care” extended to medical evacuations of people from PNG to the Australian mainland and Thursday Island Hospital,17 outside the Torres Strait Protected Zone. Only patients with acute life-threatening conditions were admitted (Box 2).15 Additional challenges identified by the committeeThe committee found that local Australian residents were concerned that Australia was sending a “mixed message” by allowing PNG residents limited access to Queensland Health services. That is, while the treaty did not allow movement for the purposes of accessing health care, Australia was nevertheless providing services on certain grounds. There was fear that this would set a precedent and foster demand for Queensland Health services, causing resentment among local Torres Strait communities and local health care managers because of the increasing use of resources. Further, Australian-based health professionals have experienced confusion over treatment protocols for visitors from PNG in the Torres Strait. The committee also acknowledged that the complex situation was muddied by the multiple government agencies operating in the region with overlapping portfolios (Box 3), resulting in inefficiencies in service provision, gaps in communication and problem planning, and potential resource mismanagement. The committee’s recommendations and the long road aheadSupport for PNG health care initiatives by the Australian Government: The aim of this recommendation is that PNG residents will eventually not need to seek Queensland Health services in the Torres Strait region. The committee acknowledged the long road ahead, particularly in the remote Western Province. While AusAID supports development of PNG’s health system substantially through cooperative capacity-building exercises, the differential between health services in Australia and PNG will persist into the foreseeable future. Reframing the health issues as a collaborative cross-border approach: Development assistance is primarily framed around a host nation’s needs. However, the Torres Strait situation warrants reframing as a regional cross-border issue and a specific project targeting the needs of both countries. This would need to move beyond the current model wherein the Torres Strait Health Issues Committee (known as the HIC), meeting twice yearly, examines health issues associated with the free border movement of PNG residents and Torres Strait islanders.7 Rather than the HIC, an adequately resourced, targeted project that deals with cross-border issues on both sides is needed, and one that particularly includes consultation with both PNG and Australian communicable disease physicians who work in the region. Increased monitoring of Australian development projects in Western Province: While the committee’s recommendation for greater accountability over how Australian development funding is spent appears to be reasonable, what is needed is a greater focus on results and mutual accountability over the outcomes that would result from a harmonised approach to this cross-border issue. Collaboration between all government agencies: The committee recognises that investment in health infrastructure by both the PNG and Australian governments in Western Province is insufficient. Continuing financial support is needed for maintenance so that the benefits of initial aid outlays are not lost — a recognition that is consistent with the redefining of sustainability in development.18 The committee encourages all agencies to work together in the use of resources, so “projects on both sides of the border should complement and strengthen each other”. The recognition that this is an “atypical jurisdiction” invites innovative solutions: the Torres Strait situation could be framed as a regional trans-border issue, and health authorities of Australia, Australian states, the Torres Strait, Western Province and PNG, as well as other stakeholders, could be invited to collaborate on developing a network of cross-border services, with defined objectives that address specific shared concerns. Given a long and continuing history of migration to the Torres Strait region from Asia and Melanesia,10 a broader regional approach could be justified. Experience from Australia’s tristate Aboriginal health services in Central Australia19 and from Mekong cross-border development collaborations20 provides appropriate models. Continued provision of services by Queensland Health to PNG residents in the foreseeable future: On humanitarian and public health grounds, the committee stated its full support for Queensland Health. Yet Queensland Health will need to be better resourced by the federal government as part of a collaborative strategy for health care services at this regional interface. Failure to recognise this as an international obligation will see Queensland Health’s commitment to communicable disease control compromised. The economic and public health implications for Australia of reducing current cross-border communicable disease strategies warrant urgent attention. This is already a demonstrable concern for Australian health professionals working in the region, with Queensland Health’s recent decision, on financial grounds, to close its TB clinics on Saibai Island. Review of Australian Government funding to Queensland to ensure it is commensurate with actual costs incurred: In view of the previous recommendation, it is unsurprising that the committee made this additional comment. Developing a cross-border project would enable clear costing of and responsibility for the agreed strategies, while building communicable disease control capacity within PNG and safeguarding Australian public health interests. ConclusionCurrent Queensland Health policy regarding access for PNG residents to health services from Australian health clinics — to provide acute services only — is in tension with public health imperatives and the long-term management of some chronic infectious diseases. Problems are compounded by the number of agencies and levels of government responsible for interlinked funding and health care provision bridging the border. Solving the problems demands a collaborative but innovative approach, with improved health services for the people of PNG in their own country as the long-term goal. In the interim, the Foreign Affairs, Defence and Trade References Committee report identifies a range of strategies and makes clear recommendations that will guide progress. These recommendations are enmeshed with concepts of health diplomacy, as international health issues have now achieved foreign policy priority.21 The risk of cross-border disease transmission in the Torres Strait is a clear demonstration that health is a global, rather than a local, agenda. People from PNG will continue to challenge the treaty provisions and seek lifesaving health services that are unattainable in their own country. A mother from Western Province making the 20-minute dinghy trip to a Queensland Health clinic seeking treatment for her young child with TB is unaware of any potential concerns of the Australian public — her need is urgent, and Australia has comparatively unlimited resources. This is the human side of the Torres Strait quandary, reminding us how intensely personal public health is, and how health and human rights arguments intersect.22,23 1 Map of the Torres Strait region, showing the boundaries between Australian and Papua New Guinean territory 2 Admissions of Papua New Guinea residents to Thursday Island Hospital, Sep 2008 – Sep 20097,15 Reason for admission* No. of patients Tuberculosis (25% had multidrug-resistant tuberculosis) 15 Obstetric case 15 Severe malaria 10 Medical trauma or care (falls, fractures, burns, violent injuries from machetes and spears, snakebite, acute and chronic eye injuries) 52 Total 92 * Only patients with acute, life-threatening conditions were admitted. 3 Overview of agencies operating in the Torres Strait Agency Government Role Torres Strait Regional Authority Australian Participate in health policy coordination, development and planning of initiatives undertaken by state and government agencies Queensland Health (QH) Queensland Manage and fund public health facilities Provide health services to PNG residents on humanitarian and public health grounds* Department of Health and Ageing Australian Provide dedicated funding to QH for Torres Strait services Undertake discrete public health activities in the Torres Strait AusAID Australian Manage Australian Government’s aid program Provide funding to PNG for health systems development in cooperation with the PNG and regional governments Department of Foreign Affairs and Trade Australian Utilise movement monitoring officers to conduct border enforcement measures to prevent breaches of treaty provisions Department of Health PNG Provide health services to PNG residents according to duty of care PNG = Papua New Guinea. * Access to QH facilities is the product of an Australian Government foreign affairs agreement.

Claire E Brolan BA, MA, LLB(Hons) · Susan J Upham BSocWk, GCIPH, PostgradDipHlthPromot · Peter S Hill MB BS, PhD, FAFPHM · Graham Simpson MD, FRCP, FRACP · Stephen D Vincent MB BS(Hons), FRACP

For many decades, Australia has been fortunate to have a low prevalence of tuberculosis (TB).1 This has resulted from a firm commitment to screening for and managing TB since early last century. Because of the low rates of disease, the current population, unfortunately, perceives TB to be a “disease of the past”. Such a perception leads to complacency, even among subgroups of policymakers, who place importance on short-sighted spending cuts over long-term TB control in an era in which drug-resistant TB is an emerging biosecurity threat to Australia. One component of effective TB control is prompt identification and treatment and monitoring of index cases and screening of contacts. In 2001, the Cairns Regional TB Control Unit initiated this response when the first case of multidrug-resistant TB (MDR-TB) was detected in the Torres Strait region.2 The initial and subsequent cases were in people from Western Province in Papua New Guinea (PNG) who resided within the Torres Strait Protected Zone and, by treaty law, are free to travel back and forth from Western Province to the outer islands of Torres Strait for traditional purposes. As new cases emerged from Western Province, the regional control unit established TB outreach services on Saibai and Boigu Islands to treat these patients, both for humanitarian reasons and to reduce the health risk to Australian citizens. The clinics employed medical, nursing and radiographic staff and had access to the Brisbane TB reference laboratory. They carried out ongoing surveillance during a patient’s treatment cycle, to detect any treatment failure or default, and post-treatment follow-up, to ensure the patient was cured. Over the past decade, the number of TB and MDR-TB cases originating from Western Province has increased substantially and the demand on the clinics has been large.2 However, the actions of the clinics have been credited with there being no MDR-TB cases detected in the Australian population in this region. The Australian clinics were set up out of necessity, as Western Province has no established, comprehensive TB service. Further, Western Province has been plagued by long-term political unrest, poverty and lack of transportation, resulting in minimal access for local residents to their regional hospital on Daru Island. The intention of the Saibai and Boigu clinics has always been to hand over care of PNG residents once a clinic and a TB outreach program were established on the PNG side of the border. Over the past few years, there have been regular meetings between Queensland TB control units, the Australian Government, the Western Province local government, the PNG national TB program team and Daru hospital staff. The aim of the meetings has been to facilitate, step by step, the transfer of responsibility for TB management to PNG, including clinical input from both Queensland and PNG health services. As yet, there is no such service within Western Province or through a clinical base at Daru Hospital with an outreach service to Western Province. Unexpectedly, during the first half of 2011, the Queensland Government directed that the TB outreach clinics on Saibai and Boigu Islands be closed in June 2011.3-5 No remedial plan for treatment continuation was included, leaving the 50 patients from PNG who were being treated for TB in a dire situation. Importantly, there was no plan for the ongoing management of patients from Western Province. Through strong pressure from TB clinicians in Australia, operation of the Australian services has been extended, and they will remain open until early 2012 to ensure completion of the treatment cycle for current patients. AusAID is supplying funding to establish TB health services within Western Province,5,6 but the program is in its infancy. There is considerable concern that extensively drug-resistant TB will emerge in the region and eventually infect Australian citizens residing in the outer Torres Strait islands.

Stephen D Vincent MB BS(Hons), FRACP

A sustained and coordinated multisectoral approach is vital Recent research has shown a striking association between gender-based violence (GBV) and lifetime mental disorders among Australian women.1 Data from the 2007 National Survey of Mental Health and Wellbeing2 offer important lessons for advancing policy and practice in this key area of human rights and public health. More than a quarter of the 4451 women surveyed had experienced one of the common forms of gender-based violence (GBV): rape (8.1%), other forms of sexual assault (14.7%), physical intimate partner violence (7.8%) and stalking (10.0%). Sexual assault and rape often occurred for the first time at an early age (median 12 and 13 years, respectively). GBV was strongly associated with a wide range of mental disorders including mood, anxiety and substance-use disorders; women exposed to one form of GBV had double the rate of any lifetime mental disorder (58%) of unexposed women (27%). GBV was also strongly associated with severity and comorbidity of mental disorder, suicide attempts, disability, poor quality of life, unemployment and overall socioeconomic disadvantage. Although major advances have been made in developing practice guidelines and policy to prevent and respond to GBV in Australia, there has been little focus on the mental health component. This oversight continues to be evident in the Australian Government’s 12-year action plan,3 which otherwise offers a comprehensive approach to the problem. The prevalence and consequences of GBV mean that it needs to be regarded as a mainstream problem for all health care providers. The primary care level is of pivotal importance. General practitioners need to be aware of the likelihood that undisclosed GBV may underlie unexplained physical injuries and mental health symptoms, particularly among repeat attenders. There is a risk that the culture of silence on this issue will hinder detection of the problem.4 Women justifiably fear that they will not be believed or that their disclosures will put them at risk of further abuse, and clinicians may be hesitant to raise this sensitive topic. The presence of partners at consultations can further inhibit disclosure. GPs may benefit from additional training in gender-sensitive interviewing techniques, to ensure accurate detection of GBV in a manner that builds trust.5 National protocols need to be implemented for referral and coordination among agencies so that women have access to protection (shelters and/or the removal of perpetrators from the household), legal advice, support for at-risk children, and financial assistance. Access to quality mental health services should be a priority, given that the disorders identified by the national study were complex in nature, disabling and associated with suicide risk. Specialised agencies, including mental health, rape crisis and domestic violence services, need to recognise more fully the close interaction between GBV and mental disorder. Mental health professionals should maintain a high level of suspicion that GBV may underlie common mental disorders. Sensitive inquiry into a history of abuse is an integral part of assessment. Abused women should be protected from situations that increase feelings of insecurity; for example, mixed-gender facilities or settings where male partners can gain ready access. Services for sexual assault and domestic violence require better resourcing to ensure seamless referral to mental health professionals with the necessary skills to address the psychological consequences of gender-related abuse. The process of referral needs to allay the woman’s fear of being labelled in a context where perpetrators commonly try to discredit reports of abuse by claiming the survivor is mentally disturbed. The study findings1 point to the importance of childhood, adolescence and early adulthood as targets for interventions. It is during these early developmental phases that women commonly are first exposed to sexual abuse, which is the harbinger of further violations as well as of a lifetime of mental disorder and disability. A greater focus on school-level and family interventions may prove valuable. The family is the setting of highest risk, but it is also the unit with the greatest potential to provide protection. At a wider level, public health campaigns are needed to change attitudes and mores that sanction the culture of patriarchy and silence surrounding GBV in our society.6,7 The strength of the nationwide epidemiological study1 is that it offers a lifespan perspective on the recursive problem of GBV, in which women are at risk of repeated exposure to abuse of various forms, and of developing a range of comorbid mental disorders and associated disabilities. Socioeconomic disadvantage and marginalisation compound the problem. Women with limited resources and alternatives are less able to leave a violent relationship. Indigenous women and women from refugee backgrounds may be confronted with additional problems related to discrimination and isolation.8-10 A sustained and coordinated multisectoral approach, in which mental health has an integral role, is vital to bringing about fundamental change to the life-course trajectory of adversity associated with GBV. The overarching aim should be to provide a comprehensive approach to intervention that empowers women to make the changes required to promote recovery and resilience.

Susan J Rees MSocPol(Hons), PhD · Derrick M Silove MD, MB ChB(Hons), FRANZCP

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

Jessica L Browne · Paul Zimmet · Jane Speight

A carbon price is vital for the public good; complementary policies should protect low-income households Anticipating the Australian Government’s announcement of a carbon tax, the Royal Australasian College of Physicians (RACP) stated that, while it accepted the need to take action on climate change, it recommended caution about a carbon tax because it could exacerbate health inequalities.1 Some in the media inferred that the RACP’s primary concern was the potentially negative health impact of a carbon tax.2 It is reasonable for health professionals to be concerned about the welfare of low-income households, because people in these households usually spend a disproportionate share of their income on energy and food. However, the larger policy issue is the incontrovertible evidence that climate change is occurring3 and will have profoundly negative health impacts.4,5 A longer lens tells us that a carbon price is especially in the interests of those with low incomes, whose lives will be more disrupted by climate change than will the lives of the wealthy, and among whom the negative health impacts will be greater.6 If the level of global warming is to be constrained below 2°C, all countries must take extraordinary policy actions. This temperature increase is the optimistic “guardrail” beyond which we are unlikely to be able to maintain the climatic stability on which our current civilisation depends. It is far from clear that we have the global geopolitical will to prevent warming in excess of this 2°C level. Because climate change is occurring at the same time as we have passed the peak of conventional oil supplies,7 and unconventional methods of oil extraction involve even more greenhouse gas emissions, all developed countries must now take urgent and effective policy action on climate change to protect human health and planetary ecosystems. Taxation is one of the most powerful policy tools avail-able to governments, but it is also one of the most politically controversial. Individuals who pay a particular tax are not necessarily those who will benefit from the revenue raised. Carbon taxes and other environmental taxes cannot be seen in isolation; such taxes should be judged by their overall distributional effect, as the revenues are disbursed through transfers or government expenditure. Putting a price on carbon will inevitably cause increases in energy prices, and failing to compensate low-income households for these increasing costs would be regressive and could lead to low-income households having to make unhealthy choices about whether “to heat or to eat”. However, governments with a clear strategic intent to reduce health inequalities have many policies available to ensure that their overall policy package is progressive, as well as effective in cutting emissions. At the same time as the Australian Government announced the carbon tax, they announced other tax changes, with more than half the money raised by the carbon tax to be redistributed to households by way of tax cuts and increases in pensions, allowances and family payments. The taxation, benefit and expenditure arrangements in developed economies constitute an integrated system, and the outcomes of any policies should be assessed by effects on overall measures of income and wealth distribution. For example, the roll-out of the United Kingdom’s Decent Homes Programme — requiring homeowners and landlords to bring their houses up to a decent standard — has made a positive contribution to lowering energy costs for low-income households.8 Similarly, American research has shown that home energy assistance programs for low-income households can reduce nutritional and health risks among children under 3 years of age.9 In New Zealand, in contrast to the recent Australian housing insulation debacle, successive governments have subsidised insulation and more effective, non-polluting heaters. This popular policy was based on evidence that these measures increased the energy efficiency of houses and lowered the household’s energy expenditure.10,11 There were also broader social and health benefits that outweighed the costs of subsidising these programs by local and national governments.12 These are all examples of policies that have required increased initial expenditure — in some cases by both households and governments — for medium- and long-term broad benefits. They are policies that balance targeting and universalism, and are appropriately proportionate to need. Putting a price on carbon, via a tax or other means, likewise enables societies to manage their carbon emissions more efficiently, creating incentives to reduce emissions where it is easiest to do so. The Intergovernmental Panel on Climate Change concluded that the greatest sectoral emission reductions can be made in the buildings sector.13 The World Health Organization has recently published a report highlighting that while there are inevitably costs involved in reducing carbon emissions in buildings and in household use of energy, the co-benefits for health are significant, particularly for low-income households.14 Health sector organisations should support putting a price on carbon and should take care with their media releases, lest any statements be taken out of context and misused by opponents of carbon pricing. These organisations need to highlight the potential health benefits of public policies15 while monitoring policy packages to ensure that, overall, they reduce inequalities in income and health.

Philippa L Howden-Chapman MA, DipClinPsych, PhD · Ralph B Chapman BE, MPA, PhD · Anthony G Capon MB BS, PhD, FAFPHM · Nick Wilson MB ChB, DIH, MPH

Objective: To determine whether an association exists between distance from radiotherapy facilities and survival outcomes of people diagnosed with rectal cancer.Design and setting: Descriptive population-based study using data from the Queensland Cancer Registry.Patients: All patients aged 20–79 years (n = 6848) diagnosed with invasive rectal cancer between 1 January 1996 and 31 December 2006.Main outcome measure: Cause-specific survival.Results: The 5-year cause-specific survival was 62% (95% CI, 61%–64%); it was strongly influenced by stage at diagnosis (American Joint Committee on Cancer, Stages I–IV), ranging from 86% (Stage I) to 9% (Stage IV). After adjusting for age, sex, and stage at diagnosis, patients who lived 100–199 km, 200–399 km and 400 km or more from a radiotherapy facility were 16%, 30%, and 25%, respectively, more likely to die from rectal cancer than patients living within 50 km of such a facility. On average, there was a 6% increase in mortality risk (95% CI, 3%–8%; P < 0.001) for each 100 km increment in distance from the nearest radiotherapy facility. Shared frailty models showed that this association persisted after adjusting for the correlation between individual cancer patients living in the same remoteness or area-level socioeconomic status categories.Conclusions: While centralisation of cancer treatment services has merit, our study provides evidence of a shorter survival for people with rectal cancer who live relatively far from radiotherapy facilities. It remains a priority to develop and implement policy, cultural and clinical measures to reduce the burden faced by rural and remote patients with rectal cancer.

Peter D Baade PhD, MMedSc, BAppSc(Hons) · Paramita Dasgupta PhD, MSc, BSc(Hons) · Joanne F Aitken PhD, MSc, BSc(Hons) · Gavin Turrell PhD, BA(Mgt/Adm)

A city specialist consulting in the country ponders the tyrannies of life, including health care, in the bush One of the many privileges I had while in clinical practice as a gastroenterologist was to work in the country. I consulted and did procedures in the beautiful regional city of Bairnsdale — in East Gippsland, about 3 hours’ drive from Melbourne — for 2 days in 1 week every month, for several years. The secretaries in my rooms in Melbourne used to dread my “Bairnsdale weeks”, because I would leave the office with a large suitcase half-full of files, and return with the same suitcase completely full of files, plus multiple dictation tapes. They also dreaded the letters, which were very long because they usually contained detailed information about the patients for the referring general practitioners, so that much of the management of the patients could be done without the need to see me again, given that I was not in Bairnsdale full-time. Bairnsdale is a lucky town when it comes to medicine. It has an outstanding collection of GPs, many of whom have worked in developing countries, so they have excellent skills in anaesthetics and obstetrics which they are keen to maintain. They are empathic, compassionate and strong advocates for their patients. Bairnsdale has a few specialists of its own, and used to have an unusually strong program of visiting specialists. But the Bairnsdale visiting specialist program has been cut back severely. People can get to the city, can’t they? Just give them a subsidised train fare. Apparently it is better to make 60 patients travel a 600 km round trip, rather than just one doctor. On my drives back to Melbourne I would have the feeling that I had done more good in 2 days’ regional practice than in a month of city practice. It felt similar to my thoughts on returning from a trip to the developing countries in which I had worked — Samoa and Zimbabwe, for example. The people of Bairnsdale, I gradually came to realise, faced multiple tyrannies, starting with the tyranny of distance. I remember once apologising to a patient for running late. “I’ve had a 3-hour drive this morning, from Melbourne”, I said. “Well so have I”, the patient shot back, “from Mallacoota” (240 km from Bairnsdale). Another patient commented to me somewhat bitterly that city folk were always reluctant to come to the country, but country people have no choice but to make trips to the city: “It’s a lot longer from Melbourne to Bairnsdale than Bairnsdale to Melbourne”. But it was not only the tyranny of distance: it was the tyranny of poverty. I could see its mark in many of the patients I saw. There were demographic patterns — the young drug users, now clean because they had moved away from “the valley” (the industrial Latrobe Valley, an hour’s drive to the west of Bairnsdale). There were the thin, careworn young mothers of four children by four different fathers, one child with autism, one or two with ADHD, and one with epilepsy. A history of childhood and domestic abuse seemed to be the rule rather than the exception. There were the toddlers destroying the consulting room — in the city, toddlers did not often come with their mothers; perhaps there was more support at home. And there were the young men with alcohol dependence, perhaps chronic pain syndrome, living in trailers in forestry towns, who could never come to Bairnsdale for review because of the cost of petrol. The tyranny of isolation meant that middle-aged farmers with body mass indices over 30, waist measurements over a metre, and abnormal liver function couldn’t walk for exercise because they didn’t have the time or company. Single mothers with chronic hepatitis C could not join an interferon program because there was no one to support them or help with the children. And then there was the tyranny of nature: in January 2003, many men and women, including all the orderlies in the hospital, had gone to fight bushfires, and the town’s economy was suffering. In February, Bairnsdale itself was threatened, the sky dark and the sun red. In March, a farmer with tears in his eyes told me about his cattle burning, and then — laughing sarcastically about government bushfire “relief” — that the authorities decided the new funded fences (replacing the burnt ones) had to be dingo-proof, with wires down to 10 cm from the ground. His farm had steep ups and downs, and this new fencing was “bloody impossible to build”, “bloody expensive” and “bloody stupid”. In April, his new fences all washed away into the Gippsland Lakes during floods. In my work in Bairnsdale, I know I changed peoples’ lives — people with gastro-oesophageal reflux disorder, hepatitis C and colitis. If I had not gone there, those people would still be suffering; they just could not, or would not, have come to the city. Subsidised train fares for them to come and see me in Melbourne would not have fixed their problems. However, many other specialties easily available in Melbourne are just not available in East Gippsland, even though we, in both the city and the country, all pay (and are effectively paid by) the same taxes. Overservicing in the city and no servicing in the country? Yes, it’s a long way from the city to the country, and distance is not the only tyranny.

Katrina J R Watson MB BS, FRACP, MPH

Emergency contraception and medical abortion are options, but education about them is vital Prevention is better than cure — especially in the field of sexual and reproductive health. Australia’s teenage pregnancy rates (17.3 per 1000 women in 2003)1 and abortion rates (19.7 per 1000 women in 2008)2 are high compared with other Western countries. Such rates are not inevitable, and recent contraceptive strategies were developed to help in reducing them. One such strategy was the rescheduling in Australia of the emergency contraceptive pill (ECP) containing levonorgestrel to Schedule 3 (over-the-counter) status, making it available from pharmacists without a prescription. Improved access to the ECP is a crucial issue, given that the sooner it is taken after unprotected intercourse, the more effective it is. By rescheduling the ECP, it was hoped that women would be able to obtain it more easily within the narrow time frame recommended, especially after hours and on weekends, when it is more difficult to access a general practitioner. A second-generation antiprogestin ECP, ulipristal acetate (30 mg), has now been released and is thought to be a more effective option up to 120 hours after unprotected intercourse.3 Our recently published Australian population study of over 600 women aged 16 to 35 years found that although 95% had heard of the ECP and 26% had used it, just under half (48%) were aware that the ECP was available over the counter.4 In addition, under half (45%) thought it was safe for the health of women, most (61%) erroneously believed that it would damage a pre-existing pregnancy, and 32% that it was an abortifacient, similar to mifepristone — all findings consistent with overseas studies.5,6 Women’s attitudes towards the ECP revealed various views and beliefs influencing their use, including moral and religious reasons, fear of side effects, and unrealistically low perceptions of pregnancy risk.4 Unsurprisingly, women with good knowledge of the ECP were more likely to report having used it. Some women (12%) thought they were unlikely to become pregnant, even when having unprotected intercourse at the most fertile time of the menstrual cycle.4 Although our linked study found that pharmacists believe further information provision following ECP dispensing is their responsibility,7 most women (84%) prefer to receive information from a doctor rather than a pharmacist.4 This offers an important opportunity for GPs to help patients prevent unintended pregnancy and abortion. GPs could include discussion of the ECP in all general consultations with women of reproductive age regarding contraception or reproductive issues, such as cervical cancer screening. Ideally, GPs should seek opportunities to discuss the ECP within an overall contraceptive strategy and with all female adolescents during routine health care visits. GPs can play a critical role in informing and educating women about their risks of becoming pregnant, the use of contraceptives generally and how to use them correctly and consistently. They can also counsel about risky sexual behaviour and the higher risk of an unplanned pregnancy resulting from such behaviour. They could encourage women to keep an advance supply of the ECP at home, if appropriate. Access to such ECP options would be more widely available if it were to be subsidised or free for women who are socioeconomically disadvantaged (eg, health care card holders). As well as the prevention of unplanned pregnancy, assistance with pregnancy termination may be necessary and should always be available if women are unable to continue with a pregnancy. There are parts of Australia where sex education is inadequate, access to contraceptive advice or support is lacking, and hospitals do not provide pregnancy termination services. This can lead to problematically late presentations for abortion.8 In Australia, the removal of the requirement for ministerial approval for the importation and supply of mifepristone means that doctors can now apply to the Therapeutic Goods Administration for approval to provide this drug to their patients for medical termination of pregnancy. Mifepristone is widely used in many countries, including the United Kingdom, the United States, France, New Zealand, Sweden and China and has been shown to be a safe, effective and highly successful treatment for the termination of early pregnancy.9,10 Already, women are being offered greater options when making the decision about an unintended pregnancy — they can choose to continue with the pregnancy, to place the baby for adoption, or if they opt for termination, a limited number of clinics, such as Marie Stopes International Australia,11 are now able to provide medical termination with mifepristone as an alternative to referral for surgical abortion. This option could, and probably should, be more widely available, but a greater emphasis on prevention is clearly needed. At the very least, a sustained public information campaign should address the misconceptions we have uncovered, and publicise the availability of effective contraceptive options. At most, a more comprehensive national sexual and reproductive health strategy should be implemented.

Angela J Taft MPH, PhD · Melissa K Hobbs MPH, PhD · Safeera Y Hussainy BPharmSci, PhD · Lisa H Amir MB BS, PhD · Kay Stewart BPharmSci, PhD · Anthony M A Smith BA(Hons), PhD · Julia M Shelley MPH, PhD · Colin B Chapman BPharmSci, BVSci, PhD

There has been much written in the medical press about general practitioners subjected to violence. Prevention of such violence has been taken on board by medical defence organisations as part of “risk management”, and this is well and good, but it implies that the violence is the problem in and of itself, rather than simply a symptom of a deeper malaise. So, while it may well be in our best interests to place our chairs near an exit, train our staff to defuse tense situations and have our panic buttons at the ready, these all represent symptomatic approaches to the problem, and should not distract us from its root cause. Thirty-five years ago, when I began my medical career, physicians were considered god-like — lofty, infallible, unassailable. The patrician doctor (usually male) would stop at the foot of the bed (with underlings in tow), utter a diagnosis, pronounce sentence (otherwise known as treatment) and move on. Questions were not encouraged. Patients remained largely ignorant of the nature of their condition, the whys and wherefores of treatment and the risks involved. Few railed against this state of affairs, which reflected their expectations, based on the assumption that the doctor would invariably act in their best interests. Cruikshank’s “British beehive” (http://collections.vam.ac.uk/item/O155895/print-the-british-bee-hive/) prevailed — everything was in its place, and all was right with the world. No doctors were stabbed. There is something to be said for “benevolent despotism”, which mostly operates far more decisively and efficiently than its Westminster counterpart, a system that remains slow, cumbersome and hamstrung by competing interests. The assumption is that doctors are benevolent in their despotism, an assumption which generally holds as true today as it did then, despite the fact that honorary medical officers have given way to consultants. But slaves have been freed, the South has been desegregated, Indigenous populations have been enfranchised and the tyranny of paternalism has been replaced with the tyranny of information, a far more prickly and elusive master who, though ruling through fear, cannot be unseated through insurrection. The role of death as society’s greatest leveller has been largely usurped by the internet, and perhaps it is no coincidence that the rise in violence against medical practitioners has been most evident in the past decade, since its inception.1 For two generations now, society has been bombarded with a tsunami of media-generated headlines, slogans, myths, misinformation, disinformation, political correctitude and dumbed-down, vastly oversimplified, reader-digestible distillations of what passes for knowledge. This has resulted in a populace as pitifully under-equipped for medical decision making as it is convinced of its credentials to engage in it. Dumping the internet into the midst of this social foment is tantamount to placing a weapon in the hands of a murderer. And this is precisely what has happened. The mirage of patient empowerment — based though it is, on the illusion of knowledge — has, by extension, resulted in doctor disempowerment. We are now the natural victims. Were our patients happy with their new-age lot in life, all of this would probably come to nought. But the handmaiden of information is choice, whose tyranny is as vicious and unremitting as it is subtle. Paucity of choice meant that the patient of bygone days harboured few expectations. Hence, they were rarely disappointed. If a person had a job at 20, it was more than likely that they would still have one at 50, even if it was the same job. And it was equally likely that they would still have the knowledge and expertise to do that job, even with little ongoing training. Things didn’t change much. Life was predictable. But we now live in an age of rapid, accelerated change —something inherently anathema to human biology. Jet-lag has broadened to “life-lag”. When we arrive at work in the morning, we are never quite sure that we will still have a job that evening. And even if we do, we remain uncertain that we can cope with the ceaseless bar-raising that has become the lot of the accreditee. Along with the technology that has “freed” us has come a plague of choice — complex, often purposeless technical choice that we, as the butt of the IT joke, are not qualified to make. So we put our trust in the “experts”, whose interests remain more vested than altruistic. Choice, it seems, comes with a price tag redolent of coercion. And once you’re on the merry-go-round, there’s no getting off. Mobile phone contracts rival the theory of general relativity in their complexity. Computers consistently malfunction, requiring the intervention of a generation of pimply, postpubertal postliterate empiricists, and invariably demand frequent and overpriced upgrading. This is capitalism at its most razor-sharp, mercilessly herding the helpless consumer before the cow-catcher of its rapacity. The consumer is now the consumed; capitalism is perfected. And so society is now peopled with waves of anxious, uncertain, harried folk, constantly feeling put-upon and ripped off, operating on a hair-trigger fuse that only requires the slightest irritation (“I’m sorry, but there are no appointments available till this afternoon”) to throw the switch. Even the role of psychosis in several of the more notable violent incidents can be sheeted home, at least partly, to the wholesale levelling of society’s playing field. For, as an ill conceived token gesture in the direction of patient empowerment, many socially ill equipped, mentally ill patients who should still be in lock-up care have been released into the community. The world, it seems, is drunk with empowerment. Suckled on the teat of so-called “reality TV” (as if there could be anything further removed from reality than the highly fabricated environments of this pernicious medium), the present generation has been led to believe that Rome can be built in the time it takes to fry an egg. Ordinary citizens, devoid of training, can become opera stars overnight. Or master chefs. Or television show hosts. Or simply celebrities, famous for nothing more than being famous. All of this supports the perennial Hollywood myth that anyone can be or do anything their shiftless heart desires, regardless of intelligence, talent or the capacity for work. But there is a time when even the drunkard must sober up; when the illusion of empowerment, based as it is on a drive for the elimination of perceived elitism, is seen in the clear light of day for what it really is: the loss of respect for knowledge. Not cereal-box-coupon sloganry, nor shotgun-style prescribing information overload, nor Wikipediatric lowest common denominatricks, but good, old-fashioned, hard-won, rote-learned, experience-based, rigorously tested knowledge. What the political correctionists among us call elitism, I refer to as expertise. Expertise based on knowledge. The patient–doctor relationship does not represent a team, it represents an unequal pairing in which the doctor has the knowledge and the power and the patient does not. At the time I entered medicine, it was seen by most of my peers as more a calling than a service, a perspective shared by many of our patients. That is no longer the case. Until society relearns the centrality of these values, doctors will continue to be stabbed. But this is just the opinion of a mere medico.

Ron Elisha MB BS

Objectives: To determine whether community-based asylum seekers experience difficulty in gaining access to primary health care services, and to determine the impact of any difficulties described.Design, setting and participants: Qualitative study using semi-structured interviews between September and November 2010. Participants were community-based asylum seekers who attended the Asylum Seekers Centre of New South Wales, and health care practitioners and staff from the Asylum Seekers Centre and the NSW Refugee Health Service.Results: We interviewed 12 asylum seekers, three nurses, one general practitioner and one manager. Asylum seekers’ responses revealed that their access to primary health care was limited by a range of barriers including Medicare ineligibility, health care costs and the effects of social, financial and psychological stress. Limited access contributed to physical suffering and stress in affected asylum seekers. Participants providing care noted some improvement in access after recent government policy changes. However, they noted inadequate access to general practitioners, and dental, mental health and maternity care, and had difficulty negotiating pro-bono services. Both groups commented on the low availability of interpreters.Conclusions: Access to primary health care in Australia for community-based asylum seekers remains limited, and this has a negative effect on their physical and mental health. Further action is needed to improve the affordability of health care and to increase the provision of support services to community-based asylum seekers; extending Medicare eligibility would be one way of achieving this.

Erin A Spike · Mitchell M Smith MB BS, MPH, FAFPHM · Mark F Harris FRACGP, MD

A unique migration: South African doctors fleeing to Australia. Peter C Arnold. USA: CreateSpace, 2010 (252 pp, $35.00). ISBN 9781452830780. As signalled by its title, Peter Arnold’s treatise is an analysis of South African doctors who migrated to Australia during the latter half of the 20th century. Arnold himself was part of this exodus, soon after graduating in medicine from the University of Witwatersrand in Johannesburg in 1961. He subsequently crafted an illustrious career in Australian medicine, moving between his roles as general practitioner in Sydney’s eastern suburbs, President of the General Practitioners’ Society in Australia, Chairman of the Federal Council of the Australian Medical Association and Deputy President of the New South Wales Medical Board. In fact, Arnold is but one of more than 2000 South African medical graduates who have adopted Australia as their home, and South Africa now joins the United Kingdom, India and New Zealand as a major contributor to Australia’s medical workforce. The book follows a logical order, with chapters on “Why did they leave?”, “Why did they choose Australia?”, “The Australian experience” and “Bringing the kids, but leaving Granny behind”. It also includes a review of the various theories on what made this migration distinctive. Above all, A unique migration is an accessible thesis, in which the wealth of data never overwhelms the narrative. At the same time, it is underpinned by admirable scholarship and an almost encyclopaedic attention to detail, neatly reduced to a series of informative diagrams. It reveals Australia’s debt to this unique migration, which now accounts for one in 30 of the country’s doctors, including luminaries such as Priscilla Kincaid-Smith, Sidney Sax and Michael Denborough. Perhaps the most controversial aspect of the book is whether this great trek was the result of “push factors” such as the social upheaval following the end of apartheid, or “pull incentives” such as Australia’s comparable geographic features. A unique migration is an intriguing journey into a previously undocumented aspect of Australian immigration, and a rewarding book for interested readers. It is compulsory reading for those dealing with the medical workforce. Conflict of interest statement: I know Peter Arnold from when I was editor of the MJA and he was a director of AMPCo, the publisher of the Journal.

Martin B Van Der Weyden

CorrectionTypographical error in base number for calculation of estimates: In “Counting the cost: estimating the number of deaths among recently released prisoners in Australia” in the 18 July 2011 issue of the Journal (Med J Aust 2011; 195: 64-68), the incorrect number 50 504 was used as a basis for calculating some estimates instead of the correct number, 50 405. This has resulted in small errors in some numbers in two tables and one paragraph of the Results in the article. These errors are not substantive and do not alter the conclusions of the study. The numbers have been corrected in the online version of this report (http://www.mja.com.au/public/issues/195_02_180711/kin10879_fm.html).

Stuart A Kinner · David B Preen · Azar Kariminia · Tony Butler · Jessica Y Andrews · Mark Stoové · Matthew Law