Social determinants of health

To the Editor: Recently, Professor Hoy argued for the full inclusion of Aboriginal and Torres Strait Islander people in the Australian Health Survey (AHS), including the measurement of clinical variables and the proposed sample repository.1 Although much of the argument is plausible, several points were overlooked that make it untenable overall. First, the current study design arose with input from at least five Indigenous representative bodies, including the National Aboriginal Community Controlled Health Organisation.2 They identified social and cultural issues as priority areas to be addressed — correctly so, as the underlying causes of health disparity are located in these domains, not primarily in the clinical and biomedical aspects of the AHS. The input from these major national bodies cannot be ignored. Second, yes — there are concerns that “the stored samples and their results might be somehow misused”.1 These concerns are legitimate and well founded in historical and contemporary experiences of Indigenous people. The argument for applying “current scientific and epidemiological knowledge, methods and safeguards”1 to the use of information held in the AHS is correct as far as it goes, but ignores equally important Indigenous knowledge and methodologies, Indigenous intellectual property issues, the principles of “ownership, control, access and possession” of Indigenous information,3 and certain aspects of the United Nations Declaration on the Rights of Indigenous Peoples. This position is therefore inconsistent with the National Health and Medical Research Council guidelines on values and ethics in Aboriginal and Torres Strait Islander health research, particularly as they relate to “survival and protection”.4 Third, denying Indigenous people control over how their health information is used by mainstream research institutions prevents accountability of researchers to communities. Using and publishing this information requires review by relevant experts, in this case Aboriginal and Torres Strait Islander community representatives. Biomedical expertise alone is insufficient to enable effective peer review and, at worst, it risks promoting destructive policies that ignore social, cultural and political realities for Aboriginal people and Torres Strait Islanders. Aboriginal people and Torres Strait Islanders rightly feel that they have been one of the most researched groups in history. And yet, even with this background of decades of being constantly studied, researched and examined, it seems that there is still not enough information being collected. Wellbeing is “grounded in the respect given to people, and the control afforded to them, in their daily lives”.5 Sometimes it’s up to Aboriginal and Torres Strait Islander people to identify what is important in Aboriginal and Torres Strait Islander health: it’s our health!

Kevin G Rowley · Alister H Thorpe

In reply: I thank Dr Rowley and Mr Thorpe for their response.1 It is hard to justify exclusion of any Australian from opportunities to participate fully in important initiatives on the recommendation of bodies whose membership sometimes has no direct link to the persons affected. There is no other population group in Australia to whom this applies. Medical and clinical approaches should complement initiatives to address critical social and cultural issues; they are not in competition nor mutually exclusive. The inclusion of health measures in the adult (but not youth) components of the Australian Health Survey (AHS) acknowledges that there is much to be learned and remediated clinically. Any interpretation of the deliberate exclusion of Indigenous youth from the “measures” elements of the survey is unsettling. There is more, not less, to be learned from this group. Their exclusion deprives policymakers of robust evidence that could improve health status. It condemns enquiry to the current sidestream method of short-term research projects on small pockets of people. These sometimes yield results of dubious generalisability and cause ongoing competition for the impossibly stretched research dollar. Alternatively, is it implied that Indigenous parents are less able to make sound decisions on their child’s participation or that the minors are less likely to cooperate? I suggest that the matter of participation in the AHS be aired through general media channels, as well as those with an Indigenous focus, such as “Living Black” (SBS television) and Imparja television, and through local Indigenous radio stations and community networks. With a developed sampling frame for Indigenous people, dialogue about elements of the examination should at least be conducted with the specific individual tribal groups or communities, if not with the targeted individuals (the preferred option). Subsequently, the whole issue of representation to policymakers in Indigenous health matters might be re-examined on a national basis.

Wendy E Hoy

Objective: To estimate the number of deaths among people released from prison in Australia in the 2007–08 financial year, within 4 weeks and 1 year of release.Design, participants and setting: Application of crude mortality rates for ex-prisoners (obtained from two independent, state-based record-linkage studies [New South Wales and Western Australia]) to a national estimate of the number and characteristics of people released from prison in 2007–08.Main outcome measures: Estimated number of deaths among adults released from Australian prisons in 2007–08, within 4 weeks and 1 year of release, classified by age, sex, Indigenous status and cause of death.Results: It was estimated that among people released from prison in 2007–08, between 449 (95% CI, 380–527) and 472 (95% CI, 438–507) died within 1 year of release. Of these, between 68 (95% CI, 56–82) and 138 (95% CI, 101–183) died within 4 weeks of release. Most of these deaths were not drug-related.Conclusion: The estimated annual number of deaths among recently released prisoners in Australia is considerably greater than the annual number of deaths in custody, highlighting the extreme vulnerability of this population on return to the community. There is an urgent need to establish a national system for routine monitoring of ex-prisoner mortality and to continue the duty of care beyond the prison walls.

Stuart A Kinner PhD · David B Preen BSc(Hons), PhD · Azar Kariminia BSc, MSc, PhD · Tony Butler PhD, MSc · Jessica Y Andrews BHSci/Comm(Hons) · Mark Stoové PhD · Matthew Law MA, MSc, PhD

To the Editor: Amid debate about growth in the number of Disability Support Pension (DSP) recipients and the increasing percentage of recipients with mental disorders,1,2 the recent federal Budget announced further welfare reforms and significant investment in mental health services.3 There are, however, limitations in the data informing the current discussion. Administrative data are restricted to coding the primary disability of DSP recipients, and do not assess comorbidity. Further, data on the health of recipients receiving other welfare payments are lacking, precluding thorough understanding of the context of the growth in the DSP population. We recently published an analysis of the 2007 Australian Bureau of Statistics National Survey of Mental Health and Wellbeing, in which we estimated the prevalence of common mental disorders in different categories of working-age welfare recipients.4 The main results showed that just over one-third (34%) of income-support recipients had a 12-month affective, anxiety and/or substance use disorder, compared with 20% of non-recipients; that, despite a decade of reform of the welfare and mental health systems and improved economic circumstances, there had been little change in the overall prevalence of mental disorders among welfare recipients since 1997 (Box, A);5 and that most income-support recipients with mental disorders received payments other than DSP. We compared data from the 1997 and 2007 surveys, focusing on welfare recipients with a mental disorder (12-month common mental disorder assessed by the World Mental Health Composite International Diagnostic Interview). Of the 10 641 and 8841 survey respondents in 1997 and 2007, 667 and 362, respectively, were identified as working-age welfare recipients with a mental disorder.5 We estimated that 31% of income-support recipients with mental disorders were DSP recipients in 1997, but in 2007 this had increased to 45% (Box, B). The increased concentration of recipients with mental disorders receiving the DSP was significant in logistic regression models controlling for age and sex (odds ratio, 1.72; 95% CI, 1.05–2.83).5 The increased profile of mental disorders among DSP recipients may reflect shifts between payments within the welfare recipient population. Although this could be due to financial incentives to receive DSP rather than lower-paying allowances (eg, Newstart Allowance), the results may reflect that some income-support recipients with a mental disorder are unable to comply with the new activity or work requirements introduced by recent policy changes.6 Careful consideration is needed of the potential adverse unintended consequences of welfare reforms for the large number of income-support recipients with mental disorders. Changes that promote DSP as the most appropriate option for people with mental disorders risk entrenching their alienation from the workforce. Mental disorders and welfare recipients (with 95% CIs), 1997 and 20075 DSP = Disability Support Pension.

Peter Butterworth · Philip M Burgess · Harvey Whiteford

To the Editor: Suthers and colleagues raise a number of significant ethical issues regarding patients’ right to privacy and the passing of genetic information to relatives.1 Although the National Health and Medical Research Council guidelines relate specifically to private practice and living patients,2 similar dilemmas arise during medicolegal autopsies. Forensic pathologists regularly encounter conditions in deceased individuals that may have implications for surviving family members. Examples include advanced coronary artery atherosclerosis in a young individual, raising the possibility of a familial dyslipidaemic syndrome; pulmonary thromboembolism, suggesting a hereditary thrombophilia;3 and haemochromatosis. However, there are no national guidelines, let alone nationally consistent laws, for the appropriate handling of such information. It would seem obvious that a deceased person’s relatives should have access to information of possible significance to their health. If a family wishes to receive such information, then mechanisms to pass it on should exist. These might range from contact with the forensic pathology service itself, to referring the family to a general practitioner or physician who has been briefed by the service. Whoever takes on this responsibility should be aware of the subtleties and pitfalls of genetic counselling. For example, the relevant condition may be an incidental finding rather than what caused the death (eg, haemochromatosis in a person killed in a road accident). The issues concerning the identification of, and appropriate medical response to, serious familial conditions at autopsy involve: accurately establishing the potential significance of postmortem findings;4 determining whether the family wish to be made aware of this information; disclosing the information to family members when a patient is deceased and not able to give consent; and deciding on the mechanisms by which this should be done. A complicating factor is the role of the coroner, as autopsies and subsequent reports are performed and written under coronial, not medical, authority. However, the authors of these reports are first and foremost doctors, and many feel a therapeutic obligation to the families of those whose autopsies they have performed. Many of these pathologists feel that the autopsy is indeed for the family — even if it is formally for the coroner and the public interest. However, it is no part of the coroner’s legislated responsibility to look after the health of surviving family members. It would therefore be a useful service to accommodate these issues in future iterations of the national guidelines.2

Roger W Byard · Stephen M Cordner

Objective: To explore the associations between self-reported racism and health and wellbeing outcomes for young Aboriginal Australian people.Design, setting and participants: A cross-sectional study of 345 Aboriginal Australians aged 16–20 years who, as participants in the prospective Aboriginal Birth Cohort Study, were recruited at birth between 1987 and 1990 and followed up between 2006 and 2008.Main outcome measures: Self-reported social and emotional wellbeing using a questionnaire validated as culturally appropriate for the study’s participants; recorded body mass index and waist-to-hip ratio.Results: Self-reported racism was reported by 32% of study participants. Racism was significantly associated with anxiety (odds ratio [OR], 2.18 [95% CI, 1.37–3.46]); depression (OR, 2.16 [95% CI, 1.33–3.53]); suicide risk (OR, 2.32 [95% CI, 1.25–4.00]); and poor overall mental health (OR, 3.35 [95% CI, 2.04–5.51]). No significant associations were found between self-reported racism and resilience or any anthropometric measures.Conclusions: Self-reported racism was associated with poor social and emotional wellbeing outcomes, including anxiety, depression, suicide risk and poor overall mental health.

Naomi C Priest BAppSci(Hons),PhD · Yin C Paradies MMedStats, MPH, PhD · Wendy Gunthorpe BPsych, PhD · Sheree J Cairney BAppSci, PhD · Sue M Sayers PhD

We report a case of compassionate use of a haemoglobin-based oxygen carrier in a severely injured Jehovah’s Witness patient, for whom survival was considered unlikely. Severe anaemia and cardiac hypoxia were reversed after slow infusion of this agent. No vasoactive side effects were associated with the treatment, possibly due to the slow infusion, and the patient survived. (MJA 2011; 194: 471-473) Clinical recordA healthy 32-year-old woman was a passenger in a vehicle involved in a high-speed collision with a truck, and she was entrapped for 2 hours. Initially, her heart rate was 100 beats/min, blood pressure was 90/50 mmHg, respiratory rate was 28 breaths/min and oxygen saturation measured by pulse oximetry (SpO2) was 92% on air. Her Glasgow Coma Scale score was 9 (eye opening, 2; verbal response, 1; motor response, 6) and her pupils were equal and reactive to light. Her family indicated that she was a Jehovah’s Witness and would not accept the units of blood that had been transported to the accident site. Paramedics performed endotracheal intubation, immobilisation, left femoral splinting and resuscitation with a 7000 mL crystalloid infusion, and applied dressings to wounds. The patient was transported by helicopter to The Alfred’s trauma centre. On arrival at the trauma centre, she was ventilated, her heart rate was 120 beats/min, blood pressure was 62/26 mmHg and SpO2 was 79% on 100% fraction of inspired oxygen (FiO2). Following discussions with the family, the trauma team agreed not to treat the patient with packed red cells, platelets or fresh frozen plasma. Thoracostomies for a right tension pneumothorax and a left pneumothorax were performed, which increased her blood pressure to 105/65 mmHg and SpO2 to 100% on FiO2 100%. Intercostal drains were inserted and connected to a cell salvage device. She was administered 1400 mL of succinylated gelatin, 10 units of cryoprecipitate and 5 mg of recombinant factor VIIa. Bleeding was controlled with direct pressure, and a scalp wound was closed. Ultrasonography demonstrated a moderate pericardial effusion with systolic right ventricular collapse and free intraperitoneal fluid. Electrocardiography demonstrated sinus tachycardia with no ST segment changes. Initial blood tests showed a haemoglobin (Hb) level of 67 g/L (reference range [RR], 113–159 g/L), activated partial thromboplastin time of 44.3 s (RR, 26–38 s), international normalised ratio of 1.9 (RR, 1.0–1.3), serum fibrinogen level of 3.2 μmol/L (RR, 5.9–11.8 μmol/L, lactate level of 3.9 mmol/L (RR, 0.6–2.2 mmol/L) and serum creatinine level of 55 μmol/L (RR, 60–105 μmol/L). Imaging showed a fractured right orbit and maxilla, bilateral rib fractures, a grade 4 splenic laceration, a likely jejunal injury with intramural haematoma, a left distal humerus fracture, a comminuted open left femoral shaft fracture, an unstable T12/L1 fracture dislocation (60% off-ended), and multilevel spinous process and transverse process fractures. Laparotomy and fixation of the patient’s thoracolumbar injury were deferred because of the likelihood of associated bleeding. Instead, she underwent splenic embolisation, external fixation of her open left femoral shaft fracture and debridement of her left humerus injury. She received 1000 mL of 4% albumin and 1000 mL of crystalloid fluid during these procedures, and 10 mg of intravenous vitamin K afterwards. On postoperative admission to the intensive care unit, her Hb level was 36 g/L and her coagulation profile was normal. Low-dose noradrenaline was required to support her blood pressure until Day 2. Her urine output over the first 24 hours was 4500 mL. A follow-up transthoracic ultrasound showed abatement of the pericardial effusion. An abdominal computed tomography (CT) scan with oral contrast excluded jejunal injury. To protect renal function, intravenous contrast was not used. Placement of an inferior vena cava filter was deferred because of anatomical distortion secondary to the thoracolumbar injury. Several strategies were used to manage the patient’s anaemia. Sedation minimised metabolic demand. A ventilation cycle of 2 hours of 90% FiO2, followed by 2 hours of 90% SpO2 and then 20 hours of 95% SpO2 was used. This was employed to maximise oxygen delivery while minimising shunt from absorption atelectasis and to promote erythropoiesis. Recombinant erythropoietin (36 000 units daily for 6 days), folic acid (5 mg daily continued until discharge), vitamin B12 (1 mg daily for 6 days) and a single iron infusion of 500 mg were administered to maximise haematopoiesis. Menses was inhibited with progesterone. Blood testing was performed using paediatric-sized samples. Pneumatic calf compressors were applied and regular lower-limb sonography was performed to exclude venous thrombosis. The trauma team considered using a synthetic haemoglobin-based oxygen carrier (HBOC) to increase oxygen delivery to the patient’s tissues. On Day 3, OPK Biotech (Cambridge, Mass, USA), the Therapeutic Goods Administration (TGA), the Australian Quarantine and Inspection Service and airline carriers were contacted to determine availability and import permissions. HBOC-201 was supplied by OPK Biotech without charge. Informed consent for use of HBOC-201 was obtained from the patient’s family. Approval for emergency compassionate use of HBOC-201 was obtained from The Alfred Ethics Committee on Day 4. The published and unpublished in-vivo and in-vitro research into HBOC-201 was reviewed at a multidisciplinary meeting, and its use was agreed to. Ten 250 mL units of HBOC-201 were imported under Category A of the TGA’s Special Access Scheme. By Day 5, the patient’s Hb level had dropped to 29 g/L and her serum troponin I level was 0.33 μg/L (RR, < 0.10 μg/L), indicating cardiac hypoxia (Box). An electrocardiogram showed widespread ST depression and an episode of non-sustained ventricular tachycardia was documented. Survival with this degree of metabolic demand, the associated anaemia, and resultant end-organ hypoxia was considered unlikely. Following advice from experienced United States physicians, 3 units of HBOC-201 were administered on Day 5, and a further 2 units were administered on Day 6 with ascorbic acid (1 g twice daily continued until discharge). Each unit of HBOC-201 was infused over 8 hours to minimise any adverse effects related to volume overload, vasoactivity or methaemoglobin. Intravenous glyceryl trinitrate was the agreed treatment in the event of hypertension,1 but this was not necessary. After the slow administration of 5 units of HBOC-201, the patient’s Hb level increased from 35 g/L to 62 g/L (Box). Echocardiography performed before and after HBOC-201 treatment showed a reduction in cardiac output from 6.8 L/min to 5.0 L/min. Electrocardiography findings and troponin I levels returned to normal and no further arrhythmias were noted. Somatosensory evoked potentials revealed intact lower-limb neurological pathways. On Day 7, closed reduction was performed and a body cast was applied to treat the T12/L1 fracture dislocation. Imaging showed improved alignment, and an inferior vena cava filter was placed. From Day 6, the patient’s temperature began spiking, secondary to femoral pin site infections and pneumonia. Despite treatment with antibiotics, temperature spiking continued. Cooling was commenced to minimise metabolic demand. A transoesophageal echocardiogram on Day 11 showed right ventricular regional wall motion abnormality but no evidence of endocarditis. A CT scan showed persistent bilateral pneumothoraces, a left pleural effusion and an epidural haematoma at L1 level. Bilateral tube thoracostomies were re-performed and an antifungal was added to the anti-infective regimen. A percutaneous tracheostomy was performed on Day 12. Low-dose heparin therapy for thromboprophylaxis was deferred until Day 17. By Day 21, the infections had resolved and the tracheostomy tube was removed. The femoral and humeral fractures were internally fixed on Day 20 with minimal blood loss. On Day 30, the patient’s Hb level was 107 g/L and operative reduction and internal fixation of her thoracolumbar spine was performed. She was well when discharged to a rehabilitation facility on Day 43 — her cognition was formally assessed as normal, lower-limb neurological pathways were intact and Hb level was 101 g/L. DiscussionWe have described compassionate use of HBOC-201 in a severely injured Jehovah’s Witness patient. To our knowledge, this is the first report to describe reversal of documented cardiac hypoxia secondary to anaemia following trauma. Haemorrhagic shock is responsible for one-third of deaths following high-energy trauma.2 Integrated trauma care systems coordinate rapid haemorrhage control, shock recognition and surgical interventions to minimise blood loss and coagulopathy.3 Healthy volunteers can tolerate Hb levels of 50 g/L without evidence of end-organ hypoxia.4 However, it is estimated that the median Hb concentration associated with mortality is about 25 g/L.5 During the phase of increased metabolic demand in our patient, there was evidence of cardiac hypoxia when her Hb level reached 29 g/L. This prevented further operative interventions and placed her at high risk of cardiac dysrhythmias and death. HBOC-201 is a modified lactated Ringer’s solution containing 130 g/L of polymerised Hb of bovine origin. It is compatible with all blood types, stable for 3 years when stored at 2–30°C and stable for 2 years when stored at 40°C. When fully saturated, HBOC-201 has the same oxygen-carrying capacity as whole blood with the same Hb concentration. The partial pressure of oxygen at which HBOC-201 is 50% saturated (40 mmHg) is higher than that for cellular Hb (27 mmHg), which facilitates oxygen delivery to tissues. The half-life of HBOC-201 is approximately 20 hours.6 Polymerisation of the Hb reduces its glomerular diffusion and nephrotoxicity. A potential complication of HBOC-201 administration is hypertension and increased left ventricular afterload. Infusing each unit slowly (over 8 hours) in our patient may have diminished any vasoactive side effects. Two case reports of using HBOC-201 to treat severe anaemia following blunt trauma have been published. The first described improved cerebral oxygen delivery, but not survival, in a patient with head injuries.7 The second described successful reversal of haemorrhagic shock in a patient whose Hb level dropped to 45 g/L before HBOC-201 administration.8 However, the lack of clear HBOC-201 transfusion indications and end points, as well as the lack of data to support widespread use of HBOCs, has been criticised.9 A meta-analysis of data from HBOC trials has demonstrated an increased incidence of myocardial infarction and death in anaemic patients without life-threatening haemorrhagic shock.10 However, the analysis did not address the issue of “risk versus benefit” for use of these agents, including HBOC-201, in cases where blood transfusion for severely anaemic patients is not possible. A subsequent series of 54 consenting non-trauma patients with a median Hb level of 40 g/L demonstrated improved chances of survival with no serious adverse events following HBOC-201 administration.11 When blood transfusion is not possible, HBOCs can sustain oxygen delivery to hypoxic tissues.12 Such treatment may represent a life-saving intervention for patients with acute anaemia.13 Interest in safe and effective red blood cell substitutes for oxygen transport is increasing. Agents such as HBOC-201 show particular promise and could make a large difference to survival of trauma patients when blood is not accessible, available or acceptable. Haemoglobin and troponin I levels of a woman who was treated with a haemoglobin-based oxygen carrier (HBOC) following severe trauma * Troponin I levels were measured using the Architect i2000 immunoassay analyser (Abbott Diagnostics, Abbott Park, Ill, USA).

Mark C Fitzgerald MB BS, FACEM · Julie Y Chan MB BS(Hons), BMedSci · Andrew W Ross MB BS, FANZCA · Susan M Liew MB BS(Hons), FRACS(Orth) · Warwick W Butt MB BS, FCICM, FRACP · David Baguley MB ChB, BSc(Hons) · Hatem H Salem MB BS, FRACP · Matthias K Russ Orthopaedic and Trauma Surgeon (Germany) · Conor Deasy FACEM, FCEM, MB BCh BAO · Katherine E Martin MB BS, BMedSci, FRACS · Joseph K Mathew MB BS, MS · Jeffrey V Rosenfeld FRACS, FRCS(Edin), FACS

The Canadian Medical Association Journal recently ran a commentary entitled “Who you calling obese, Doc?”.1 It noted that in most Western nations, obesity, as defined by a body mass index of 30 kg/m2 or higher, has assumed epidemic proportions, and the word, like many others in the medical lexicon, has been absorbed into the vernacular. However, the word “obesity” is weighed down with negative connotations, both personal and social. Because of the capacity of the pejoratives “obese” or “obesity” to stigmatise, people use these words with great care and strip away as much of the implicitly judgemental language as possible by substituting terms such as “a person with obesity” or by suggesting that an individual is “medically obese”. The motivation underpinning such verbal gymnastics is idealistic and laudable, intending to give minimal offence and shifting the focus from the person to the condition. It has become an integral part of the new medical lexicon, removing the bluntness of certain medical terms and replacing them with more politically correct (PC) language. However, this fear of hurting an individual’s sensibilities can drive language into foggy territory. This is as true in medicine as it is in other areas of human endeavour. Dr Sally Satel, psychiatrist and resident scholar at the American Enterprise Institute for Public Policy Research in Washington, DC, has published her thesis on the weakening and dilution of medical language in PC, M. D. How political correctness is corrupting medicine.2 She claims that twisting language to avoid occasioning hurt can sometimes be more insulting than edifying: “You are basically sending the message that people are so fragile that they can’t tolerate reality”. A further example of the handiwork of the PC brigade in medicine is the substitution of the traditional term “patient” with “consumer”, “customer” or “client”. As some wag has noted, in our more socially restrictive past, the term “clients” was notoriously reserved for “customers” of the sex industry! However, to fall back on a well worn cliché: there is nothing new under the sun. Euphemisms have always been embedded in our language as we have habitually sought to cushion our emotional response to taboo subjects, such as these examples noted elsewhere: death (“going to sleep”), pregnancy loss (“born still” or “stillborn”) and menstruation (“time of the month”).1 Moreover, this watering down of language can also be found in everyday medical parlance. We now speak of “cardiac impairment” or “cardiac insufficiency syndrome” instead of “heart failure”. This filtering and twisting of reality through feel-good rhetoric may well come back to haunt us in the long run. Interestingly, political correctness is not the only movement changing the medical vernacular. Another is the corporate world. We witness daily the many ways, subtle and not so subtle, that the incompatible corporate structures of the world of business, with their bureaucratic language and allure of success and fortune, have intruded into the medical world. Indeed, the purist may well claim that the medical world has been traduced by corporatisation and business modelling. Like many other things in medicine, we have lost control of our language. Martin B Van Der Weyden

Martin B Van Der Weyden

Objective: To describe an in-depth analysis of the content and quality of stories about new cancer interventions in Australian media.Design and setting: Search of the Media Doctor Australia media-monitoring website for stories about newly reported cancer interventions, including drugs, diagnostic tests, surgery and complementary therapies, that had been collected from June 2004 to June 2009 and rated for quality using a validated rating instrument. A mixed-methods approach was used to analyse data and story content. Data from the website on stories about other new health interventions and procedures were compared.Main outcome measures: Differences in quality scores between cancer-related news stories (“cancer stories”) and other stories, and between types of media outlet; differences in how cancer was reported in terms of cancer type, morbidity, mortality, and in the use of hyperbole and emotive language.Results: 272 unique cancer stories were critically reviewed by Media Doctor Australia. Cancer stories had significantly higher scores for quality than other stories (F = 7.1; df = 1; P = 0.008). Most cancer stories concerned disease affecting the breast or prostate gland, with breast cancer appearing to be over-represented as a topic relative to its incidence. Pairwise comparisons showed statistically significant superiority for broadsheet newspaper stories over online stories (F = 12.7; df = 1; P < 0.001) and television stories (F = 10.7; df = 1; P = 0.001). Descriptions of morbidity and mortality were variable and often confusing in terms of numbers, time periods and locations. Literary devices including hyperbole and emotive language were used extensively, mostly by the researchers.Conclusions: While reporting of cancer in the general media is of low quality, many of the poorer aspects of content are directly attributable to the researchers. Researchers and journals need to do more to ensure that a higher standard of information about cancer is presented to the media.

Amanda J Wilson PhD · Billie Bonevski PhD · Alison L Jones FRCP · David A Henry FRCPE

Sex, lies and pharmaceuticals. How drug companies are bankrolling the next big condition for women . Ray Moynihan. Sydney: Allen & Unwin, 2010 (256 pp). ISBN 9781742370187. SEX SELLS, as does the implication of a good scandal, so the title alone should generate some sales of Australian investigative journalist Ray Moynihan’s latest exposé of Big Pharma’s marketing machine. Building on the success of his earlier work, Selling sickness, Moynihan here teams up with Dr Barbara Mintzes (Assistant Professor in the Department of Anesthesiology, Pharmacology and Therapeutics at the University of British Columbia in Canada) to disassemble the story behind “female sexual dysfunction” or FSD. The story of FSD is traced through an investigative journalist’s eyes, from the revolution in sexual medicine in the late 1980s, through the launch of the now infamous phosphodiesterase type 5 inhibitors, to today. Along the way, with the benefit of hindsight, the authors assemble the jigsaw pieces of pharmaceutical company influences on researchers and clinicians to paint a picture of a series of disorders being created by the very industry which then fortuitously provides the panacea. Moynihan and Mintzes are no strangers to highlighting the effects of pharmaceutical company promotion and largesse. While it could be argued that this work is part of a sustained attack on the industry, Moynihan takes great care to emphasise the usefulness of pharmaceuticals for some women who have a sexual disorder. The main theme is that these women form a small minority — not 43% or similar figures quoted by proponents of such medical treatment — and that many non-drug therapies are as effective as drugs, if not more so. Sex, lies and pharmaceuticals is very readable, and its target audience is consumers, not health professionals. Its main aim is to encourage consumers (or patients) to ask questions of their doctors to gain an understanding of the diagnosis with which they are being labelled, and for which they are subsequently treated. It is $30 well spent to see what your patients may be reading and to question “Where did those useful diagnostic tools really come from?”.

Greg Kyle

Objective: To estimate the cost of the extra time worked by Australian workers due to their co-workers’ alcohol drinking.Design, setting and participants: A secondary analysis of data obtained from 1677 Australian workers aged 18 years or older collected as part of a broader national study into the third-party harms of alcohol. Computer-assisted telephone interviews were conducted between October and mid December 2008.Main outcome measures: Self-reported measures of the time spent covering for other people at work because of their alcohol drinking; measures of other impacts from co-workers’ alcohol drinking; and self-reported income.Results: Around a third of Australian workers have experienced negative effects from their co-workers’ alcohol drinking, with 3.5% of workers reporting having to work extra hours to cover for others. The total annual cost to the Australian economy of this extra work is estimated to be $453 million.Conclusions: The results of this study suggest that Australian workers are significantly affected by other people’s alcohol drinking, at considerable cost. This finding highlights the significant cost to the workplace of alcohol consumption, extending previous work which has focused only on alcohol-related absenteeism.

Caroline E Dale BA, MSc · Michael J Livingston BAppSc, BInfTech, BA(Hons)

To the Editor: We read with interest the article by Cleland and colleagues describing an urban–rural comparison of weight status among women living in socioeconomically disadvantaged neighbourhoods.1 After adjusting for socio-demographic factors, the authors reported no difference in prevalence of obesity, determined using women’s self-reported height and weight, between urban and rural areas. We would like to provide further evidence for the suggestion that obesity might be attributable to sociodemographic composition of areas. We have previously examined the association between area-based socioeconomic status (SES) and different measures of obesity in a randomly selected, population-based female cohort (aged 20–93 years, 77% participation)2 and in a similarly recruited male cohort (aged 20–96 years, 67% participation)3 within the Barwon Statistical Division in Victoria. An inverse association between SES and obesity was observed for both sexes,2,3 and was evident across three different SES indices developed by the Australian Bureau of Statistics (ABS).4 Within our female cohort, we investigated body mass index (BMI) in urban versus rural areas across the SES continuum, for 192 participants aged 20–45 years. We used standard geographical classification5 of 2006 ABS Census data to define participants’ residences as urban or rural (incorporating rural and semi-rural areas). Participants were further grouped according to the 2006 ABS Index of Relative Socio-economic Disadvantage, based on Barwon Statistical Division cutpoints. In our multivariable regression analysis, SES was categorised into the lower 30% (most disadvantaged), mid 40%, and upper 30% (least disadvantaged). Approval for this analysis was obtained from the Barwon Health Human Research Ethics Committee. No differences in unadjusted BMI were observed between participants residing in urban and rural areas (Box). These results were sustained after adjusting for age (data not shown). No interactions were identified between SES and urban or rural residence. No differences in BMI between urban and rural residence were observed for any SES group. These data suggest the lack of difference in BMI between urban and rural residents may be consistent across the SES spectrum. SES was associated with BMI (P = 0.001), while urban–rural residence was not (P = 0.5). Given these data, we suggest that SES is a stronger driving force for BMI than urban or rural residence. In our population, participants in the most disadvantaged group were more likely to be resident in urban areas. This is indicative of Geelong, the main urban centre of the Barwon Statistical Division, being one of the largest public housing areas in Victoria; urban areas provide more low-cost housing options than do rural areas. In contrast, residence in rural areas may be influenced by factors such as the “sea change” movement or prestigious real-estate options, such as the scenic coastal areas located away from the urban centre of Geelong. Mean body mass index (95% CI) of 192 women aged 20–45 years in the Barwon Statistical Division, Victoria, by area of residence Socioeconomic status* Urban† Rural† P‡ Lower 30% (most disadvantaged) 29.5 (26.8–32.1) 37.4§ 0.3 Mid 40% 27.8 (26.1–29.4) 25.3 (21.8–28.9) 0.2 Upper 30% (least disadvantaged) 25.5 (21.2–29.7) 25.5 (24.1–26.9) 1.0 Total population 27.3 (26.3–28.4) 26.1 (23.4–28.7) 0.43 * Defined by the Australian Bureau of Statistics (ABS) Index of Relative Socio-economic Disadvantage of the Socio-economic Indexes for Areas using 2006 Census data, and cutpoints of Barwon Statistical Division for 2006. † Defined by the 2006 ABS Australian Standard Geographical Classification Urban Centres/Localities. ‡ For pairwise difference. § There was only one participant in this category.

Sharon L Brennan · Margaret J Henry · Geoffrey C Nicholson · Julie A Pasco

Australia’s general practitioners are working fewer hours, and many are leaving medical practice. Little is known about when and why experienced mid- and late-career GPs move away from clinical practice. Although career downsizing is often seen as an abrogation of vocation, it may reflect a desire to broaden work experiences within a constrained set of options. Policy should focus on supporting and enhancing the development of GPs’ careers. This approach should acknowledge that career trajectories for GPs are often relatively flat from mid career onwards, and that a GP’s working life extends beyond clinical work in one general practice.

Lesley M Piko MBA, FCPA, FAICD · Christine B Phillips MB BS, MA, FRACGP, Associate Professor

Objective: To investigate community attitudes to abortion, including views on whether doctors should face sanctions for performing late abortion in a range of clinical and social situations.Design, setting and participants: An anonymous online survey of 1050 Australians aged 18 years or older (stratified by sex, age and location) using contextualised questions, conducted between 28 and 31 July 2008.Main outcome measures: Attitudes to abortion, particularly after 24 weeks’ gestation.Results: Our study showed a high level of support for access to early abortion; 87% of respondents indicated that abortion should be lawful in the first trimester (61% unconditionally and 26% depending on the circumstances). In most of the clinical and social circumstances described in our survey, a majority of respondents indicated that doctors should not face professional sanctions for performing abortion after 24 weeks’ gestation.Conclusions: Our data show that a majority of Australians support laws which enable women to access abortion services after 24 weeks’ gestation, and that support varies depending on circumstances. Simple yes/no polls may give a misleading picture of public opinion.

Lachlan J de Crespigny MD BS, FROCG, COGU · Dominic J Wilkinson MB BS, MBioeth, FRACP · Thomas Douglas BMedSc, MB ChB, BA(Hons) · Mark Textor BEc · Julian Savulescu MB BS, BMedSci, PhD

Riwayat. Sanjay Patole, Ajay Rane, producers. Horizon Films, 2010. http://www.riwayatmovie.com. It’s not often that the Journal publishes film reviews. It’s not often, however, that two busy Australian clinicians get together to produce a full-length Bollywood extravaganza, complete with swooning love scenes and beautifully crafted song sequences. While the essential ingredients of love, death, family feuding and a happy ending are all present, Riwayat is no ordinary Bollywood set piece. Instead, Indian-born Townsville urogynaecologist Ajay Rane and Perth neonatologist Sanjay Patole have taken on the serious medical and social topic of “the missing millions” of Indian women — those female infants who, over the past few decades, were conceived and sometimes born but either aborted or killed at birth simply because they were female. “Riwayat” means “tradition” in Hindi — and, traditionally, many female infants in India have been killed at birth, mainly in poor communities. More recently, ultrasound has been misused, by those who can afford it, to detect female fetuses for the purpose of abortion. The film is in Hindi, with English subtitles, and will be screened in India as well as overseas. Riwayat is the story of three generations of the upper-class Desai family, whose two sons and their wives are expected to follow the dictates of its autocratic patriarch. This has already led to two abortions and the consequent psychological distress of the elder son’s wife. (Conveniently, the Desais include a private hospital and ultrasound facility in their substantial property portfolio.) The wife of the younger son, who had a love match rather than the traditional arranged marriage, is made of sterner stuff. Having also conceived a female child, she leaves the family home when ordered to abort and returns to the village where she has been working for a non-government organisation (NGO) — an opportunity for the filmmakers to display the beautiful Indian countryside, take a few digs at the doubtful benefits of NGOs to poverty-stricken Indian citizens, and demonstrate the weight of traditional customs at village level. Her Portia-like intervention in the court case of a villager who kills his daughter at birth is designed to show Hindi-speaking viewers the urgent need to cast off this dreadful aspect of their “tradition”, disastrous for those girls and women denied life, but also for society as a whole. Riwayat is both an enjoyable romp and an important piece of social commentary. Hopefully, it will be widely shown in Australia.

Caroline M De Costa

Mental health across cultures. A practical guide for health professionals. Jill Benson, Jill Thistlethwaite. Oxford: Radcliffe Medical Press, 2008 (xiii + 208 pp). ISBN 9781846192197. In an increasingly multicultural Australia, a medical practitioner is called upon, on a daily basis, to treat patients from diverse cultural backgrounds: migrants, refugees, students from other cultures and Indigenous people. This cultural diversity extends to differences in social status, age, religion, sexual orientation and many other sociodemographic aspects. A medical consultation across the cultural divide is fraught with the risk of miscommunication. Jill Benson and Jill Thistlethwaite, in this small information-packed volume, provide an antidote to such a predicament. Both authors are doctors who have worked in diverse settings in Australia and overseas, have treated patients from many different cultural backgrounds, are knowledgeable about diverse cultures and sensitive to differences, recognise the importance of mental health consultations in general practice, and take a keen interest in their patients’ stories. The first call they make in the book is for physicians to become aware of cultural differences. They then present a model for working across the cultural divide, beginning with self-reflection, developing an understanding of another culture through networking and mentoring and, most importantly, listening to the patient’s story. The primary care physician is first and foremost a healer, and this book presents a succinct view of the issues that come up when psychotherapy, behaviour therapy or narrative therapy must bridge a cultural divide. Even pharmacotherapy is not immune to transcultural challenges as miscommunication can affect adherence and appropriate use of drugs, and ethnic or racial differences can influence drug kinetics and dynamics. The strength of this book lies in the distilled wisdom of two practitioners who teach through real-life examples and present practical solutions. It can therefore be recommended to all physicians and medical students. If you are an international medical graduate practising in Australia or an Australian graduate wishing to work overseas, you will find the case studies particularly appealing. The book fills a gap in the cross-cultural health literature.

Perminder S Sachdev

The pill and other forms of hormonal contraception. The facts. 7th ed. John Guillebaud, Anne MacGregor. Oxford: Oxford University Press, 2009 (xix + 193 pp). ISBN 9780199565764. Does life begin at fertilisation or implantation? At times, the sticky question about whether certain types of contraception are actually causing an abortion arises with patients or colleagues. This book helps by providing a discussion of some ethical aspects of contraception in one of the appendices, where the authors argue that one can write an equation for the definition of conception as follows: CONCEPTION = FERTILIZATION + IMPLANTATION (being with child) (crucial) (also crucial) This equation makes it possible to argue that methods of contraception which may block implantation are contraceptives, and not abortifacients. John Guillebaud is Emeritus Professor of Family Planning and Reproductive Health at University College London, and a guru in family planning. He first wrote this guidebook in 1980 as he is passionate about sharing his knowledge with women: “here are the facts, now you decide”. Anne MacGregor is an Instructing Doctor in Sexual and Reproductive Healthcare at the Royal College of Obstetricians and Gynaecologists, London. This “book about the Pill for a general readership” is a user-friendly explanation of the contraceptive pill and other hormonal contraceptive methods. There are plenty of diagrams, tables and flowcharts to assist the reader’s understanding of reproductive physiology, choice of pill and what to do about breakthrough bleeding and other management issues. Tables present the risks and side effects, but also the benefits of taking the Pill. Although many people regard the Pill as “unnatural”, one could argue that having regular menstrual cycles is an unnatural condition. Before contraception was available, women would have been pregnant or breastfeeding for most of their reproductive lives. Although the Pill is not suitable for all women, many women find that taking the Pill and being “a little bit pregnant” works well at one or more stages of their life, or “contraceptive ages” as this book puts it.

Lisa H Amir

Incorrect revenue amount: In “Cost-effectiveness of volumetric alcohol taxation in Australia” in the 19 April 2010 issue of the Journal (Med J Aust 2010; 192: 439-443), there was an error in the taxation revenue amount specified in the Abstract and Results section. In the Abstract (fourth sentence of Results paragraph), the wording should be “a tax on all alcohol at a spirits rate would reduce consumption by 23.85% and increase revenue by $3094 million”. In the text of the article (first paragraph of Results section), the wording should be “A volumetric tax set equal to the current spirits tax rate provided a substantially greater reduction (23.85%) in consumption of alcohol and an increase in taxation revenue of $3094 million”.

Joshua M Byrnes · Linda J Cobiac · Christopher M Doran · Theo Vos

I was asked to review the article below, and found it a compelling read. Zimmet has clearly gone to central Australia with an open heart and mind, and has discovered an intriguing world previously not known to him. He ends his article with a gentle challenge to those of us who have the privilege to work in health care, to consider whether our current methods are best practice, and whether they are best suited to all who seek our help. Having read this article, I found myself with two unanswered questions. First, given that there have now been several generations of Aboriginal people advocating for improvement to the dire circumstances in Aboriginal health, how is it that our young colleagues are still so shocked when they come to our communities? What is it that we (older Aboriginal people) have failed to say to get the attention of our health care providers, and their teachers? Second, how can we see to it that we produce many more graduates of the quality of Zimmet, who see the world with fresh eyes, are not afraid to ask the obvious questions, and are bold enough to tell us all that the Emperor is indeed naked? I strongly recommend that Journal readers take the time to read this article, and spend a moment or two in reflection to examine their own souls, to see if they can rise to this young man’s challenge. Louis G Peachey, BMed, FACRRM, Foundation President, Australian Indigenous Doctors Association, Canberra, ACT. In the Alice Springs paediatric ward, the vast majority of the 20 or so children are Aboriginal. They often have unique first names with an African–American or biblical flavour and distinctive spellings. Some come from town, while others travel from hundreds of kilometres away. Parents often lie with their children on mattresses on the floor, watching Disney DVDs, drawing, and waiting for the sporadic visits of hospital staff. For families, a visit to the ward can mean a period of isolation from their community or time with relatives who live in Alice Springs or who also happen to be in the hospital. It may be an unwanted upheaval from relatively peaceful community life, or an urgent and welcome respite from upheavals at home. What distinguishes the Alice Springs ward most is the type and severity of paediatric health issues. There is a whole other spectrum of health and disease in central Australia — one that challenges the heart and the mind. Labels that don’t stickThe categorisations of disease as I knew them after several years working in Melbourne seemed to collapse when I arrived in Alice Springs. Trying to apply learnt diagnostic and management techniques proved futile in the face of the ostensibly distinct nature of “common” illnesses like gastroenteritis, pneumonia and ear infections in central Australian children, let alone their coexistence with nutritional, social, cultural and historical factors. It is not uncommon to see 4-month-old infants with perforated ear drums. In contrast to coastal city paediatrics, “pink” or “red” tympanic membranes suggesting otitis media do not show up as threats on the diagnostic radar. Ear examination in central Australia is focused on detecting the presence or absence of pus or perforation of the tympanic membrane. Anything less is considered “healthy”. A child presenting with “gastroenteritis” can mean anything from a prolonged cryptosporidium infection to multiple parasitic and worm infestations. Families often refer to these different ailments generically as “guts ache”. Treatment ranges from frequent correction of significant acidoses and hypokalaemia, to using nitazoxanide to treat cryptosporidium. This drug is only available on the special access scheme in Australia, not because it is unsafe, but because so few children need it. The evidence for its use, however, is limited to a few studies, mainly in settings somewhat different to Alice Springs. This is a recurring theme in paediatric medicine here — that evidence from either “first-world” metropolitan research centres or the “third-world” does not necessarily translate to what health workers see in central Australia, a “fourth-world” inside our country. Further, century-old pathological definitions that define disease rather than causation or environmental and social contributors often do not provide us with adequate solutions today. They help us to heal the surface of the skin or lungs, perhaps the lining of the gut, but not always the deeper tissues. The tragically prevalent conditions of chronic suppurative otitis media and chronic suppurative lung disease in children could perhaps be more accurately defined as “chronic exposure to over-crowding, tobacco smoke, inadequate nutrition and bacterial respiratory tract colonisation”. Similarly “failure to thrive” might often be described as “failures of family and community structures, supports and function”. Effects on causesAs paediatric doctors at the hospital, we work closely with families, Aboriginal liaison officers, community organisations and even traditional healers. However, I feel we see the causative cycles of the social determinants of Aboriginal child health, yet cannot always avert the outcomes. Just like someone watching the desert heat evaporate the land’s water over several days, I often feel incapable of doing more than merely waiting for the storm to arrive. Chronic ear infections cause endemic conductive hearing loss. The result for many children is developmental, learning and behavioural issues with profound ramifications for schooling, employment prospects, parenting capabilities, their own future children and their communities. We try to encourage and empower adults to mop their children’s suppurating ears regularly to facilitate healing and help antimicrobial ear drops reach the middle ear, but, often, we don’t properly explain why this is important, or there are no tissues available at home, no refrigerator to safely store the antibiotics, or more urgent daily issues arise. The daunting challenges of social disadvantage, disharmony, and physical distance can cause health practitioners to minimise our efforts. Sometimes optimum care is not provided on the basis of assumptions about what families will do when they leave. Rationalisations such as “they are not going to give the medication so why bother” or “they’ll be back with the same problem in a week” are sometimes heard. This can be a result of us not being able to see the children and families we look after in the foreground, with their own unique strengths and weaknesses, existing within and beyond these pervasive problems. Seeing difference, seeing ways through the gapsOur lack of flexibility and our inability to — accommodate difference can potentially perpetuate the health gaps. There are many situations in which the pressures of the ward have limited my time to be patient with a family, listen carefully, or negotiate a treatment plan meaningfully, in order to understand the family’s perspective better and expedite the child’s recovery. I have also found it extremely important always to look for differences between individual Aboriginal children and families to prevent comical gaffes, therapeutic disasters and the spectre of racism. Aboriginality is not homogenous. Alice Springs and central Australian people have a complexity that is at odds with the predictability of the desert heat. If we accept that a fundamental component of racism is generalisation, then we are all caught in its web more than we would like to admit. This can be as simple as me assuming that a very dark skinned Aboriginal mother could speak an Indigenous language, or that her English would be limited. Neither was true and she spent much time articulating her worries about breastfeeding. Language difficulties play a major role in paediatric health gaps in central Australia. So much still seems to be “lost in translation” in the gap between English and the multitude of local Aboriginal languages, and between differing understandings of symptom durations, rationales for treatment and discharge plans. Translators are not available after hours, when clarity is often critical. There are other dimensions. There are well known and beautiful places near and around Alice Springs called “gaps”, where the mountain ranges part to reveal waterholes and jagged red rock facades. These geographical gaps were given names like Heavitree Gap or Emily’s Gap by Anglo-European explorers. They are important dreaming sites for the local Arrernte people. Heavitree Gap is a place where the local traditional owners would formally welcome and accept visiting people onto their lands. For Arrernte people then, talk of closing “gaps”, may have very different meanings from our own. Dr Patricia Miller, a senior Arrernte woman, recalls another elder fearing that someone would literally close Heavitree Gap, thereby preventing people and transport from entering Alice Springs directly. She could not understand why there not been meetings to explain the closure of such a significant cultural place. “Closing the gap” can also have an array of ramifications for different families. For some, it may mean having to bring their children to clinics for a seemingly endless array of needles, whether for vaccinations, antibiotics or iron supplementation. For others, it is about not having to tell three or four different doctors in one day what has happened to their child after being transferred from a remote area, or not having to explain the same thing repeatedly because community and hospital information systems are in silos. For some Aboriginal people, “closing the gap” may mean doctors learning to “speak” to each other better. For one family, “closing the gap” is a hope for a larger home in which 20 people do not have to share two bedrooms, so their child can get some sleep away from noisy adults. For another family living in town, it may be that “closing the gap” means not having their child’s Aboriginal status questioned because of his or her lighter skin colour and mixed descent. Looking and listeningSome of the health gaps and misunderstandings in health care also relate to how, for many Aboriginal people, conceptions of space and time are significantly different to medical thought. The chain of cause and effect, and the ideas that illnesses have names, time courses and scientific reasons for appearing are often not the main paradigms for our patients in central Australia. A grandmother explained to me, with the assistance of an Aboriginal liaison officer, that the reason why her 18-month-old grand-daughter was not eating or growing properly was not because she was still breastfed by her mother and had trouble eating solids, but because the unborn baby her mother was carrying was playing tricks and interfering with its sibling’s eating habits. A few mothers on the ward told me about the changing winds and misplaced internal rocks that had ravaged their children’s bodies. They had taken their children to see the traditional healers before seeing a doctor. One mother, a painter and former Aboriginal liaison officer, told me she struggled with prioritising one form of healing over the other. This mother and her child are just one example of the astounding resilience of children and families in central Australia. Their ability to remain healthy, keep a sense of humour, stay positive and return to the hospital or clinic for a visit is remarkable. It is even more extraordinary considering the harsh environment and limited resources. This resilience needs to be supported and harnessed at all costs. It is critical that we strengthen Aboriginal families by using their unique structures, dynamics, hopes and needs. The challenge, then, is to balance a paediatric perspective with an Aboriginal one. The two are not mutually exclusive. We have to keep our paediatric medical gaze sharp and unprejudiced. An evidence base should be built for treating the unique conditions that are seen in central Australian children. Concurrently, ensuring that national standards of nutritional and child development health are implemented in the region is paramount, as a matter of health equity and human rights. We need to make sure that what we know as “truth” in paediatric medicine is applied equally to children living in remote areas and, at the same time, keep our eyes, ears and hearts open to the varying strengths and needs of each child, carer, family or community. We should listen to what they tell us and be comfortable with the silences. We need to find ways through the gaps from several vantage points, with Aboriginal people leading the way back to their own health.

Marcel D Zimmet MB BS/BA(Hons)

The politics of suffering. Indigenous Australia and the end of liberal consensus. Peter Sutton. Melbourne: Melbourne University Press, 2009 (xii + 268 pp). ISBN 978 0 522 85636 1. Have you spent a day or three in a sweltering clinic in a remote Aboriginal community in northern Australia? No? Then read this book, for you will learn why the appalling state of Aboriginal health heads the list of national moral and political challenges. It may encourage you to fill the second gap, that between rhetoric and action, needed to “close the gap” (in health and life expectancy between Indigenous and non-Indigenous Australians). Sutton’s polemic is a cri de coeur from a true warrior. From the early 1970s, his academic interest in Indigenous language and sacred art led to a life-long deep engagement with the Wik people, and to a role in negotiations that have led to landmark political achievements. In the first chapters, he urges a critical re-analysis of causality beyond that of systematic oppression. He argues that more recent dislocations have stressed beyond tolerance the tension between the conflicting imperatives towards modernity versus traditional social values, and that these are relevant in accounting for the endemic domestic violence, alcohol abuse, and ill-health in remote communities. Halfway through the tone mellows, and the reader is treated to a series of charming vignettes of “Unusual Couples”; stories of deep black–white friendships in the landscape of Indigenous history. These lead into his final chapter, “On feeling reconciled”, where we are challenged to confront our own moral thought patterns: Is collective reconciliation about the politics of appeasement? Are our notions of apology and reconciliation, based on European moral and intellectual traditions, compatible with an Aboriginal morality forged over 60 000 years in this land? Sutton navigates us through this moral maze to the conclusion that reconciliation is a personal experience. This fits with what an Aboriginal writer told me in my own searching: “You change one heart at a time.” Sutton’s book should open many hearts to being changed, one at a time.

John Boulton

Objective: To estimate the potential health benefits and cost savings of an alcohol tax rate that applies equally to all alcoholic beverages based on their alcohol content (volumetric tax) and to compare the cost savings with the cost of implementation.Design and setting: Mathematical modelling of three scenarios of volumetric alcohol taxation for the population of Australia: (i) no change in deadweight loss, (ii) no change in tax revenue, and (iii) all alcoholic beverages taxed at the same rate as spirits.Main outcome measures: Estimated change in alcohol consumption, tax revenue and health benefit.Results: The estimated cost of changing to a volumetric tax rate is $18 million. A volumetric tax that is deadweight loss-neutral would increase the cost of beer and wine and reduce the cost of spirits, resulting in an estimated annual increase in taxation revenue of $492 million and a 2.77% reduction in annual consumption of pure alcohol. The estimated net health gain would be 21 000 disability-adjusted life-years (DALYs), with potential cost offsets of $110 million per annum. A tax revenue-neutral scenario would result in an 0.05% decrease in consumption, and a tax on all alcohol at a spirits rate would reduce consumption by 23.85% and increase revenue by $3094 million. All volumetric tax scenarios would provide greater health benefits and cost savings to the health sector than the existing taxation system, based on current understandings of alcohol-related health effects.Conclusions: An equalised volumetric tax that would reduce beer and wine consumption while increasing the consumption of spirits would need to be approached with caution. Further research is required to examine whether alcohol-related health effects vary by type of alcoholic beverage independent of the amount of alcohol consumed to provide a strong evidence platform for alcohol taxation policies.

Joshua M Byrnes BComm, MEconStud, MHealthEcon · Linda J Cobiac BEng(Hons), MEngSc, MPhil(Maths) · Christopher M Doran BEcon(Hons), PhD · Theo Vos MSc, PhD · Anthony P Shakeshaft MA(Psych), PhD

Suicide and intentional self-harm are issues of major importance in public health and public policy, with rates widely used as progress indicators in these areas. Accurate statistics are vital for appropriately targeted prevention strategies and research, costing of suicide and to combat associated stigma. Underreporting of Australian suicide rates probably grew from 2002 to 2006; Australian Bureau of Statistics (ABS) suicide data were at least 11% or 16% undercounted (depending on case definitions) in 2004. In coronial cases with undetermined intent for 2005 to 2007, intentional self-harm was found in 39%. Systemic reasons for undercounting include: (i) absence of a central authority for producing mortality data; (ii) inconsistent coronial processes for determining intent, as a result of inadequate information inputs, suicide stigma, and high standards of proof; (iii) collection and coding methods that are problematic for data stakeholders; and (iv) lack of systemic resourcing, training and shared expertise. Revision of data after coronial case closure, beginning with ABS deaths registered in 2007, is planned and will reduce undercounting. Other reasons for undercounting, such as missing or ambiguous information (eg, single-vehicle road crashes, drowning), differential ascertainment (eg, between jurisdictions), or lack of recorded information on groups such as Indigenous people and gay, lesbian, bisexual and transgender people require separate responses. A systemic coordinated program should address current inaccuracies, and social stigma about suicide and self-harm must be tackled if widespread underreporting is to stop.

Diego De Leo MD, PhD, FRANZCP · Michael J Dudley MB BS, FRANZCP · Caroline J Aebersold BA(Hons) · John A Mendoza DipTeaching, BEd, GradDipHealthSci · Michael A Barnes BA, LLB, LLM · James E Harrison MB BS, MPH, FAFPHM · David L Ranson BM BS, LLB FRCPA

Objective: To determine why more than 2000 doctors have migrated from South Africa to Australia since 1948.Design, setting and participants: South African-trained doctors living in Australia and the spouses or adult children of deceased practitioners who had emigrated from South Africa were contacted by email between August 2008 and February 2009. The sample of doctors was gathered and expanded by an email “snowball” technique and through advertising in alumni and professional journals and newsletters. A questionnaire was emailed to 653 contacts.Main outcome measure: Primary reason given for migration.Results: Responses were received from 469 of the 653 email contacts (72%), from a population of about 2200 South African doctors in Australia. Of the 469 respondents, 434 (93%) had been motivated to emigrate by a wish to leave South Africa, rather than by Australian inducements. The primary reason for emigration before 1990 was opposition to apartheid (142/205 [69%]); the primary reason for emigration after 1990 was the level of violent crime (including “safety” issues) (116/264 [44%]).Conclusion: Most South African doctors who migrated to Australia were impelled to emigrate by South African issues, rather than attracted by Australia.

Peter C Arnold BSc, MB BCh BA · David E Lewinsohn DipAppChem, GDipDP, PGDipPDM

Objective: To compare the weight status of women and children living in socioeconomically disadvantaged rural and urban neighbourhoods in Victoria.Design, setting and participants: Cross-sectional study of data collected between August 2007 and July 2008 as part of the Resilience for Eating and Activity Despite Inequality (READI) study. Women aged 18–45 years living in 40 rural and 40 urban socioeconomically disadvantaged Victorian areas were surveyed by postal questionnaire. Data from a subset of their children aged 5–12 years were also analysed. Weight and height were self-reported for women and measured for children.Main outcome measures: Women’s weight status based on body mass index (BMI): underweight; healthy; overweight; or obese Class I, II or III; children’s weight status based on International Obesity Taskforce BMI cut-off points.Results: Of 11 940 women randomly selected, 4934 (41%) replied to a postal invitation to participate. After exclusions for various reasons, data were available on 3879 women and 636 of their children. Twenty-four per cent of urban and 26% of rural women were classified as overweight; a further 19% of urban and 23% of rural women were classified as obese. Twenty per cent of both urban and rural children were classified as overweight; a further 10% of urban and rural children were classified as obese. In crude analyses, rural women had higher odds of Class I and II obesity (odds ratio [OR], 1.34 and 1.72, respectively) compared with urban women. After adjusting for sociodemographic factors (age, number of children, country of birth, education level, employment status and marital status), there was no difference between urban and rural women in odds of overweight or obesity Class I, II or III. No significant urban–rural difference in odds of overweight/obesity was evident among children.Conclusions: The higher prevalence of obesity in rural women compared with urban women was largely explained by individual-level sociodemographic factors, such as age, number of children, country of birth, education level, employment status and marital status. This suggests that higher obesity levels among women in rural areas may be attributable to the sociodemographic composition of these areas.

Verity Cleland PhD · Clare Hume PhD · David Crawford PhD · Anna Timperio PhD · Kylie Hesketh PhD · Louise Baur MB BS, PhD · Nicky Welch PhD · Jo Salmon PhD · Kylie Ball PhD

Robust evidence, rather than political pressure, should inform decisions about maternity care The status of home birth in Australia has become more contentious than ever with the introduction of legislation which requires that all services provided by registered health professionals be covered by appropriate indemnity insurance. Although never intended to prevent registered midwives from providing care in planned home births, the absence of insurance for home birth has meant that any midwife assisting in a planned home birth appeared to have to forgo midwife registration, or risk penalty. The Maternity Services Review1 recommended that home birth not be supported, but this recommendation was based on the lack of consensus among providers of maternity care that would be required for its safe implementation. The Review remained silent on whether or not home birth should be considered as a safe model of care for the Australian maternity system. Previously published Australian evidence shows that planned home birth in Australia is associated with a higher risk of intrapartum perinatal mortality.2-5 An article by Kennare and colleagues in this issue of the Journal reviews the outcomes of all planned home births in South Australia from 1991 to 2006, and confirms previous findings.6 Although women with recognised risk factors such as nulliparity, Indigenous status, lower occupational status and residence outside metropolitan areas were less likely to plan home birth, planned home birth was associated with a sevenfold increase in risk of intrapartum perinatal mortality compared with planned hospital birth, and a 27-fold higher risk of death due to intrapartum asphyxia.6 These differences were significant despite a sample size of only 1141 home births. Overall perinatal mortality standardised for gestation and birthweight was more than double that of planned hospital births, but because of low numbers these differences were not statistically significant. Of course, not all severe adverse perinatal outcomes in labour can be avoided, but they are better avoided, statistically speaking, when birth is planned to take place in a hospital birth unit. Perinatal mortality is not the only relevant outcome, but it is generally accepted as a most important outcome measure. It is also significant that the incidence of intrapartum perinatal mortality due to asphyxia had halved in South Australian hospital births during 1991–2006 compared with the outcomes recorded for 1976–1987, but hardly improved for planned home birth.2,6 Rates of interventions such as caesarean section and instrumental delivery were lower in the planned home birth group in Kennare et al’s study, but, as there was no adjustment for risk, it is unclear to what extent this is due to the model of care, and to what extent it is due to the fact that hospitals care for higher-risk pregnancies.6 There were no measurable increases in rate of postpartum haemorrhage,6 and it appears that the adoption of oxytocin into home birth practice has resulted in improvement in this outcome compared with data from previous studies in Australia.5 Notwithstanding Australian data, calls for integration of planned home birth into mainstream maternity services continue, based on international evidence of comparative safety.7-9 Advocates argue that the poorer outcomes measured in Australian studies are due to inappropriate inclusion of high-risk pregnancies that will have poorer outcomes in home birth and, if restricted to low-risk pregnancies cared for by accredited practitioners, planned home birth outcomes would be comparable or superior to hospital birth outcomes . Home birth models of care have been adopted by a small number of maternity units within the state hospital systems. The federal Minister for Health and Ageing, Nicola Roxon, has been under much pressure to move beyond the recommendations of the Maternity Services Review and provide indemnity insurance and funding for planned home birth. The decision to exempt registered midwives from the indemnity insurance requirements but not extend further support is a political compromise. It is consistent with evidence that current planned home birth practice in Australia increases the risk of perinatal mortality, but recognises that a small minority of women will continue to choose to give birth at home and that it is safer for these women to be cared for by registered midwives, rather than give birth unassisted. As with most compromises, it angers both home birth advocates, who want indemnity and funding provided, and opponents, who argue that a different professional standard is being applied for the benefit of a noisy minority. The decision essentially maintains the status quo. Uninsured midwives can continue to provide care for women planning to give birth at home without risk of professional sanction (as they have since 2002). But, given the accumulated evidence from Australia spanning 30 years, facilitating and funding home birth in an autonomous setting would be contrary to the principles of evidence-based health administration. The outcome is that midwives can continue to provide care for women who have planned home births, but are required to provide full disclosure to their clients that they are not indemnified, and in return must provide data and participate in a safety and quality framework that will be overseen by the Victorian Department of Health. This should ensure a gradual accumulation of data (including statistics on outcomes such as maternal and perinatal morbidity) that can inform future policy direction, and also encourage adherence to proper clinical risk assessment and management to minimise preventable mortality and morbidity. Those who argue that planned home birth in Australia can be safe will have to show this on the basis of accumulated evidence before any further changes can be considered. With time, the gulf between the politics and science of home birth in Australia should narrow, allowing health policymakers to focus on evidence-based decisions, rather than political ones.

Andrew F Pesce MB BS, FRANZCOG