Social determinants of health

On health grounds, immigration detention should be used in very limited ways Like all rich nations, Australia has experienced an increase in people crossing its national borders without the documents authorising them to do so. Since 1992, Australia has had a policy of mandatory detention for these people. About a third of the people in immigration detention are asylum seekers who are requesting sanctuary under the 1951 United Nations Convention Relating to the Status of Refugees, to which Australia was an early signatory. Although some form of immigration detention exists in most developed countries, asylum seekers are generally released into the community after a period of time in detention, while their claims are being processed. Australia pioneered the notion that detention for asylum seekers was a kind of endgame, in which people arriving without authority stayed in detention until they obtained a visa or were deported. Among the Convention signatories, no other nation has followed suit. As an island nation, our protection obligations are most frequently engaged by asylum seekers arriving by boat. In the financial year 1999–2000, in response to the Taliban insurgency and escalating crises in Iran and Iraq, 4180 asylum seekers arrived by boat.1 This was more than triple the total number of asylum seekers arriving by boat over the previous 3 years combined. By the following year, Australia’s immigration detention centres, many recently opened in remote Australian settings, admitted a total of 11 439 people.2 In 2000, the mean duration of stay in Australia’s immigration detention centres ranged from 1 month to 9 months.3 The study by Green and Eagar in this issue of the Journal counts the health costs of immigration detention.4 This is the largest Australian study to date of the health of people who have been in detention, and the first to follow up a cohort over an entire year. Studying the health of such people in the past in Australia has been challenging;5 previous studies, although valuable, were necessarily small scale.6-8 In the absence of on-the-ground research, we relied on testimony to a national inquiry by the Australian Human Rights and Equal Opportunity Commission,9 and the People’s Inquiry into Detention.10 For Green and Eagar’s study,4 a new policy of openness by the Department of Immigration and Citizenship (DIAC) gave the researchers access to databases containing the health records of people who had been in detention. Their study highlights the contribution of immigration detention to mental illness. Asylum seekers, and other detainees who experienced prolonged detention, were more likely to develop mental illness as a new diagnosis. However, all people who had been in detention for long periods of time had higher attendance rates for a range of health conditions compared with those detained for a shorter time. Sultan and O’Sullivan, in their characterisation of immigration detention syndrome, describe a three-stage process of escalating mental distress and depression, with people in long-term detention being overwhelmed by hopelessness and a sense of being trapped and alone.6 A follow-up of Mandaean refugees noted that prolonged immigration detention was associated with the most severe mental disturbance, which continued for an average of 3 years after release from detention.7 The location of the immigration detention centre where these refugees were held was not stated. The remote onshore detention centres (now all decommissioned) were operating at the time of Green and Eagar’s study; the geographical isolation of some of these centres may have also affected detainees’ mental health. The number of children included in Green and Eagar’s study was small, as policy changes were made during the study period to limit immigration detention of children. Between 1999 and 2003, over 2000 children arrived without visas, by air or sea, and most spent time in immigration detention (these figures exclude the children in offshore immigration detention centres on Nauru in the Micronesian South Pacific; and Manus Island, Papua New Guinea).9 Immigration detention centres fostered emotional in-stability, and children witnessed violence and security crackdowns. The family unit was often too fragile and damaged to provide stability through the vicissitudes of detention life. At the time of writing (23 October 2009), there were 126 children in immigration detention, housed outside the main immigration detention centres.11 Diligence will be needed to ensure that the residential housing options near immigration detention centres remain supportive of children’s development. As pioneers of the practice of long-term immigration detention for children, Australia has a responsibility to collect data on the health outcomes of this social policy. Internationally, there is now a move to better monitoring of the conditions in immigration detention. In Australia, detention centres in remote locations have been decommissioned, leaving four in large urban settings, as well as one on Christmas Island. In Australia, the Detention Health Advisory Group provides input into the health services of detention centres, and the DIAC provides more transparency and mechanisms to enhance service quality for immigration detention centres and their health services. In the United States, where 400 000 people currently enter immigration detention each year, the Department of Homeland Security recently announced the creation of an Office of Detention Policy and Planning to oversee immigration detention. There will also be greater input from a health advisory group.12 The openness of the Australian Government to improved oversight mechanisms for detention centres is welcome. Such mechanisms are essential. Immigration issues can inflame public imagination and lead to calls for harsher detention measures for “queue-jumpers”. There is a need for the definition of a clinically relevant, immigration detention centre minimum dataset, and for good prospective research to be performed on the health of detainees after their release into the community. The evidence is growing that asylum seekers are likely to be those most psychologically damaged by immigration detention, and that their children are particularly vulnerable. There is a good case to be made on health grounds that immigration detention should be used in very limited ways for asylum seekers, and never for children.

Christine B Phillips MB BS, MPH, FRACGP

Objective: Design, setting and subjects: An analysis of the health records of 720 of the 7375 people in detention in the financial year 1 July 2005 – 30 June 2006, with oversampling of those detained for > 3 months.Main outcome measures: Health encounters and health condition categories; estimated incidence rates of new health conditions, new mental health conditions, and new injuries for each cohort (defined by time in, and reason for, detention).Results: People in detention had an estimated 1.2 (95% CI, 1.18–1.27) health encounters per person-week. Those detained for > 24 months had particularly poor health, both mental and physical. Asylum seekers had more health problems than other people in detention. The main health problems varied depending on the length of time in detention, but included dental, mental health, and musculoskeletal problems, and lacerations. Both time in, and reason for, detention were significantly related to the rate of new mental health problems (P = 0.018 and P < 0.001, respectively). The relationship between these variables and the incidence rates of physical health problems was more complex.Conclusion: People in immigration detention are frequent users of health services, and there is a clear association between time in detention and rates of mental illness. Government policies internationally should be informed by evidence from studies of the health of this marginalised and often traumatised group.

Janette P Green MStat · Kathy Eagar MA, PhD, FAFRM(Hon)

The number of unemployed patients presenting in general practice will increase over the next 12 months. Unemployed patients are likely to present with physical and psychological problems, including insomnia, depression, anxiety and a worsening of cardiovascular risk factors; family members are also likely to be affected. GPs have an important role in early detection and management of these health problems; effective approaches include cognitive behaviour techniques, goal-setting and motivational counselling. Appropriate provision of medical certificates, advocacy and social support help redress the loss of the personal and social “vitamins” of work. While access to psychological services has improved, patients may also need to be referred to social workers, and employment and welfare services. Divisions of General Practice can have an important role in helping to broker access to services and raise awareness of the health effects of unemployment.

Mark F Harris FRACGP MD · Elizabeth Harris MPH, BA, DipSocWk · Timothy D Shortus MPH, PhD, FRACGP

My 16-year-old daughter’s heart saved the life of another teenage girl, and her other organs were used to save or improve the lives of six other people. I still believe in organ donation, but there are facts about the donation process that are emotionally confronting and difficult, and we should be given better information so that we are more prepared for the realities of it. These facts should be made clear to anyone considering organ donation, but especially to those who have to make the final decision. The hospital bedside is neither the place nor the time to discover these facts for the first time. In February 2009, my family was eight months into a global circumnavigation aboard our sailing yacht. We had called into a marina in Phuket, Thailand, and our daughter Ali was watching a huge superyacht tie up at a jetty. An error was made during the docking procedure, which caused a cleat to be torn out of the jetty and the heavy mooring rope to whiplash with extreme force. Ali suffered serious head injuries and was rushed to the Bangkok Hospital Phuket, where she was examined by neurosurgeons. That first night we were told there was no brain activity and no brain stem function, but as certain tests had to be carried out before she could be legally pronounced brain dead, we then waited for five days with her in the hospital before life support could be “turned off”. Late on day four, the neurosurgeon told my husband and me that Ali had failed the final tests and would now be declared legally brain dead. He then asked — gently and with no urging — if we wished to consider organ donation. It was not something we had thought about. For four days we had stayed by Ali’s bedside, keeping shifts with the rest of our immediate family who had flown in from Australia, talking, singing, weeping, telling jokes, massaging her hands and feet, unable to lose that flickering of hope for a miracle. Organ donation was part of a step we hadn’t yet reached. The doctor explained that, if we agreed to donation, the transplant team would arrive from Bangkok the next day — or whenever we were ready — and Ali would be taken to the operating theatre and the useful organs removed. She would be returned to us later in the week, and we were assured that she would look perfectly fine. The doctor also pointed out that he had nothing to do with the transplant team, that they were from a different hospital altogether, and that Ali’s organs would not be used in this hospital. We could also change our minds at any time, regardless of signing the document. That sounded acceptable, and we signed. Without actually discussing it, each one of us assumed that we would sit with Ali while life support was disconnected and be with her as she stopped breathing, and that she would then be taken to theatre. Later that evening, the person in charge of organising the organ donation came to see us and explain how it would happen. Awkwardly, the woman explained to us that, no, we couldn’t sit with our precious child as she drew her last breath and her heart stopped its beating. For the organs to be in perfect transplant condition, they had to be removed from a body that was technically still functioning. She would be taken to theatre still attached to life support. Our immediate response was one of horror and disbelief, and we told her that no one would be taking our child while she still had a heartbeat, that they would have to wait until she was dead. The woman, obviously feeling very awkward and uncomfortable, said that was fine, that was our prerogative, but the only organs that might then be able to be used would be the corneas, and not much else. We spent the rest of the night in turmoil. Logically, we knew that our daughter was gone, that an exhaustive testing regime proving brain death meant she was dead. We understood the reasons why the procedure had to happen that way — that as soon as the heart stopped beating and oxygen stopped being delivered to the cells in the body, the organs would immediately begin to deteriorate. We also knew Ali would want her organs donated. She was the kind of kid who couldn’t walk past someone with his hand out or someone who looked upset. But the sudden reality of what her donation asked of us was unbearable. Early the next morning, I phoned a doctor we knew in Australia. He confirmed that it was the correct procedure; that for the best possible transplant potential, the organs had to be removed from a body still attached to life support, with a beating heart supplying oxygen to the tissues. This was why organ donation was such a controversial issue. We wanted to honour what we knew Ali’s wishes would have been, and we wanted the donation to be as useful and as beneficial as possible, to make the best possible gift on her behalf. But doing so meant that we had to absorb these confronting facts about organ donation at a time when we were overcome with grief. I knew that none of us could walk away from her while she still seemed to be alive — her skin warm, her chest rising and falling, the machine beeping her pulse rate, all those signs you hang on to as proof of life even though you know it’s hopeless. I talked to the rest of the family and explained the procedural requirements. We had to accept — emotionally as well as rationally — that the only things keeping Ali’s heart beating and her chest rising were machines. We had to acknowledge that she was already gone. When the team was assembled, we would say our goodbyes and then call them in when we were ready to let Ali be taken from us. It was the hardest thing I’ve ever had to do in my life, and it should not have happened that way. No family should have to face the shock of discovering these details for the first time at that point. I am an educated, widely read, well informed Australian woman and, then and still, a registered donor, but I knew nothing about the procedural requirements for organ donation. No one I have spoken to since, apart from doctors, has had any idea either. None of us had ever been in the situation where we needed to know. Since returning to Australia, I have studied the Medicare leaflet about organ donation — the one that comes with your drivers licence renewal — and the new organ donation website (http://www.donatelife.gov.au). There was no mention anywhere of the emotional impact you might need to be prepared for, nothing that said: You need to know certain facts about organ donation that may be emotionally confronting and difficult. It’s a good idea to talk about these facts with your family before they might be called upon to face them in a hospital ... The deceased will be taken to the operating theatre still attached to life support. This may be upsetting for the donor’s family because the person has the appearance of being alive. You will need to remind yourself that a diagnosis of brain death means that the person is already dead. Breathing and heartbeat are being maintained by machines in order to ensure the organs stay healthy and usable ... If clear information was provided in advance about brain death, life support procedures and the requirements for organ removal, then at least we might have been a little more prepared. At some point in the past most of us would have talked about it, academically and dispassionately, but with further information we could have already considered the notion of “beating heart donation” and had the chance to consider the sacrifice the family of an organ donor is called upon to make. It might be argued that in Australia we would have had these facts carefully and sensitively explained to us at the hospital. I am sure it also happens in Thailand, and certainly an effort was made to explain it to us, in spite of language barriers. However, the real point here is that the hospital bedside is not the place or the time to find out these facts for the first time. If such information was available, then perhaps there might be more consent to organ donation at the hospital bedside. I never previously understood why a family would go against a potential donor’s signed consent. Now I can completely understand a family countermanding their child’s wishes when they discover at the last moment what it means — that they have to hand over their apparently still living child, and that they must give up the final solace of the survivor, of holding their loved one in their arms as they take their last breath. We are parents, sisters, brothers and children of the dead person. We are not all going to be rational and sensible at such a time. Ali was a very healthy 16-year-old who had never had a serious illness. Her heart saved the life of a teenage girl in Bangkok a day later, and her other organs were used to save or improve the lives of six other people. I still believe in organ donation. But human beings often make decisions based on emotional responses. We are already facing the most unutterable grief when our children, our husbands or wives, our parents or siblings, are declared brain dead. Please, make people aware of everything involved in organ donation through the leaflets and websites, so that the ordinary person is better prepared, at least in some way, to deal with it if they’re unlucky enough to have to face it one day.

Joanne M van Os

Comment: Death is a reality that confronts us all at different times and in different ways. Death of a child, especially your own child, is an ever-present fear. Sadly, every day, somewhere in the world, parents will be confronted by the death of their child in an intensive care unit (ICU). Surrounded by the paraphernalia of high-tech medicine, those who work in the ICU must bring understanding to the family with both sympathy and empathy. Brain death does not seem like death in the same way as cardiac death, and that disconnection between what we know and what we feel is described here with exquisite pain by Ali’s mother.1 van Os first calls for sensitivity from the medical, nursing and other staff in emergency and intensive care departments — clearly spoken here, and indeed spoken before by others. This call has been well heard in Australia and New Zealand, where specific training has been provided to ICU teams for the past 15 years by a program called ADAPT (Australasian Donor Awareness Programme).2 It is not possible to qualify as an intensive care specialist without first completing this training program. The process of gaining permission to proceed to organ donation in Australia should leave none of the uncertainties that crept up unannounced on van Os and her family.1 Our transplant coordinators are trained, and our organ donation agencies have specific bereavement counselling programs to provide care for the donor’s family after organ donation. Emotional doubt over brain death is inescapable, but we try harder here to resolve these concerns than in many places in the world, which may be one reason why our organ donation rates fall behind those in many other countries. The second call from van Os is to ensure that the community is better informed about the realities of organ donation. Providing appropriate information to the community has been a continual struggle. The expenditure of sufficient advertising money to get these complex messages across has been deemed an unacceptable use of the health dollar. However, there are other ways, and we can always improve our act. The recently created Australian Organ and Tissue Authority is doing just that.3 Ms van Os, your calls have been heard. Somewhere, every minute of every hour of every day, someone dies for lack of the decision that you and your family took — but it was not that day for a teenage girl with heart failure in Thailand.

Jeremy R Chapman

Comment: The families of organ donors are usually deprived of the opportunity to be present when the donor’s heart stops beating. As this personal account by van Os eloquently demonstrates,1 forsaking this opportunity can be experienced as an additional loss — one that exacerbates a family’s trauma during the donation process and that possibly imperils the donation itself. We should not underestimate the cultural significance of heartbeat and breath, and the symbolic importance of the moment in which they cease. Neither is diminished by medical redefinitions of death. Should we do more to educate Australians about the fact that a donor must enter the operating theatre attached to a respirator with a heart still beating? There may be some reluctance to do so on the grounds that drawing attention to this might drive Australia’s low donation rates even lower. There is also no strong precedent to do so; countries with high donation rates such as Spain, France and the United States do not generally make this information publicly available. On the other hand, information provided to Australians about organ donation does now routinely include discussion of other sensitive issues, such as the diagnosis of brain death, the organ retrieval process and the physical appearance of the donor’s body after surgery.2 Although no amount of disclosure can fully prepare a donor’s family for the experiences they are about to face,3 a more detailed and carefully worded explanation of why brain death necessitates the mechanical ventilation of a donor immediately before surgery may help address the key issue identified by van Os: that the hospital bedside is not the place to find out about this for the first time. Overseas experience suggests that organ donation after brain death depends heavily on trust.4,5 Trust surely rests on frank and open disclosure. If the latter also helps to prevent one nasty shock to a family being exacerbated by another, then there are two sound reasons to pursue this policy.

Aric Bendorf

I have always dreaded that moment at funerals when you see the coffin for the first time. Perhaps it’s the finality of death or the sadness of the loss, but that moment seemed an inevitable consequence of the dying process, until I was faced with the impending death of my father. My father was 75 years old when he died of cholangiocarcinoma. He was a man with many friends. He was curious and loved to chat, he loved a beer, he made people laugh, he worked hard and was well loved. He was cared for at home, mostly by my mother. Friends and family came to pay their respects, and some came again for another “last time”. We sat with him, tended to his needs and contemplated life without him. The palliative care team visited often and waited for the cue to arrange hospice care because we could no longer cope; to us, this meant dad leaving and being cared for by someone else. The cue never came. The family rallied and dad stayed at home. This raised another issue I had with dying — the moment of separation when the body is taken away from the family. I had witnessed it often in my working life and wondered how families determined the right time to go and how they felt about leaving their loved one behind. Would they want to take the body with them? A few days before dad died, the funeral director came to the house. We leafed through folders of coffins and flowers, and discussed the service. She said to call them at any time when he died and they would come to the house (to take him away). I took a breath. “Can’t we keep him here?” My mother looked at me. “Are you sure you’re allowed to?” We hadn’t discussed this option so I had no idea what she thought about it. In fact, I didn’t think I would raise it. I hadn’t thought it through completely but felt intuitively it was the right thing to do, for me and possibly for her. Between us we had attended many funerals but had no knowledge of anyone who had kept the body at home. Ultimately, the decision would be hers; he was her husband, and she would continue to live in the house. Maybe it would be too much for her to bear, but she didn’t seem opposed to the idea, and it was possible. In the warmer months a cold table can be provided, but we were in the middle of winter and the garage under the house was particularly cold, so a body could rest down there. After some discussion, we decided that dad would go to the garage and not leave us until the last. That decision would have a profound effect on my view of death and grieving. Dad died early one Sunday morning at home, with my mother by his side. The rest of the family slowly arrived. Dad stayed in his bed, where we washed him and dressed him as if ready for golf. The children came in and out of the bedroom. They tied up his shoes and added things to his pockets. We ate lunch. The civil celebrant conducting the funeral came over and we talked about dad. Someone would disappear into the bedroom for a while and come out with red eyes. In the afternoon, the funeral directors arrived. We carried dad downstairs and placed him in the coffin, next to the caravan my parents used as their second home on travels. His golf clubs were beside him and his work bench just behind. Mum moved into the caravan for two nights. Dad was now in the garage. Mum’s sister arrived after a long journey. After cups of tea, they went downstairs to see dad. The garage became a sanctuary where people came and went and the children ran and danced around the coffin. Being close by allowed many quiet moments to sit next to the coffin, talking, weeping and taking time. Mum sat beside him in the early hours of the morning. On the day of the funeral, the family gathered for more food, more cups of tea and last-minute writing of speeches. We went down to the garage and lifted the lid of the coffin. Dad was still the same, looking pale and peaceful. We cried, laughed and added extra things that we thought he might want, or that we wanted him to have. The hearse arrived and we carried dad out and drove slowly to the church in this small country town. The family carried the coffin into the church that was filled with dad’s family and friends, and the friends of his children and friends of friends. Many burst into tears at the sight of us and the coffin. It was a good ceremony, and then we carried him out again. We arrived at the cemetery and carried the coffin to the graveside. The children wondered whether we would also have to dig the hole. The coffin was lowered and we all went for more cups of tea, and sherry and cake. The death of my father was an experience I had not expected. I imagined being inconsolable with grief and unable to make decisions. However, it was a gentle time that brought the family together and created a wonderful memory. He had a good death at home and a good after-death. Keeping his body at home was an unusual decision in the eyes of many. For the family, it represented an opportunity to do something special for someone we loved, but it also facilitated the grieving process. It seemed to slow down the period from the death to the funeral. There was no pressure to have the body removed or to pay visits to the funeral home for a “viewing”. He was in the garage and we could see him whenever we wanted; we grew accustomed to looking at the coffin and began to come to terms with his death. There was also comfort in continuing to offer care until the end, rather than his body being in the care of someone else. There are cultures where it is the norm to keep the body at home. I had witnessed it in Tonga on my student elective, where I equally appreciated the symbolism of coming together and sharing a meal (or cups of tea!) at these times. In contrast, the ritual of keeping the body at home is uncommon in Australian culture. It certainly seemed uncommon to the funeral director and others I have spoken to. Maybe people think about it but don’t ask. Perhaps we should ask for them.

Karen L Dunn MB BS, FRACP, PhD

Objective: To describe the content and structure of health and medical news and current affairs reportage on free-to-air television in Sydney, New South Wales.Design and setting: Review of content of all health-related evening news and current affairs items recorded over 47 months (May 2005 – March 2009).Main outcome measures: Number and length of health-related items on news and current affairs programs, and topics covered in these (21 broad content areas and the leading 50/237 specific content areas); use of news actors, soundbite duration and apparent news triggers.Results: 11 393 news items and 2309 current affairs items were analysed. Health news items lasted a median of 97 seconds. In a randomly selected sample of 251 items, items featured a mean of 2.2 news actors (3.9 in longer current affairs items). Median soundbite duration was 7.2 seconds for news items and 8.9 seconds for current affairs items. People affected by disease or injury were the most commonly featured news actors (84% of items), followed by experts and health professionals (56%). Many items (42%) appeared to be trigged by incidents, but a further 42% could have been triggered by press releases and other forms of publicity.Conclusions: Health workers wishing to participate in news coverage should be aware that complex issues are reduced to fit the time constraints and presentational formulae of the news media. Advocates should plan their communication strategies to accommodate these constraints.

Simon Chapman PhD, FASSA · Simon J Holding BA · Jessica Ellerm BSc · Rachel C Heenan · Andrea S Fogarty MIPH · Michelle Imison MIPH · Ross Mackenzie MA · Kevin McGeechan BSc

Waiting room. A memoir. Gabrielle Carey. Melbourne: Scribe, 2009 (217 pp). ISBN 9781921372629. I’ve got mixed feelings about memoirs. Having cringed my way through the insipid or vitriolic ramblings of a number of previously admired politicians, actors and journalists, I’ve come to the conclusion that some people’s inner worlds are best kept that way. Nonetheless, I had high hopes as I read the blurb for well known Australian writer Gabrielle Carey’s Waiting room, and plucked it from the review pile to read over a long weekend. All doctors should read patient stories and Carey is an accomplished Australian writer of my generation — surely there would be much in the book to learn from and relate to. I was not disappointed. Waiting room details the diagnosis and management of Carey’s elderly mother’s meningioma. As a medical story, it appears accurate and straightforward and its portrayal of the clinical encounters, surgery and hospital stay is surprisingly undramatic. Without labouring the point, and with a very Australian sense of acceptance and ultimate trust in the medical system’s competence, Carey documents long hours spent waiting for life-changing medical appointments and the all-too-common experience of having planned surgery delayed by a lack of hospital beds. The medical characters are in the book for their functionality rather than their personalities. In fact, the medical story is really a backdrop to the main business of the book; Carey’s relationship with her enigmatic mother. When you reach a certain age, you realise that life is filled with unanswered questions, incomplete understandings, ambiguous meanings and relational loose ends. The beauty of a memoir is that it can unapologetically reflect this chaos without the need for momentous conversations, dramatic revelations and eventual resolution. As a doctor, writer, daughter, wife and mother, I found much to learn from and relate to in Carey’s Waiting room. Sometimes the truth may be stranger than fiction, but generally it is just much more real.

Ruth M Armstrong

Objective: To examine how performances by the Staff Christmas Choir of the Peter MacCallum Cancer Centre (“Peter Mac”) affected inpatients, outpatients and visitors in 2008.Design, setting and participants: During the Christmas season 2008, the Peter Mac Staff Christmas Choir gave seven performances at the Centre. Locations included inpatient wards, outpatient waiting areas and a cafeteria. To assess their response to the choir, oncology inpatients, outpatients and visitors (including early-departing bystanders) were given anonymous, semi-structured questionnaires during and after performances. To analyse the responses, we used a constructivist research approach informed by grounded theory.Main outcome measures: Participants’ descriptions of the choir’s effects on them.Results: Questionnaires were returned by 111 people. The performances were received favourably by 93.7% of respondents, including nine from Jewish, Hindu or atheist backgrounds. Many said the music aroused positive emotions and memories. Several described transformative thoughts and physical reactions, felt affirmed by the Christmas spirit or message, and/or appreciated the peaceful or enlivened and social atmosphere. The choir also elicited personal perspectives about Christmas and Judaism, and the importance of “enjoying the moment”. Only three respondents (2.7%) reported adverse effects, relating to emotional and audible intrusiveness.Conclusions: The Staff Christmas Choir created a supportive and uplifting atmosphere for many oncology patients and their visitors. However, responses from people from non-Christian backgrounds were limited, and further investigation is warranted to extend our understanding of the effect of Christmas music in Australian public health settings.

Clare C O’Callaghan PhD · Colin J Hornby FIR, MAppSc, GradDipEd · Elizabeth J Pearson BAppSc(OT) · David L Ball MB BS, MD, FRANZCR

We were cruising at 5000 feet, enjoying beautifully clear winter weather, just south of Tennant Creek in the Northern Territory. My friend Don and I were flying in his Cessna 182 and about to turn east and follow the Barkly Highway to a large cattle property known as “Avon Downs”. We were planning to visit an old patient — let’s call her Claire. Originally from England, she was working for the South Australian Government in the NT looking after Aboriginal children in a kindergarten. The story began when a letter arrived from Claire asking if I would make a flying visit to her “back country” village. She heard that I had taken up private flying and had an interest in visiting the bush. My friend Don was a novice private pilot like myself, and we were both very keen to take the opportunity to test our wings on a long flight to the country. Claire lived alone in a large caravan that could accommodate four adults. It was grouped in a large, protected area with three other similar caravans: one served as the ablution block for the children, another was for their changing and rest rooms, and the third was a large classroom where lessons were conducted. Claire was endeavouring to help with training in health and education for young Indigenous children from deprived areas. The excitement was immense as we landed in a cloud of dust on the bush airstrip. We taxied up to Claire, who was surrounded by dancing and shouting children. It was not long before we were chatting about bygone years and about how Claire was coping with the various demands while attempting to introduce Western culture into the Aboriginal community. Claire described her disappointment with the lives of some of her former pupils — for example, girls aged 10 or 12 who, on returning to their Aboriginal communities, were allocated as wives to elders of the tribe. She was anxious to visit some of these older children, who now lived on the coast at Borroloola, about 500 km north of Avon Downs. Why not make a flying visit to Borroloola? It was soon decided that we should. We quickly cleared the aircraft of unwanted gear so that Claire would be able to join us on the flight. We took off early the next morning and arrived at Borroloola after about two and a half hours. Claire was very excited to see her former pupils and learn about their lifestyle and activities in the years since leaving school at Avon Downs. We spent a happy day meeting all the young mothers and their children, and the time passed very quickly. Then we suddenly remembered that the airstrip at Avon Downs did not have landing lights! We realised we had to leave quickly because the calculated flying time would only just allow us to arrive home before last light. When I turned to walk to our aircraft, I met the anxious gaze of the hospital matron: “Could you possibly help with a desperately ill little Aboriginal baby? The Flying Doctor can’t come till tomorrow and this wee child is seriously distressed and unfortunately the hospital sisters can’t help.” I looked across to Don and Claire as I followed the matron running to the sick child’s bedside. He was seriously ill from dehydration after protracted vomiting and diarrhoea and needed an intravenous saline drip. So a small baby with collapsed veins set the challenge for time and urgency. Naturally, my flying companions were a bit anxious about the prospect of delaying our departure. However, the nursing staff were all very grateful for my help. After some effort, the needle entered the vein of this brave little boy, who began to improve with the added fluid. I stood back with relief, which was shared by us all. After a quick farewell we went out to the aircraft. We checked the seatbelts, oil and fuel, then warmed up the engine and leapt into the air on track for Avon Downs. We checked our calculation on the time for last light for Avon Downs with a radio call to Mt Isa traffic control. Our calculations were correct — we would be 25 minutes late for last light on arrival! There were no options at this stage, so we pressed on, hoping the last light of the sunset on the flat landscape would give us sufficient vision. But look! What was that unusual glow ahead on the track near the horizon? That must be close to the Avon Downs airstrip! As we flew nearer to this bright area, while the natural light was failing rapidly, we saw we were being welcomed by numerous cars that had their headlights lighting up the airstrip to guide our return. It seemed the hospital staff from Borroloola had called the folk at Avon Downs and told them about our problem and why we had a delayed departure. Claire was sad to say goodbye to us but, happily, she wrote to say what fun our visit had been and that the little boy had recovered and was doing well. North-eastern region of the Northern Territory

Anthony H T Hodgkinson FRCS, FRACS, FAOrthA

To the Editor: In 2008, considerable publicity was given to the diagnosis and treatment of prostate cancer in two Australian celebrities: retired Australian Football League player Sam Newman and radio announcer Alan Jones. Newman’s cancer was reported on 5–9 March 2008, culminating in a 12-minute item on the high-rating Australian television program 60 Minutes, when Newman said, “Be tested and enjoy life”. Jones’s announcement of his forthcoming surgery was reported on 3–4 July 2008, and his recovery on 16–27 July. We investigated whether this publicity was associated with changes in the rate of prostate specific antigen (PSA) testing. We used Medicare Australia data on claims for Medicare Benefits Schedule item 66655 (which allows “one annual PSA test for an individual without prior prostate disease”) to determine the mean number of PSA tests and age-standardised testing rate between January 2002 and March 2009. We fitted a linear regression model to the log of the age-standardised rates, modelling secular trends using natural splines with two degrees of freedom (splines were piecewise cubic within the data range and otherwise linear), with indicators set for the average effect of the second, third and fourth quarters and an indicator for the second quarter of 2008. We calculated predicted values and prediction intervals (which take into account both uncertainty in the predicted mean and individual variation), excluding observed data for the second quarter of 2008 (Box). The mean monthly number of PSA tests was 72 064 in the 12 months before April 2008, increasing to 107 633 in April 2008, and 90 813 in July 2008. The seasonally adjusted age-standardised rate of PSA tests rose 17% above the secular trend in the second quarter of 2008 (95% CI, 8%–27%), with the observed data point falling outside the prediction interval (Box). This represented an additional 39 000 PSA tests during the second quarter of 2008. These data show that prostate cancer screening increased significantly in the quarter after media coverage of Newman’s prostate cancer diagnosis. Screening seemed to have returned to the expected seasonal rate by the time of Jones’s diagnosis, in the third quarter of 2008. The impact of celebrity cancer diagnoses on population screening has been demonstrated previously, most recently by an increase in breast cancer screening following news of pop singer Kylie Minogue’s breast cancer diagnosis in 2005.2 In a survey of US men, almost a third stated they would be more likely to have a PSA test after hearing celebrities endorse prostate cancer screening.3 In addition, coverage of melanoma by 60 Minutes in 1987 was followed by a 167% increase in melanoma detection in the subsequent 3 months. Whether the additional 39 000 PSA tests performed in the second quarter of 2008 result in a surge in diagnoses of prostate cancer remains to be seen. Despite continuing uncertainty about the benefits of PSA testing, but unequivocal evidence of harms,,6 Australian men’s willingness to be screened for prostate cancer appears to have been boosted by this celebrity endorsement. Age-standardised* prostate-specific antigen testing rates in Australia (assessed quarterly) Prostate-specific antigen (PSA) testing rates showed a consistent seasonal pattern, with the highest rates in the third quarter (July–September) for all years except 2008, when they were highest in the second quarter. * Standardised to Australian 2001 population.

David P Smith · Mark S Clements · Melanie A Wakefield · Simon Chapman

Objective: To identify individual and household factors associated with violence among Australian Indigenous women with dependent children.Design and participants: Univariate and multivariable analysis of data from the 2002 National Aboriginal and Torres Strait Islander Social Survey, stratified by area.Main outcome measure: Self-reported experience of being a victim of violence in the previous year.Results: One in four Indigenous women living with dependent children younger than 15 years reported being victims of violence in the previous year; this corresponds to an estimated 24 221 Indigenous mothers (95% CI, 21 507–26 935) nationwide. Violence was more prevalent in regional areas and cities than remote areas. In remote areas, mothers who had been removed from their natural families during childhood had nearly threefold greater odds of being victims of violence (odds ratio [OR], 2.90; 95% CI, 1.82–4.61); in non-remote areas, the odds were 72% greater (OR, 1.72; 95% CI, 1.23–2.39). Older maternal age (≥ 45 years) was associated with lower odds of experiencing violence in both non-remote areas (OR, 0.39; 95% CI, 0.25–0.60) and remote areas (OR, 0.46; 95% CI, 0.30–0.70). Women with partners residing in the household faced lower odds of violence in both non-remote areas (OR, 0.54; 95% CI, 0.41–0.72) and remote areas (OR, 0.46; 95% CI, 0.32–0.67).Conclusions: The prevalence of violence against Indigenous mothers with young children is alarmingly high across remote and non-remote areas. This study identified distinctive characteristics of victims, but further research is needed to assess potential risk factors, such as history of removal from natural family.

Kyllie Cripps BA(Hons), PhD · Catherine M Bennett PhD, MAppEpid · Lyle C Gurrin PhD · David M Studdert LLB, ScD

I am an Aboriginal Kuku Yalanjii and Birri Gubba man. My Yalanjii people are from north of Mareeba, near Cairns, and my Birri Gubba connection is in Proserpine, right next to the beautiful Whitsunday Islands. My family grew up in Inala, on the outskirts of Brisbane, where we have lived for over 25 years. I come from a family of eight children. My mother is from Woorabinda and my father is from Proserpine and they are both Aboriginal. I have always heard about Aboriginal and Torres Strait Islander men having heart attacks at a young age and in higher proportions than non-Indigenous men. I have lost a number of uncles from heart disease, through not eating right, hereditary factors, high alcohol consumption and lack of exercise. In terms of my own health, I thought I was fine because I was always physically active, playing rugby league and touch football and being very involved in the community. I would never have believed it possible that at 34 years of age I could suffer a heart attack. I am sharing this story with other Aboriginal and Torres Strait Islander people around Australia in the hope that it will make some kind of impact on their lives. My story demonstrates how working in the Aboriginal and Torres Strait Islander community can have both a positive and a negative impact on yourself, your family and your community. I started working in the Inala Indigenous Health Service in 2001 as a research assistant and then moved to the role of community health worker. Before this, I’d had no experience in the areas of health or education. The main experience I’d had in community work was as a youth worker with the Queensland Department of Family, Youth and Community Care and as a teacher aide at the Glenala State High School. I’d also had experience as a volunteer coach of a Junior Rugby League side at Inala that has a high proportion of young Aboriginal and Torres Strait Islander people, parents and families involved. Working in the service gave me valuable experience under the guidance of our Aboriginal doctor Noel Hayman and Aboriginal nurse manager Nola White. Together, they gave me the confidence to undertake a Bachelor of Applied Health Science in Indigenous Primary Health Care at the University of Queensland in Brisbane. It took me 5 years to complete the course, while simultaneously juggling commitments to my family, community and employer. All I ever wanted to do was give back to the community that I grew up in, and working at the Inala Indigenous Health Service has given me that opportunity. In the 8 years I have worked at the Health Service, I have been involved in all areas of Indigenous health, including hearing health; drugs and alcohol; health status research; mental health; nutrition; counselling; transport; Indigenous leadership; youth issues; youth and adults incarceration; and health promotion. A major role I shared with my mentor Matilda Bani (Indigenous Service Officer with Centrelink) was coordination of the Inala Aboriginal and Torres Strait Islander Interagency Forum. This forum, which has been going for over 12 years, promotes information-sharing between departments and other agencies working with the Inala Aboriginal and Torres Strait Islander community. Shared Responsibility Agreement: making a differencePerhaps one of the biggest achievements in my life (besides having children) was being involved in establishing a Shared Responsibility Agreement (SRA) between my community and the federal government in 2006 (Box 1). The central aim of the SRA was to improve the health and wellbeing of Aboriginal and Torres Strait Islander men in our community via their engagement in rugby league. Rugby league has been an institution within our community, particularly among Aboriginal and Islander boys and men. For 5 years prior to the SRA, there was no opportunity for men in Inala to play rugby league, due to a lack of activities and sporting programs for Aboriginal and Torres Strait Islander men, and few Aboriginal and Torres Strait Islander men were likely to go outside the community to play rugby league. Without football in the community, few men played sport, and this contributed to many problems such as boredom, poor health, low self-esteem, and high intake of drugs and alcohol — all of which can lead to incarceration. Through conversations with the federal government, I developed a proposal to get a group of respected Aboriginal and Torres Strait Islander men to look at ways of getting our brothers involved in sport, employment and healthy living for themselves and their families. The federal government agreed to fund two open rugby league sides at Inala, on the condition that men in the community participated in health, employment, education and mentoring opportunities within the community. My role as the Community Health Worker was to encourage Aboriginal and Torres Strait Islander men to come to the Inala Indigenous Health Service for adult health assessments, and to participate in other health promotion activities such as the Inala Indigenous Health Calendar (Box 2) and workshops on nutrition and physical activity. The men were also enlisted to participate in mentoring activities, such as coaching, refereeing, volunteering with junior teams, participating in local training and employment initiatives (if they were unemployed), promoting healthy lifestyles, and demonstrating positive behaviour on the sporting field and in the community. Through this process, many local men also participated in training that saw them become qualified referees, coaches and first aid officers. Since being involved with the SRA in Inala, I have seen some great success stories. Seeing other young Aboriginal and Torres Strait Islander men putting their hand up to be involved in rugby league as coaches, referees, first aid officers and volunteers at the club has really built the self-confidence of men in our community. The pressures of community work, family and volunteering: my healthDuring this time, I was so passionate about my work that I forgot who I was. I was doing this as part of my role as Community Health Worker, but was also a volunteer. I was so busy taking care of everyone else that I forgot to take care of myself. I was at the club nearly 7 days a week with the junior and senior teams, feeling constantly stressed, spending a lot of time away from my family, and not taking time out for myself. Because I was always on the go, I was not eating healthily. I just wanted the SRA to succeed and be sustainable, so that Inala Aboriginal and Torres Strait Islander men could be strong, self-reliant, and able to source other avenues such as sponsorship and fundraising. I was also a rugby league player at the time, so I was heavily involved in the game, both on and off the field. Rugby league has always been my passion and, although I would go to games to help with strapping and make sure everything was taken care of, I would often jump on the field and play if the team were short of players. It was towards the end of the 2008 season that I put on the jersey for Inala, like so many times before. But during this particular game, I started experiencing dizziness, came off the field and collapsed. Although I didn’t know it at the time, I had just had a heart attack. Fortunately, the coach of the team (one of my closest friends and a participant in a first aid course delivered under the SRA) and the registered first aid officer kept me alive until an ambulance arrived. It was only their quick actions that saved my life. All I remember is drinking a sports drink and then waking up in the ambulance. When I asked the ambulance officer if I had been knocked out on the field, he told me I’d had a cardiac arrest and said that, if it wasn’t for the coach and first aid officer, I wouldn’t be alive. Since then, I have had three operations on my heart and am now fitted with a defibrillator in my chest in case a similar episode happens again. At 34 years of age, I am very lucky to be alive, and to this day I feel enormous gratitude to the coach and first aid officer to whom I owe my life. There is an irony in the fact that the very thing that caused so much stress in my life was also the very thing that led to my life being saved. My illness also made a big impact on the Inala Aboriginal and Torres Strait Islander community in the south of Brisbane. There has been an increase in the number of people attending the Inala Indigenous Health Service, and the number of health checks has doubled. Many Aboriginal and Torres Strait Islander people aged 35 years and over are now attending the health service. I’m glad that some good has come out of my heart attack, not only for me and my family, but also for the community as a whole. It has changed my life dramatically — I thought I was OK, and then all of a sudden my whole life was turned upside down. Lessons I have learntAfter having all the operations and undergoing mainstream cardiac rehabilitation at a hospital in Brisbane, I started to get my confidence up with doing exercise such as walking and playing tennis and doing things around the house with my family. Back at work a month after having surgery, I am slowly easing my way back into work, eating more healthily, and getting lectures from family and community members about taking it easy in the community. I am doing OK now and just taking life one day at a time. I am grateful to everyone for their support — my family, my work colleagues and my community. There is much good that is happening, and Inala is continuing to grow and develop into a really great community. After all the operations and cardiac rehabilitation, I decided to get married to my lovely partner of many years. I put the pain behind me to set up a new chapter in the lives of me and my family. At times I don’t think about the heart attack, I just think every day what I can do to get my kids out of the house and do something active. My family is my life, my community is my strength, and my work keeps me active. I share my story with people who are reluctant to go for a heart operation and encourage them to have it done so they will be able to live longer and see their children and grandchildren grow up. Today I am enrolled in a Master of Philosophy by research at the University of Queensland, while working as a research fellow with the Inala Indigenous Health Service and at the George Institute for International Health in Sydney. This will broaden my role in my line of work and will enhance my capacity to be a good role model and mentor for my community. I feel very passionate about working in Indigenous health, especially in the field of heart disease, kidney disease and diabetes, with the support of the Inala Indigenous Health Service and the George Institute’s Kanyini program. Rugby league is continuing to thrive in Inala with the keen involvement of other Aboriginal and Torres Strait Islander men in the community. They have been playing the game for 3 years now without any funding assistance from the federal government. They won a grand final in 2007, were runners-up in 2008 (Box 3), and are very actively involved in community events and the junior club. I am slowly working my way back into the community, having learnt some valuable lessons from this journey — in particular, the need to balance my family commitments, work and volunteering. I have taken a big step back from being involved in the community in a voluntary capacity. Inala is going forward in a very positive way, and members of the next generation are putting up their hand to give back to the community that has supported them. 1 Some of the people involved in our Shared Responsibility Agreement Left to right: John Brady, Tricia Button (State Manager, Indigenous Coordination Centre), Mal Brough (former Minister for Families, Community Services and Indigenous Affairs), Robert Duncan (Junior Club President). 2 Health messages from the Inala Indigenous Health Calendar 3 Inala rugby league team members and young supporters

John P Brady BAppHlthSc

To the Editor: Compared with the Australian population, all-cause mortality rates among prisoners are four times greater among men, and eight times greater among women.1 Fatal drug overdoses and suicides comprise the overwhelming majority of deaths in post-release cohorts;2 hence, a large proportion of post-release deaths are preventable. However, the information necessary to determine appropriate public health responses to the issue of post-release mortality is largely absent, because there is no routine nationwide collection of numbers of prison separation episodes as there is, for example, for prison receptions.3 We aimed to estimate the number of inmate separation episodes occurring in Australia for the financial year 2007–08, using benchmark data obtained from public documents on the websites of each state and territory government department responsible for prisons. For each state and territory, we attempted to obtain the total number of inmates (ie, sentenced and on remand) released from prison for the financial year 2007–08. This figure was available for Victoria (5356), South Australia (4177) and the Northern Territory (2857). For New South Wales, data could only be obtained for separations of sentenced prisoners (7645). Hence, data on separations of either total or sentenced inmates were available for jurisdictions covering 62% of the national prison population. To adjust for separations of prisoners on remand in NSW, we assumed that separations of sentenced prisoners comprised 40% of all separations, reflecting the ratios of sentenced to total separations in other jurisdictions. Hence, the total number of separations in NSW was estimated to be 19 113. A multiplier of 1.6 (1/0.62) was applied to the sum of separations from Victoria, SA, the NT and the adjusted figure for NSW separations, in order to estimate separations for the national prison population. This produced an estimate of 50 405 prison separations nationally for 2007–08. Each of these separations is associated with a significant increase in risk of death. We have made an estimate of the number of prison separations in Australia for 2007–08, but believe that a more appropriate and precise method for obtaining this information would be to include separations for the total number of prisoners and for sentenced prisoners as items in routine data collection systems such as the Australia Bureau of Statistics Prisoners in Australia collection. This would enable better through-care service planning and provision of life-saving pre-release and post-release health services, such as prison-based opioid substitution treatment4 and overdose prevention and treatment interventions such as distribution of naloxone.5

Kristy A Martire · Sarah Larney

To the Editor: Pet abuse is considered another form of family abuse, and is a powerful marker for other forms of violence happening in the home. Women and children living with violence, isolated by their abuser, often form intense bonds with their pets. Perpetrators will use animal cruelty as a means to intimidate and control their partners and children.1,2 Women will put themselves at increased risk due to concern for their pets.1-5 RSPCA New South Wales acknowledges the link between domestic violence and cruelty to animals. In 2004, it initiated the Safe Beds for Pets program, which provides emergency accommodation for pets of women and children seeking refuge from domestic violence (http://www.rspcansw.org.au/programs/safe_beds_for_pets). The Central Coast, NSW, arm of this program conducted an anonymous, self-administered survey to identify the prevalence of perpetrator violence against the family pet and its effect on decision making by women. The survey was offered to local women who owned a pet, were aged 18 years or over, were experiencing domestic violence and had attended the Central Coast Domestic Violence Court Advocacy Service, and was conducted between August and November 2007. Of 187 women, 92 owned a pet, 85 of whom completed the survey. Almost 75% (63/85) owned at least one dog, 45% (38/85) owned at least one cat and 22% (19/85) owned at least one bird. We found that 27% (22/82) of partners had threatened to hurt or kill a pet, and 23% (18/80) had done so. These data are at the low end of findings of other studies, which found that 40%–53% of partners threatened to hurt or kill a pet, and 26%–57% had done so.3 Out of concern for their pets, 27% (22/83) of women in our study delayed leaving home (compared with 33% in another study3), and 27% (23/85) returned to their partner. Women also delayed calling the police (17%, 14/84) and refused to lay charges (11%, 9/83) out of concern for their pets. Women whose partners had threatened or killed a pet were more likely to delay leaving, return home, delay calling police, or refuse to lay charges than women whose partners had not (Box). The study’s main weakness was that it was restricted to current pet ownership, thus excluding women who may have recently rehomed or abandoned their pets, or whose pets may have already been killed.3 Clinicians do not necessarily ask clients about the role of pets in their health. If the issue is not raised, women often feel reluctant to speak up.4,5 We encourage clinicians to: ask patients experiencing domestic violence whether they have pets, whether their pets are at risk of abuse, and whether they need help to keep their pets safe; and talk with human and animal service providers about opportunities for cross-service programs, such as Safe Beds for Pets. We support the development of a nationwide strategy allowing the simultaneous relocation of a woman, her children, and pets from a violent home.3 Relative risk (95% CI) of women’s decisions if their abusive partners threatened or hurt their pets Partner’s action Delayed leaving Returned home Delayed calling police Refused to lay charges Threatened to hurt 3.00 (1.54–5.83) 3.78 (1.95–7.30) 34.29 (4.74–247.97) 9.00 (1.97–41.07) Threatened to kill 2.41 (1.23–4.71) 3.64 (1.91–6.94) 5.58 (2.21–14.09) 4.12 (1.28–13.32) Threatened to hurt or kill 2.81 (1.44–5.50) 3.55 (1.82–6.89) 32.18 (4.44–233.18) 8.43 (1.84–38.57) Actually hurt 1.93 (0.92–4.07) 2.12 (1.04–4.30) 7.63 (2.66–21.88) 6.78 (1.88–24.43) Actually killed 1.35 (0.26–7.01) 4.59 (3.01–6.99) 5.78 (2.57–12.97) 6.33 (1.82–22.00) Actually hurt or killed 1.93 (0.92–4.07) 2.12 (1.04–4.30) 7.63 (2.66–21.88) 6.78 (1.88–24.43)

Cheryl Travers · Andrew Dixon · Karen Thorne · Kaye Spicer

To the Editor: Eslick and Eslick believe that the television program The Simpsons causes children to smoke.1 What they gloss over is that in this show, only “losers” smoke. The characters Patty and Selma are old, ugly, mean-tempered, sexually frustrated sisters working in deadening jobs at the motor vehicle licensing office. They don’t just smoke, they chain-smoke — a well established television trope for sleaze and disease — and then they cough, hack, and wheeze. Krusty the Clown, if the name doesn’t tell you already, is a beaten-up, ageing, balding guy. He’s nasty, neurotic, and estranged from his father for abandoning his orthodox Jewish roots for the sinful life of television. Mrs Krabappel, the schoolteacher, is old, divorced, ugly, hates her job, hates her life, and hates children. It may be that children watch The Simpsons. I don’t know, and Eslick and Eslick cite no data that show they do. The questions, though, are: Do children understand what a loser is? Do they emulate losers, or shun them? Eslick and Eslick cite studies showing that any portrayal of smoking causes children to smoke.1 If this is so, why bother to differentiate between “neutral”, “positive” and “negative” portrayals of smoking? And what, precisely, do these labels mean? If, as they say, the “most notable characters” who smoke are these four loser characters, it is strange that they have coded most smoking instances as neutral rather than negative. Even if the authors have a valid labelling system, and even if neutral portrayals cause children to smoke, the question then becomes: is this effect greater than any countervailing effects, such as, perhaps, that of discouraging adults (and adults who are parents) from smoking, or that of creating a broad cultural association between smoking, social failure, and sickness? The logic of the argument put by Eslick and Eslick is that smoking should not be depicted at all in television programs that children watch. Given that children see people smoking in real life, and presumably look around them for some guidance as to whether they should do it too, it seems to me that it is actually commendable to tell them that only losers smoke. Strong evidence and argument that this approach does more harm than good would be very valuable.

Nicholas Jefferson-Lenskyj

To the Editor: The article by Eslick and Eslick1 caught my attention, as the sophisticated parodying of the tobacco industry on The Simpsons has been a much discussed topic among my tobacco-control colleagues. In the introduction to the article, the authors ask if the smoking and tobacco industry portrayals in this program are “just satire, or does the repetitive nature of characters smoking on The Simpsons have an influence on young children watching?” The study design employed cannot answer this question. I was surprised then that the authors concluded that the portrayals of smoking on The Simpsons negatively influence young children. The study results indicate that positive portrayals of smoking on the show are, in fact, extremely rare. It could equally be the case that the more numerous negative portrayals of smoking on this popular and subversive comedy reach young viewers in a way no government-sanctioned health promotion campaign can. Health education messages presented through social satire may not be politically correct, but this does not mean they are ineffective in communicating antismoking sentiments.2 The two most prominent smokers in The Simpsons, Patty and Selma Bouvier, are not characters that any teenager would aspire to be like — disgruntled, middle-aged sisters who live together, work in depressing jobs at the local Department of Motor Vehicles, Selma constantly bemoaning her lack of a husband and fantasising about 1980s heart-throb MacGyver, and Patty best known for her utter joylessness and cynicism. Surely these grim stereotypes would cause most young people to turn away from smoking, and not towards it? Tobacco-control policies themselves were recently lampooned in The Simpsons, with the Simpson family opening a pub in Ireland that illegally allowed patrons to smoke. Much mayhem ensues, and the Simpsons are eventually deported back to the United States for breaking the Irish antismoking laws.3 I am delighted that tobacco control has such universal momentum that it can be parodied on a pop-culture phenomenon like The Simpsons.

Becky Freeman

The wisdom of whores. Bureaucrats, brothels, and the business of AIDS. Elizabeth Pisani. Sydney: Granta, 2008 (xvii + 372 pp). ISBN 978 1 84708 024 0. Given the provocative cover, I approached this book with reservations. And irritatingly, the author scatters the terms “AIDS mafia” and “AIDS industry” throughout the book. She never defines the terms, but she would probably class me as a member of both! Yet after two careful readings, I am totally disarmed. While I disagree on some points, Elizabeth Pisani tells the truth about AIDS clearly and unequivocally. Only global warming is more topical than HIV/AIDS. Any thinking person, lay or professional, must have serious questions. Why is the epidemic in sub-Saharan Africa so different from everywhere else? Why has the long-awaited Grim Reaper scenario (spreading throughout the general community) never eventuated? Why, with a virus which is “not actually all that infectious” but which has nonetheless caused 70 million infections world-wide, are we no nearer to controlling the epidemic? Pisani answers these questions with devastating clarity. She is eminently qualified to do so, with a PhD in epidemiology and more than 10 years’ field experience. She retains, too, the sharpness and ruthlessness of the investigative journalist she once was. There are ribald stories and humour here, but throughout runs a barely repressed strain of anger. Bucket-loads of money are being wasted, good science is often ignored, truth has been replaced by lies and, as the author reminds us, prevention “programs based on lies don’t work”. There is a softer side to this author. She is a friend of harlots and sinners. It is people considered the dregs of society who are most at risk. She says, “Getting HIV prevention services for people who needed them most has begun to seem like a debt I owe”. By her forthright analysis and outline of what needs to be done, she has gone some way towards paying her debt.

David L Bradford

Incorrect author affiliation: In the letter “Avoiding the tragedy of another balcony collapse” in the 1 June 2009 issue of the Journal (Med J Aust 2009; 190: 651-652), James W Nixon was incorrectly described as a paediatrician at the Royal Children’s Hospital, Brisbane. James W Nixon is Chair of Kidsafe Queensland, Brisbane, QLD. The html and pdf versions of the article published online were corrected on 5 June 2009.

Shinichiro Sakata · Craig A McBride · James W Nixon · Roy M Kimble

Objective: To determine the frequency of smoking on The Simpsons television show, and the relationship with the sex and age groups of characters shown smoking, and with positive, negative and neutral connotations associated with instances of smoking.Design and setting: Content analysis (performed from January to October 2008) of instances of smoking that appeared in the first 18 seasons of The Simpsons television show, which aired from 1989 to 2007.Main outcome measures: Frequency, impact (positive, negative, neutral) of instances of smoking; and frequency associated with age (child or adolescent versus adult characters), sex and types of characters on the show.Results: There were 795 instances of smoking in the 400 episodes observed. Most (498; 63%) involved male characters. Only 8% of instances of smoking (63) involved child or adolescent characters. Just over a third of instances of smoking (275; 35%) reflected smoking in a negative way, compared with the majority, which reflected smoking in a neutral way (504; 63%) and the minority, which reflected smoking in a positive way (16; 2%). Child and adolescent characters were much more likely to be involved in instances of smoking reflected in a negative way compared with adult characters (odds ratio, 44.93; 95% CI, 16.15–172.18).Conclusions: There are a large number of instances of smoking in The Simpsons television show. Child and adolescent characters are much more likely to be portrayed in instances of smoking reflected in a negative way than adult characters. Viewing The Simpsons characters smoking may prompt children to consider smoking at an early age.

Guy D Eslick PhD, MMedSc(ClinEpi), MMedStat · Marielle G Eslick

To the Editor: In November 2008, a residential balcony collapse in Brisbane, Queensland, resulted in one person killed and 25 injured.1 Moments after the accident, tertiary hospitals across the city were placed on alert. Valuable hospital resources, including intensive care beds and staff, were allocated to the care of potential casualties; surgical theatres were kept on standby; and elective operating lists were cancelled. In 2008, injuries in more than 40 people across Australia and New Zealand were caused by residential balcony collapses.1-3 About 8000 Australian timber balconies are considered at risk of collapsing and potentially causing human fatality.4 Timber balconies constructed between 1970 and 1990 are at most risk of collapse.4 Many were constructed with inappropriate timber, without building approvals, and by unqualified tradespeople. When properly constructed, a well maintained timber balcony generally lasts for about 20 years.4 Collapse is not limited to timber balconies. In February 2002, a concrete cantilever balcony on a Sydney apartment fell under its own weight, shearing off the balcony under it.5 According to the Australian Concrete Repair Association (ACRA), many concrete balconies appear “safe” but have never been loaded to their maximum capacity, giving residents a false sense of security.5 As balcony parties and outdoor living become more popular, the ACRA believes that it is only a matter of time before more balconies collapse.5 A well maintained concrete balcony can be expected to last for about 40 years.4 In April 1995, the Cave Creek disaster in Pararoa National Park, NZ, resulted in the deaths of 14 people when an unstable wooden viewing platform, unable to support the weight of the 18 park visitors who had crammed onto it, collapsed into a gully.6 Following the accident, the NZ Department of Conservation made it mandatory that warning signs, indicating the maximum number of people permitted, be installed at every public viewing platform in the country.6 Why do suspended structures and public transport vehicles (such as viewing platforms, elevators and buses) have clearly displayed maximum capacity warning signs, but not balconies? Warning signs showing maximum capacity and recommended inspection dates would remind people to maintain and use their balconies safely. A prospective buyer of a home with a balcony should find out when the balcony was built and check local government records for building approvals. If no record exists, a balcony should be professionally inspected. We believe regular safety inspections and clearly displayed maximum capacity warning signs should be mandatory for all balconies. We also believe a review of building codes and standards is needed to protect residents of older homes and apartments — perhaps with an initial amnesty on unapproved balcony constructions — to encourage owners to seek professional inspections and have structural deficits corrected so that future tragedies need not occur.

Shinichiro Sakata · Craig A McBride · James W Nixon · Roy M Kimble

We need a stronger focus on the social determinants of health Since 2006, Australia’s peak Indigenous and non-Indigenous health bodies, non-government organisations and human rights organisations have worked together on the Close the Gap campaign for Aboriginal and Torres Strait Islander health equality by 2030. The key elements of their approach are: A comprehensive national plan of action that is properly resourced and that has the goal of closing the health and life expectancy gap between Indigenous and non-Indigenous Australians within a generation. This is vital to ensure that governments work towards Indigenous health equality in a coordinated fashion (including the many reform processes currently underway), and that none of the determinants of Indigenous health inequality are missed. A partnership for Indigenous health equality between government and Indigenous peoples and their representatives. Within the national plan, a targeted approach to achieving Indigenous health equality, focusing on a wide range of health conditions and health determinants. The campaign partners have developed a comprehensive set of Close the Gap National Indigenous Health Equality Targets (http://www.humanrights.gov.au/social_justice/health/targets) to guide this target-setting process. These were presented to the Australian Government in July 2008. Support for Aboriginal community-controlled health services. The good news is that Australian governments have already committed to this approach through: Bipartisan support for the Close the Gap Statement of Intent, signed by the Prime Minister in March 2008 (see: http://humanrights.gov.au/social_justice/health/statement_intent.html) — this alone represents a historic turning point in the approach to Indigenous affairs in this country; and Commitments by the Council of Australian Governments, where Australian governments have committed to closing the life expectancy gap within a generation, halving the mortality gap between Aboriginal and Torres Strait Islander and non-Indigenous children under 5 years of age, and the provision of record levels of new funding to support this. However, despite substantial investments in Indigenous health as a result of the campaign, progress has been slow in turning the commitments around planning and partnership into action, and there needs to be a stronger focus on the social determinants of health rather than simply a health sector response. This remains the challenge of the campaign partners over 2009–2010.

Tom Calma

In June 2008, the ABC screened a television documentary involving a couple who decided to have an additional child in the hope of obtaining umbilical cord blood to treat their daughter who had leukaemia. The couple conceived naturally, meaning that there was a one in four chance that their child would be suitably matched. They seemed to be unaware of technologies that, if successful, could provide a near certainty that the next child would be a matched “saviour sibling”. This story raises questions about whether clinicians have an obligation to discuss emerging and morally contentious treatment options. Ignorance of technology, assumptions about availability, and medical assessment of burdens and benefits may affect attitudes towards treatment options, but they do not justify non-disclosure of information.

Kimberly A Strong BSc, GradDipGenCouns

To the Editor: I read with interest the research article by O’Connor and colleagues, which concluded that the medical and retrieval costs of road crashes in rural and remote northern Queensland represent “a considerable economic burden”.1 Although the authors noted that the broader Rural and Remote Road Safety Study aimed to also gain an understanding of the social costs of such crashes, they focused on the monetary costs in this report. As we all know, road crashes not only cost money but have enormous personal impact, in both the short and long term, on the patients and their families. This impact is likely to be even greater for patients from rural and remote areas who are unable to be cared for in their local hospital. Remember that for almost all patients transferred, there are families who must also find their way to, and temporary accommodation (sometimes for months) in, an unfamiliar large town or city. Close family members, in addition to the patient, also suffer loss of income, disruption of schooling, and loss of personal network support due to the geographic dislocation. Thank you to the authors of this study, which reinforces the desperate need to continue to improve local health services in rural and remote Australia, including “more efficient trauma management”,1 to contain costs and to lessen patient and family suffering.

Susan M Gorton