Social determinants of health

In reply: We can only agree with Gorton about the high level of costs to families and communities caused by road trauma. While our report attempted to provide estimates of the immediate, direct costs to the medical system,1 we were well aware of the additional costs to families, particularly those from rural and remote areas, as they attempted to support their injured family member. These costs, unfortunately, are difficult to quantify, and have a long-term impact on families and communities. Although our study was able to estimate some of the costs associated with road trauma, there is a need for prospective studies with specially formulated costing tools to capture the costs more fully. An associated study describing the impact of road trauma on the work of general practitioners in rural and remote areas2 outlined the problems that GPs have in managing chronic vehicle-related trauma without access to specialist rehabilitation services. Improving local health services may reduce some costs to families, but many of the patients retrieved from rural road crashes initially require specialist care in tertiary-level facilities. Changing the behaviour of drivers who take risks on roads will also reduce the costs of road trauma. Unfortunately, this is a difficult process.

Teresa M O’Connor · Heather A Hanks · Mark S Elcock · Richard C Turner · P Craig Veitch

Evidence shows that cost does affect alcohol consumption, and reducing consumption improves public health There is strong evidence that increasing the cost of alcohol reduces the overall amount that is consumed.1 In a range of countries, price increases have been consistently shown to reduce alcohol consumption and related harms in both the general population and at-risk populations such as young people and heavy drinkers. Conversely, price decreases have resulted in an increase in consumption and harm.1-3 In this context, the Australian Government’s April 2008 increase in excise tax (Bill introduced on 11 February 2009) on ready-to-drink (RTD) spirit-based products (RTDs; “alcopops”) is an evidence-based strategy to reduce excessive RTD consumption among young people. The alcoholic content of RTDs is now taxed at a similar rate to that of other spirits (tax increased from $39.36 to $66.67 per litre of pure alcohol). Critics have argued that the RTD tax increase has not reduced alcohol consumption by young people, and will not do so. One claim is that young people will merely switch to other beverages. These arguments have been made by some from the alcohol industry and some researchers. Doran and Shakeshaft, for example, argued that young people “ seem to be price inelastic about their alcohol demand”.4 Citing a national school survey, they claimed that “spirits are by far the beverage of choice for the 45% of 16–17-year-old Australians who drink, despite spirits being the most highly taxed beverage in Australia, and the most expensive per litre of alcohol”. This is not evidence for price inelasticity. They also argued that “overall rates of usual or binge consumption in Australia are unlikely to substantially fall, because spirits hold a smaller market share than beer, and young people will more than likely switch their preference”.4 The weight of scientific evidence suggests otherwise — that overall consumption is likely to decline because young people’s demand for alcohol is elastic.1-3 The survey series on which Doran and Shakeshaft rely shows that beverage preferences vary between boys and girls and over time. In 1999, before reductions in tax and in the retail price of RTDs in 2000, RTDs were the preferred beverage of about 23% of 12–17-year-old female drinkers. By 2005, after the tax decrease, 48% of young females drank RTDs, while the preference for higher-taxed spirits fell from 42% to 30%. For 12–17-year-old males, RTD consumption increased from 6% to 14%, a small share compared with spirits (39%) and beer (33%).5 Although new products and marketing strategies may have contributed to this substantial change, these data suggest that young Australians, like their counterparts in other countries,2 do alter their beverage choices in response to price changes. Definitive statements about the impact of the “alcopops tax” are premature in the absence of independent alcohol sales data. It is regrettable that there are no readily available, official monthly sales data for all alcoholic beverages, like those obtained by the detailed monitoring that we know is conducted by private industry.6 However, available evidence does indicate that the tax has reduced sales of RTDs and the reduction was far from wholly offset by a switch to other beverages. A market research company that regularly compiles reports on sales of alcohol products has estimated national monthly sales of packaged alcohol (sold for off-premises consumption by liquor licensees across the five mainland states of Australia) by beverage type for 2007 and 2008 ().7 These data show that in the 3 months after the April 2008 tax increase, 91 million fewer standard drinks were sold as RTDs than in the same months in the previous year. Standard drinks sold as spirits and beer increased but wine sales decreased. The increase in spirit and beer sales (48 million standard drinks) was only 53% of the 91 million fewer RTD drinks sold. A decline in RTD sales was also reported on the basis of Australian Tax Office data. These showed a 54% reduction in sales of RTDs and a 7% increase in spirit sales from April to June 2008.8 In presenting the Excise Tariff Amendment Bill to Parliament, the Minister for Health and Ageing confirmed that: “Tax office figures drawn from the first nine months of this measure show that alcopops sales have dropped by 35 per cent compared to the previous year”.9 Critics have been hasty in predicting that young people’s drinking would be unresponsive to the RTD tax increase. In keeping with a large body of research evidence, the early indications are that RTD sales declined in the first few months after the tax increase. Previous research suggests that this decline in alcohol sales (a reliable proxy for consumption10) will produce a public health benefit.1-3 Further investigation is needed to determine specifically in which population group(s) the benefit accrues; for example, whether this reduction in RTD purchases occurred primarily among young drinkers (the target of the tax increase), and what other factors may have contributed to the reduction. Informed policy debate requires independent evaluations of short-term and long-term effects of these tax changes on consumption and harm indicators (eg, injuries). Nevertheless, the evidence to date is that the “alcopops” tax is a step in the right direction. Number of standard drinks* consumed in May to July, 2007 and 2008, by beverage type Beverage type Million standard drinks consumed Difference in million standard drinks % Change 2007 2008 RTDs 348 257 − 91 − 26.1 Beer 886 899 13 1.5 Wine 797 776 − 21 − 2.6 Spirits 313 348 35 11.2 Total 2344 2280 − 64 − 2.7 Source: Nielsen Liquor Services Group (NLSG) 2008.7 RTDs = ready-to-drink spirit-based products. * One standard drink = 10 g pure alcohol. To accurately convert beverage volumes to pure alcohol, the NLSG applies alcohol conversion factors at the subsegment level for beer (eg, regular, mid-strength, low-strength beer) and RTDs. Average alcohol contents by beverage type: RTDs 5.0%; beer 4.8%; straight spirits 38.0%; and wine 13%.

Tanya N Chikritzhs BA(Hons), PostGradDip(Epi · Paul M Dietze BSc(Hons), PhD · Steven J Allsop BSc, PhD · Michael M Daube BA(Hons), HonDSci · Wayne D Hall BSc(ApplPsych), PhD · Kypros Kypri BA(Hons), PhD

A good death. An argument for voluntary euthanasia. Rodney Syme. Melbourne: Melbourne University Press, 2008 (xviii + 301 pp). ISBN 978 0 522 85503 6. In facing the management and termination of intolerable situations, a caring doctor involved in alleviating the final agonies of patients can berate the legal system’s impotence and governmental procrastination. Oncologists are frequently confronted by situations involving the end of a painful existence. Most are now assisted by specialists in palliative care, often disempowered by shortages of beds and frustrated by staff inadequately trained or less than sympathetic to the views of those who would like to see “physician-assisted by specialists in palliative care, often disempowered by shortages of beds and frustrated by staff inadequately trained or less than sympathetic to the views of those who would like to see “physician-assisted dying” as an alternative to only partially effective, cerebrally numbing analgesia. Cancer, of course, is not the only cause of a prolonged and tormented end to life. Some of the most distressing cases are associated with the neurological prisons that mean a fully conscious person is cut off from mobility, self-care, sensory input and communication. In a deeply personal, well researched and detailed book, Rodney Syme relates his own experiences which, over 30 years, have honed his ideas of how best to achieve the relief requested by the sufferer. Conditions that have to be met include a clear, unequivocal request to die by the patient. This is extremely difficult when communication has become impossible, and points to the need for a “living will”, assigning that responsibility to a nominated person. Nevertheless, euthanasia on demand is not his aim. Rationality is paramount, as is the physician’s responsibility in the decision process. Syme lays emphasis on the need to allow relatives and/or close associates the opportunity to say farewell and discusses the reasons for recommending the methods he does. He makes it clear why he has never adopted the execution-style injections of sedatives, analgesics and cardio-respiratory paralytics adopted in other countries. Although this is scarcely a textbook of suicidal methods or a scientific treatise, it is a valuable addition to the discussion of the subject. It may help medical practitioners to know that others have had to go through the same convolutions of conscience, and be of comfort to family members to follow the thoughts of a clearly caring doctor.

Thomas F Sandeman

Biting anorexia. A first-hand account of an internal war. Lucy Howard-Taylor. Sydney: Finch Publishing, 2008 (ix + 214 pp). ISBN 9781876 451929. I undertook reviewing this book with some trepidation. I presumed it would be yet another distant “tortured” account of anorexia. I found it quite the opposite. Lucy is an 18-year-old Australian university student. Her depiction of her mental state in anorexia is quite extraordinary. I know that anorexia affects the brain negatively, as a result of both malnutrition and the pervasive thinking disorder. It isn’t until the later chapters that you realise the extreme blunting of her intellect that has occurred. Lucy’s diary is an extraordinarily honest, most intelligent account detailing the process of her illness and pathway towards recovery. I was particularly struck by the difficulties she experienced at all times, and by the depth and sophistication of her thoughts and the enormity of the struggle she went through in attempting to overcome her illness. This book really is the most lucid document and one I have started to recommend to colleagues and to patients. It gave me an insight I had not expected to gain into the extent of the damage done by this illness and the extreme difficulties endured to overcome it.

Simon D Clarke

Cryopreservation of unfertilised oocytes for later use in initiating pregnancy is now a viable technology, with acceptable pregnancy rates (over 20% per thaw cycle). Oocyte cryopreservation used as a form of insurance against “social” (age-related) infertility can improve the lifetime chance of pregnancy in women who defer pregnancy into their late 30s or early 40s. We report two pregnancies using oocytes that were frozen for social rather than medical reasons, as part of a larger series of nine pregnancies using cryopreserved oocytes. Use of oocytes harvested and frozen from women aged under 35 years may more than double the chance of pregnancy for a 41-year-old woman. The disadvantages of oocyte freezing for social infertility reasons include cost, the usual risks associated with in-vitro fertilisation, and the lack of a guarantee of eventual pregnancy.

David Molloy MB BS, FRANZCOG · Barbara A Hall MB BS, FRANZCOG · Marianne Ilbery MB BS, FRANZCOG · Jacqui Irving BSc(Hons), MSc · Keith L Harrison BSc, MSc

Objective: To describe the incidence and outcomes of assault resulting in serious injury in Victoria.Design and setting: Analysis of population-based data from the Victorian State Trauma Registry for assaults between 1 July 2001 and 30 June 2007.Main outcome measures: Overall trends in the rate of assault-related major trauma, inhospital mortality, and functional outcomes 6 months after injury as measured by the Extended Glasgow Outcome Scale.Results: The rate of assault-related major trauma rose significantly over the 6-year study period (incidence rate ratio [IRR], 1.21 [95% CI, 1.16–1.26]), particularly for blunt assault (IRR, 1.33 [95% CI, 1.26–1.41]). There were 803 admissions for major trauma related to assault: 484 (60%) were for blunt trauma and 319 (40%) for penetrating trauma. Most patients were young men. Compared with penetrating trauma, blunt trauma was associated with more severe injury; 396 patients (82%) with blunt trauma had serious head injuries, and 102 (24%) of these required inpatient rehabilitation. A higher percentage of patients with penetrating trauma died in hospital compared with those with blunt trauma (35 [11%] v 23 [5%]; P = 0.001). Follow-up at 6 months showed that only 19% of respondents (42 patients) had made a complete recovery; outcomes at 6 months were worse for patients with blunt trauma than for those with penetrating trauma.Conclusions: The incidence of assault resulting in severe trauma rose significantly between 2001–02 and 2006–07, mostly due to a rise in assault resulting in blunt trauma. The increase in incidence, the young age of the victims, and the potential for high burden of injury and poor outcome, combined with the preventable nature of assault, highlight the importance of developing effective assault-prevention strategies.

Phebe A O’Mullane BSc, MB BS · Antonina A Mikocka-Walus MA(Psych), MA(InternRelations), PhD · Belinda J Gabbe BPhysio(Hons), MAppSc, PhD · Peter A Cameron MB BS, FACEM

Severe childhood obesity and its associated comorbidities are increasing in prevalence. Extreme childhood obesity may be viewed as a mirror image of severe non-organic failure to thrive. Parental neglect may be a causative factor in both circumstances. When suspicion of parental neglect arises, health care professionals may have both an ethical obligation and a statutory duty to notify child protection services. Guidelines on the point at which medical practitioners should seek state assistance in cases of severe childhood obesity would be helpful, not only for medical practitioners, but also for child protection services.

Shirley M Alexander MB ChB, MRCPCH, FRACP · Louise A Baur BSc(Med), PhD, FRACP · Roger Magnusson BA, LLB(Hons), PhD · Bernadette Tobin MA, MEd, PhD

Final exam: a surgeon’s reflections on mortality . Pauline Chen. London: Souvenir Press, 2008 (xv + 267 pp). ISBN 978 0 28563 811 2. Although it is more than 40 years since I graduated, reading A surgeon’s reflections on mortality revived memories of my own undergraduate and postgraduate years. Replete with detailed recollections of the author’s initiation into medicine and specialist practice, this is more than a trip down memory lane. At its heart resides a concern that many will, as was the case with the author, find challenging and unsettling. Pauline Chen uses narrative and reflection to tell us of her transition from a frightened and anxious medical student to a compassionate transplant surgeon. The stories reveal a maturation process that inevitably leads her to evaluate the agendas that direct her life as well as her clinical practice. The journey brings her face to face with her own mortality and the realisation that to become a good doctor she needs to prepare for her “final exam”, namely her own death. The book ultimately confronts the issue of end-of-life care and, somewhat bravely, the author suggests it is not the disease process, place of death or service delivery but a doctor’s fear of and aversion to dying that influences outcomes. This, she asserts, is “the most difficult and fundamental human obstacle in changing end of life care.” Not everyone will agree with this conclusion, but the issues raised within the book cannot be summarily dismissed. Is it the art or the science of care that matters most? According to Ken Wilber, a transpersonal psychologist of some repute, the crucial ingredient is not the doctor’s bag with all its tricks but the holder of that bag. In “doctor speak”, this can be translated as “physician heal thyself”. Chen invites us to heal.

Michael P Barbato

Objective: To investigate whether the relationship between socioeconomic status and breastfeeding initiation and duration changed in Australia between 1995 and 2004.Design and setting: Secondary analysis of data from national health surveys (NHSs) conducted by the Australian Bureau of Statistics in 1995, 2001 and 2004–05. The Socio-Economic Indexes for Areas (SEIFA) classification was used as a measure of socioeconomic status.Main outcome measures: Rates of initiation of breastfeeding; rates of breastfeeding at 3, 6 and 12 months.Results: Between the 1995 and 2004–05 NHSs, there was little change in overall rates of breastfeeding initiation and duration. In 2004–05, breastfeeding initiation was 87.8%, and the proportions of infants breastfeeding at 3, 6 and 12 months were 64.4%, 50.4% and 23.3%, respectively. In 1995, the odds ratio (OR) of breastfeeding at 6 months increased by an average of 13% (OR, 1.13 [95% CI, 1.07–1.19]) for each increase in SEIFA quintile; in 2001, the comparative increase was 21% (OR, 1.21 [95% CI, 1.12–1.30]); while in 2004–05, the comparative increase was 26% (OR, 1.26 [95% CI, 1.17–1.36]). Breastfeeding at 3 months and 1 year showed similar changes in ORs. There was little change in the ORs for breastfeeding initiation.Conclusion: Although overall duration of breastfeeding remained fairly constant in Australia between 1995 and 2004–05, the gap between the most disadvantaged and least disadvantaged families has widened considerably over this period.

Lisa H Amir MB BS, MMed, IBCLC · Susan M Donath BSc, MA

Objective: To assess public perceptions of Australia’s doctors, hospitals and health care systems.Design and participants: A cross-sectional national telephone survey of a random sample of 800 Australian adults in August 2007.Main outcome measures: Ratings of subjective trust in health care providers, public and private hospitals, private health insurers and Medicare; attitudinal ratings for the current health care system, and public and private health care systems.Results: Australians reported high trust in doctors (general practitioners more than specialists), low trust in alternative practitioners, moderate trust in hospitals (private more than public), and greater trust in Medicare than in private health insurers. Older adults had the greatest trust in physicians, hospitals and Medicare, but all age groups held similar attitudes toward public and private health care systems. Support for the current health care system with its mix of public and private funding was moderately strong, but all respondents reported weak pro-private attitudes and very strong pro-public attitudes.Conclusions: Public perceptions of Australian medical professionals, institutions and systems are generally positive. This sample did not endorse an individual user-pays private health system, but strongly favoured a universal public health system that is collectively funded by the public purse.

Elizabeth A Hardie BA, PhD · Christine R Critchley BA, PhD

Patient-reported outcomes (PROs) are reports coming directly from patients about how they function or feel in relation to a health condition and its therapy, without interpretation of the patient’s responses by a physician or anyone else1 (Box 1). PROs are increasingly used in clinical research, and their usefulness to inform clinicians’ and patients’ decisions about treatment alternatives is beginning to be understood.3 But results of empirical testing of using PROs in clinical practice have been inconsistent, and ascertaining the circumstances under which PROs are truly helpful beyond research settings remains a challenge. What benefits and harms can we expect from using PRO measures in clinical practice?The potential benefits of using PRO assessments in daily clinical practice include facilitating patient–clinician communication about issues that are important to patients, thereby promoting shared decision making; monitoring disease progression and response to treatment; identifying vulnerable patients; and enabling continuous assessment of quality of care.1,3 These benefits could lead to improvement in outcomes that are important to patients. On the other hand, the use of PROs may interfere with doctor–patient communication and patients may be concerned about who will review or use the information. Even in the absence of harm, the use of PROs would carry an opportunity cost, which is an important consideration given that administering some of the currently available measures is already burdensome, and scarce resources would be consumed in computing and reviewing PRO scores. What is the evidence for using PRO measures in clinical practice?A number of systematic reviews have assessed the impact of measuring PROs in clinical practice. The most recent included 28 randomised controlled trials and the results were consistent with previous reviews: in most trials, the impact of PROs was limited.1 Feedback of PROs to health professionals has, in some studies, had an impact on the process of care, with a less evident impact on health outcomes. In cancer clinics, feedback of PROs to health professionals has been shown to increase the frequency with which doctors discuss issues such as quality of life and symptoms with their patients, without an increase in the visit duration.4,5 In one of these studies, physicians informed by PROs had greater agreement with their patients about how well the patient was functioning.5 A meta-analysis showed that PRO reports of mental health status in a variety of settings resulted in a higher likelihood of diagnostic notations recorded in patients’ medical records.6 There are a number of additional steps that must be taken before changes in the process of care can be translated into changes in outcome (Box 2). For instance, routine provision of feedback to health professionals may not necessarily translate into routine use of the information for all patients. Thus, those who demand evidence of improved patient-important outcomes will not be impressed simply by improvements in process. Moreover, randomised controlled trials on PROs have been highly heterogeneous in setting (primary care; specialised outpatient and inpatient clinics), participants (new and known patients; experienced and more junior clinicians), the intensity and content of the PRO intervention implemented, and diversity of outcomes reported.1 This heterogeneity poses a major challenge in interpreting the evidence and in identifying the clinical contexts and strategies for measuring and reporting PRO results to clinicians that will result in improved patient outcomes. Some additional methodological weaknesses affect these trials. Often, the investigators analysed the data as if they had randomised patients, when in fact they had randomised clinicians or groups of clinicians.1 This error would bias results in favour of the intervention. Some interventions were suboptimal in the degree of training clinicians received in interpreting the results, and in the manner of presentation of results to the clinicians.8 Methodologically stronger trials successfully implementing feasible interventions with clear positive effects are required to provide clear direction for clinicians. What are the challenges for implementing PRO measures in clinical practice?The systematic use of PRO instruments in clinical practice has the potential to bring about significant improvements in a number of relevant areas of health care. But possible barriers to implementation would need to be overcome, including scepticism about the validity and potential utility of PRO data; unfamiliarity with the interpretation of PRO information; a paucity of direct face-to-face instrument comparisons; costs of data collection; and the need for rapid data manipulation and processing. Significant progress has been made in some of these areas. A recent review comparing common medical measurements and their associated error with PRO measurements concluded that the latter were comparable with commonly used outcome data.9 The next step is to convince clinicians that this is the case and that they may reliably benefit from information derived from PROs. Researchers are also finding new, imaginative ways to help clinicians understand the magnitude of treatment impact on quality of life. One useful measure in this regard is the Minimal Important Difference (MID) — the smallest change in instrument score that patients perceive as important.10 For instance, the MID for the Chronic Respiratory Questionnaire is 0.5 on a scale that ranges from 1 to 7. This means that changes smaller than 0.5 should not be considered relevant, regardless of the statistical significance of the comparison. Some authors propose linking PRO scores with expected performance profiles to facilitate interpretation of results.7 The development of standardised tools relying on sound criteria11 is making direct comparison between instruments and their devised purposes easier. These evaluative approaches should facilitate the selection of the most appropriate PRO for each occasion. Also, efforts are being made to develop very brief questionnaires by either shortening existing ones or applying computer-based methods to tailor the content of the instrument to each patient based on the responses provided to each previous item. This approach should reduce the burden of collecting PRO data. Finally, the development of new PROs specifically devised for use in the clinical setting might also help to overcome barriers to successful implementation. Where to from here?PRO instruments used in clinical research can theoretically provide important information to guide decisions about alternative treatments. There are some grounds for optimism that the use of PROs could have a positive impact on clinical practice (specifically in improving diagnosis and recognition of problems and in patient–physician communication), but considerable work is still required before clinicians can invest resources in the process and confidently anticipate benefits for their patients. 1 Examples of patient-reported outcome (PRO) instruments Medical Outcomes Study short-form health surveys (SF-36, SF-12, SF-6D): the most used family of PRO measures EuroQol (EQ-5D): a well known econometric preference-based measure, and one of the shortest instruments available McGill Pain Questionnaire: the most widely cited PRO instrument for measuring pain KIDSCREEN: a specific tool for PRO measurement in children and adolescents Patient Health Questionnaire (PHQ-9): a tool for assessing severity of depression; currently part of the “pay-for-performance” incentives scheme for primary care practitioners in the United Kingdom2 Schedule for the Evaluation of Individual Quality of Life (SEIQoL): an individualised measure, eliciting both the content of the items and the ratings from the respondent 2 Assessing the impact of patient-reported outcomes in clinical practice: a model for feedback on functional assessment* in clinical practice7 * The assessment of a patient’s ability to perform tasks.

Jose M Valderas MD, PhD, MPH · Jordi Alonso MD, PhD · Gordon H Guyatt MD, FRCPC

Objective: To quantify the impact on the Western Australian health care system of hospitalisations due to interpersonal violence, and to identify risk factors for a repeat hospital admission for interpersonal violence.Design and setting: A population-based, retrospective study of interpersonal violence in WA using linked data (1990–2004) from the Western Australian Mortality Database, the Hospital Morbidity Data System and the Mental Health Information System.Main outcome measures: Number of hospitalisations and associated length of stay; risk factors for repeat hospitalisation.Results: Over the period 1990–2004, there were 36 934 hospital admissions due to interpersonal violence, with 11 507 of these hospitalisations due to a subsequent episode of interpersonal violence. The average length of stay was 2.6 days (SD, 4.9 days). People who were more likely to be readmitted for interpersonal violence included women (adjusted hazard ratio [AHR], 1.31; 95% CI, 1.23–1.39), Indigenous people (AHR, 1.37; 95% CI, 1.28–1.46) and patients with a mental illness (AHR, 1.46; 95% CI, 1.37–1.54). People with more affluent backgrounds tended to have a lower risk of being readmitted than people in the most disadvantaged socioeconomic group.Conclusion: Greater priority should be directed towards the primary prevention of violence. Groups at high risk, such as women, Indigenous people and those with a mental illness, should be targeted for special attention.

Lynn B Meuleners PhD · Delia Hendrie MSc · Andy H Lee PhD

Social marketing. Why should the devil have all the best tunes? Gerard Hastings. Oxford: Butterworth-Heinemann, 2007 (xvii + 367 pp). ISBN 978 0 7506 83500. Not so long ago, it seemed businesses couldn’t swap their products for our money fast enough before disappearing. Now we can’t even have a haircut without surrendering our name, address, phone number and date of birth. Welcome to relationship marketing. Today’s companies really do care about our satisfaction because customer satisfaction underpins repeat business, explains Gerard Hastings in Social marketing. Why should the devil have all the best tunes? Hastings, the United Kingdom’s first professor of social marketing, argues that public health needs to expand the use of these successful marketing strategies to make health promotion more powerful. By examining commercial practices and dissecting case studies of public health interventions, he demonstrates how health promotion is moving beyond fear campaigns and short-term interventions to building relationships with people and providing practical, ongoing assistance to encourage risk reduction and healthier living. Hastings clearly and succinctly explains the theories underlying social marketing: stages of change, social cognitive theory and exchange theory. He argues that social marketing requires strategic analysis of the problem, of the competing forces and of the target population to underpin solutions that work. Hastings and his colleagues at the University of Stirling, Scotland, recently demonstrated the power of analysing a problem by systematically reviewing the impact of junk food advertising and finding there are adverse effects on children’s food preferences, purchases and consumption. Understanding competing forces is crucial, he argues, because one of the reasons we have binge-drinkers, smokers and people who eat and drink unhealthily is that companies have been better at marketing than have health professionals. Hastings’ well structured and clearly written book equips readers with a valuable tool of public health that can be used to counteract the “hazard merchants”, who market death and disease through products (such as tobacco), and to promote healthier living.

Catriona M F Bonfiglioli

There is a heavy burden of disease associated with family violence, discrimination, bullying and social exclusion. These important causes of suffering and loss of productivity all relate to a very fundamental feature of human existence and civil(ised) societies — the way we treat each other. We can, and do, make each other sick. Reducing the resultant human and economic costs has major implications for the way we distribute opportunity, wealth and amenity. These, in turn, have implications for the way we protect and empower minority groups, and for legislation, education and the availability of, and access to, services.

Rob Moodie FRACGP, FAFPHM, MPH

Objective: To investigate primary health care service utilisation and health presentations among asylum seekers living in Melbourne.Design and setting: Retrospective audit of files of people who attended three Melbourne asylum-seeker health clinics between 1 July 2005 and 30 June 2006.Main outcome measures: Rates of reasons for the encounter, diagnostic tests or investigations required, treatments prescribed and referrals.Results: Data were collected from 998 consultations corresponding to 341 people. Eighty-eight per cent of visits involved people with no Medicare access, owing to their visa status. The most common reasons for the encounter were general and unspecified symptoms or problems (rate, 59.9 per 100 encounters; 95% CI, 55–65), followed by musculoskeletal conditions (27.1; 95% CI, 24–30), and psychological problems (26.5; 95% CI, 23–30). The rate of referrals was 18.3 per 100 encounters (95% CI, 16–21).Conclusions: The three clinics providing services to asylum seekers in Melbourne are delivering care to a considerable number of people with complex health needs. A substantial number of asylum seekers present to clinics with psychological and social problems. Most cannot access government-subsidised health care. This must be addressed urgently by policy change at the federal and state and territory levels.

Ignacio Correa-Velez MB BS, PhD · Vanessa Johnston MB BS, MPH · Joanne Kirk RN · Angeline Ferdinand BA

Gender is more than just a variable to be controlled for in statistical analyses Does ageing affect men and women equally? If not, how might differences affect research — and subsequently clinical practice? To answer this and related questions, the Mars and Venus: Does Gender Matter in Ageing? conference was convened by the University of Newcastle’s Research Centre for Gender, Health and Ageing, in association with the Australian Association of Gerontology and the Healthy Ageing Theme of the Australian Research Council/National Health and Medical Research Council (NHMRC) Research Network in Ageing Well.1 The 2-day conference, held in Newcastle in July 2007, featured longitudinal studies of ageing that have given specific attention to the health of men or the health of women, and introduced an NHMRC-funded initiative to link two of these studies. The conference also included a 1-day research workshop, sponsored by the Ageing Well Network, which involved researchers from longitudinal studies of ageing being conducted in Australia, and considered how such studies might take greater account of gender in their design and analysis. The conference attracted 85 participants from across Australia and overseas, who came together to consider ways in which the effects of ageing are unequal between men and women, and how these differences might be further exaggerated through interactions with socieconomic status and background. Conference overview: seeking balanced debateThe theme of the conference was set by Cherry Russell (School of Behavioural and Community Health Sciences, University of Sydney), who gave a keynote address, Ageing and the gender agenda: a critical reflection, which outlined gender differences in life expectancy, health, income, care needs, and level of social isolation, along with a discussion of gender biases in policy and service provision. Compared with men, women have more chronic illness and greater health service use at older ages; but they also live longer. Men have more fatal illness at younger ages.2 For instance, men have coronary artery disease earlier and have a higher death rate. Lung cancer is more common among men, who have had higher rates of smoking than women. Women have a higher incidence of musculoskeletal problems and a higher prevalence of incontinence, although these problems are also important for men. Although hip fracture also affects older men, the incidence increases at a later age and fewer men survive to the age of high risk. Women, therefore, dominate the clinical picture. Some health differences are related to biological sex; however, many differences are strongly linked to social influences of gender. These less obvious differences include environmental, occupational and behavioural risks, behaviour, and different adaptive techniques. There are also considerable differences in social roles and access to financial and social resources — which significantly affect the experience of ageing. Cherry Russell noted that there has been little balanced debate as to what the unequal effects of ageing for men and women mean and where they stem from. Debates about gender and ageing have focused on loss of men’s work roles, older women’s double disadvantage from age and gender inequality, and on a “paradigm of competitive suffering”. In contrast, this conference aimed for greater balance in considering how gender influences the health and wellbeing of men and women as they age. This theme was reflected in the proffered papers and workshops. Papers explored age and gender issues such as living arrangements; health and engagement for older men; gender bias in health service programs; retirement issues; and current research on gender differences, including results from the Household, Income and Labour Dynamics in Australia (HILDA) study and Melbourne Longitudinal Studies of Healthy Ageing (MELSHA). Workshop topics explored the needs of homosexual and transgender people, gender issues in dementia and sexuality in residential aged care, and the practicalities of conducting a large longitudinal study: the Australian Longitudinal Study on Women’s Health. Longitudinal studies: a focus on genderKeynote addresses throughout the conference featured longitudinal studies of older men and women. The Concord Health and Ageing in Men Project (CHAMP), presented by Bob Cumming (Centre for Research and Education on Ageing, School of Public Health, University of Sydney), involves 1705 men aged 70 years and over. Early findings from this study show a sharp increase in multiple falls, and declines in continence, cognitive function, and activities of daily living starting after the age of 80.3 The Florey Adelaide Male Ageing Study (FAMAS), presented by Gary Wittert (School of Medicine, University of Adelaide), focuses on chronic physical and psychological disease and reproductive and sexual health.4 Measures of testosterone show an age-associated increase in sex-hormone-binding globulin and a decrease in free testosterone, a change that may be adaptive rather than pathological. The Health in Men Study (HIMS), presented by Leon Flicker (Graduate Research School, University of Western Australia), involves 4262 men, and focuses on physical and psychosocial morbidity (including depression), health risks, weight and body mass index, cognition and mortality. One finding from this study has been the importance of health and lifestyle factors in determining cognitive function, even in advanced old age.5 Emily Banks (National Centre for Epidemiology and Population Health, Australian National University) provided an overview of the United Kingdom’s Million Women Study (MWS), which has shown increased risks of breast cancer,6 endometrial cancer,7 and ovarian cancer with use of hormone replacement therapy,8 and a protective effect on fracture.9 Annette Dobson (Division of Epidemiology and Social Medicine, University of Queensland) represented the Australian Longitudinal Study on Women’s Health (ALSWH), which has been running since 1996, and has investigated many factors affecting women’s health and ageing, particularly the influence of social context on health and health care use.10 Recent reports from this study emphasise the burden of illness associated with non-fatal conditions such as arthritis, the preventable burden of obesity, and safe levels of alcohol intake for older women.11 Leon Flicker, Annette Dobson and Julie Byles (Research Centre for Gender, Health and Ageing, University of Newcastle) also gave an overview of the recently funded Men, Women and Ageing Study, linking HIMS and ALSWH to generate cross-gender analyses. Additionally, Gita Mishra (University College, London) showed how gender interacts with effects of childhood socioeconomic status in determining early mortality in the 1946 British Birth Cohort. For example, a father’s occupation had a strong effect in women, but no significant effect in men. Studies of men and studies of womenWhat are the similarities and the differences?A workshop involving investigators from longitudinal studies and other researchers compared and contrasted issues, approaches and findings of longitudinal studies of men and women. Identified commonalities and differences between studies of men and women are shown in the Box. The main differences were conditions that could not be experienced by the opposite sex, such as hysterectomy for women and prostate disease for men. However, studies of men had a focus on testosterone and sexual function that was not mirrored by female equivalents. Studies of women measured oestrogen levels and sexual problems in relation to menopausal changes, not in relation to health in later life. Other differences were more subtle. For instance, while prostatism is a male issue, lower urinary tract symptoms are also experienced by women. It was agreed that more emphasis on these symptoms may be appropriate for studies involving women. As a general observation, studies involving men applied a biological framework, whereas studies of women applied a social model. For instance, caring has been emphasised in women’s studies but caring may be an equally important, although different, issue for men. Health after the death of a spouse has also been given greater emphasis in studies of women. Men are more likely to repartner, but this comparison is confounded by the construction of relationships, with men preferring to cohabit and women preferring to live apart from a new partner. Transport and mobility were also identified as major issues for women. This need may be experienced differently by men, for whom loss of a drivers licence may present more than a practical problem of “how to get around”, as it may also lead to depression and general decline. Cross-gender analyses: what are the opportunities?The workshops also explored how longitudinal studies of ageing can be analysed from a gendered perspective. It seems that almost any question on the ageing research agenda can be subjected to a gendered analysis. For instance, comparing genders: Which differences exist at a biological level, and which are socially determined? Does socioeconomic disadvantage have a differential effect on health? Does caring by men and women involve different activities and dimensions? What is the effect of ageing on sexual function, sensuality and spirituality? Is there a differential change in the importance of these outcomes with age? How do men and women engage with the health care system? Does health care need to become more gender-sensitive? Are there differences in diet and nutrition? Does nutrition have a differential effect on health outcomes according to gender? Are the predictors of survival and longevity different among women and men? For example, does comorbidity have a stronger effect in men? Do men and women have different health goals? If health is seen not as an end, but as a means to achieving life goals, then health will have different effects in men and women if their life goals are not the same. Gendered comparisons: simple or complex?However, gendered comparisons may not be as simple as stratifying variables by age and sex. Men and women may exhibit different levels of accuracy and reliability in reporting exposures and outcomes, and many measures have a strong gender bias. For instance, caring appears to have very different meanings and manifestations for men and women. Physical activity has a different nature, context, and inherent value. Even when the same measures can be used, different categorisations may be needed, especially if underlying distributions and associations vary by gender. Further, influences of gender may interact strongly with cognitive status, marital status and other socioeconomic factors. Cohort effects are also likely to be important, with changes in the social meaning of gender over time (for instance, disparities in education, employment, occupation, and assets have changed over the past century). The power that can be achieved by combining data from existing longitudinal studies, as will occur in the Men, Women and Ageing Study referred to above and in the Dynamic Analyses to Optimize Ageing (DYNOPTA) project led by Kaarin Anstey of the Australian National University, will allow robust statistical analysis of gender interactions and, in the case of DYNOPTA, the use of nested cohorts to control for cohort and geographical effects. Closing remarksJulie Byles and Hal Kendig (Faculty of Health Sciences, University of Sydney) noted that the discussion from the conference and the longitudinal studies workshop provided valuable insights into basic gender differences and will inform research for years to come. Sex and gender differences matter not only to the experience of ageing, but are also manifested in the design of the research projects which, to date, have shown a clear gender-specific focus. Participants agreed that gender is more than just a variable to be controlled for in statistical analyses — it needs to be understood within a social context and be included in all future analyses. In this way, we may achieve not only greater understanding but also greater benefits in future clinical practice. Commonalities and differences between studies of men and women identified at the workshop Commonalities Medication Obesity and weight Cardiovascular outcomes (heart attack, stroke) Health risks: smoking and alcohol Diabetes and the metabolic syndrome Falls Fracture and osteoporosis Hearing and vision Anxiety and depression Sleep Other medical history Quality of life Mobility and dependence Housing and neighbourhood Social support Health service availability, access and use Living arrangements and marital status Differences Men (Mars) Women (Venus) Testosterone levels Effects of hormone replacement therapy Hysterectomy Dementia and Alzheimer’s disease Sarcopenia (age-related muscle loss) Incontinence: urine flow Incontinence: leaking urine Lower urinary tract symptoms Dysuria Widowhood Caring Transport Prostate cancer Breast cancer Endometrial cancer Ovarian cancer Erectile dysfunction

Julie E Byles BMed, PhD · Matthew Carroll BA(Hons), PhD · and the Mars and Venus Writing Team

Suffering and healing in America: an American doctor’s view from outside. Raymond Downing. Oxford: Radcliffe Publishing, 2007 (xii + 126 pp). ISBN 978 1 84619 130 5. In an age of increasing disparity between the health systems of rich and poor countries, Suffering and healing in America offers an analysis of how America’s health system can learn from the achievements of those in more poorly funded settings. The author argues that health care in America risks the charge of hubris as it increasingly fails to address the needs of poorer members of the community. Furthermore, Western medicine has so raised the expectations of cure that it has contributed to the loss of capacity to cope with suffering when cure is not possible. He discusses the comparative notions of cure and healing and the evolving role of family medicine within the health care system. While many of the questions the author raises are undoubtedly serious challenges facing health care and therefore worthy of discussion, his subjective analysis rarely penetrates far below the surface of the more complex issues. The author makes heavy going of his cure versus healing discussion but never really mounts a clear argument. The way he uses anecdotes to illustrate certain points is reminiscent of parables, and too often they shed little light on the labyrinthine world of modern health care. The chapter on culture offers perhaps the most pertinent example of this, leaving the reader frustrated by the simplicity of the analysis. The title of the book is itself a curious example of the false trails the author follows: he spends more of the book discussing his experiences as a medical practitioner in Africa than America, and not all the comparisons he makes are relevant given the cultural, social and economic disparities between the two worlds. The repeated pattern of raising topical issues but then not really addressing them undermines the value of the book as anything more than a mildly interesting narrative.

Damien W Morgan

Lands of shame. Helen Hughes. Sydney: The Centre for Independent Studies, 2007 (xv + 237 pp). ISBN 978 1 864321 35 7. Lands of shame was the blueprint for the Howard Government’s “national emergency” intervention in the Northern Territory. In spite of its influence, I would not recommend Lands of shame to anyone desirous of gaining an insight into the history of Indigenous policy, because of its simplistic generalisations and ideological bias. According to Hughes, poverty in remote Indigenous communities is a legacy of the “Coombs socialist homeland model” introduced 30 years ago. Elements of this model included communal property rights, the apparent use of customary law and other “separatist policies” designed to resurrect “hunter–gatherer economies”. Hughes’ description of the evolution of Indigenous policy is incongruous with the history of my home state of Queensland. Many of Queensland’s remote Indigenous communities are former reserves that were established during the protectionist era that preceded the 1970s. Far from being hunter–gatherer economies, the reserves were akin to Dickensian workhouses that left little room for human dignity, let alone the sanctity of family life. I can still remember the first time that I visited one of the former reserve communities, and a colleague pointed out to me the old dormitory where young children were once forced to live. Years later, the inevitable pain that would have been suffered by the children’s parents still makes me shudder. Arguably, such indignities offer a far more plausible explanation for the contemporary social problems of some remote Indigenous communities, than communal land tenure. Yet this history is largely overlooked by Hughes. Hughes’ greatest flaw is her failure to comprehend the immorality of writing a manifesto for Indigenous people in the absence of a meaningful dialogue with us. Hughes routinely dismisses the Indigenous leadership as corrupt “Big Men”, with only Noel Pearson (who conveniently shares her ideological position) spared rebuke. Her apparent view of respectful engagement with Indigenous people as superfluous makes Hughes no better than those she condemns. Indeed, the very lack of empathy that enabled bureaucrats to remove Indigenous children into dormitories is a disturbing, though unacknowledged, presence throughout the entire book.

Nicole Watson

Meningitis and mentors seeded a passion to remedy health inequalities in Africa We have the capacity to feed everybody on our planet. We have the capacity to ensure that everybody has clean water . . . [and] affordable health care. We can prevent many of the diseases to which our children in the poorer parts of the world succumb . . . A person is a person through other persons . . . You can’t be human in isolation; you are human only in relationships. — Archbishop Desmond Tutu I’ll never forget the pounding, throbbing headache that heralded meningococcal meningitis. I remember leaning against the wall in the bathroom of my local doctor’s waiting rooms, steaming with a temperature of 40°C, and thinking “This is it. I must be dying”. The pain was so intense I just couldn’t see how my body could survive. Every skerrick of light seeping through my shut eyelids felt like lasers beaming through to burn my brain. As I was a boarder in a rural school, I was alone — I was afraid — and I was 14. After losing consciousness and a helicopter flight to Sydney, I awoke after a week, in the intensive care unit of the Children’s Hospital at Westmead. One week later, when I could stomach food, I was moved into a ward. I was sharing with a 2-year-old boy who also had meningitis, but whose septicaemia had taken hold of his young body more aggressively than it had of mine. I remember watching him being wheeled out of the room one morning, only to return 6 hours later with no lower legs. The author, surrounded by orphans in Nairobi, Kenya. Days passed, and much to everyone’s shock, I continued to recover, with no residual disability. The months to full health were many, yet the realisation of surviving a fatal disease, completely unscathed, began to sink in. I was left with a sense of “survivor’s guilt” — an intense appreciation of life and how fortunate I was, a realisation of the gift that life is, and a yearning to make the most of every living, breathing moment that remained. My first decision was to study medicine, to fulfil a desire to give something back to the profession that had saved my life. A month in a children’s hospital is the best work experience one could have, and despite coming from a family with generations of strength in the arts, especially music, I decided to take up chemistry at school and begin to focus on the sciences. Unprepared, I sat the undergraduate medicine admission test in my final year of high school, and my marks were nowhere near those required for entrance. Undeterred, I headed off on a gap year abroad, working as a music and drama teacher in the United Kingdom before studying Italian in Florence. I returned in 2001 to the Australian National University (ANU) in Canberra to study for a Bachelor of Science (Psychology)/Bachelor of Arts, following my sister’s footsteps to John XXIII College. A year later, a summer internship on the trading floor at Macquarie Bank in Sydney saw me shift to a Bachelor of Commerce/Bachelor of Science, and I returned to Macquarie Bank for three more challenging summers in finance. Equity markets and medicine are deceptively similar: both are fast-paced, intellectually demanding, unpredictable and exciting work environments. Yet despite the “buzz” of my experience in the financial world, I couldn’t shake my medical aspirations. During lunch hours in Martin Place, I would sit and stare at the homeless people seeking shelter under the buildings in which others were making millions, and I knew that a profession in medicine would be the only way to satisfy my desire to help people while challenging me intellectually. Education session and distribution of subsidised insecticide-treated nets by Hands of Help volunteers and health workers in Uganda. After two more unsuccessful attempts at the undergraduate medical admissions test, I turned to the postgraduate admission procedure. In the penultimate year of my undergraduate course, I sat the Graduate Australian Medical Schools Admissions Test (GAMSAT) as mere practice for the following year, but fortunately, my marks were high enough to result in a placement at the University of Sydney. I was bursting with enthusiasm to begin the postgraduate medical course after 4 inspired years as an undergraduate. To pay the bills during my days in Canberra, I had worked as a therapist for children with autism, conducting applied behavioural analysis for children with profound disability at a special education school in Woden. What began as a job soon turned into a passion as I learned how to communicate with children who had no speech, honing my empathy skills as I tried to learn to read their expressions and mannerisms to understand how they were feeling and what they were trying to say. These children, with beautiful personalities frustratingly stuck in less useful bodies, absolutely grew on me. My appreciation of life continued to grow and, while I hope the hours of therapy I did with those children helped them become a little more capable, ultimately they taught me far more. In my last holidays before beginning medicine, I made a trip to Africa, a continent which had fascinated me since reading Bryce Courtenay’s The Power of One as an impressionable teenager. In my commerce degree, I had majored in development economics and was inspired by a senior lecturer at the university, Dr Alan Martina, who brought to light for me the inequalities existing in our world today. My passion for the subject saw me begin to devour novels on the area, and an inspirational meeting with Nobel Prize nominee Professor Jack Caldwell, who has devoted much of his life to demography in Africa, sealed my interest. Thanking the Bufuula community for their hospitality at the end of the volunteers’ 3-month stay to build a primary school in 2005. I spent a month in East Africa those holidays, and was changed forever by the experience. In Africa, the continent on which we all began as Homo sapiens, it is impossible not to feel alive. There is a magic about the place and its absolute determination to defeat the myriad obstacles that have been placed in its way — geographical disadvantage, slavery, colonialism, and continuing epidemics — and this fiery determination burns through to your heart, making it impossible to walk away unchanged. I remember my plane taking off from Nairobi and promising to myself that I would return, but next time with more money, more time, and more people to make a difference. I graduated from the ANU and started studying medicine 6 months later. I had already emailed all my family and friends to rally interest in working and raising funds for the continent, but as the work began, the interest dissipated. Not knowing a soul in my new medical course, I took the plunge to email my entire year group about my idealistic plan. The response was amazing. The following summer, in December 2005, 17 volunteers, including 12 medical students from the University of Sydney, headed to Uganda to live in a remote community for 3 months, with no water or electricity, as we built a primary school for 650 children. We paid our own way to get there, juggling part-time jobs on top of full-time medical degrees, and left with our backpacks and $100 000 in the Hands of Help bank account — the result of an exhausting year of fundraising and the generosity of those supporting our idea. On the back of such enthusiasm, I set in motion the wheels to register ourselves as a charity, and Hands of Help was born, with a grassroots commitment to ensuring all funds raised reached the areas of the world that needed them most. To date, over 98% of our hundreds of thousands of dollars has been spent “on the ground” in Africa or Indigenous Australia, something we are proud of, and a figure not often achieved in the world of charitable organisations. A young girl in Bufuula, proudly wearing a Hands of Help armband. Living in an African community, experiencing life the way Africans do, is a once-in-a-lifetime opportunity. We grew close to the children, their parents and the local community council, and developed an understanding of health care in the developing world through visits to local clinics and hospitals. I rustled together a survey, which we conducted with local interpreters, of every household in Bufuula — the tiny village we were living in, located 3 hours south-east of Kampala, the capital of Uganda. As we sat in each home, showered with papayas, fresh milk from their cows and raw peanuts or coffee beans, we listened intently to their stories. We swallowed hard past the lumps in our throats as we heard recollections of their many children lost to malaria, while smiling toddlers sat in the corner of the hut eating cardboard to ward off their grumbling tummies. We stood humbly at the grave sites of mothers lost to AIDS while holding the hands of their children left behind, and we listened to their desperate pleas for access to health care and education. The first Hands of Help group of volunteers. Inspired, we headed off to Kampala to meet with Dr Ian Clarke, of the International Hospital Kampala (IHK), who agreed to support us to begin a community health project in Bufuula, training and employing Ugandans selected by their own communities to become grassroots health workers in areas where hospitals are out of reach. The project began in Bufuula and surrounding villages, and this year will reach as far afield as the war-torn areas of northern Uganda. Over 50 Ugandans have been trained as health workers by a public health specialist. Subsidised mosquito nets have been distributed, water sanitation satchels have been added to jerry cans, and HIV testing has been made available, along with education sessions on all relevant diseases, by these health workers who are proud and honoured to be trained as such. They see their new knowledge as such a privilege that they feel a responsibility to spread it to as many towns as possible. That summer was the beginning of years of achievements for Hands of Help. Seventeen volunteers, to whom I — and Africa — are forever indebted for believing in me and my ideas, left that initial project enlightened and inspired to be part of improving the inexcusable health inequalities facing so many in our world today. On the way home, our chance trip to an orphanage with unparalleled atrocious living conditions resulted in a commitment to help 250 orphans in Nairobi, Kenya. These orphans are now being given a chance at life, receiving a secondary school education through our child sponsorship program. Yet, also conscious of the issues in our own backyard, we returned to Australia and established a project to allow medical students to work with local Aboriginal medical services in remote Indigenous communities. And so I approach the final year of medical school, with years of hard work, sleepless nights and exhaustion from overwork behind me — and that’s before internship has even begun! It would be unrealistic, and lying, to say it has been easy, and I often look longingly at those enjoying a weekend off or a holiday. Yet, thanks to the hard work of dedicated committee members, a balanced partnership with medical student and Vice-President Joe Dusseldorp, who believed in Hands of Help from its inception, an extremely supportive family and partner, and the generosity of the Australian public, the charity has achieved more than I could ever have hoped for in that moment my plane took off from Nairobi. Over 100 volunteers have now given up their summers to build three new primary schools in Uganda, 50 Ugandans have been trained as community health workers, 250 Kenyan orphans have been given another chance at life, and a further 25 medical students have spent their holidays experiencing health care for Indigenous Australians. Meanwhile, awareness of African issues, and a chance for Africans to speak with their own voice, is provided by our Sydney African Film Festival1 and photographic exhibitions every year by a professional photographer (my partner, Hamish Gregory, who travels the globe with me). This summer, a further 30 volunteers will travel to the war-ravaged areas of northern Uganda to build a fourth school, while the Community Health Project will expand to service the two million people displaced by years of civil war in Gulu. Conducting hut-to-hut health surveys with local interpreters in Uganda. As I approach the coming years of my junior medical and specialty training with trepidation and curiosity as to where the path of medicine will take me, I find solace and inspiration from the thought that dozens of medical students now have a passion for our world’s health inequalities. I am continuously supported and encouraged by my parents and motivated by the work of doctors such as Catherine Hamlin, whose work with women with obstetric fistulas in Ethiopia has turned around the lives of 32 000 women, and Rowan Gillies, the former President of Médecins Sans Frontières. I am encouraged by supportive lecturers and honours supervisors, and always astounded by the passion of selfless doctors who take the time to pass on the secrets of medicine by teaching and motivating young students every day. But without a doubt, the thoughts that stay closest to my heart are the memories of an African child’s piercing stare delving deep into my soul, and the throbbing pain of that meningitic headache — and I pinch myself and remember how lucky I am to be here, where I am today, and I think of how much there is to squeeze into these short years — and how wonderful it is to be alive.

Phoebe C M Williams BComm, BSc

Doctors and paintings. Insights and replenishment for health professionals. John Middleton, Erica Middleton. Oxford: Radcliffe Publishing, 2006 (x + 102 pp). ISBN 978 1 84619 052 0. I wanted to like this book. The idea of a husband British GP educator and wife artist/art historian coauthoring a book about the interface of painting and medicine intrigued me. The structure is also quite novel. It follows four fictional general practitioners starting up a group learning course about painting and medicine, listening in on their discussions in a play-like format. Superimposed on this are two more layers, the first being two other characters walking through an art museum, listening in on and commenting on the group of doctors. Secondly, there is a non-fictional analysis of various famous artists and their works, as well as the art-in-medicine movement. Strangely, the artist co-author includes her own works in the book for analysis, putting herself up against some of the most famous artists in history. All of this in a book under 100 pages long! It did come across as confusing to me; on many occasions, I found myself unaware of who was talking (author or character) or whether I was reading fiction or non-fiction. That said, both authors seem knowledgeable in their respective fields. Analysis of communication techniques, of empathy and listening, and of “patient-centredness” are well discussed and referenced. Philosophical points on the role of the doctor, of death and dying, and even faith suffuse both the fictional and non-fictional sections. Artists as diverse as traditionalists like Rembrandt and Rubens through to modern artists such as Francis Bacon and Mark Rothko are analysed both in terms of how their lives and personalities helped shape their works and in how their philosophy and its expression can influence us as doctors viewing their works. Rather than being printed in the book, the works discussed have web addresses for viewing (except for the coauthor’s work!), I suspect to reduce cost. While interesting in parts, Doctors and paintings may be trying to be too many things. Nevertheless, those with a passion for painting and/or medical philosophy might find it worth a read.

James A Best

Basic health care is often out of reach for millions of Australians still living in poverty Poverty and ill health are frequent companions. This is relatively easy to establish in poor societies where the living standards of people are so low that the problems of ill health “can be laid fairly directly at the door of poverty”.1 However, the evidence linking low income to poor health is also accumulating in wealthy nations, including Australia.2 This is literally a matter of life and death. In Australia in 2001, a boy born in one of our most disadvantaged regions could expect to live 3.6 years less than a boy born in an area of least disadvantage, while a girl could expect to live 2.4 years less.2 The gap in average life expectancy between Indigenous and non-Indigenous men is 18 years.2 This situation is compounded by the fact that basic health services are often beyond the reach of the poorest Australians, especially when major out-of-pocket costs apply. For example, the Australian Council of Social Service (ACOSS) estimates that 40% of Australian adults do not have access to a comprehensive oral health check or a course of basic dental treatment every 2 years. There are more than 500 000 people on waiting lists for public dental care.3 A recent Senate Committee report argued that the “link between health and socioeconomic status has been clearly shown in studies both in Australia and overseas” and recommended that providing people in poverty with broad access to health care services is an essential component of the fight against poverty.4 The importance of these issues has been obscured by disagreement over how to measure poverty. However, although measurement problems are universal, this has not stopped other countries, with active government support and involvement, from measuring poverty, seeking new and better indicators, and setting poverty reduction targets. For this to happen in Australia, we need to reignite a public conversation about the role of poverty reduction in the pursuit of social justice more generally. The focus needs to move beyond the achievement of higher average incomes to look at how that increased prosperity is (and should be) distributed, including to those below the poverty line. It seems that poverty has fallen off the agenda in Australia through fear that acknowledging it exists will result in pressure to do something about it, and will raise questions about the wisdom of policies that pay inadequate attention to distributional issues. This calls for a better understanding of the extent of poverty in Australia and who it affects. A report recently published by Australia Fair (http://www.australiafair.org.au),5 an alliance of organisations promoting action to improve fairness in Australia, contained a range of international comparisons of wellbeing and attracted wide media coverage. The report featured new research from the Social Policy Research Centre (SPRC) at the University of New South Wales, which indicates that the war on poverty has by no means been won; almost two million Australians live in households with income below the most austere poverty line commonly used in international poverty research.6 The proportion of Australians living below this poverty line has also risen sharply over the past decade or so — a period of strong growth in the economy and employment. The lowest poverty line used in the SPRC study, which is also used by the Organisation for Economic Co-operation and Development (OECD), was set at 50 per cent of the median disposable income of all Australian households, after adjusting for differences in household size and composition. Many countries use poverty lines set higher (at 60 per cent of median income), but none use a relative benchmark set at a lower percentage of median income, so it is hard to argue that the line is too high. In the 2003–04 financial year, the 50 per cent of median income poverty line was equivalent to $249 per week for a single adult, $373 for a couple, and $522 for a couple with two children. These incomes are required to meet all household needs: food, housing, clothing, transportation, schooling, household bills, and so on. Poverty lines are widely used in Australia and overseas as indicators of the risk of financial hardship. Although low incomes tell only part of the story of deprivation and social exclusion, it is an important part. Research underway at SPRC, in collaboration with ACOSS, Mission Australia, the Brotherhood of St Laurence, and Anglicare, indicates that people living below poverty lines have a significantly greater risk of missing out on the “essentials of life”, such as access to medical treatment, warm clothes, and a substantial meal at least once a day,7 and of experiencing exclusion from effective participation in the labour market, community services and social networks. Using the 50 per cent of median income measure, the SPRC study indicates that in 2004, 1.935 million people, or 9.9% of all Australians, including 365 000 children, were living below the poverty line. If the higher (60 per cent of median income) poverty line is used, the number of people in poverty increases sharply to 3.859 million, or 19.8% of the population. Using this measure, 786 000 children — a fifth of all Australian children — were living in households below the poverty line. Consistent with previous poverty studies, the new estimates show that the risk of poverty is much higher among certain groups. For example, the Australians living below the 50 per cent of median income poverty line include: 40.2% of all unemployed people; 39.0% of single adults over 65 years of age; 31.5% of all people whose income derives mainly from social security; 22.8% of single adults of workforce age; and 11.4% of sole-parent families. Examining trends in poverty over time using the two poverty lines, the SPRC research found that poverty in Australia increased significantly over the decade to 2004: from 7.6% to 9.9%, using the 50 per cent of median income poverty line; and from 17.1% to 19.8%, using the 60 per cent of median income poverty line. It is notable that, in proportionate terms, the increase in poverty is significantly greater using the lower poverty line: an increase of 32% compared with less than 16%. Thus, the lower poverty line makes the situation appear better at the end of the period, but shows less improvement during the period. Australian and international research indicates that the correlates of poverty include unemployment and joblessness, the adequacy of income support, and the incidence of low pay. Strong employment growth over the past decade should have made it possible to stop poverty from rising in Australia, but it has not reduced it (at least by 2004). The concentration of joblessness within disadvantaged families and communities, and slower growth in income support payments and low pay compared with average incomes are factors behind the increase in poverty during this period. To convert strong economic growth into reductions in poverty, a determined effort is needed to improve the skills and capacities of jobless people and increase income support and wages of the most vulnerable. These are among the reasons why the British Government has succeeded in reducing poverty among children over the past decade.8 But economic growth by itself will not automatically reduce poverty, although it does generate the resources required to tackle the problem. Combating the cycle of poverty and putting an end to deprivation and social exclusion also requires taking a broader view of living standards than simply income alone; investment in low-cost housing; early child education and care; and sustained, whole-of-government strategies to renew the most deeply disadvantaged communities. Achieving improved health outcomes becomes more difficult when poverty is high — and rising — because inadequate resources lead to deprivation and low subjective wellbeing, both of which have adverse health effects. It is for this reason that the health care sector should be concerned about Australia’s lack of progress in addressing poverty. Tackling poverty will improve social justice and lay the foundation for our future health and prosperity.

Peter Saunders · Peter Davidson BSocWk

Objective: To determine the risk of suicide and drug overdose death among recently released prisoners.Design, setting and participants: Retrospective cohort study of 85 203 adult offenders who had spent some time in full-time custody in prisons in New South Wales between 1 January 1988 and 31 December 2002.Main outcome measures: Association between time after release and risk of suicide and overdose death.Results: Of 844 suicides (795 men, 49 women), 724 (86%) occurred after release. Men had a higher rate of suicide than women both in prison (129 v 56 per 100 000 person-years) and after release (135 v 82 per 100 000 person-years). The suicide rate in men in the 2 weeks after release was 3.87 (95% CI, 2.26–6.65) times higher than the rate after 6 months. Male prisoners admitted to the prison psychiatric hospital had a threefold higher risk than non-admitted men both in prison and after release. No suicides among women were observed in the 2 weeks after release. No increased risk of suicide was observed among Aboriginal Australians in the first 2 weeks after release. Of 1674 deaths due to overdose, 1627 (97%) occurred after release. Drug-related mortality in men was 9.30 (95% CI, 7.80–11.10) times higher, and in women was 6.42 (95% CI, 3.88–10.62) times higher, in the 2 weeks after release than after 6 months.Conclusions: Prisoners are at a heightened risk of suicide and overdose death in the immediate post-release period. After 6 months post-release, the suicide rate approaches the rate observed in custody.

Azar Kariminia MSc · Matthew G Law PhD · Tony G Butler PhD · Michael H Levy MD · Simon P Corben MSc · John M Kaldor PhD · Luke Grant MSc

Objectives: To determine (i) the relationship between asthma management and socioeconomic status; (ii) whether recent estimates from the International Study of Asthma and Allergies in Childhood (ISAAC) conducted in Melbourne apply to a broader cross-section of Victorian children; and (iii) age-related trends in asthma prevalence.Design: A questionnaire survey, based on the ISAAC protocol.Participants and setting: Subjects were children aged 4–13 years from a random sample of primary schools in the Barwon region of Victoria. The survey was conducted between March and September 2005.Main outcome measures: Parent-reported wheeze and wheeze-related use of health resources during the preceding 12 months.Results: Questionnaires were returned by 7813/9258 students (84%). Lower socioeconomic status was associated with increased frequency of regular asthma reviews (P < 0.01 for trend), but not of emergency department visits (P = 0.19). The prevalence of wheeze among 6- and 7-year-old children in the Barwon region was similar to that in Melbourne children (20.2% v 20.0%, respectively).There was an age-related increase in the proportion of children with ≥ 12 episodes of wheeze (P = 0.01); but an age-related decrease in emergency department visits (P = 0.02).Conclusions: Disadvantaged children have good access to regular asthma reviews and are no more likely to attend an emergency department with an episode of acute wheeze. Asthma prevalence in 6- and 7-year-old children in the Barwon region is similar to that in Melbourne. The prevalence of children with very frequent wheeze increases with age, but their use of health resources decreases.

Peter J Vuillermin FRACP · Mike South MD · John B Carlin PhD · Maree I Biscan Mstrs · Sharon L Brennan Mstrs · Colin F Robertson MD

Search for Oz Richard Bronson. New York: Padishah Press, 2006 (102 pp). ISBN 0 9776405 2 3 A 12-year-old girl is playing the violin. The poet asks if she hears the tunes in her head. “No”, she replies, “My fingers know the way, and I follow them”. It’s a measure of how much meaning Richard Bronson’s poems can sustain that this glorious, insouciant piece of “found poetry” (the girl presumably said just this) reads as a brief image of the link between body and mind, the physical and the inspirational. Bronson is an endocrinologist, and this is his first collection of poetry. Some of his work draws directly and successfully on his medical experiences, but most does not. There is a cool intelligence and compassion throughout which one can think of as exemplifying the ideal doctor, but little which fits easily with lazier notions of “medical humanities”. Rather, the driving force is an awareness of cultural heritage. Music and literature are everywhere. The girl, the poet, his late father are all musical, and we learn that Bronson’s library includes Rilke’s magnificent (and fiercely difficult) Duino Elegies and the like. Indeed, two poems are addressed to Hypatia, murdered by Christian fanatics in 5th century Alexandria and one of the first women of learning whose name we know. The destruction of a civilisation which this event symbolises is at the heart of some bleak meditations for a post 9/11 world: The world has come to this no heat, no water, no food, but boxes of books in my basement. The half-dozen love poems with which the volume concludes are serious but occasionally awkward (“a chamber of rules/ where carnal love reigned”), and there are a couple of pieces of whimsy; but Bronson at his best is very much worth reading. (A video log of Bronson reading four of his poems — rather well — is at http://www.poetryvlog.com/rbronson.html, and one of Bronson’s poems was published in the 2 July issue of the Journal [Med J Aust 2007; 187: 46].)

John R Skelton

Australian prisons have been identified as a focus of the ongoing hepatitis C epidemic. Harm minimisation is the major strategy directed to community-based public health measures to control hepatitis C. Harm-minimisation strategies to protect inmates and workers are incompletely and inconsistently applied in Australian prisons. Overseas experience has demonstrated that introducing injecting-equipment exchange programs and professional tattoo parlours in prisons could at least partially reduce the risks of ongoing hepatitis C transmission, and would support prevention and treatment programs. A two-stage approach is suggested: firstly, implementing programs of proven effectiveness consistently across the eight Australian jurisdictions, and, secondly, expanding current initiatives in the light of international “best practice”.

Michael H Levy MB BS, MPH, FAFPHM · Carla Treloar BSc(Hons), PhD · Rodney M McDonald BAppSc · Norman Booker GradDipAdultEd