Social determinants of health

Individual values sometimes lead patients to make lifestyle choices that have negative effects on their health. Doctors tend to feel responsible for delivering best-practice health outcomes to such patients, but also feel inclined to respect their patients’ values. The adoption of a harm reduction model may provide a strategy for delivering the best care that is compatible with each patient’s chosen lifestyle.

Bradleigh D Hayhow BA(Hons), BM BS · Michael Peter Lowe BMed, FRACP

Katina Kardamanidis,* Bruce Armstrong† * Research Fellow, Injury Prevention and Trauma Care, The George Institute for International Health, PO Box M201, Camperdown, NSW 2050; † Head, School of Public Health, University of Sydney, NSW. kkardATdoh.health.nsw.gov.au To the Editor: Not all asylum seekers in Australia are confined to detention centres. Those who arrive with a valid visa live in the community. If they apply for refugee status within 45 days of arrival, they are entitled to work and to Medicare while their refugee claims are processed;1 if they apply too late, they are denied these benefits. In New South Wales in 2003 about 1500 men, women and children were in this situation, which may last from 3 months to 3 years. Asylum seekers who appeal a refusal of their application, or are released from mandatory detention with an application outstanding, are in the same situation.2 Some are eligible for the federally funded Red Cross Asylum Seeker Assistance Scheme, but, for most, access to health care is jeopardised because they are unable to pay full fees for medical services.3,4 We asked health professionals working with asylum seekers about the costs of asylum seekers’ difficulties in accessing health care. Their responses, with illustrative quotes, are divided into “tangible costs” and “intangible costs” (Box). Some individuals and institutions sympathetic to the plight of asylum seekers give their professional time or donate money to pay for health care, but are not able to address the full range of health care needs. Obtaining access to secondary care, particularly admission to hospital, is very difficult. There is no uniform approach to charges, either between hospitals or within any one hospital on different occasions. The approach seems to depend on the decision-maker present. Such difficulties in accessing care may lead to uncomplicated health problems developing into chronic and more serious ones. The attempt to save costs is likely to lead to higher costs in the future. The effect on asylum seekers is increased physical, psychological and social disadvantage and diminished opportunities for a healthy life. Health professionals are faced with the dilemma of turning these people away, or aiding them without financial compensation. In either case, they cannot provide the necessary standard of care. Although many Australians are conscious of the hardship of these people, the society as a whole seems unaware of it or of the impact that its unfairness may have on the social fabric of their communities. If all Medicare-ineligible asylum seekers in NSW were to have the same access to health services as other Australians, we estimate that the total annual cost would be about $3.4 million.5 This is about 0.015% of the total annual recurrent health expenditure in NSW in 2000–01.6 This economic cost, some if not most of which will be spent regardless, does not justify the disadvantage created by the Australian Government’s immigration rules. We suggest that state governments consider giving this small group of asylum seekers free access to public hospital services. Costs of asylum seekers’ difficulties accessing health care and who bears the costs: responses of health professionals working with asylum seekers Theme Illustrative quote Tangible costs Insufficient voluntary aid to address all health needs “We have one patient . . . with a urinary infection, and it was decided that . . . he needed a TURP [transurethral resection of the prostate], and then they realised he didn’t have any funds and they discharged him . . .” Inconsistent attitudes of hospitals “There’s quite a difference between different hospitals. For example, the X hospital at Y is very tough. . . . much tougher than the hospital here, on refugees. . . . They are different Area Health Services . . . it may not even be the Area Health Service directors, but the hospital manager’s idea that these people should pay.” More costs in the long term “I have a lot of patients with diabetes and high blood pressure . . . Now if their diabetes or their blood pressure or their cholesterol is not managed properly, then they get heart disease or strokes. So, I have a patient who has had a stroke . . . high blood pressure and so on . . . if he had [had] better access to health care, would he have had the stroke? . . . So [now], the government has had to pay . . . it doesn’t make any sense really.” Intangible costs To the asylum seeker (recounted by a health professional) “If you say to someone, I really think you need to have this test, but, if I refer you, you have to pay a lot of money, so I’m not going to refer you, how does that make you feel? It makes you feel worried and powerless.” To health professionals “. . . if someone came in complaining about it [diarrhoea, losing weight], you would do a whole lot of checks, and with that particular lady . . . we were able to negotiate to get a couple of tests done free, and the family and she paid a certain amount of money to get some others [done] . . . if the person had Medicare, you’d take it that step further and do extra just to be 101% sure. So, there is that real ethical dilemma . . .” To the Australian society “. . . if people actually knew on a face-to-face level . . . what it meant to deny a newborn baby the right to health care, [or] . . . turn away someone who is extremely depressed . . . [Would they] actually be able to say ‘No, they don’t [have a right to health care]’.”

Katina Kardamanidis · Bruce Armstrong

The last well person. How to stay well despite the health-care system. Nortin M Hadler. Montreal: McGill-Queen’s University Press, 2004 (viii + 313 pp) ISBN 0 7735 2795 8. Somewhat paradoxically, reading this book left me disturbed and critical, despite my wholehearted agreement with most of the imperatives presented in this critical analysis of modern medical practice. The basic message is accurate and important: too many with minor ailments who enter the health care system are convicted of being ill when in fact they are healthy. Well people, Hadler suggests, are those individuals yet to be investigated by a doctor! The health care system is, he argues, poorly evidence-based in far too many areas. Over-diagnosis and the reflexive resort to the prescription pad, rather than reassuring dialogue, is endemic. There is much truth in this of course, but he “doth protest too much, methinks”. For example, Hadler’s views on modern cardiological practices fail to avoid the bias and selective reporting of data he so strongly criticises in others. Individuals with suspected angina are advised to enter into a contract with their doctor that will exclude both angiography and bypass surgery as diagnostic or therapeutic options. In warning patients that much of what a doctor recommends may be of questionable benefit, he fails to educate the lay reader of the possible advantages of early diagnosis and intervention in a person who indeed still feels “well”. Hadler tells us that the book is written for those who are well but nonetheless tempted to stray into a doctor’s office from which they will undoubtedly emerge medicalised. In fact, the contented well are unlikely to pick up this volume while the worried well are unlikely to be persuaded that their concerns are baseless. No, this book is one for students and practitioners of clinical medicine. It is laudably academic in discussing most of the topics covered, with an extensive bibliography and no less than 56 pages of annotated critiques of the studies that, when analysed accurately, support the author’s contentions. Being challenged to re-analyse investigative and therapeutic approaches that are entrenched but by no means evidence-based is, of course, no bad thing, nor hardly revolutionary. Hadler’s challenge to improve statistical analysis to provide outcomes that are undoubtedly clinically relevant is welcomed. Meta-analyses and the Cochrane library have not served our patients well, he argues, wanting us to better define real rather than relative risk. A rheumatologist, Hadler is perhaps at his best when discussing the myriad dubious approaches to the management of musculoskeletal discomfort, turning many patients into invalids entangled in a nightmare of medico-legal wrangling. Such patients, he argues, will receive more help from their therapist than their pharmacist. It is modern medicine’s emphasis on investigations and pharmacy that is driving many patients, who want to ventilate their problems, into the offices of unscientific “alternative” practitioners. Hadler is on shakier ground when he argues that most of us have genes that program us to live for 85 years (plus or minus a few), and will do just that whether or not we treat high cholesterol or moderate hypertension. He doubts the ability of human strategies to have us live longer (a brave assumption given the remarkable increases in longevity achieved even in the post-antibiotic era), and opines that we have made too much of the obesity epidemic in modern societies. He argues that our approach to the diagnosis and management of prostate cancer is often too aggressive, but fails to call for better decision-making that may well save the lives of many who currently die in much discomfort from this malignancy. I’m glad I read this book and have no hesitation in recommending it. We have a long journey ahead of us before we consistently avoid the pitfalls forthrightly identified by Hadler. Doing so will give us our best chance of having many more people remain chronically well because of rather than despite the health care system. John M DwyerEmeritus Professor of Medicine, Sydney, NSW

John M Dwyer

When a prominent Australian politician, the then Premier of Tasmania, The Honourable Jim Bacon, publicly announced in February 2004 that he had lung cancer, he was inundated with well-wishing communications sent by post, email and other means. They included 157 items of correspondence recommending a wide variety of complementary and alternative medicines (CAMs). The most common CAMs recommended were meditation, Chinese medicine, “glyconutrients”, juices, Laetrile and various diets and dietary supplements. Although proof of benefit exists or promising preliminary laboratory studies have been carried out for a small number of the recommendations, no scientific evaluation has been performed for most of these treatments. Their potential benefits and harms are not known. Several recommendations were for treatments known to be useless, harmful or fraudulent. Bacon’s experience suggests that cancer patients may receive unsolicited advice to adopt one or more forms of CAM. Both patients and practitioners need access to authoritative evidence-based information about the benefits and dangers of CAMs.

Ray M Lowenthal MD, FRCP, FRACP

Religious or spiritual values often influence health care decision-making by patients and their families, particularly in times of crisis. Though religious values might seem to be irrelevant where continuing treatment is judged to be “futile”, such clinical assessments should instead serve to open a dialogue about values and beliefs. The six major religious traditions in Australia have some similar values and principles about death and provision of care for the dying, but differ in their processes of ethical reasoning, cosmologies, and key moral concepts. Engaging with religious traditions on the common ground of basic values (such as human dignity, care, the sacredness of human life, non-violence, compassion, and selflessness) promotes negotiation of the manner in which care is provided, even where conflicts exist.

Rachel A Ankeny PhD · Christopher F C Jordens PhD · Ian H Kerridge MPhil, FRACP, FRCPA · Ross Clifford MA, MTh · Rod Benson BMin(Theol), MA

The challenge for health authorities is to implement effective preventive strategies and a zero-tolerance policy Although in Australia the risk of death or serious physical injury from a violent workplace incident is quite remote, each year about one Australian health worker is murdered at work1 and large numbers are either verbally abused, bullied or assaulted.2 Claire Mayhew and Duncan Chappell have been involved with research and public policy development related to workplace violence for over a decade. They both worked at the Australian Institute of Criminology (Canberra); they were involved in the NSW Health “Taskforce on prevention and management of violence in the health workforce”; they conducted the most extensive study on violence in the health industry in Australia to date and have collaborated in the development of publications for the International Labour Office in Geneva. Workplace violence has been defined in various ways, and behaviours ranging from verbal abuse and threats to sexual harassment, physical assaults and homicide may be included. The precise definition adopted will affect incidence and severity rates of workplace violence. An inclusive definition developed specifically for the health sector is: Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health.3 There are two core risk factors for violence in any workplace: face-to-face contact with clients or customers; and cash or high-value goods on site which may attract perpetrators of instrumental violence.4 Marked variations in risk exist between different occupational groups, reflecting the relative presence or absence of these two core risk factors.5 These patterns generally hold across different countries so that high-risk jobs in one country tend to also be high-risk jobs in others. For example, throughout the industrialised world there is a very high rate of homicide of taxi drivers, who also experience high levels of verbal abuse and assault. Conversely, white collar workers, with little face-to-face contact with members of the public, generally have very low incidence and severity rate. Fast-food outlet workers tend to experience high levels of verbal abuse but homicide is rare (apart from those located in suburbs with a high risk of hold-ups). Other occupational groups have diverse experiences essentially determined by levels of exposure to known risk factors. In health care settings, one of the two core risk factors — face-to-face contact with patients and visitors — is particularly common. The Box gives workplace verbal abuse, bullying and assault rates for various Australian industry sectors. These estimates were collated after separate face-to-face surveys conducted with representative samples of employees. In each case, interviewees were requested to state precisely what, if any, form of workplace violence they had experienced over the previous 12-month period. While space prohibits an exposé of these different studies here, it is clear that health care ranks fairly highly compared with many of the groups.6 Almost all the cited “bullying” events were from one staff member to another (Box). A similar pattern of variable risk across industry sectors and occupational groups is also evident in Britain.4 In 2001–02, representatives from the International Labour Office, International Council of Nurses, World Health Organization and Public Services International initiated an international collaborative program to develop policies and approaches to prevent and eliminate violence in the health sector. Outcomes included: a series of country-specific research studies (Brazil, Bulgaria, Lebanon, Portugal, South Africa, and Thailand and a linked Australian study; see <http://www.icn.ch/sewworkplace.htm>); a Synthesis report of the commissioned country reports;3 and finally the drafting of Framework guidelines for addressing workplace violence in the health sector.7 Across the various country-specific research studies, more than 50% of health workers reported experiencing one or other form of workplace violence in the previous 12 months; ambulance officers were at greatest risk, followed by nurses. The linked Australian health study involved face-to-face interviews with a representative sample of 400 public health employees, including medical officers, nurses, allied health, ancillary and ambulance workers.2,6 About two-thirds (67%) of all interviewees said they had been verbally abused in the previous 12-month period, 10.5% had been bullied, and 12% assaulted, rarely resulting in physical injury. As in other countries, incidence rates varied between and within health occupations, with ambulance officers most at risk, followed by nurses. Among medical officers interviewed, 62% had been verbally abused, 15% bullied and 17% assaulted over this period. The perpetrators of verbal abuse and assaults were predominantly clients and visitors, however, other staff members were responsible for almost all bullying events. Nevertheless, only a small proportion (between 8% and 10%) of these events had been formally reported — providing health authorities with limited evidence on which to base preventive planning. Similar incidence rates have been reported in general medical practice,8 including the study by Magin et al in this issue of the Journal (page 352).9 Comprehensive workplace violence prevention strategies have been developed and are available.4,10-12 However, in our experience, there is a tendency among health workers to favour preventive strategies that have only been trialled at other health sites. We would encourage health workers to consider the full range of prevention strategies, many of which have been well documented and evaluated in other industry sectors — including, in particular, those published in the scientific literature for criminology and occupational health and safety (OHS). All workplace violence prevention strategies — regardless of the setting, health care or otherwise — should be multifaceted and organisation-wide, and involve widespread consultation with all workers (including casuals and those off-site) in their development and implementation. In health care settings, this may involve nursing agencies, ambulance officers, and workers in the community and remote locations. In the OHS “hierarchy of control” approach to violence, designing out risk is the preferred action in all workplace environments, and should include health care settings such as hospitals, clinics, general practices, and ambulances and other vehicles. For example, to remove or minimise risk, careful attention can be paid to the design of buildings (eg, placement of windows) and their fittings (eg, counter height and width, and choosing chairs for waiting areas that cannot be easily lifted and thrown).2,10,13 The least preferred action is sole reliance on staff training, as the causes of workplace violence are multifactorial and hence simplistic solutions are unlikely to be effective in prevention. Chief executive officers (CEOs) should demonstrate commitment to zero tolerance of workplace violence. They should encourage cultural change and show enhanced concern for workers’ safety. Strong encouragement should be given to formal reporting of workplace violence, including the removal of covert penalties and the excessive filling in of forms. Regular violence vulnerability audits should be conducted by independent OHS professionals. The files of serial perpetrator patients should be “flagged” to forewarn other staff (the best predictor of violence is past aggression), and, ultimately, such patients should be sanctioned, which, although difficult, is an essential component of a comprehensive workplace violence prevention strategy.14 Particularly in the UK National Health Service, the sanctioning of perpetrators of violence has become increasingly common; however, the deterrent reach of penalties can be limited by the lack of capacity of certain patients to control their behaviour, including those suffering from mental illness and dementia. Under the OHS legislative framework in each Australian state and territory, primary responsibility rests with employers and CEOs to provide a safe place and a safe process of work for their employees, including those who work off-site. OHS obligations are not diminished by the rights of patients to confidentiality or to treatment. Employers (including public health departments) and CEOs may be prosecuted for a breach of this “duty of care” with respect to their employees, as well as being liable under common law.15 The core challenges for health authorities will be to: implement a zero-tolerance policy with effective prevention strategies encompassing all health occupational groups, and especially those working off-site and in general medical practice; adopt preventive strategies which have been successful in other industry sectors; and develop and implement a deterrent sanctioning policy for perpetrators. The group of articles in this issue of the Journal will further assist the health industry to recognise the potential benefits from involvement with the Australian Patient Safety Foundation (APSF) database (Benveniste et al, page 348);16 identify verbal cues of imminent overt aggression in mental health settings (Forster et al, page 357);17 understand possible causes of under-reporting of violence against emergency department staff (Kennedy, page 362),18 and to also recognise the particular vulnerabilities faced by those working in general medical practice.9 Workplace violence experiences of 1362 workers over a 12-month period (% of respondents) in Australia6 Workplace Verbal abuse Bullying Physical assault Juvenile justice 68% 12% 17% Tertiary education 50% 65% 1% Health care 67% 10.5% 12% Seafaring 19% — 1% Long-haul transport 33% — 1% Fast-food 48% — 1% Taxis 81% — 10%

Claire Mayhew BAdmin(Hons), PhD · Duncan Chappell LLB, PhD

Medical termination of pregnancy with mifepristone, a progesterone antagonist, is available to women in North America, the United Kingdom, much of Western Europe, Russia, China, Israel, New Zealand, Turkey and Tunisia, but not Australia. Experience of mifepristone use in around two million abortions has shown that it is safe, effective, cheap to produce, and highly acceptable to women. Mifepristone is usually used in combination with a prostaglandin analogue, such as misoprostol; these drugs have been added to the World Health Organization’s list of essential medicines for developing countries. Availability of this drug in Australia might largely overcome many of the inequities of access to abortion, and is critical for many women in rural areas and women in some ethnic groups whose access to surgical abortion is limited.

Caroline M De Costa FRANZCOG, FRCOG

As Indigenous Australians, our health lags behind that of indigenous groups in other settler colonial nations such as the United States, Canada and New Zealand.1 Similarly, we are far behind these nations in relation to Indigenous participation in the health workforce and the professions generally. A compelling illustration of this is the fact that the first indigenous doctors in North America and New Zealand graduated in 1889 and 1899, respectively, while the first Indigenous doctor in Australia graduated almost a century later, in 1984.2,3 It is undeniable that our poor health and our low participation in the health workforce are related. Increasing recognition of this has led to a situation in which there are now over 80 qualified Indigenous doctors and almost 100 Indigenous medical students in Australia.4 This achievement has only been possible because we live in the era of “self-determination” that was born, as was I, during the 1970s. I am a multiracial Australian, with Aboriginal, Anglo and Asian ancestry. Because my grandmother (being my only Indigenous ancestor) was a member of the “stolen generations”, and because I am fair-skinned, I started life with an ambivalent Indigenous identity which has been profoundly shaped by the policies of affirmative action (or positive discrimination) that epitomise the era of self-determination. My first experiences with affirmative action occurred in high school, when I was showcased as a role model for other Indigenous students. I went on to gain a degree in science and start a career in health research through an Indigenous cadetship. Affirmative action also provided me with the financial means to complete a Master of Medical Statistics — the first Indigenous Australian to do so — and with preferential access to scholarships, which allowed me to complete a Master of Public Health and to undertake a PhD. In return for this assistance, I have spoken at Indigenous youth summits and school career days, tutored, taught, and donated prize money to Indigenous tertiary students, and conducted research and teaching in Indigenous health on topics of importance to Indigenous people (such as the health effects of racism).5 In addition, I have brought an “Indigenous” perspective to a range of committees, forums, round tables, community groups, conferences, colleagues and students. These experiences are in keeping with the goals of affirmative action, which are to create equality of opportunity and outcome for Indigenous Australians and, for the benefit of all Australians, to promote diversity through equitable representation of Indigenous people in society. Affirmative action is achieved, in practice, by assisting individual Indigenous people to become more “successful”. In addition, there is often an implicit assumption that the Indigenous recipients of affirmative action will themselves strive to reduce social inequities, promote opportunities for and enhance representation of Indigenous people, and act as role models. While medicine has made some progress towards these goals, and the role played by Aboriginal and Torres Strait Islander health workers has been crucial, other areas of health have not fared as well. There has been little government support for increasing the number of Indigenous nurses or allied health professionals,2 with the notable exception of the recent Puggy Hunter Memorial Scholarships.6 Health research is a particularly lonely field. I knew of no other Indigenous person studying at my institution in the same degree program as me. Also, milestones such as the first Indigenous doctor and the first Indigenous clinical psychologist to gain a PhD have only been achieved in the 21st century. Clearly, there is still considerable scope for applying affirmative action in health and other sectors in which Indigenous people continue to suffer from disadvantage. However, I believe there are complexities inherent in both the aims and practice of affirmative action that need to be considered in order to improve social outcomes for Indigenous Australians and allow our diversity to contribute to Australia’s future. In this essay, I will share with you what I have learnt about the benefits and pitfalls of affirmative action as an Indigenous health professional during the past decade. The most obvious difficulty faced by Indigenous people who are beneficiaries of affirmative action is the self-doubt stemming from accusations that we do not merit such support. Unfortunately, it appears that many Australians still think Indigenous people get “too many benefits”. In one survey, almost a third of participants believed that car loans are paid for us by the government, and almost two-thirds thought that we receive more social security benefits than non-Indigenous people.7 In another survey, more than half of respondents believed Indigenous people were “treated over generously by the government”.8 The hostility to affirmative action programs, which is compounded by these misconceptions, can only be reduced through education that explains the benefits of diversity and the need to remedy historical injustice.9 There is also an urgent and profound need to tackle systemic racism in Australia, which, in its most extreme form, led to the death of Private Damien Palmer. After entering the army through an affirmative action policy, he committed suicide following racist taunts and intense ridicule from fellow soldiers and instructors.10 Systemic racism is something that white Australians, as those who benefit most from the system of racial oppression, are in the best position to combat. Indigenous people, in contrast, face anguish and rapid “burnout” when leading the fight against this insidious form of racism. The intense doubt of our self-worth which some Indigenous people experience as a result of affirmative action can be reduced by ensuring that Indigenous people are only placed in positions and given training or learning opportunities for which they have the appropriate commitment, skills, abilities and qualifications. If we cannot do a job or don’t have the capacity to benefit from a program, this is no doubt due to a legacy of oppression and colonisation. However, this situation is not remedied by the tokenism being engaged in by far too many organisations around Australia. Not only are those caught up in tokenism unable to effectively advance the goals of affirmative action, but they are also being set up to fail or, worse, set up as ever more prominent “tokens”, whose increasing visibility as such severely hampers ongoing efforts to redress Indigenous disadvantage. It is clear that affirmative action, no matter which segment of the Indigenous population is targeted, is most helpful to those who are most advantaged to begin with.11 It is easiest, and perhaps most appropriate, for those who have the most capacity to benefit to take up whatever opportunities are on offer. However, there is still a tendency for both Indigenous and non-Indigenous people to assume that being Indigenous is synonymous with a certain “marginality or victimage”.12,13 This misconception can leave Indigenous recipients of affirmative action not only doubting their self-worth but also being seen as threatening “tall poppies”2 and having their Indigenous identity questioned. I have certainly been accused of taking positions that should have been given to “real blacks” who weren’t as acculturated to white society as me and/or who had darker skin. These issues need to be brought into the open, so that Indigenous people who are beneficiaries of affirmative action can share these difficult experiences and learn from each other about effective coping strategies. In implementing affirmative action policies, we need to stop simply seeing “Indigenous people” as a single entity and instead see individuals with multiple personal and professional identities, including Indigeneity. We need to believe in and respect Indigenous people as individuals who have their own goals, principles, flaws and foibles and who may or may not be interested in, capable of, or suitable for a specific affirmative action policy or program. Despite what is often assumed, some Indigenous people — just like some non-Indigenous people — are not effective role models or interested in working towards emancipatory goals. Therefore, it is vital to consider, in every case, whether, and to what degree, affirmative action is aimed at helping an individual become more successful, at increasing diversity, or at aiding recipients who will then contribute to the goals of affirmative action themselves. These questions need to be addressed by all Australians and will require us to grapple with the historical baggage that accompanies the stereotyped Indigenous identity we have inherited as a nation.14 All of us need to truly come to terms with the diversity of Indigenous people in Australia, rather than just paying lip service to this notion. To do this, non-Indigenous Australians must overcome their reluctance to engage in debate about Indigenous affairs,15 and Indigenous Australians must stop acting as if dissenting views are nothing more than simplistic attacks on Indigenous people.2 If there is one thing that most people agree on, it is that there is no simple solution to the complex problems in Indigenous health.2 In relation to our history as a nation, the struggle to improve the lives of Indigenous people in Australia has only just begun and has a long way to go before equity is achieved. In the field of Indigenous health research, in which I work (and, I suggest, in many other fields), we require a greater clarity of purpose and increased patience in relation to affirmative action if we are to avoid jeopardising our efforts at improving the plight of Indigenous people. Not all health research can involve Indigenous researchers, because those with sufficient training and experience are few and far between. We are not well served by setting up Indigenous people as “researchers” when they are not, or by prioritising affirmative action to such an extent that the very research we do is compromised. Let us hope that the spectacular rise in the number of Indigenous doctors continues until equity in medicine is reached and that we can match this achievement in Indigenous health research. In working towards these goals we need to recognise that the era of self-determination, like those before it, won’t last forever. What could perhaps be called the “partnership era” may already be replacing it, as exemplified by policy approaches such as shared responsibility agreements.16 The role of affirmative action in this new era is not assured and will only be maintained by addressing the difficult issues now, so that Australia may one day become an inclusive nation where, as Indigenous people, we can maintain our unique identity while playing a full role in society and enjoying the same level of health as other Australians.

Yin C Paradies BSc, MMedStats, MPH

Objective: To compare trends and rates of HIV and sexually transmitted infections in Indigenous and non-Indigenous people of Western Australia.Design and setting: Analysis of WA notification data for chlamydia, gonorrhoea, and primary and secondary syphilis in 2002, and for HIV infections from 1983 to 2002.Main outcome measures: Rates of HIV and sexually transmitted infection by Indigenous status.Results: In 2002, there were 3046 notifications for chlamydia, 1380 for gonorrhoea and 64 for syphilis. When information on Indigenous status was available, Indigenous people accounted for 41% of chlamydia and 76% of gonorrhoea notifications, with Indigenous : non-Indigenous age-standardised rate ratios of 16 (95% CI, 14–17) and 77 (95% CI, 67–88), respectively. Indigenous people accounted for 90.6% of syphilis notifications (age-standardised Indigenous : non-Indigenous rate ratio, 242 [95% CI, 104–561]). From 1985 to 2002, HIV notification rates for non-Indigenous people in WA declined and rates for Indigenous people increased. From 1994 to 2002, there were 421 notifications of HIV infection in WA residents, 52 (12.4%) in Indigenous people and 369 (87.6%) in non-Indigenous people. Indigenous people accounted for 39% and 6.2% of all notifications in WA females and males, respectively. The Indigenous : non-Indigenous rate ratios were 18 (95% CI, 12–29) for females and 2 (95% CI, 1–3) for males.Conclusions: Indigenous Western Australians are at greater risk of HIV transmission than non-Indigenous people. Strategies to prevent further HIV infection in Indigenous Australians should include control of sexually transmitted infections.

Michael R Wright BSW, MAE(IH) · Carolien M Giele RN, BSc(Hons), MPH · Phyll R Dance BA, PhD · Sandra C Thompson FAFPHM, PhD

Vietnam veterans reported a high prevalence of health problems among their partners and children in a 1998 survey. Data about the effect of our veterans’ war service on the health of their families are quite limited. These data are mainly from the Vietnam and Gulf Wars; cover veterans, partners and children independently; and largely focus on the individuals’ medical conditions and risk factors. Australia should develop a broad research strategy that uses a wider definition of health, looks at veterans’ families as a whole, and does so from a range of perspectives, including sociological, life-course and trans-generation perspectives. Preventive research should be emphasised, especially into enhancing resilience of veterans’ families. The use and usefulness of current services should be evaluated, including whether they need to be more family-inclusive.

Hedley G Peach PhD, FFPH

Although children in Australia generally have good health, some alarming indicators of poor health and wellbeing exist, which are related to major socioeconomic discrepancies. The pathways connecting socioeconomic disadvantage to child health outcomes are complex and poorly understood. Reducing social disadvantage requires strategies beyond the health arena, involving political, moral, cultural and economic initiatives. Developing “social capital” — cohesion in communities, a sense of belonging and involvement in community affairs — may be a key strategy in improving health indicators. Overseas studies of early intervention and home visiting programs in early childhood have shown improvements in child health and development outcomes. Similar programs have been introduced in Australia and face considerable challenges in their widespread roll-out and evaluation. Health professionals need to develop practical ways to interact with community programs and thus improve social capital.

Karen J Zwi FRACP, MRCP, MSc · Richard L Henry MD, FRACP

Canteens are not the main source of food for Australian school kids, but their symbolism is big There is widespread awareness of the obesity epidemic in Australian children,1 and the focus has now, quite appropriately, turned to action. In the United Kingdom, celebrity chef Jamie Oliver is trying to transform a 100-year-old school lunch service from “soggy and fried” to “crisp and fresh”. In Australia, the question is whether school canteens should be a high priority for action, because of their accessibility and visibility, or a low priority, on the grounds that canteen foods contribute little to children’s energy intake. Negative ripples from canteensOver the period of a year, children aged 5–15 years obtain only about 16% of their total energy intake from food eaten at school, and probably less than 3% comes from canteens.2 But while the energy contribution is small, the symbolism is big. Canteen users consume significantly greater amounts of foods likely to promote unhealthy weight gain, such as fast foods, confectionery and packaged snacks.2 The types of foods and beverages that predominate in school canteens not only undermine the health and nutrition curriculum, but also create the impression that foods and drinks that are high in fat, sugar and salt belong on the plate as “everyday foods”, rather than on the side as “occasional foods”. Other common practices in schools that undermine healthy eating messages include rewarding children with sweets, having soft-drink and confectionery vending machines, holding sporting events with fast-food vouchers as prizes, and using chocolate drives for fundraising. All these practices create negative ripple effects on Australian family eating practices and beliefs.3 Children are developing the food preferences that they will carry with them into adulthood, so strengthening family and school environments for enjoying healthier food choices is critical. In a 2004 survey of 18 Victorian primary schools (unpublished data), we found that, of the 17 with a food service, all sold meat pies, but only five sold fruit on a regular basis. As a rule, canteen managers provided foods that sold well and had a long shelf life. They usually had no mandate or support to do otherwise. A reliance on profits from canteens, vending machines and “junk food fundraising” also makes it hard for schools, particularly high schools, to model healthy eating. In common with a survey of 500 New Zealand schools,4 we found that schools readily recognise the rather poor job they do of providing a healthy food environment. Most schools do not see food provision as part of their core business and lack the inclination or resources to take on this “added” responsibility. Private enterprise fills this vacuum, with the result that the health of profits increasingly dominates the health of pupils. An extreme example is the “cola war” in the United States, in which the weapons of choice have been contracts with schools to sell minimum volumes of Coca Cola or Pepsi.5 Creating a new epidemic?Perhaps we should consider the task ahead of us as the creation of a new epidemic of healthy eating rather than reducing an obesity epidemic. Using the principles in Gladwell’s recent bestseller The tipping point,6 the school canteen and students themselves could be the catalyst for healthier eating among children and adolescents — turning negative ripples into positive waves. Can a “tipping point” be created from a handful of champion schools that decide to embrace the whole-of-school policies and strategies needed to get their canteens right (healthy, enjoyable, profitable and supported), hoping that others will follow their lead? This is almost certainly too much to expect to happen in 9000 schools across Australia, which tend to function semi-autonomously on these matters. Lessons from successful public health programs, such as sun protection and injury prevention, show that tipping the balance in targeted behaviours from unhealthy to healthy requires a backbone of strong central policy, ongoing social marketing, and supported and coordinated implementation of programs. Some Australian modelsVarious government-supported models influence how school canteens operate in Australia. Probably the least effective include the Victorian model of simply disseminating canteen guidelines7 and the Australian Government model from the pre-election spending spree, wherein each school could apply for $1500 to reinvent the “healthy canteen” wheel. Neither has policy, social marketing or implementation support. A third model, which has some merit, is exemplified by the Western Australian (StarCAP8) and Tasmanian (Cool CAP9) school canteen accreditation programs. Both have well developed criteria and processes for schools to work through to achieve program accreditation. StarCAP is backed by the WA government, but is managed on a shoestring budget, without policy and social marketing support, and thus has a low accreditation rate (7% of schools) and declining reach.10 Cool CAP is newer, with a higher accreditation rate (42% of schools accredited or working towards it), and so far has been successful in securing legislative and monetary support. Ultimately, however, the impact of these types of programs will probably be modest as long as the impetus to change remains with each individual school. Because they are well supported and centrally driven, the most promising models come from New South Wales and South Australia. The NSW Healthy School Canteen Strategy (“Fresh Tastes @ School”)11 grew out of the NSW Government Childhood Obesity Summit in 2002. It is now mandatory for state schools to provide food and beverage choices consistent with the Australian guide to healthy eating.12 NSW Health has also boosted support for the NSW Canteen Association so that it, in turn, can support schools to operate economically viable, nutrition-oriented school canteens. Early positive waves include support from parents, canteen managers, some food companies and, increasingly, local health and education services. A similar model released in 2004 in South Australia brings SA government backing to a set of healthy eating guidelines.13 The guidelines encourage links between the canteen, the community and teaching about nutrition food skills. Both the NSW and SA government models would now benefit from social marketing explaining the rationale, processes and support for the program. It would make sense, for example, to link these strategies with the national “Go for 2&5” (2 serves of fruit and 5 serves of vegetables) campaign.14 If we are serious about the childhood obesity epidemic, school canteens are a good place to start, because they carry a symbolism that ripples into the Australian diet far beyond their contribution to energy intake. At the moment, the ripples are a negative and undermining force. However, full implementation of the NSW or SA models for school canteens throughout the country could just tip the balance towards an outbreak of healthier eating.

A Colin Bell BSc(Hons), MSc, PhD · Boyd A Swinburn MB ChB, MD, FRACP

No single voice nor one perspective can claim to represent the whole of bioethics “Deep listening: bridging divides in local and global ethics” was the theme of the 7th World Congress of Bioethics, held in Sydney in November 2004. Preceded by the 5th Feminist Approaches to Bioethics Congress and followed by the 10th Australasian Bioethics Association Conference, the conference had 550 registered attendees from 35 different countries.1 The three conferences, running over 8 days, provided the biggest event in bioethics thus far in Australia and the Asia–Pacific region and demonstrated the breadth and heterogeneity of bioethics. The theme of the Congress — suggested by the word “dadirri”, meaning “deep listening”, from an Australian Aboriginal language — expressed the intention of the Planning Committee to explore a wide range of approaches to ethics in relation to health care and to provoke vigorous and productive discussion of the issues from different perspectives. The approaches ranged from those with a traditional focus on local issues in a clinical setting to broader reflections on bioethics at a global level. Emphasising the central importance of the indigenous theme, the keynote address of the Congress was delivered by Marcia Langton (Professor of Australian Indigenous Studies, University of Melbourne) on “Aboriginal intellectual and property rights”. Speakers at major plenary sessions included Thomas Pogge (Professor of Philosophy, Columbia University) on “World poverty”; Daniel Wikler (Professor of Public Health, Harvard University) and Daniel Brock (Professor of Social Medicine, Harvard University) on “Ethical issues in population health”; and Catriona MacKenzie (Associate Professor of Philosophy, Macquarie University) on “Conceptions of the body and autonomy”. There were 15 special symposia presented by specialist groups covering a wide range of subjects, including equity, refugees, torture, genetics, stem cells, biopolitics and HIV/AIDS, in addition to over 200 individual oral and poster presentations. The Congress program covered many topics of intense current interest — most notably cloning and stem cell research — and included many styles of presentation, such as talks, debates, panel presentations and group discussions. There was a program of Australian Indigenous dance and music, storytelling, poetry and art. There were also events for the general public that were well attended and aroused considerable interest, such as an open forum on biotechnology, stem cells and cloning and a debate between George Annas (Professor of Health, Law and Bioethics, Boston University) and Alex Capron (Director, Department of Ethics, Trade, Human Rights and Health Law, World Health Organization) on human rights and bioethics.2,3 A broader view of bioethicsThe Congress deliberately sought to extend the focus of bioethics discussions from traditional and important concerns about problems arising between doctors and patients to issues of wider compass, such as the broad social, cultural and political contexts that affect health and shape health care delivery. Also on the agenda were concerns about public health programs and the responsibilities of developed countries to contribute to health care in the developing world, as well as feminist and indigenous perspectives on bioethics. This combination of approaches precipitated some trenchant critical reflections on the philosophical assumptions on which bioethics itself has been based and revealed some tensions between differing views. Feminist perspectiveMany feminist writers have been critical of a prevailing assumption that individuals are autonomous decision-makers. From this perspective, Catriona MacKenzie argued that bioethics developed with a narrow, highly individualistic conception of personhood and autonomy. As an alternative, she outlined a “relational” approach to autonomy, according to which individuals and the decisions they make are understood as constituted within relationships of interdependence and embedded in complex social situations. Such a model necessarily draws attention to power relations within intimate and familial relationships and to oppressive or unequal social structures.4 Responsibility for health in the developing worldSome speakers built on this critique of power relations by drawing attention to power inequalities at a global level. For example, Solomon Benatar (Professor of Medicine, University of Capetown) proposed that HIV/AIDS be viewed not in isolation but as symptomatic of problems of poverty and injustice afflicting the developing world.5 Thomas Pogge argued that trade agreements between affluent countries disadvantage poorer countries and lead to systematic impoverishment and poor health of many people living in the developing world. As a result of this, he claimed, citizens in Western countries are not just innocent bystanders, but carry an unavoidable responsibility.6 One practical measure he proposed was to establish a system of financial incentives to encourage pharmaceutical companies to develop effective and inexpensive treatments for the major illnesses afflicting these countries. Tension between population health and individual perspectivesIn a controversial presentation that stimulated vigorous and sometimes heated debate, Daniel Brock and Daniel Wikler, using a rights-based framework, drew attention to the particular concerns of population health (rather than health care) and argued for a shift of emphasis away from managing disease to promoting health. While those who responded accepted the importance of a population perspective, they suggested that it did not go far enough in dealing with the problems of impoverished countries, and challenged those who engage in bioethical debates to become personally and politically engaged. One participant expressed concern that the proposed new focus on public and population health would lead to a diminished appreciation of the importance of issues affecting individuals. This brought to the surface a tension between those concerned with issues of individual freedom (including individual autonomy and human rights) and those who emphasise the role of society and culture in establishing ethical conduct and relationships. Human rights and bioethicsA further tension, expressed in the public debate, was between a human rights approach and more traditional approaches to topics in bioethics. In essence, the question became whether bioethics can (and should) be properly understood and addressed entirely in its own language and concepts, or whether it needs to be supplemented (or even replaced) by a human rights perspective. Indigenous ethics Aboriginal dancer: Clarence Slockee, Mindgingbal Clan of the Bundjalung Tribe, Northern NSW. There were also tensions evident in discussing the experiences of indigenous people in relation to majority cultures within their countries, and tensions surrounding issues of cultural difference. In her address, Marcia Langton adopted a broad approach to these issues and raised fundamental questions about knowledge and its dependence on culture, power and economic forms of relationship.7,8 Speakers from India, Sri Lanka, South Africa, New Zealand and Australia showed that indigenous populations face challenges in the delivery of health care that are in common across the world, such as disenfranchisement, lack of control over health programs and research, imposition of programs from outside, displacement from the land, prejudice and poverty. Nonetheless, there was a recognition of irreducible differences between cultures that require effective responses to be based on specific local needs and conditions. The discussion of indigenous issues, perhaps more than any other topic, made evident the need for openness to multiple perspectives. The challenge of accommodating diversityWhat can be concluded from this Congress, with its emphasis on listening across broad divides? One obvious conclusion is that there is no single voice nor one perspective that can claim to represent the whole of bioethics. There is no predominant theory or homogeneous position, nor is it constituted by just one focus. There are many areas of bioethical interest, including issues in the clinic, issues arising from new understandings in medicine (such as genetics) or possibilities presented by new technologies (such as stem cell research), and issues arising from feminist (and other) theoretical perspectives. Moreover, different levels of approach, ranging from a focus on individuals to a focus on populations (such as public health and indigenous health) raise different sets of ethical interests and concerns. In this context, “deep listening” can be understood as listening to each other, listening to different groups and listening to those with different voices. It implies an openness to a multiplicity of approaches. In drawing on a variety of perspectives on a health care issue, it is possible that some central concerns may rise above and be strengthened by this multiplicity, leading to an outcome that is recognised as ethical by all interested parties. It is also possible that some views will be incommensurable, some voices discordant, and decision-makers will have to determine that one set of values needs to take precedence over another. Nevertheless, we believe that many perspectives are needed to provide a wide vista and adequate understanding in preparation for informed, appropriate and nuanced decisions in health care. Human rights, population health and indigenous ethics can complement traditional perspectives. There is a need, both within health care education and in policy development, to consider issues from individual as well as wider social and cultural perspectives and to address disparities in power as part of a broader understanding of bioethics. The Congress demonstrated that diverse views can be accommodated, even when they are held passionately and discussion is vigorous. Listening for, and openness to, differences and commonalities worked well as a theme for the Congress. It is a capacity that remains to be encouraged in bioethics and applied in health care more generally.

Paul M McNeill MA, LLB, PhD · Ruth Macklin PhD · Angela Wasunna LLM · Paul A Komesaroff MB BS, PhD, FRACP

Anna Peeters,* Reannan L Cashen,† Paul E O’Brien‡ * Senior Research Fellow, † Honours Student, Epidemiology and Preventive Medicine, ‡ Director, Centre for Obesity Research and Education, Monash University, The Alfred Hospital, Commercial Road, Melbourne VIC 3004. anna.peetersATmed.monash.edu.au To the Editor: We support the warning of Talbot and colleagues regarding the inequities of the current system for provision of bariatric surgery to the morbidly obese in Australia.1 We recently analysed data on the number of separations for bariatric surgery for morbid obesity in Australia. The two most common procedures in Australia are gastric reduction surgery (procedure code 30511, which includes gastric stapling, laparoscopic adjustable gastric banding [LAGB] and gastroplasty) and gastric bypass surgery (procedure code 30512). The number of separations for procedure 30512 has remained quite stable and relatively low (around 200 a year) over the past few years. By contrast, the number of separations for procedure 30511 has been continually increasing. While the exact number of LAGB procedures can not be identified from this single code, it is assumed that the majority of the increase is due to LAGB, as it is a less invasive pro-cedure and therefore generally more acceptable to patients.2 However, the number of separations for gastric reduction surgery in public hospitals is low and has remained so. In the financial year 2000–01 there were 1529 separations for gastric reduction for morbid obesity across Australia, only 194 (13%) of which were performed in public hospitals (see Box). In 2001–02 the total number increased to 2351, but the number performed in public hospitals increased only marginally, to 238 (10% of the overall number). In 2002–03, the last year of available data, there were 2612 separations, of which only 287 (11%) were performed in public hospitals (unpublished data, courtesy of the Australian Institute of Health and Welfare). Clearly, if this issue is not addressed systematically, it will only serve to widen the socioeconomic inequalities in health associated with obesity in Australia. Separations for all gastric reduction surgery for morbid obesity, Australia

Anna Peeters · Reannan L Cashen · Paul E O’Brien

Shared responsibility agreements between the Australian Government and Indigenous communities are based on a concept of mutual obligation but have overtones of paternalism and imposition. The nature and extent of choice in any such agreements need to be established. In 2004, the Australian Government announced a new approach to the provision of services to Indigenous communities.1 Part of the initiative involved the forging of “shared responsibility agreements”, defined by the government as being agreements in which “both governments and Indigenous people have rights and obligations and all must share responsibility”.1 Shared responsibility agreements are based on the concept of mutual obligation. While intuitively the meaning of “mutual obligation” might appear to be clear, in practice it is not, as Aden Ridgeway, Federal Parliament’s only Indigenous member, pointed out quite forcefully in a Senate debate.2 Prominent Aboriginal leaders Pat Dodson and Noel Pearson3 describe mutual obligation as “a natural principle of human society”, which, in Aboriginal terms, is normally referred to as “reciprocity”. According to Larissa Behrendt,4 Professor of Law and Indigenous Studies at the University of Technology, Sydney, “the concept of Aboriginal reciprocity implies that those who have resources share them with those who do not, and that those who receive this generosity have the same duty to provide for and share with others”. We believe that the Australian Government’s new approach smacks of paternalism and imposition and, in the absence of both respect and equality, runs counter to the Aboriginal notion of reciprocity. We believe that there has not been adequate dialogue and negotiation between the government and Indigenous communities in relation to shared responsibility agreements. How that dialogue is initiated and how it is then used to promote policy are crucial, and there has been too little debate on these two issues. The Mulan shared responsibility agreementLate in 2004, the details of a shared responsibility agreement between the government and Mulan Aboriginal Community in the Kimberley region of Western Australia became public. Part of that agreement was that the federal government would supply the community with a petrol bowser on the proviso that members of the community meet certain standards of personal and community hygiene. These included washing children’s faces twice a day and families keeping their homes free of rubbish (see Box). Not surprisingly, the proposal provoked considerable public debate.6 On the one hand, it has been argued that the Mulan community wanted to enter the agreement with government and that the wishes of the Mulan community should be respected by those who, like us, are opposed to such contracts.3 On the other hand, we are concerned that the “choice set” that Mulan was offered was very restricted (perhaps simply “take it or leave it”). The current Australian Government appears to favour neoliberalism in the market place, the central tenet of which is freedom of choice of the consumer. But for neoliberal markets to work well, there is a need for well informed consumers and freedom of choice over a wide range. We are not proposing market solutions for Mulan, but want to draw attention to the issue of choice. What choices were the Mulan community offered? Are the “consumers” of Mulan well placed to judge whether the benefit they will get from a petrol bowser will be worth the “price” they have agreed to pay? Is the government in a position to ensure that the price is paid or even to monitor the “payment”? Our concerns about mutual obligation schemesWhile the leadership of Mulan has publicly assured the Australian community that they are comfortable with the terms of the agreement,7 we have general concerns about whether such “mutual obligation” deals respect communities’ autonomy. The literature on the social determinants of health shows strong links between autonomy and health.8,9 A community which has autonomy and self-respect is more likely to be a healthy one. Such a community is able to build trust, respect, reciprocity and, in turn, improve health standards within the community. Encouragement from the outside can foster these features, but trying to impose them will not work and may be deleterious. There are also human rights issues, and the need to avoid solutions that discriminate against Indigenous people. For example, it would be discriminatory if the “rewards” involved in mutual obligation agreements only provide Indigenous people with access to infrastructure that other Australians expect or take for granted (which, incidentally, is the case for petrol bowsers). It can also be argued that the government’s concept of mutual obligation breaches Australia’s international obligations and denies certain basic rights to Australia’s Aboriginal and Torres Strait Islander citizens. The rationale is one of social control. This, for example, breaches Article 1 of the International Covenant on Civil and Political Rights: people’s right to self-determination and the right to freely pursue their economic, social and cultural development.10 An understanding of the background to this initiative is important. The government’s mutual obligation scheme comes in the wake of, firstly, its continuing refusal to apologise, as an act of reconciliation, for the “stolen generations”. This is seen by many as a denial of the mental and spiritual havoc wreaked by colonialism and dispossession of land and culture. Instead, the government has supported “practical reconciliation” — “addressing social and economic disadvantage”.11 Mutual obligation is a natural extension of this “let’s fix it” approach. Secondly, the disbanding in April 2004 of the Aboriginal and Torres Strait Islander Commission (ATSIC),12 an organisation based on principles of self-determination, is a direct lead-in to the policy of mutual obligation. ATSIC’s successor, the new National Indigenous Council (NIC),13 is not a representative body, as the government has acknowledged: “Members of the NIC have been chosen for their expertise and experience in particular policy areas and are not representing particular regions, organisations or agencies. The NIC is not a replacement for ATSIC and not intended as a representative body.”13 The mutual obligation scheme and NHMRC guidelines for ethical research in Indigenous communities14Given that, to our knowledge, there is little evidence for the effectiveness of mutual obligation strategies in the context of improving health, it is relevant to examine such strategies in terms of the principles applied in formulating guidelines for ethical conduct of research in Aboriginal and Torres Strait Islander communities. According to the National Health and Medical Research Council guidelines,14 it is crucial to involve the relevant communities in the development of any research proposal in Indigenous health. The guidelines are based on the principles of reciprocity — in the context of research, reciprocity implies inclusion and recognition of partners’ contributions, and ensuring equitable benefits of value to communities or individuals. “. . . communities have the right to define the benefits according to their own values and priorities”14 respect — a respectful relationship induces trust and cooperation; equality — the equal value of people; responsibility — includes, among other things, “the mainten-ance of harmony and balance within and between the physical and spiritual realms”14 survival and protection — protecting culture and identity; and spirit and integrity — an overarching value binding all others into a coherent whole. “Any behaviour that diminishes any of the other values could not be described as having integrity”.14 Thus, the government’s mutual obligation scheme does not appear to comply with the principles of respect; almost certainly those of responsibility; and perhaps, most importantly, the overarching notions of spirit and integrity. To demonstrate reciprocity, the guidelines suggest the need for the researcher to show “willingness to modify research in accordance with participating community values and aspirations”. Again on this criterion, government policy would appear to be deficient. Any research proposal in health today is likely to be rejected if it cannot show how it would quantify any changes it is attempting to bring about. These standards should apply even more to policy. There needs to be some evidence-based attempt to determine whether the policy works. Our concern at this level is simple. What performance indicators are appropriate for Mulan, for example? Good policy needs to establish these in advance. There is a need to conduct research to establish whether, and if so to what extent, shared responsibility agreements work — and what “works” means in this context. It would have been useful to gather this evidence before beginning to implement the policy. It is now crucial to get that evidence as soon as possible. Alternative or complementary strategiesWe believe that the most important strategy for improving health in Aboriginal communities such as Mulan involves building up infrastructure — management, economic, social and human infrastructure.15 If a community lacks leadership and good management and does not have this infrastructure then all other efforts will fail. This aspect seems to have been neglected by government. Many Indigenous communities need help to be able to help themselves on their own terms. Secondly, respect is needed — respecting the preferences of Aboriginal and Torres Strait Islander peoples. Strategies to improve Indigenous health will only get off to a good start if the people want the strategies, and their autonomy has been respected in allowing them to make choices regarding the strategies. Thirdly, there is a need to avoid being paternalistic or patronising. If mutual obligation is an option that Indigenous communities seek, then there must be an adequate range of choices offered, respect for the preferences of the people, and ways of monitoring whether the obligations on each side are in fact carried out. Draft agreement between the government and the residents of Mulan5 Government The federal government will contribute $172 000 for the installation of fuel bowsers at Mulan. The Government of Western Australia will undertake to “monitor and review” the adequacy of health services in an area where trachoma rates are “arguably the worst in the world”. Mulan Aboriginal Community The residents will: Ensure children shower daily and wash their faces twice a day; Ensure rubbish bins are at every house and are emptied twice weekly, through the local work-for-the-dole scheme; Undertake household pest control four times a year; Act to prevent petrol sniffing. Families and individuals will also make sure children attend school, crêche and the health clinic; and they will keep their homes clean and pay rents (to ensure the local council can afford pest control and repairs like plumbing).

Kim S Collard · Heather A D’Antoine · Barbara R Henry · Gavin H Mooney · Dennis G Eggington · Carol A Martin

It takes humility to walk along the path towards better Aboriginal health Marni and her two cousins crowded together on our couch watching the Saturday footy. Like many of the Aboriginal children who regularly visited us, they laughed and chatted and found fun in almost everything. We were all still damp after a cooling swim at the nearby waterhole, and were about to tuck into a freshly baked cake from our oven. It seemed there could be nothing better. But 8-year-old Marni was unusually breathless. In fact, she was wheezing and gasping for air. With a stethoscope we could hear the crackles of pulmonary oedema. A few months earlier she had spent several weeks in hospital, and there had been talk that she might need valve replacement surgery. She narrowly avoided it then. Now her cardiac failure had worsened again. Marni has rheumatic heart disease — a disease of poverty and overcrowding. We had never seen a case before we went to work in Yambarr. However, in this small community of about 900 people, at least 25 have rheumatic heart disease. As doctors, we had sought the challenges of working in a remote Aboriginal community. Admittedly, we also found some romantic appeal in the mythical and timeless aspects of Aboriginal culture, which are said to embrace the earth, its creatures and the spirit world in what is often referred to as The Dreamtime. Inevitably, however, we found real people living lives of hardship. More than finding The Dreamtime, we were awakened to some stark realities about health in remote communities. Yambarr Aboriginal communityYambarr is hundreds of kilometres from the nearest city. From the air, the collection of tin roofs and shady trees is hardly noticeable in the rugged landscape traversed by vein-like rivers quivering in the 40 degree heat. Closer up, a permanent waterhole can be seen, flanked by scattered houses, a school, a store and a police station, and the ramshackle old clinic. The clinic’s exterior is adorned with traditional paintings of animals and birds, once radiant but now faded and peeling, weathered by years of monsoonal storms and grassfires. The doors and windows are barred, and ageing plywood inserts take the place of occasional missing panes. Standing outside, hearing only the rattle of straining air conditioners, it seems a long way from modern specialised medical centres. Inside, however, activity thrives in the relative coolness. Patients, families, and staff mill among the five consulting rooms, the drug dispensary and the emergency room. Lining the corridor are posters of Aboriginal athletes and footballers bringing health messages. This clinic has three nurses and six Aboriginal health workers — men and women who work as clinicians, interpreters and cultural aids for transient non-Aboriginals like us. Non-Aboriginal people have been in the area for a little over 100 years, a tick of the clock compared with the more than 40 000-year history of Aboriginal people. Nevertheless, white traders, missionaries and developers have left no corner untouched. Indigenous communities today are melting pots of traditional and modern ways. Coca-Cola and ice-cream go well with a meal of fresh kangaroo. Faded jeans, Nike shoes and stereos are just part of the scene at tribal dances and cultural ceremonies. Children like Marni seem to embrace both their traditional and modern worlds with an ease and simplicity that only children know. But the postcard pictures of painted faces, spears and boomerangs conceal some unspeakable suffering. Tucked away in the remote outback, communities like Yambarr are Australia’s equivalent of urban slums, where poverty, illness, illiteracy and unemployment coalesce in vicious circles. Nationally, Aboriginal people die on average 20 years earlier than other Australians, half before the age of 50 years. Rates of chronic disease and substance abuse are increasing. On nearly every social, economic and health indicator Aboriginal people are much worse off. The human faces of disadvantageLiving in Yambarr we saw these statistics in the faces of our friends, neighbours and even the clinic staff themselves. Within months of our arrival, two important Aboriginal men in the community had myocardial infarctions. One was a health worker and the other a community councillor. Both were still in their 20s. Never had we seen AMIs at such a young age. The first, Elijah, died only minutes after he had been laughing with us in the tearoom during a busy morning clinic. Then he was on the floor, his lifeless eyes staring at us, surrounded by monitors, tubes and wailing patients. We had no defibrillator, and he died amidst our helplessness. Only weeks later Bill collapsed during a football match and his team-mates carried him in, his black face pale with fear. Bill had been our chaperone when we arrived in the community, ensuring that we were welcome and safe, involving us in community activities and including us into his family. He survived his heart attack, receiving thrombolytic treatment as he lay on a trolley at Yambarr’s desert airstrip, shaded from the sun by the wing of a twin-propeller air ambulance. Such inexplicable events occurred with tragic frequency. The statistics dissolved into the faces of people we knew — at work, in the street, down at the shop, hanging around the playground. From a medical perspective, three words seemed to describe our patients’ lives (in so far as words could capture them) — “hardship”, “sufferance” and “invisibility”. Hardship refers to the struggle of daily living. In Yambarr 900 people live in fewer than 70 dwellings, lined up in neat rows and differing only in the colour of their faded exteriors. Bill’s mother, Marjorie, rents a three-bedroom, orange-painted house covered with graffiti. Its concrete floors are cracked, its window screens are broken, and the plumbing occasionally blocks. Bill lives there with his family, and so do his brother and sister and their families, usually more than a dozen people. The children play in the small yard — mud in the wet season and dust in the dry — among free-roaming, unhealthy looking dogs that pick through scraps. Both Bill and his brother have been wait-listed to rent another home for over 10 years, but a new house has not become available. Despite the popularity of hunting and fishing, families have become accustomed to shopping for food at the Yambarr store. Due to the heat and distance from markets, the supply of fresh fruit and vegetables is limited, and what is available is very expensive. Most families buy tinned produce, which may be high in fat and sugar. Most available hot food is greasy and fried. When Bill was told in hospital that he had impaired glucose tolerance, like at least 100 of the adults in Yambarr, he knew a suitable diet would be virtually impossible. Alcohol is also part of the hardship, especially for children who grow up with the impression that drinking, often excessively, is a normal part of adult life. Youth programs have been short-lived, and in the end the only established gathering place for entertainment for anyone, including kids, is the licensed club. For many Yambarr people there is simply no escape from the hardship of daily existence and few opportunities to improve their situation. Housing management, the running of the store and the activities of the club depend, to a greater or lesser degree, on externally provided non-Aboriginal contractors and administrators. Poor literacy is one of the biggest barriers to local Aboriginal people assuming real responsibility in imposed systems that are complex and unfamiliar. Bill and Elijah were quite exceptional in completing vocational training. A recent independent inquiry into Aboriginal education reported that only 4% of Aboriginal students in remote communities reach national reading benchmarks at fifth-grade level, compared with 80% of non-Aboriginal students. It also revealed that many leave school with English literacy and numeracy levels equivalent to 6 or 7 year olds and are, therefore, virtually unemployable. The fact that many are fluent in at least three or four other Aboriginal languages helps little when hunting for a mainstream job. We wondered about this as Marni (despite her breathlessness) and her cousins laughed, smiled and chatted away on the couch. They variously attended school, sometimes every day, sometimes less frequently. Their parents all had an English-speaking education, but most were now unemployed, because few jobs existed in Yambarr, and the big city was a hostile, unfamiliar white-person’s place away from family and friends. It’s easy to imagine that they had seen little value in their own education, and hence were often indifferent about their children’s school attendance. Furthermore, it is well known that good nutrition and good hearing are essential for learning. Yet, in remote areas, 20% of Aboriginal children younger than 5 years are underweight, and almost four out of five children have hearing disabilities. In some communities the prevalence of chronic otitis media has been recorded as 50%, more than 10 times that which the World Health Organization regards as a significant public health problem. Sufferance describes a resignation to illness that we found both perplexing and disturbing. We were amazed that families could quietly tolerate such sickness. Perhaps, in the context of so much disease, people grow up expecting illness as part of life. Perhaps they are unaware of available treatment. Many parents seemed unworried when pus oozed from their children’s ears. Even Bill’s cheerful 7-year-old daughter, Stephanie, had recurrent ear infections and perforated ear drums. Although Bill’s mother was a health worker, both of them seemed to be as numbed by the sheer prevalence of illness as nearly everyone else in Yambarr. Over the years they had developed no better expectations. Invisibility refers first to the level of undiagnosed and untreated illness in the community. Many chronic diseases, for example, do not become apparent to local health care providers until acute complications present. In Bill’s case, it was only after his heart attack that he was found to have rheumatic heart disease. Rheumatic heart disease provides a good illustration of the invisibility of Aboriginal peoples’ health problems to metropolitan specialist centres — despite our clinical experience, there remains a perception among some that rheumatic fever has been eradicated from Australia. Invisibility also refers to our impression that, in many ways, progress has passed by communities like Yambarr, and that many well-meaning health professionals have little understanding of Aboriginal people’s difficulties obtaining health care. Even when disease is recognised, barriers to accessing mainstream health services arise because of cultural differences, language and communication difficulties, remoteness and poverty. Forty per cent of Aboriginal communities are over 250 kilometres from the nearest hospital, most without regular public transport. From Yambarr, a simple 15-minute hospital appointment requires a day of travelling in each direction and two nights’ accommodation at crowded urban hostels. A recent survey at one hospital’s outpatient clinic showed that nearly two-fifths of people from remote communities did not keep their appointments. Non-attendees’ appointments are usually rescheduled weeks later, and their travel subsidies are often forfeited. The reasons for such non-attendance are rarely straightforward. We realised this after we sought a specialist ENT opinion for Stephanie. She and two other children waited 10 weeks for an initial appointment. Stephanie’s grandmother accompanied them in the back of a Toyota Troopcarrier to meet the public bus about 200 kilometres away. This bus service provides both public transport and occasional tourism. The non-Aboriginal driver often gives an en-route commentary about Aboriginal culture, much to the amusement of any Aboriginal passengers. This time, however, we found the old lady and the three children still at the bus stop long after the bus had departed. Embarrassed and ashamed, they asked us for a ride home. They explained that the driver had refused to let them board because they had no shoes, despite the fact that Aboriginal people in Yambarr rarely wear them. The driver had promised that he would wait while they purchased some in a nearby store. When they returned with the footwear only a few minutes later, the bus was gone. On the way home we lamented the effort that went into organising their appointments, the disruption to their families and, above all, the fact that the children would have to wait another 2 months to see a specialist. So, on top of the long-lasting health effects of poor nutrition, overcrowding, alcohol and unemployment, Aboriginal people struggle to obtain the full benefits of modern health care. Even at the Yambarr clinic, their health seemed to take one step forward while they were there and two steps back as soon as they left. Much of the clinic’s work was “band-aid medicine” — a result of both insufficient resources and overwhelming social forces. As health professionals, we were humbled by our patients’ hardship, sufferance and invisibility. A sense of humilityHumility is not often discussed in the health professions. Everyone seems much more interested in modern medical triumphs. Humility instead refers to an awareness of one’s limits. In theology, it refers to a sense of “smallness” in relation to God’s greatness, encouraging receptiveness and solidarity with all people, especially the poor, “lowly” and “sinners”. To us, in Yambarr, humility had secular relevance. A sense of smallness was evident in many ways, including our limited ability to improve the health of Yambarr’s people. It’s not that our medical knowledge didn’t provide answers to many health problems. It usually did, one person at a time. (Marni, for example, eventually had a successful valve replacement in a hospital thousands of kilometres away.) It’s more that our training provided no simple answers to preventing the enormous burden of illness that existed in Yambarr or to overcoming the difficulties of getting modern health care to the people who need it most. Furthermore, problems of housing quality, alcohol-related harm and food quality often seemed insurmountable to the overstretched clinic staff. It would take a community-wide effort to improve these things. We felt solidarity with our patients and with the community. Getting to know the people as friends and neighbours, we realised that we shared common human values and goals — things such as health, love and happiness, the centrality of family and the importance of community, and the need to imagine a bright future. With them, we experienced the pain and frustration of their medical conditions and their difficulties getting treatment. We reflected their sadness about intractable problems that made the future seem so uncertain. Eventually, we found ourselves doing things that weren’t part of ordinary medical practice, such as participating in community projects and lobbying for various hospital and community improvements. For example, the clinic staff joined with other community organisations to address scabies, a skin infection that is a risk factor for rheumatic heart disease. After developing screening, surveillance and treatment programs, and producing locally an educational video, the prevalence of scabies infections in children under the age of three fell from 33% to 8%. At other times, after Elijah’s death, we were advocates, lobbying for cardiac defibrillators in communities. After all, they are available in shopping centres, sporting venues and ambulances in many parts of the world. And the central health services agreed. By the time we left, many communities in the area had them. But solutions to many problems are not so simple. By knowing the difficulties our patients faced, however, we felt obliged to bring these to the attention of others who may be more able than we are to bring about lasting improvements in Aboriginal health and community life. Doctors and other health professionals can do a lot for people in places like Yambarr, but not all of it uses tools from the traditional black bag. Much of it is about advocating for change, highlighting problems, and refusing to be passive about hardship, sufferance and invisibility. We learned that it takes humility to walk along the path towards better Aboriginal health. And most humbling of all is that, along that path, we have changed more than our patients.

Russell L Gruen MB BS, PhD, FRACS · Theresa F M Yee MB BS, FRACGP

A major theme of the 2004 World Congress of Clinical Pharmacology and Therapeutics was worldwide equity of access to medicines The 8th World Congress of Clinical Pharmacology and Therapeutics was held in Brisbane in August 2004. There were 940 participants from 60 countries, with Japan, Germany, Korea, South Asia and the United Kingdom well represented. The Congress featured three themes: Medicines and Society; Therapeutic Horizons; and Drug Discovery, Development and Disposition. Our report focuses on the Medicines and Society theme, which was strongly emphasised at the 8th Congress, differentiating it from previous Congresses. The prominence of this theme was to encourage the participation of clinical pharmacologists from South Asia and the Pacific regions, where access to lifesaving medicines and confidence in their quality are matters of everyday importance. The Congress also sought to encourage clinical pharmacologists from the developed world to engage with the serious global inequities in access to medicines for the major infectious diseases in the developing world, such as tuberculosis, malaria and HIV/AIDs, as well as the emerging developed-world lifestyle disorders, notably cardiovascular disease. Equity of access to medicinesSeveral plenary lectures focused on access to medicines in developing countries. Suwit Wibulpolprasert (Senior Advisor on Health Economics, Ministry of Public Health, Thailand) gave an inspirational and challenging presentation Philanthropy for the few — equity of access for the many?, tackling the difficult issue of donated medicines. He exposed the increasing gap between rich and poor in both developed and developing countries, and the many interacting social, political and financial influences that conspire to take resources away from the people who most need medicines. He concluded with practical steps that clinical pharmacologists could take to alleviate problems of access to medicines, such as promoting the use of the World Health Organization (WHO) model list of essential drugs in their own countries.1 This theme was reinforced by Sri Suryawati (Head of the Department of Clinical Pharmacology, Gadjah Mada University, Yogyakarta, Indonesia) who challenged all clinical pharmacologists to become involved in achieving the three “As” of medicine use in their own countries: access, affordability and appropriate use. An important and contentious recent issue has been access to cheap, generic versions of fixed-dose combinations of antiretro-viral drugs to deal with the HIV epidemic in Africa. Lembit Rago (Director of the WHO Division of Quality and Safety of Drugs, Geneva, Switzerland) discussed the difficult progress towards international acceptance of WHO guidance regarding registration of these products. Attention was also given to the rapidly expanding complementary medicines sector. Charlie Xue (Program Leader, Division of Chinese Medicine, RMIT University, Melbourne, Vic) outlined the WHO’s perspective on traditional medicine, and provided examples of the role of complementary medicine as a mainstay of public health systems in South-East Asia and the Pacific regions. Chu Quoc Truong (Director of The National Hospital of Traditional Medicine, Hanoi, Vietnam) related that the Vietnamese government has formally integrated traditional medicine with Western conventional medicine, with apparent good effect, notably wide acceptance of both traditions, allowing selection of cost-effective options from each. Tony Smith (Emeritus Professor of Clinical Pharmacology, University of Newcastle, NSW) summed up the unfinished business for clinical pharmacology and world health. He reminded Congress participants that clinical pharmacology arose as a discipline largely in developed countries and continues to be vital to the stellar advances in drug discovery, providing guidance to early-phase human studies, interpretation of pharmacokinetic, clinical and adverse-effects profiles, and development of product information for virtually every significant new chemical entity entering clinical practice. However, many of the needs of developing countries remain unmet, partly because of the limited numbers of clinical pharmacologists. He highlighted the vital tasks of these “few”: political advocacy for appropriate drug use; elaboration and implementation of national medicines policies; and specific “bread and butter” tasks, such as the collaborative development of standard treatment guidelines and essential medicines lists, and the promotion of rational prescribing, especially through training programs in medical schools. All the plenary speakers uniformly encouraged the international umbrella organisation for clinical pharmacology, the International Union of Basic and Clinical Pharmacology (IUPHAR), to continue to become more proactive in these areas, particularly through strong collaborations with WHO and similar organisations. This paradigm shift was strongly endorsed at the IUPHAR council meeting held during the Congress. Proper use of medicinesAnother theme running strongly through the meeting, and prominent in the Medicines and Society stream, was the concept of QUM (quality use of medicines), which was developed in Australia in the early 1990s. The Congress was an important opportunity for Australia to showcase our progress in QUM, through the gathering of evidence about what actually works, followed by implementation of effective strategies through networks, products and services. The major sponsorship of the Congress by our own National Prescribing Service — itself a prominent outcome of the QUM movement — effectively emphasised the importance of the movement in Australia and its potential for other parts of the world. Tom MacDonald (Professor of Clinical Pharmacology, Ninewells Hospital and Medical School, Dundee, UK) delivered an entertaining contribution with the important message that large returns in population health outcomes would accrue if we could better implement evidence-based guidelines and improve patients’ adherence to therapy. For the prevalent cardiovascular disorders, lowering blood pressure is the intervention with the best evidence. Despite its proven benefits, blood-pressure control is poor worldwide. There are good arguments to support a more aggressive approach to blood-pressure management and treatment of younger individuals, but long-term compliance is a problem. Drug safetyAn increasing concern echoed in the Congress is the safety of medicines in older people, who are likely to have multiple comorbidities and increasing exposure to multiple, potent medicines. The future conduct of pharmacovigilance for new drugs is being shaped by interesting therapeutic risk management initiatives across the world, some of which were presented in a lively symposium entitled Medication safety and pharmacovigilance. These initiatives seek to better identify, evaluate and minimise the impact of adverse reactions, and to communicate evolving safety risks throughout the life cycle of a drug. Susana Perez-Gutthann (Senior Director, Global Epidemiology, Safety and Risk Management, Pfizer Worldwide Development, Barcelona, Spain) emphasised the need for this process to be proactive. The techniques of pharmacoepidemiology and use of advanced information technology to “mine” large automated health databases have revolutionised pharmacovigilance. The problem of the “therapeutic orphan” status of children was examined in depth by speakers from Europe, the United States and Australia. Incentives to pharmaceutical companies to evaluate already marketed medicines in children, along with mandatory studies for new medicines in this age group (provided they are potentially useful) has been a successful strategy in the US since the mid-1990s and is now having a positive impact in Europe. A paediatric working party has advised Australian Health Ministers via their Advisory Council on steps to improve access to prescription drugs registered for use in children and the quality use of these medicines. However, the Congress heard that political pressure still needs to be maintained to overcome this problem for children in all countries. Advertising medicinesA symposium on the controversial topic of direct-to-consumer advertising of prescription pharmaceuticals drew great interest, as the situations in Canada, the US, Europe, Thailand, New Zealand and Australia were compared. This advertising is legal only in the US and New Zealand. There were two main themes: first, that regulation is difficult; and secondly, as presented most forcibly by Barbara Mintzes (Postdoctoral Fellow, Centre for Health Services and Policy Research, University of British Columbia, Vancouver, Canada), that there are many, and increasing, instances of advertisements that skirt the boundaries of existing laws and regulations in jurisdictions where this advertising is illegal. In developing countries, Krisantha Weerasuriya (Regional Adviser, Essential Drugs and Medicines Policy, WHO Regional Office for South-East Asia, New Delhi, India) pointed out that there is, in reality, often no distinction between supposed prescription and over-the-counter medicines in terms of access. It is very difficult to control direct-to-consumer advertising of so-called prescription drugs when prescription-only status is not upheld at law — the case in most countries in South-East Asia. However, in countries where direct-to-consumer advertising is currently illegal, there appears little appetite for its introduction because of concerns about quality use of advertised medicines, consumer demand leading to distortion beyond the “reasonable” need for medicines, and finally, morbidity and mortality from the adverse effects of medicines whose use was unnecessary. However, it was emphasised that there is continuous and considerable pressure from industry and advertising interests to reverse this attitude. We have concentrated on the theme Medicines and Society, not because the other core themes of the Congress were less important, but because the urgency of addressing inequities in access to essential medicines around the globe is overwhelming. We were delighted that there was strong support to build on this focus at the 9th World Conference of Clinical Pharmacology and Therapeutics, which will be held in Montreal, Canada, in 2008 (http://www.cpt2008.com/).

Richard O Day MD, FRACP · Donald J Birkett FRACP, DPhil · John Miners PhD · David A Henry FRCP · Gillian M Shenfield PhD, FRACP, FRCP · J Paul Seale PhD, FRACP

Objective: To evaluate the effect of a behaviour modification program, taught to parents in a single visit to a trained nurse, in improving sleep performance in newborn infants.Design: Randomised controlled trial.Setting and participants: 268 families with normal newborn infants in the community, recruited between October 1996 and March 1997 from birth notices published in a South Australian daily newspaper.Intervention: A 45-minute consultation with a nurse 2–3 weeks after the birth, including a tutorial discussion on normal sleep patterns in newborn infants, supported by retained written material and, for infants with weight gain < 30 g daily, referral to their usual postnatal care provider.Main outcome measures: Hours of daytime sleep (0600–1800), night sleep (1800–0600) and total sleep per 24 h; and number of daily records with total sleep ≥ 15 h per 24 h, assessed by 7-day sleep diary at ages 6 and 12 weeks.Results: 268 families returned at least one sleep diary (137/171 intervention, 131/175 control), recording 3273 days. Two intervention infants were referred for low weight gain. Total sleep time was 15 h or more per 24 h on 62% of recorded days in the intervention group, compared with 36% in the control group (P < 0.001). At 6 weeks of age, intervention infants slept a mean 1.3 h per day more than control infants (95% CI, 0.95–1.65), comprising a mean 0.5 h more night sleep (95% CI, 0.32–0.69) and 0.8 h more daytime sleep (95% CI, 0.56–1.07). At 12 weeks, intervention infants slept a mean 1.2 h per day more (95% CI, 0.94–2.14), comprising 0.64 h more night sleep (95% CI, 0.19–0.89) and 0.58 h more daytime sleep (95% CI, 0.39–1.03). There was no significant difference in crying time between the groups.Conclusions: A single consultation supported by written material in the first 3 weeks of a child’s life improves sleep performance at 6 weeks of age. This improvement is maintained at 3 months.

Brian G Symon MD · John E Marley MD · A James Martin MD · Emily R Norman MB BS

The UK needs to revitalise metropolitan medicine as Australia has done for rural medicine With over half of the world’s population living in cities and towns, one of the great challenges of the 21st century is to define and deliver effective and affordable health and social care to urban populations. In the United Kingdom, this is nowhere more apparent than in the deprived parts of its great metropolitan areas. Here, the ratio of general practitioners to population numbers is significantly lower than the national average, there are more solo-doctor practices, and these practices frequently lack the critical mass required to support a full range of services. Overall, inner-city general practice has been a running sore for the National Health Service. To make matters worse, many of the principals of these practices are within cooee of retiring. . . country practitioners in Australia . . . are rediscovering the independence and ingenuity that the nation holds as central to its self-image The looming crisis in metropolitan medical manpower has thrown into focus a general difficulty in attracting health professionals of all kinds to work specifically in primary care, but also in other parts of the NHS serving the big cities. As ever, London is the most extreme case, but it is not unique. The combination of low wages, expensive accommodation, and difficulties in out-of-hours travel (underground trains stop soon after midnight and buses are then infrequent) leaves one far short of Dr Finlay’s idyllic country practice, as depicted in A J Cronin’s books and the TV series. If you are a general practitioner in Harris, in the Outer Hebrides, your nearest specialist in a particular discipline might be in Aberdeen, on the other side of Scotland, but your life and work will have other personal and professional compensations, starting with a beautiful environment, neighbours you know and a stable population of patients. In 2001, the UK government launched a program of “teaching” primary care trusts (PCTs), eventually conferring this status on one trust in each of the 25 strategic health authority areas in England and Wales and making equivalent arrangements in Scotland. Curiously, the background documents for this initiative stressed not education but recruitment and retention of health professionals to work in primary care. Although this seemed a non sequitur, eventually the penny dropped — metropolitan medicine in the UK is, in effect, rural health in Australia turned upside-down. Many of the difficulties faced by practitioners in the two settings are virtually identical: long working hours, often in solo practice; lack of suitable pre-placement training; limited locum cover for holidays and professional development activities; and major concerns about housing, education for children, jobs for partners, and transport. What is not the same is the systematic effort and investment to make a virtue out of necessity. Going beyond early experiments in protected quotas for students from country areas, many Australian medical schools have created departments of rural health, and there are vibrant undergraduate student societies supporting this interest. There are now dedicated postgraduate training schemes for both GPs and specialists seeking a career in the bush, and the profile of the Australian Journal of Rural Health is growing steadily. While medical schools worry that a mismatch between political enthusiasm and dollars invested has increased competition for limited resources, and outer metropolitan areas struggle to attract doctors, country practitioners in Australia from all health disciplines have a growing sense of pride in themselves and their work and are rediscovering the independence and ingenuity that the nation holds as central to its self-image. The UK badly needs to revitalise metropolitan medicine in the same way, but, apart from some dedicated appointments of GPs made under a new system of contracts, this is not happening. The “teaching” budgets of the teaching PCTs are tiny and time-limited, and the university-affiliated hospitals of the biggest cities have one eye on solving the problems referred by their local district general hospitals and the other on research. Any sense of serving a “patch” is much more about defining the geographical boundaries of legitimate referrals than mutual “imprinting” between institution and community. Providing primary care services to their local, inner-urban populations via accident and emergency departments is an inherited responsibility descended directly from giving alms to the poor — a form of noblesse oblige. The features of urban populations that make metropolitan practice exciting — their youth, mixture and mobility — are seen as a source of complication, not stimulation. Nor are the medical schools showing heightened interest. Outside academic departments of primary care, which have been leaders in research on ethnicity, poverty and health, UK medical schools have mostly been lukewarm in their response to requests from government to improve the breadth of access to medical training to include more mature students, entrants from poorer socioeconomic groups, and members of black and other ethnic minorities. The last, in particular, are far more prominent in the large UK cities. In a manner akin to Australian initiatives to attract and graduate rural and Indigenous students, some medical schools have actively recruited from the nominated target groups to new, in-house “foundation programs” to help bridge any gaps between secondary and tertiary education.1 Other schools have “out-sourced” such activities to less prestigious universities eager to boost their more modest reputations as higher-education institutions. While that might be a win–win solution for both parties — as well as for the students — it does highlight a stark difference in degree of connection with pressing issues in the wider community and health service. Australia might have been short-sighted in cutting numbers entering medical training in the early 1990s, but, in trying to limit the contraction, several medical schools responded by earmarking places for students of rural or Indigenous origin. The lead-time is very long, and we can not yet be sure about the careers these pioneers will follow, but the seeds were sown and the trees are growing. Britain, by contrast, has been agonising about metropolitan medicine since at least the late 1970s,2,3 but has taken a decade longer even to begin preparing the soil. Conceivably, recent by-election victories by the Liberal Democrats in economically poor, immigrant-rich urban constituencies might lead the other two major political parties to realise that “things need not be forever thus” and prompt some real reform.

Konrad Jamrozik DPhil, FAFPHM, MFPH · David P Weller MPH, PhD, FRACGP, FAFPHM · Richard F Heller MD, FRCP, FRACP, FAFPHM

Modern medicine’s picture of human nature offers challenges and opportunities to the humanities There is much talk these days about “the medical humanities”, although we still await agreement on its meaning and importance. I think the key lies in appreciating how medicine and the humanities share in an endeavour larger than either alone — the endeavour of understanding the human condition. In this, medicine and the humanities have much to offer each other. My framework begins with an observation about knowledge, scientific and otherwise. All knowledge is to some extent concerned with the knower: our attempts to know things about the natural world are also part of a much larger attempt to understand ourselves (Box 1). Sometimes, this is obvious. For instance, in economics, the laws of supply and demand tell us about how we, as consumers, can be predicted to behave. It is still more obvious in the arts and humanities. Knowledge — about musical forms, the rise of impressionism in painting, Aristotelian influence on medieval Church scholars, or the ambiguous role of the narrator in the psychological novel — is knowledge about how people have tried to make sense of the world, how they saw themselves in the natural order, whether they liked what they saw, and whether they were going to “come along quietly” or were going to struggle. This is true in the natural sciences as well, even if only implicitly. When physiologists study the relations between form and function, when scientists of virtually any discipline attempt to create models of the world, they construct knowledge which not only tells us something about the world, but also something about us. They disclose and specify our need for explanation and prediction: our material need to govern our environment and to harness Nature, and our inner compulsion to understand, dissect and demystify it (Box 2). Enquiries in the natural and life sciences also raise questions about us. What is the nature of observation? How can we contain observer bias? Why do we crave simple explanations? Why do we derive such pleasure from making satisfying theoretical models? This relationship between the known and the knower has important implications for medicine’s role in our culture. Following Raymond Williams, 20th-century pioneer of cultural studies,1 I take “culture” to be the stock of meanings and purposes and shapes in a particular society (which we learn in our education and upbringing) and also the process of challenging these meanings and purposes, and making new ones. So, a “cultural good” is something that helps us learn the meanings, purposes and shapes that our society already embodies, or that helps us create new meanings, purposes and shapes. Medicine itself has a big role in this today. If knowledge implies something about the knower as well as the known, then equally a society’s meanings and purposes tell a story about that society and its members, collectively and individually. Medicine today makes a powerful, uncomfortable and as yet unchallenged claim to supplying part of that story. For me, this conclusion emerges from analysing medicine as a “cultural good”, by which I mean something that gives us resources in reflecting upon ourselves, or in articulating or expressing ourselves, or in developing ourselves, or in criticising ourselves, or in encountering ourselves — all key aspects of what it is to “tell our story”. Art or literature, history or philosophy, politics or theology are initially more obvious resources for doing these things. For instance, to reflect upon ourselves we might read a psychological novel, or study the conventions of classical Greek tragedy. To articulate or express ourselves, we might turn to social history, or to popular music, or to newly commissioned writings or public art. To develop or to criticise ourselves we might cultivate a taste for philosophy, or study the work of dramatists from Aristophanes to Arden. To encounter ourselves we might grapple with expressionist painting, and so on. Western cultures are partly defined by our habitual turning to these particular resources or cultural goods. However, I think that less obvious resources are all around us in scientific and other practices — but they are usually overlooked. And the practice that strikes me most forcefully in this regard is modern technological medical and health care (hereinafter “medicine”). So, how does medicine do these things? Reflecting upon ourselves: Modern medicine has given us new models of our own nature, seen in molecular genetics and in biological psychiatry’s story about our behaviour and character traits. Public health and preventive medicine purport to prescribe our “proper” conduct and spell out our individual responsibility, in line with the unargued assumption that good health is a self-evident benefit, rather than a contingent or instrumental one. The values that medicine presumes — such as the absolute benefit of health — show its heritage and its potency as a “cultural good”. Articulating or expressing ourselves: Medical practice has given us abundant material for artistic, literary or other creative purposes, arising, perhaps naturally, from the linear and “narrative” form that illness, disability, treatment and recovery seem to take. Thanks to the episodic form that clinical medicine acquires in individual clinical cases, intimate and compelling aspects of the experience of being human are explored in literature as diverse as Chekhov’s A case history,2 Camus’ allegorical The plague,3 and John Sayles’ film Passion fish.4 Of course, medicine is not unique in providing material for creative reflection on life’s conditions: all of lived experience does this. I simply want to note that medicine amply satisfies this characteristic of a “cultural good”. Developing ourselves: By contrast with the dominant theological determinism of earlier ages, according to which bodily suffering was seen as a necessary part of our journey through “this vale of tears”, medicine apparently offers a reassuring alternative, placing us within a flawed but eminently improvable natural world, from which we could in principle remove the deadlier stains, be they smallpox or polio or, in utopian mood, congenital anomalies. If, for most humans, life in the time of Thomas Hobbes was truly poor, nasty, brutish and short,5 medicine has already improved the odds and has ambitions to do vastly more. In the process, it has extended the range of stories we can tell about ourselves and about the human condition. It confirms our development beyond fatalism (Box 3). Criticising ourselves: Medicine has given us a vocabulary of criticism, whereby we draw on health, sickness, diagnosis and treatment for images that capture larger areas of our experience — think of “the body politic”, of “healthy” and “unhealthy” behaviour, societies or subcultures. The general idea of “diagnosis” has colonised human affairs, giving us a model of what it is to function well or badly in the social and cultural arena; we commend processes, teams and institutions for their “organic” development, and condemn them for their atrophy, decay or paralysis. Of course, this — sometimes dangerously — implies a rhetoric for action:6 to call one thing a treatment, remedy or therapy is to impugn some other things as a pathological problem in need of change. We now have “remedial” processes in education, in management, in urban regeneration. Certainly, there are grievous problems in these areas, but the vocabulary of remedy and therapy spuriously distinguishes expert agents from lay “patients” in matters where public dispute ought to remain legitimate. Encountering ourselves: This final aspect is perhaps the most interesting and suggestive. One of the conceptual foundations of medicine is the assumption that what lies beneath, or inside, holds the key to what lies outside or on the surface. Gross clinical pathology is explained by disruptive processes at the cellular or even molecular level. The once-astounding optical microscope now seems no more than a feeble and naive beginning: the slice-by-slice scanning of computed tomography, and the “unpeeling” made possible by magnetic resonance imaging, give us a new visual vocabulary for human nature (Box 4). By making the invisible become visible, we invert surface and substrate, seeming to locate the truth about ourselves at the level of physiology and neurology — rather than at the level of the ordinarily visible face and whole body, where we as selves ordinarily function and experience. The “medical body”7,8 is itself a substantial, if incomplete, story of encounter with the human condition, and one that invites critical interpretation and imaginative response. In all these respects, modern medicine is indeed a “cultural good”. The challenge that we face is to find an adequate response to the persuasive power of its reductionist picture of human nature and the human condition. Today, in the West, this picture is virtually unopposed by earlier claimants for our adherence: religious, Marxist or psychoanalytic world-views. We have an opportunity to reinvigorate enquiries into human nature within the established humanities disciplines — prominent among them being philosophy, recently rather coy about asking the real “meaning of life” questions.9 As a philosopher, it seems to me that coyness is no longer a serious option in the face of a story of human nature rooted at the molecular level. If we are to create a more satisfying conception of the human condition, it is time we recognised the need for a re-engagement between the humanities and medicine. All illustrations reprinted with permission from The illustrated history of medicine, by Jean-Charles Sournia. Published by Harold Starke. 1 The anatomist Vesalius, by Pierre Pons All knowledge is partly concerned with the knower. 2 Insulin molecule We have an inner compulsion to understand and demystify Nature. 3 Public health poster, post World War II Medicine’s promise to improve the human condition confirms our development beyond fatalism. 4 Magnetic resonance image of the brain Grey matter appears reddish-brown, and white matter green and blue.

H Martyn Evans BA, PhD

Re: “The hidden tragedy of offender deaths”, the editorial by Stuart Ross in the 1 November issue of the Journal (Med J Aust 2004; 181: 469-470). The reference numbering in the text is incorrect because of a computer error. In the first 3 paragraphs, references 12, 13, 14 and 15 should be references 1, 2, 3 and 4, respectively. All other references are correct, except for reference 13 in the last paragraph of the text, which, again, should be reference 2. The html and pdf versions of the article published in the eMJA were corrected on 17 December 2004.

Stuart Ross

How did I come to be in East Timor? That is the exact question I asked myself upon arriving in Dili, the national capital, with my husband Ben, our 2-year-old son Oscar and 6-month-old daughter Chloe in tow. It was very hot and humid and there was a real threat of a looming dengue epidemic from Indonesia. My anxiety for the health of our children was in no way eased when, a few days after our arrival, an Australian expatriate asked, “What sort of a place is this to bring kids?”. Main entrance to the Dili National Hospital I had been aware of a program coordinated by Eugene Athan, an infectious diseases physician, whereby Australian physicians could work at the Dili National Hospital. As an infectious diseases physician with an interest in medicine in developing countries, and having been assured of the political stability of the country, I put up my hand to go. Ben was able to take time off work to care for our children. After many months of planning, multiple vaccinations, and reassuring family and friends of our safety and wellbeing, we arrived in Dili in late January 2004. The Dili National Hospital is run by the East Timor Ministry of Health. The hospital medical staff consists of overseas visiting specialists, Indonesian emergency department doctors, and Timorese resident doctors working on the wards and in the outpatient department. There are no locally trained specialists — a major limitation to the long-term goal of having an autonomous Timorese hospital. I worked on the women’s medical ward for 2 months. While not arduous, the work was emotionally draining. In my first week, there were three postpartum deaths due to presumed sepsis. Like anyone, I found this difficult to deal with, but being there with my family, and still breastfeeding Chloe, made it even harder. My emotions were fuelled by the thought that one family now consisted of a husband without a wife, and four kids without a mum. The harsh reality of the estimated maternal mortality in Timor (around 800 per 100 000 live births) is that this family circumstance is not uncommon. Despite Portuguese being the official language, the majority of Timorese people speak either Tetum, Indonesian, or one of 16 indigenous languages. As my Tetum capabilities were limited to pleasantries, I relied heavily on certain hospital staff to interpret for me. Needless to say, taking an adequate history and communicating with the patients and hospital staff proved to be a challenge — like a combination of charades and Pictionary. The language barrier became even more difficult towards the end of my stint, when a Chinese medical team arrived that included doctors, a nurse and a translator. They had spent 6 months learning Portuguese, which, despite the best of intentions, was of no practical use to the majority of people at the hospital. One of the beaches within an hour’s drive of Dili. These were a favourite place for expatriates and United Nations staff to gather on Sunday afternoons. The hospital was serviced by hospital and national laboratories that performed basic testing, which was intermittently available and of variable standard. Malaria films were regularly performed, with frequent positive results. Biochemical tests, including tests for urea and creatinine, were not available during my stay. Minimal microbiological investigations (including tuberculosis smears, and serology for HIV, hepatitis B, hepatitis C and syphilis) were available. Pathology specimens were sent to Australia, with a 6–8-week turnaround time. The major medical problems I encountered at the hospital included tuberculosis, malaria, renal failure, heart failure, thyroid disease and hypertension. As all patients had varying degrees of malnutrition, I kept them in hospital for as long as possible, knowing that the hospital would provide nutritious meals. Of concern was the lack of a single positive sputum smear test for acid-fast bacilli during my stay. For whatever reason (be it deficiencies in collection, transport, processing, laboratory technique or reporting), all sputum smears were negative. Aware that this could not be accurate, I introduced antituberculosis therapies in patients for whom there was a high suspicion of tuberculosis based on clinical features and x-ray results. Of greater public health concern was the lack of mycobacterial culture and sensitivity testing facilities. A national tuberculosis control program has been established to monitor patients during treatment, but some patients did not complete their therapy and it is unclear whether drug resistance is a problem. It was hard to believe we were only a 1-hour flight away from Australia. Drug therapy options were limited to an essential drug list; however, even these, at times, were unavailable. Although we had previously worked in Africa, we found it difficult to comprehend that the national hospital of one of Australia’s close neighbours could have such limited resources. Despite their many hardships and difficulties, I was touched by the loving nature and strong sense of family among the Timorese people. They were very receptive to us as a family, but we certainly raised some eyebrows. For starters, I was working while Ben stayed at home with the kids, which many locals found amusing! Ben spent most of the time fighting off malaria and dengue-carrying mosquitoes and keeping the kids and himself cool by whatever means, including a staple diet of ice-cream for the kids and beer for himself. During weekends off, we were able to hire a car and explore many beautiful parts of the country. Having spent only a short period of time at the Dili hospital, I was grateful for the welcome I received and the warmth of the hospital staff. Upon leaving, I felt I had contributed to the health of my patients, and yet had a deep sense of sadness because it seemed that the healthcare system may worsen before it improves. So, were we foolish to take our kids to Timor? On the contrary — we believe that we took them to a place full of caring, loving and welcoming people who deserve the chance to live a better life.

Carolyn L Beckett MB BS(Hons), FRACP

Your position never gives you the right to command. It only imposes on you the duty of living your life so that others can receive your orders without being humiliated. Dag Hammarskjöld, UN Secretary-General, 1953–1961 awarded the Nobel Prize for Peace I grew up in Canberra in the 1920s and ’30s, then, as now, a planned and favoured town awash with politics, politicians and public servants. Although interested in these dynamics, our caring, skilled family doctor was the person who most impressed me. John James FRCS was our community’s quiet medical leader, later recognised through the John James Medical Centre, now part of Canberra’s teaching hospital system. My parents were typical of their time. My father had emigrated from Britain in his teens and served in France in World War I. He was a public servant with the Federal Capital Commission (which from January 1925 was responsible for the planning and development of Canberra). He had a vocational flair for amateur theatricals of music hall and comedy genre. My mother was a capable homemaker. We became aware of the Great Depression just about the time my sister was born. My parents combined to have our large yard supplement our pantry. Mother became a genius in food preserving with the Fowler Vacola steam preservation kit, providing a great variety of foods. As children, my sister and I had warm and strong emotional, social and aspirational support, but our choices for our futures were our own. My parents offered two aphorisms: “Hard work is not lethal” and “Loyalty and fairness are necessary for success”. I have not found either to be wanting. In choosing a career, medicine held no competitor for me, although I dallied momentarily with veterinary science. I experienced the grief of three of my school classmates succumbing to diseases that now rarely cause death: poliomyelitis, mastoiditis and diphtheria. Polio returned to the class several times, and, although not lethal, it was damaging beyond reason, both physically and psychologically. Polio, in particular, marginalised those it affected. I felt that more could be done to alleviate this unfairness. “The effect of a teacher may be infinite”My undergraduate days during World War II were spent at the University of Sydney and at St Vincent’s Hospital, Darlinghurst. I commuted daily on the on-time “red rattler” (today we say “if only”) and travelled between campuses on the tram. Hospital life as a student was immensely fulfilling, and I matured among competitive peers. Two of my tutors made these days particularly memorable: Justin Markell, the meticulous, kindly physician in outpatients, and Douglas Miller, later Sir Douglas Miller, who became a leader in neurosurgery and President of the Royal Australasian College of Surgeons. Both encouraged and taught a careful approach to physical examination, diagnosis and patient care. They provided a sound basis for my future clinical endeavours. I became a junior resident at Marrickville District Hospital in 1947. At that time, 18 months to two years after graduation saw most graduates enter general practice. I also aimed to do so. Marrickville Hospital was general practitioner oriented, with specialist honorary staff drawn from Royal Prince Alfred Hospital. These included role models like the late Sir Thomas Greenway, a charismatic, thoughtful and instructive physician, and Frank Mills, a friendly, insightful surgeon who had made his reputation in Changi and Sandakan in World War II. He visited his patients often and always left a dusting of his knowledge on the junior staff. Looking further afieldAfter 18 months and still attracted to general practice, it was time to move forward. Two positions presented themselves: one for a medical officer on Macquarie Island, the most southerly point of Oceania in the Australian Antarctic Basin; and the second, for Medical Superintendent at Collinsville, a small coal mining town in north Queensland. My colleague Bob Allison and I applied for both and were interviewed together by the Antarctic pioneer, Phillip Law, in front of the dying embers of the log fire in the common room of the (old) University Club in Phillip Street, Sydney. Bob went to Macquarie Island and I to Collinsville. As the only doctor in town, I enjoyed 18 months of rich clinical experience. Post-term obstetric deliveries, head injuries, critically ill children, motor vehicle accidents and accidents involving horses all hastened my clinical maturity. I remember a young jackeroo with a perinephric abscess after a nasty horse-related accident. As we were stranded by floods at the time, a surgeon in Mackay took me through the operative steps by phone. All ended well. The community was full of reliable, loyal Aussies with enormous hearts. They were openly friendly and had a great bank of skills, and gave their local doctor the comfort often absent today. An outbreak of croup in some young children was the most formidable of my experiences. They desperately needed steam inhalation, but I was a little nonplussed as to how to supply it. One father spoke with his boss at the mine workshop, who rapidly produced a large galvanised watering can with four arms, each capped with a watering-can rose. Placed on a primus stove, this device effectively dispensed steam to four mosquito-netted cots simultaneously. Problem solved! Surgeon by serendipityI was no longer sure that I wanted to pursue general practice and planned to undertake postgraduate work in the United States. I applied for several positions and was appointed to a rotating internship at Albany Medical College, New York State. At my request, it included a term of psychiatry. I arrived to take up my appointment in 1950, just as the Korean War began. Given my previous surgical experience, I was promptly moved from psychiatry to surgery. The experience was life-changing. As the American surgical residents were drafted to Korea, I was promoted after six months, subsequently accepting the offer of five years’ graduated surgical training in the Halsted tradition at Albany Medical Center. William Halsted had been Foundation Professor of Surgery at Johns Hopkins University in Baltimore, and laid the basis for graduated surgical training. This proved to be five years of restricted finances, but top professional fulfilment and growth. My workday would start with 5.30 am ward rounds (before the chief arrived at 7.30 am), followed by a day in theatre, then admissions and lab work before falling into bed. How much more civilised work practices are today. I was embarrassed when my previous senior resident returned from Korea to be my junior, and his view “c’est la guerre” was most generous and the basis of a long friendship. My training was predominantly in general surgery (with much exposure to thyroid surgery) and included my introduction to clinical investigation, which initially centred on bleeding varices and the monitoring of serum ammonia concentration.1 A three-month exchange with the Women’s Clinic at Johns Hopkins in Baltimore allowed me to work under the dynamic Richard Te Linde, Head of the Gynecology Department. Another privileged memory was witnessing the early development of cardiac surgery, as Alfred Blalock, under the watchful eye of cardiologist Helen Taussig, performed his “blue baby” procedure for tetralogy of Fallot and for alleviating the effects of congenital cardiac defects.2 My final 18 months were spent in Albany in thoracic surgery at the time of its greatest development, as the pump oxygenator was introduced. These five years were shared with a global workforce from 27 nations including Japan and Germany. The chiefs of medicine and surgery offered opportunity and education to all, hoping to heal wounds from World War II. This global experiment was clearly ahead of its time, and resulted in many firm international friendships. Being Australian was a significant plus, as Australia was popular after its Pacific role and genuine friendliness to US troops. In 1953, I married Mary Jo, whom I met in the operating room at Albany Medical Center. She has been my loyal supporter and valued confidante since. Return to Australia — spreading my wingsI returned to Sydney in 1955. Many doors were initially closed, but, with recommendations from mentors, I was eventually employed by Frank Rundle, Director of the Unit of Clinical Investigation at Royal North Shore Hospital (RNSH). After six months I received a full-time research fellowship with clinical responsibilities in my areas of interest, giving me the opportunity to be involved in thyroid surgery and studies; isotopes and cancer chemotherapy; a prospective database for thyroidectomy; and ultrasound of the breast. Thyroid clinic: I worked with Rundle in his multidisciplinary thyroid clinic and helped develop an animal experimental facility. This brought me into contact with Ian Monk, a cardiothoracic surgeon, who, with a pump expert, Viv Ebsary, was exploring open-heart surgery.3 The use of animals for experiments caused significant angst, especially when clandestine activity was required — such as transporting anaesthetised sheep by wheelbarrow to a ground floor angiographic facility for experimental studies. From such humble beginnings, the entire unit later evolved to become the Wellcome Laboratories. Rundle was a perfectionist, demanding that our every activity be of the highest safety and quality. The preoperative checklist was instituted (now indispensable in modern risk management) to ensure nothing was omitted in preparing patients. Every operative step was to be as haemostatic as possible,4 and postoperative care empathic and supportive. These requirements became expected of all who worked or trained in what later became the University of Sydney Academic Surgical Unit at RNSH. Cancer chemotherapy: A grant from the NSW State Cancer Council in 1958 enabled me to spend four months with cancer specialists Joe Burchenal and David Karnofsky (known for the Karnofsky Performance Scale for assessing terminally ill patients) at Memorial Sloan-Kettering Cancer Center in New York. I returned to initiate the provision of cytotoxic therapy at RNSH, which later established a formal medical oncology unit. Even then, the need to embrace randomisation and the careful accrual of evidence was seen as crucial.5-7 Thyroid database: On leaving the United States in 1955, I had been encouraged by my surgical mentors to embrace the computer age and “develop a prospective databank to record progress and results” — “outcome” as a word was still aborning. Our first cases at RNSH were accrued in 1957 and, over time, we honed the database into a useful clinical and research resource. All thyroid and parathyroid surgical procedures by the Endocrine Surgical Unit at RNSH are recorded, and at my retirement in 1988 numbered 10 000 entries. Intrathoracic goitre: During the period of compulsory mass x-ray surveys for pulmonary tuberculosis in Australia between 1948 and 1975, many people were diagnosed with intrathoracic goitre. A prevalence study we conducted in metropolitan Sydney in 1953–1956 showed that intrathoracic goitre occurred in 1/5040 subjects examined (compared with 1/750 with active tuberculosis and 1/3500 with lung cancer) (Box 1). Unexpectedly, the prevalence of intrathoracic goitre was about three times greater among people born in England (then the main source of immigrants) than in those born in Australia.8 Diagnosis of intrathoracic goitre improved with the introduction of computed tomography scanning, as did the safety of operative procedures. We used a surgical approach based on embryology — a transverse incision in the lower neck (a collar incision) — delivering the goitre into the neck, which, with appropriate control of vascularity, resulted in minimal sternal splitting and avoided a transthoracic approach.9 This technique was refined over time with much input from surgical colleagues Alan Poole and Leigh Delbridge (and the surgical registrars) and particularly our anaesthetist Bruce White. Superb scrub and bedside nursing helped to ensure success. This led to a rethink in the treatment of recurrent goitre and provided leadership in optimising total thyroidectomy for nodular goitre, now a widely accepted procedure despite earlier controversy.10-13 Breast ultrasound: A visit to RNSH in 1962 by George Kossoff (who with David Robinson in 1961 built the first ultrasound scanner at the Commonwealth Acoustic Laboratories) led to another fortunate and fruitful long term collaboration — ultrasound of the breast (Box 2). Surgery — academic and vascularIn 1961, Academic Clinical Units were established at RNSH, with the support of Sir John Loewenthal, then the Chair of Surgery at the University of Sydney. I was appointed Senior Lecturer in Surgery and subsequently became the inaugural Professor of Surgery in 1974. I believed, like Osler (quoting John Henry Newman), that: “An academical system without the personal influence of teachers upon pupils, is an Arctic winter.”18 Students were involved as far as possible in all unit activities, and teaching students and residents in the operating theatre became a major thrust of our program, although initially we were limited by a lack of full-time teachers.19,20 Graham Coupland was appointed senior lecturer in surgery in 1967 and was as great a friend and associate as I could have hoped for. With fellow surgeon Harry Cumberland, and encouraged by Douglas Piper, Professor of Medicine, he refined the investigation and surgical treatment of peptic ulcer, for which their preferred procedure was highly selective vagotomy.21 Coupland’s untimely death in 1982 came at a time of unit growth, as we taught exceptional undergraduates, trained bright young people of integrity, and produced quality surgery and research. Vascular surgery was developed by Douglas Tracy with my assistance.22 However, with his departure to the University of New South Wales in 1961, this specialty grew very demanding of those remaining — Ray Hollings, myself, and later Graham Coupland. Ruptured aneurysms, which require immediate surgery, became the bête noire of our social and family life. At that time, pagers, which were the size and weight of a house brick, only emitted an alarm, and a telephone call determined the reason for the call. In 1977, RNSH agreed to the appointment of a full-time academic vascular surgeon, Michael Appleberg, an excellent leader who took the department through to substantial strength in surgery,23 research and training. A stream of overseas and domestic visitors and interactive visits between the RNSH unit and overseas units promoted clinical and research strengths (Box 3). RetirementAll these activities have provided a springboard for continued enjoyment of life after I retired from academia in 1988. Elected President of the Royal Australasian College of Surgeons in 1989, I have travelled extensively in Australia and New Zealand. This experience has reinforced my perception that the exceptional compassion and service given in war are still given in peace. Australasian surgery and surgeons stand high with me. I was asked to report on quality assurance in clinical management to the Australian Government Department of Health,24 and now follow with interest the progress of the Australian Council for Safety and Quality in Health Care. As Chair of the working party developing the Clinical Practice guidelines on the management of early breast cancer25 and as a member of the board of the National Breast Cancer Centre (1995–2003), I have found it very satisfying to see women empowered to handle a life-threatening disease. Working with the Cancer Council Australia and the Clinical Oncological Society of Australia to develop the Australian Cancer Network has, since 1994, also kept me happily in contact with clinicians and consumers in promoting better cancer care. I have also maintained a clinical interest through surgical assisting. I have more time to “smell the roses” and travel with Mary Jo to see friends and enjoy our grandchildren in the United States, with side trips to Europe. I read more, but am unable to keep up with all the good books that are published. I also have time to think over the contrasts between then and now and what is to come. Surgery in 1947 was more uneven than today. There were top-level surgeons who performed to their level. A good deal of surgery, however, was done in small hospitals across the community, and too frequently exploratory laparotomy was performed for an obscure diagnosis. The limitations were primarily in training and diagnostic technology. The idea that doctors “owned” the patients was diminishing, but still prevalent. This limited patients in obtaining a second opinion, when perhaps it should have been embraced. I have observed changes and been pleased to have the opportunity to be involved, and sometimes been supportive in promoting change. Strong academic units centred in training hospitals across Australia have, together with the Royal Australasian College of Surgeons and specialist surgical societies, embraced strong mentoring and graduated and proficient training. The quality of surgery and hospitals has been improved by these educational and vocational developments. Australian patients have access to surgery of the highest quality. The future for surgery should know no limits, with increasing precision of diagnosis, limited wounding associated with surgical access, and developments in pharmacological and genetic interventions. Surgeons will be expected to understand and fully explain the complexities of many new approaches to treatment, some of which will not be operative surgery. The psychosocial aspects of surgery will reinforce the benefits patients should enjoy from the science and art of surgery, in which the level of trust between surgeon and patient must remain inviolable. I am delighted that opportunity for betterment for patients expands apace. Fortune has indeed smiled on me. As I look to the future, remembering colleagues, nurses, students and patients, I remain aware that I have gathered a posy of other men’s flowers and only the ribbon which binds them is mine (Sanskrit). 1 Age distribution of intrathoracic goitre detected by mass x-ray surveys for tuberculosis (1953–1956) Source: Reeve et al8 2 Development of breast ultrasound imaging — from weather maps to quality images Initial attempts to develop breast ultrasound involved many women volunteers and a bistable waterpath machine, which provided linear, sector and compound scans. Sonograms were initially derived through a water bath in contact with but above the patient. Water sometimes spilled (Figure A), or leaked (Figure B), saturating staff and patients, but not dampening their enthusiasm. Technology (Figures B and C) rapidly improved the quality of sonograms, and, in 1974, the patient’s comfort (Figure C). With Kossoff and his associate, Jack Jellins, ultrasonographer Kaye Griffiths and her team, surgical registrar Bruce Barraclough, and sonograms from our volunteers, we were able to determine the “normal” sonographic appearance of the breast. It was hard going until Kossoff introduced “grey-scale” contrast into sonography,14,15 which allowed tissue contrast and better identification of breast disease, a principle later applied to virtually all tissues16 and “leading to the widespread adoption of ultrasound throughout the world.”17 Ultrasound now plays a significant role in breast cancer diagnosis — no more wet shoes and soaked patients! A. CAL Closed water bag breast echoscope (1966). The bag was lowered onto the chest, and the transducer moved through the waterbath. Coupling with the skin was incomplete and the breast compressed. B. CAL Open water bag breast echoscope (1968). This method allowed for improved coupling to the breast and removed the problem of compression of tissue. The breast floated freely in a water bath. C. CAL Open water tank breast echoscope (1974). A new approach, patient prone and breast freely floating, thus eliminating the need for coupling drapes. (Photos courtesy of George Kossoff.) 3 International Surgical Week — International Association of Endocrine Surgeons, Hong Kong 1993. Back row: Joe Tjandra (Melbourne), Tom Reeve, Leigh Delbridge (Sydney). Front row: Raj Nambiar, Abu Rauf (Singapore), Martin Liepins (Riga, Latvia).

Tom Reeve AC, CBE, FRACS, Emeritus Professor of Surgery, The University of Sydney

At seventy-seven it is time to be in earnest Samuel Johnson — A journey to the Western Isles of Scotland Nothing about my life has been planned, including medicine. When, to my surprise, I obtained one of the rare scholarships then available to the University of Sydney after the Leaving Certificate, I asked my father what I should do. “Medicine”, he said, “that’s a good career for a woman”. So, despite having no sciences and braving the fierce opposition of my Latin teacher, I obeyed. Nor did I know, even after graduating, what field of medicine to aim for, having spent much of my undergraduate years at Arts lectures and playing bridge. After doing the odd locum and a bit of general practice, I married a naval aviator and had six children. This removed me from medicine for 13 years. Returning to Sydney from Perth (following the fleet) and being short of money, I went to Royal North Shore Hospital (RNSH) and asked to do a refresher course by attending outpatient clinics. Although feeling like a middle-aged frumpish housewife, I was treated by each of the senior consultants, all men, with the utmost courtesy. I have honoured RNSH ever since. It was not easy to get a job. I worked first at Grosvenor Diagnostic Centre, assessing children with intellectual disability. The medical officers were at the fringe of a revolution in genetics, constantly learning about recently discovered syndromes and how to identify these as the underlying causes of the conditions in the people we saw. Yet, we were not esteemed by the medical profession, who referred to us as “guardians of the waiting list”, because we assigned priority to those most urgently in need of the few residential care places available. Our chief concern, however, seemed to be for the parents, and how to reconcile them with the pain of accepting that their children were “different”. From institutions to community careWhen my husband was posted to Melbourne, I worked in a large institution in Victoria, which taught me a lot about institutions and the danger of just accepting what occurred in them. I remember admitting a teenage boy, clinging to his tearful mother. She was at last persuaded to leave, too soon to notice that his bed had no pillow. I asked for one, but the busy charge nurse’s reply was, “I won’t allow pillows in my ward. They might fight with them or smother themselves”. Of course, we were understaffed, the few staff we had were overworked, and the residents had little supervision. So little, in fact, that one girl wandered out of her ward one night and fell into an uncovered hole containing a steam pipe — she was scalded to death. When I recollect this tragedy, I find it hard to accept the pious phrase “the dignity of risk”, which is too often used to justify neglect of people in residential care. Returning to Sydney, I was lucky to be at the start of the deinstitutionalisation program in New South Wales, but soon realised that this was not to be an easy path. Among the first people to move were a group from a large institution on Peat Island. They moved into a small cottage in Hornsby, and soon the neighbours were complaining, not because of discrimination, but because of the frequent noisy quarrels among the four residents about who should do the dishes! Human nature is no different whatever the IQ level. This same quartet looked marvellous — dressed for the first time in dinner jackets and evening gowns — for their first formal, a ball in Hornsby. As I grew older, I became interested in exercise and nutrition. I started to jog in the streets near where I lived, embarrassing my children and husband. It felt so good that I wondered how exercise would work for people with a disability. I obtained a Master of Public Health degree by doing a simple research project on this subject. Then RNSH allowed me to start a health promotion clinic for adults with developmental disability. This was soon enhanced by the arrival of a dietitian, Lyn Stewart, and an exercise physiologist, Caroline Bruce, and we became very busy. It was obvious to me that my colleagues, using nutrition and exercise, improved health faster than I did. Caroline also organised the people into teams and they went for trips at weekends, playing indoor cricket and soccer, and returned with amazing stories of their hijinks. This was a time of fanatical adherence to the philosophy of normalisation — all people with disabilities should live in the community, whatever their special needs, and participate in all community activities. Our staff struck some unrealistic expectations, including carers who refused to be involved in our sports programs, one proclaiming, “We’d rather our residents sat at home all day and never exercised, than take part in segregated activities.” We ignored these thought police, and took one group ourselves for their first sight of snow to luxurious quarters donated by a generous hotelier. At breakfast they sat down to silver and snowy table linen. “Oh look!” said one delighted young man, “we are going first class!” A trip to the snow Royal North Shore Hospital Health Promotion Clinic for Adults with Developmental Disability enjoying a weekend in the mountains. Latin and the logic of epidemiologyThe best teacher I ever had was a Dominican nun, Sister Anselm. She made me love Latin as much as she did. I later took the same delight in epidemiology, the closest thing I have found to thinking in Latin. This prompted my postgraduate studies in public health, completed with a part-time scholarship (awarded to promising public servants in the enlightened practice of the day). I applied epidemiology to the little-studied burden of disease in our patients, in whom I noticed diverse chronic and complex health problems. I obtained a Research and Development Grant from the Commonwealth Department of Community Services and Health for the first population study of health disorders in people with intellectual disability. This showed that, of a random sample of 202 adults with intellectual disability, each had an average of 5.4 medical disorders, half of which had not previously been detected.1 Colleagues in Victoria and Queensland reported that these findings supported their argument for specialised health clinics in those states. Not so enlightened were authorities in NSW, who closed the RNSH Health Promotion Clinic, in the face of many objections. The Department of Community Services’ mys-terious decision ended what was, as far as I know, the first health promotion clinic of its kind in the world. Since then I have tried unsuccessfully to reopen this clinic. An attempted retirementAt that stage, RNSH enforced retirement at the age of 65 years. I was a bored, cross, retired person, so I leapt at the chance to work for a while at Stockton Centre, a large NSW institution for people with intellectual disability. The enlightened administrator at the time, Lorraine Yudaeff, asked if I could find someone to assess the nutrition of the residents. I recruited Lyn Stewart, who had worked with me at RNSH. Lyn ran a tape-measure over some emaciated residents and recommended an enriched diet. This resulted in another study showing that 69 of the multiply-disabled residents in this 550-bed institution were severely underweight, with low levels of vitamin D, iron and folate. They were given a diet with increased caloric density for 12 months, with significant improvements in weight, in serum calcium and vitamin D levels, and in haematological indicators.2 We succeeded in increasing the weight of some very hungry people, but not without protest: one carer said we had ruined the quality of life of an adult resident who now weighed more than his previous 20 kg. He required two people, instead of one, to lift him, and was considered too heavy to take on outings, as they had no hoists. However, the noble staff of Stockton rose to the challenge. Several residents now verge on the overweight, not underweight! As a result of this work, there is now a policy of screening the nutritional and swallowing status of all people with intellectual disability in residential care in NSW. Microarrays — miniaturised assay systems allowing the structure and expression of thousands of genes to be evaluated My mentors and medical detective work I first met Professor Gillian Turner as her locum at Grosvenor. Gillian is now known internationally as a geneticist and has done the fundamental work on identifying the Fragile X syndrome, the most common inherited genetic cause of intellectual disability. This work began when Gillian was a medical officer at Grosvenor and introduced me to the intellectual fascination of dysmorphology and genetic disease. I enjoyed being a medical detective and identifying syndromes. The explosion then occurring in genetics is about to recur, with new technologies such as microarrays (Figure) that will make diagnosis more accessible. Given that a diagnosis can make all the difference to prognosis and treatment of associated physical disease or behavioural phenotype, a group of people much ignored by medicine will be taken more seriously in the future. I once excitedly asked Associate Professor Aidan McElduff (Endocrinologist) in the corridors of Royal North Shore Hospital whether a patient I had referred to him could have Kallman’s syndrome. Aidan looked surprised and said he supposed she could. This turned out to be the underlying aetiology. I was in awe of Aidan’s many qualifications and his far greater knowledge of medicine, but he has since become a mentor, a coauthor of published articles, a collaborator in studies on osteoporosis and hypogonadism, and an expert on the endocrinology of intellectual disability. Aidan once thanked me for introducing him to a new medical specialty, Intellectual Disability Medicine. Battling medical nihilismIt was generally considered inevitable that people with intellectual disability die young, which prompted Seeta Durvasula (Medical Lecturer in Developmental Disabilities, Centre for Developmental Disability Studies, University of Sydney), Wes Baker, Senior Planning Officer, Northern Sydney Health, and myself, to investigate mortality rates in a previously identified cohort of 693 people with intellectual disability in northern Sydney.3 We found that the death rate was five times higher than that of the general population of Sydney’s Lower North Shore.4 Furthermore, the causes of death were quite different from those in the general population, being predominantly respiratory disease and accidents. Seeta Durvasula recently presented data from this ongoing study at an international conference, showing that up to a quarter of these deaths were preventable. Contributory factors, such as inadequate supervision, delayed presentation and delayed diagnosis of illness, were identified. The challenge is now to reduce premature mortality and to treat remediable disease. The NSW Ombudsman is charged with the responsibility for reviewing all deaths of people with disabilities in care, looking at the causes and patterns of death and recommending ways of improving services to reduce early or preventable deaths. This important initiative has been noted internationally and may be replicated in Scotland. We also need to beware of medical nihilism. It is one thing to strive officiously to prevent the demise of an elderly person ravaged with disease. It is another thing to deny treatment to a young person with spastic quadriplegia who is enjoying life but swallows unsafely. I am reminded of a senior consultant with whom I discussed the need for supplementary feeding in some young individuals. “Why treat them”, he said, “aren’t they just vegetables?”. An international movement in intellectual disabilityI presented papers at meetings of the International Association for Intellectual Disability (IASSID) every four years, but found health professionals at these conferences often cowed by our non-medical colleagues, who considered us relics of the past, detested institutions. Encouraged by the then Australian President of IASSID Professor Trevor Parmenter (now Foundation Chair and Director, Centre for Developmental Disability Studies, University of Sydney), a Dutch physician Professor Heleen Evenhuis and I formed the Health Special Interest Research Group of IASSID. This Research Group now has yearly international meetings, and its achievements include developing health targets for adults with an intellectual disability.5,6 These targets address conditions that are highly prevalent, easily identified and amenable to available treatments (eg, regular assessments of hearing, especially if communication problems exist, and of dental and ocular health). The targets have been accepted by IASSID and presented to the World Health Organization for ratification. The future: developmental disability medicineA medical specialty will be established in this field. In The Netherlands, such specialists already exist, while, in the United Kingdom, psychiatrists who have specialised in learning disability are often attached to multidisciplinary teams working with people who have learning disabilities. It is clear, too, that doctors with such specialist knowledge must collaborate with nurses, psychologists, dietitians, speech pathologists, physiotherapists and occupational therapists. If it is possible to have multidisciplinary teams in aged care, such teams should also be available for people with disabilities. Of Australia’s total population, 1.86% have an intellectual disability.7 Thus, this group of people constitutes a population about the same size as our Indigenous population. In my opinion, a specialist clinic at each teaching hospital in Australia is required to support general practitioners caring for people with intellectual disability. In Victoria and Queensland, at least, university-affiliated academic centres for developmental disability provide government-funded medical services. In NSW, the Centre for Developmental Disability Studies at the University of Sydney is not so funded, but has helped me to establish a medical clinic with two other doctors, funded by billing Medicare. Our six-month waiting list illustrates the level of unmet need. Australians with disabilities —predominantly receiving pensions and with no political clout — are caught in a dysfunctional system. Formal responsibility for health and other services has largely passed from the federal to the state governments, with further buck-passing between health and social service departments within the states. Yet, much of their healthcare rests with GPs, funded by the federal government. I was founding chair of the NSW-based Association of Doctors in Developmental Disability (ADIDD), which lobbied for people with disabilities and their need for specialised health services. As it became obvious that this was a national problem, we have now formed the Australian Association of Developmental Disability Medicine (AADDM), which aims to establish national standards in healthcare delivery, lobby federal politicians, issue policy documents and position statements, and, eventually, train specialists in this field. I am lucky to have been present at the beginning of a new branch of medicine. I hope that advances in genetics will eventually lead to a therapeutic revolution for people born with intellectual disability. Meanwhile, we need more medical champions for this vulnerable but silent minority. Receiving an award Member of the Order of Australia (AM) in 2004, receiving the award from Her Excellency Professor Marie Bashir, Governor of New South Wales (left).

Helen P Beange AM, MB BS, MPH, FAFPHM

Weeks after beginning its winding journey, a redirected letter finally finds its destination. In our eagerness to open it, we almost tear in half the neatly folded crisp white sheet that lists a series of results: angina, pass; asthma, pass; preeclampsia, pass; bulimia, fail, could not elicit history of vomiting; croup, pass. The list continues to a dispassionate conclusion that the candidate has demonstrated adequate knowledge at the examinations of the Australian Medical Council (AMC) to secure a passing grade. The accompanying card graciously thanks us for our tutoring 1 year ago. We stare wordlessly at the sheet, our joy obliterating its sterility. So far, he has fled state persecution, worked 10 years in a factory, and supported a family of four on a minimum wage. The iatrogenic death of his father served as a powerful impetus to return to his calling in life, medicine. Forty years old, he has juggled swimming and soccer lessons, school homework and, lately, running a small business to steal time to prepare for his own examinations. “I promised myself at my father’s bedside that I would go back to medicine. Every day in the factory, I used to dream about becoming a doctor again, but we needed that job to survive.” Now he will forever be known as an “AMC”. As we exuberantly write him a congratulatory note, a vision of his journey ahead involuntarily crosses our mind. As he begins his quest for a job, he will quickly learn that, although all foreign graduates seeking to enter the Australian medical system must take the AMC exam, the term “AMC doctor” automatically carries the connotation of inferiority. Irish, American and German doctors will be identified by country, while he and his peers from the developing world will be separated by an invisible, but distressingly tangible, line. Deeming himself unsuitable for the elite hospitals, he will apply instead to those considered more “foreigner-friendly”, their reputation earned not necessarily for their greater tolerance of foreign graduates, but because of their inability to attract the more aspiring. These hospitals too will first select local graduates before yielding the leftover spots to the AMCs. At the scant interviews he secures, he will be summarily discarded at some on account of his thick (yet understandable) accent and his slow (yet considered) speech. At others, he is unlikely to receive ticks in the boxes that say “team player”, “enthusiastic” and “makes good eye contact”, because he is unfamiliar with the buzzwords and gestures (although not the inherent concepts) that interviewers seek. His first job is almost certain to be in a hospital staffed largely, if not almost exclusively, by foreign doctors. Collegial support will be tentative, the focus being on surviving each day without raising the staff’s ire. He will be greeted cautiously, unaware of an unspoken probation, and he might only enjoy a few days’ grace before barbed remarks escape their loose restraint. Despite his commitment, he will be slow, never having had the benefit of observing local protocol as a student or a subintern. Despite having passed his exams, he will hesitate with most tasks, including the essential ones of documenting directions, checking blood tests and making a physiotherapy referral, because he is a stranger to them all. Some doctors and nurses might lend a kind and guiding hand, but he is more likely to (over)hear the following: “You are the resident — it’s your job!” “Why do I always end up with the AMCs?” “He might be a nice person, but he doesn’t have a clue!”. Occasionally, the remarks will be deliberately hurtful: “Excuse me, this desk is for doctors only!” “Why don’t they just go back where they came from?”. He is most likely to miss tutorials because of unfinished work, and, when he does get to one, he is the diminutive figure in the corner, too self-conscious to ask a legitimate question. He is the one you will see biting on a stale sandwich most evenings as he ploughs through piles of paperwork between braving phone calls to the registrar, irate at his inability to articulate a problem in 30 seconds. When the desperately needed interpreter is hours away, he will meekly announce his grasp of two other languages. Relief and gratitude on the part of the staff will be somehow inexplicably replaced by righteousness. “At least he can do that!” He will often wonder why his best attempts to contribute meaningfully seem antagonistic, why there is such a glaring lack of encouragement, and why he is finding this initiation harder than he had ever imagined. In a private wish list, he craves for a little more understanding and a little less hostility; then, scoffing at such imagined luxuries, he returns to face another day. Slowly, one unit then another shares the AMC burden, each one “preparing” the next, so that his perceived shortcomings always precede him. Soon he must think about the following year’s jobs. What should he do? Who knows him well enough to provide the references? Who are his role models? Should he follow the majority of his AMC peers and enrol in general practice training or should he make a concerted attempt to pursue a long-desired specialty? The obstacles seem magnified in advanced training. Even if he manages to enter a specialty program, who will supervise the children’s homework? Who in the hospital appreciates the needs of an older foreign doctor, also a son, father, husband and small business owner? The conflict between personal aspirations and life’s larger concerns routinely ravages his mind. In the course of our own training, we have been frequent witness to, and no doubt creators of, the hurdles that the medical community puts in the way of foreign medical graduates. These hurdles are not only academic, but also personal, based on our uninformed and unchallenged perception of their culture, education and work ethic. Every foreign graduate we have taught has understood the rationale for an Australian exam, but, after attaining the very standard demanded by the profession, it is the indignity of working in an unsupported and hostile environment as a second-class doctor that turns out to be the insurmountable hurdle. Although the issues surrounding foreign medical graduates are genuinely difficult and bear no glib resolutions, we suggest the following considerations. Integrate foreign medical graduates preparing for the AMC exam into hospitals by allowing them to observe educational seminars, outpatient work and grand rounds. Knowledge of local medical practice is far more accessible in this manner than by spending countless lonely hours in the library in search of assimilation. Access should not be limited to peripheral hospitals, which are often difficult to travel to and lack consistent teaching programs. Expand the educational program for foreign graduates by encouraging local physicians to teach. (With the assistance of just one other colleague, each of us spent just 2 hours a week to adequately address the exam syllabus.) It is crucial that program directors sanction such activity rather than be dismissive of its goals — a volunteer teaching program will enjoy success only if personal gain is sometimes set aside. Assign a specific mentor for foreign doctors at each institution. Such a mentor must be sensitive to the different goals and needs of foreign doctors compared with those of their local counterparts. Neither excessive pressure to conform nor total immunity from compliance with local standards should take the place of a deliberate process of integration. Practise what we preach. Medical students are taught from inception about the value of empathy and communication. We repeatedly examine their grasp of such skills, yet, once they are doctors, these skills are perceived to be an optional extra. Apply the open-ended question to foreign doctors: “Tell me how you feel.” Appreciate the worth of foreign doctors as a pillar of our increasingly cosmopolitan society. The very doctors we may deride will go on to serve entire populations, which the average Australian graduate is ill-equipped, and hence uncomfortable, to serve. The statistics on migrants, ageing populations and chronic illnesses do not bear repetition, but the overwhelming need to help our foreign doctors to help us take care of all our patients does. In medicine, the road is long for us all, but for the foreign medical graduate it is inevitably more winding and rough. It is our obligation to not abandon our colleagues along the way, but to seek to ease their journey with small, personal gestures and larger, administrative measures. While they tend our society’s sick, we must not deny them their own bruises that often lie just beneath the surface. It is only then that as physicians we can truly call ourselves healers.

Ranjana Srivastava MB BS(Hons) · Declan J Green MB BS(Hons)