Social determinants of health

How can we restore some semblance of sanity to a world spinning out of control? Some years ago now, Terry Gilliam (of Monty Python fame) produced something of a screen gem, enigmatically entitled Brazil. It was set in some indeterminate period in the near future, at which we now seem to have arrived. The world of Brazil was a world out of control — a world in which the infrastructure of daily living had become so complex that it required the intervention of a quasi-supernatural being when things went wrong in the lives of its inhabitants. Played (brilliantly) by Robert de Niro, this being descends (like Superman) from nowhere to rip open the offending section of wall — behind which there pulsates an incredibly complex, almost organic, mass of wires, tubes and other assorted technological viscera — “fix” the problem and then disappear once more. While immensely grateful, the mortals whom he has thus aided are none the wiser as to how he has effected this minor miracle, which leaves them very much at his mercy the next time the system fouls up. This threat is never far off, as the more complex things are the more often they go wrong. It would be possible to run a society with such a quasi-supernatural saviour at hand, assuming, of course, that some terrible mishap does not befall your hero. The gamut of potential mishaps must be extensive: kryptonite, alien forces, death rays, evil geniuses, or even the appearance of a Bizarro-quasi-supernatural being. But, in Brazil, hero de Niro did not succumb to any of these. He succumbed to paper. Yes, you heard me: paper. One day, he is walking along a road when a wind springs up. A piece of paper blows up against his leg, then blows away. Then a second, then a third — before a veritable barrage. Some of these papers are whisked away, while others adhere to his flailing limbs as he struggles to free himself. Soon he is trapped, struggling to breathe in this swirling, smothering maelstrom. But the onslaught of the paper is relentless, torrential, unforgiving. Soon, his struggles falter, and he drops to his knees. We sense that he has lost the battle. His struggling figure wanes, the paper begins to disperse, and soon there’s nothing left where de Niro once stood. He has been utterly subsumed — drowned and obliterated — by paper. Any of this sound familiar to you? It should. Simply substitute “computerisation” for “complex infrastructure” and “red tape” for “paper”. But what is red tape? Red tape consists of the requirements of a complex bureaucracy. How is it manifest? As documentation. Why is it seen as necessary? In order to prove that we are doing what we say we are doing. But to whom are we demonstrating this proof? Ultimately, to a bunch of lawyers, whether they are the hired guns of a litigious patient or the hired “suits” of a government department. Our society is drowning. It is on the verge of being utterly subsumed by the complexity of its own systems. Anyone who doesn’t realise this is ready for a wake-up call. This is that call! Litigation was originally put in place to protect the rights of the individual, but it now oppresses the very people it was sent to protect! Every day around the world, billions of ordinary citizens — from doctors to nurses to accountants to engineers to shopkeepers to craftsmen to fishermen to you-name-it — spend a substantial part of every hour devoting themselves to the documentation of their job as opposed to its execution. And with every year that passes, the level of documentation becomes more exacting, more oppressive, more intrusive, less conducive to the effective management of the job and, perhaps most damaging of all, insidiously undermining of trust. Everybody out there is hurting. A patient of mine who runs a small woodwork workshop for children (in which no child has ever been injured) told me that he now finds himself paying out $15 000 a year in insurance to an insurer he had to hunt for interstate. A well-known fishing identity from Sorrento, near Melbourne, speaking on a local radio station, said that he spends half his working day on dry land filling out government forms. Another of my patients, a family accountant, has to drop all of her loyal, regular, small clients because the documentation requirements of even the simplest transaction have placed the cost of her accounting services out of reach of these people — the very people for whom she set up her business in the first place. On a macro scale, in my opinion, the productivity of modern society has been virtually halved by the requirements of documentation (while the consumption of paper has sextupled). The situation is no longer sustainable. As a society, we can no longer afford the luxury of mistrust. Yes, it’s nice to have the right to sue, but the other side of that coin is that each of us must expend half of our working lives in efforts to prevent others from suing us. Ironically, the exponential rise in documentation that was supposed to protect us from such litigation has failed miserably. We are being sued more than ever before. At a recent risk management seminar I learnt that the United States experience of capping damages is that it doesn’t work and that lawyers simply launched more actions so as to bring their total income back to what it was before the capping. We need to create legal systems that virtually exclude lawyers entirely (eg, the New Zealand system of compensation for medical mishap), and we need to limit their numbers quite sharply — as it seems to me that each lawyer will fill the litigious airspace available to him or her. And, we need to become aware of the price we pay for each so-called “right” we claim. Moreover, we need to trust one another more. The world is spinning out of control, and nobody is yelling: “Stop!” “The Brazil Project” is about doing just that. It is about bringing these issues into the public eye in a balanced fashion, without compartmentalising them to the point of meaninglessness. It is about calling a moratorium on worthless documentation — ie, any documentation that is not essential to the actual running of a particular enterprise. It is about loosening the stranglehold of lawyers, whom we ourselves have aided and abetted with our actions. It is about recognising that there is another way of conducting our society — a way based on trust rather than adversarial acquisitiveness. My intention is to make The Brazil Project a functioning reality — not an institution bound by meetings and minutes and mission statements, but a loose association of like-minded individuals whose aim it is to restore to the world some semblance of sanity. This will take time, effort, energy, faith, determination and, yes, some money. As a 70-hour-per-week medico, I can’t do it alone (although success in this venture would probably render me a 35-hour-per-week medico!). If you are interested in joining me in this endeavour, please contact me. I do not pretend to have all the answers, nor am I entirely certain of the way to proceed, but there has to be a better way, and I believe the first step in achieving a better way is a cry of protest. The more voices that join in this cry, the better it will be heard.

Ron Elisha MB BS

Objective: To describe fall-related injuries due to pets in an older population.Design: Case series.Participants and setting: Patients aged 75 years and over presenting to the emergency department of a metropolitan hospital in northern Sydney over 18 months, with a fracture directly related to their pet.Main outcome measures: Type of fracture; circumstances of injury.Results: 16 cases (mean patient age, 81 years) are described; 13 (81%) involved women. Animals of five species were involved, with cats and dogs being the most common pet hazard.Conclusions: Pets are a potential environmental hazard in the occurrence of fall-related injuries in older people, with dogs and cats most likely to be involved. Women appear more likely than men to be injured.

Susan E Kurrle PhD, DGM · Robert Day FACEM · Ian D Cameron PhD, FAFRM(RACP)

To the Editor: While the article by Henry and colleagues provides food for thought and possible action,1 do they exhibit the fairness they exhort to solve the problem they perceive? There appears to be a distinct lack of logic in some of their deductions in the Box on page 517. “Body part funding” is not confined to Aboriginal health. For the 43 years I was associated with NSW Health, it was an integral part of the system and, together with its variations, increased as the years passed. The authors claim that as only $80 per head being spent on medical and pharmaceutical benefits in a remote Aboriginal community compared with the $900 spent in Double Bay is an example of racism. Surely, it is only a reflection of the lack of both a pharmacy and doctor in the remote community compared with the easy access to both in the inner-Sydney suburb. Comparison between the remote Aboriginal community and an all-white community of similar characteristics would have more validity.

Raymond S Hyslop

To the Editor: In their challenging article, Henry and coauthors assert that the poor health of Australian Aboriginals is the result of the “divided, divisive, racist, socially unjust society” of “this Australia”.1 I cannot agree. The health standards enjoyed by “white Australia” are not an isolated phenomenon, but rather a part of the fabric of an advanced technological society. Efforts to bring Australian Aboriginal health to the same standard without the Indigenous Australians being fully part of this 21st-century society will never be successful, even with limitless resources and endless goodwill. It is possible to maintain cultural identity and remain cognizant of past hurts while playing a full, if not leading, role in this technological society. If the Aboriginal elders were to lead their people into mainstream society they would find, I’m sure, an inclusive, tolerant, exciting and advancing society where they could play a full role, enjoy the same health as the rest of Australia, while still maintaining their unique identity.

Christopher R Strakosch

To the Editor: The Postcard from Heller, Weller and Jamrozik1 may reflect a nostalgic and unrealistic view of how good things are back home. They suggest that, in New South Wales, the health chances of both advantaged and disadvantaged populations are improving, and, in relative terms, social inequalities in health may also be showing “some improvement”. In fact, despite impressive overall declines in mortality, there remain important differences in health status between NSW populations. Figures for the mid-1990s show that life expectancy at birth for both Aboriginal males and females is markedly less (by 20 years and 18 years, respectively). Similarly, socioeconomic disadvantage shortens life expectancy for both rural men and women (by 14 and 10 years, respectively) and urban men and women (by 10 and 7 years, respectively).2 The relative gap is also widening for some important health indices. For example, from 1980 to 2000, the percentage difference in premature death rates (< 70 years of age) between high and low socioeconomic groups has increased from 30% to 52% for men and from 24% to 32% for women, and for potentially avoidable mortality from 34% to 63% for men and from 27% to 40% for women.3 How should one respond to such inequalities? Heller et al suggest universal rather than targeted programs, as they are based on sound population health principles. To construct this as a simple choice is not helpful. Unless we recognise and address the barriers facing people in adverse social circumstances, universal programs may unintentionally widen health inequalities. For example, universal access to healthcare in the UK and Australia has not equally benefited those from the most disadvantaged circumstances compared with wealthier and better-educated populations.4 The Postcard authors suggest that Australia is saved from class divisions by the established “fair go” tradition, where shared values overcome structural inequalities in “socioeconomic status”. In fact, social class continues to be a powerful but complex and changing influence in Australia.5 It is important to acknowledge the evidence that structural inequalities are significant and worsening in Australia,6 and that the most disadvantaged experience continued social exclusion.7 We need to shift from a “trickle down” perspective that sees the greatest health gains accruing to the most advantaged — with a hope that these benefits will eventually be achieved by everyone — to a more explicit social justice perspective that ensures that resources for health are allocated in ways that produce fair outcomes. This may help address “socially entrenched self-denial of the chance for better health”.

John Furler · Elizabeth Harris · Don Nutbeam · Mark Harris

The justice system could go further in supporting the needs of those it detains after they are returned to the community Nearly 20 years ago, public attention was drawn to the previously hidden tragedy of deaths in prison and police custody. Initially, attention was focused on deaths of Indigenous people. However, it quickly became apparent that the death rate for all people held in custody was much higher than that for the general population. The result was a detailed investigation into the causes of the problem, in the form of the Royal Commission into Aboriginal Deaths in Custody.1 The Royal Commission made over 300 recommendations on penal policy, cell design, custody management regimens, treatment programs, services to Indigenous offenders and a host of other topics. In addition, the Deaths in Custody Monitoring Program was established at the Australian Institute of Criminology (AIC) to scrutinise and report on deaths in prison or police custody.2 In parallel with the acknowledged problem of deaths in custody, there is an equally significant tragedy in the form of high death rates among released prisoners3-5 and offenders in the community.6,7 In the decade after the Royal Commission (1990 to 1999), the AIC monitoring program recorded 628 deaths in police or prison custody. Over the same period, in Victoria alone, 820 men and women who had been released from prison died unnatural deaths.4 The study by Coffey and colleagues in this issue of the Journal (page 473) shows that the problem is not confined to adult offenders but affects juveniles as well.8 The high rate of unnatural deaths among offenders living in the community is a major public health issue, but what can we do to reduce these rates? One of the groups at greatest risk is injecting drug users — over half of the unnatural deaths examined in the earlier Victorian study were heroin related,4 and drug-related offences were an indicator of high mortality risk in the study by Coffey et al.8 Drug treatment and maintenance (methadone) programs lower the risk of death by overdose.9 However, many of those at greatest risk are profoundly alienated from society, and we need to find ways to engage them. For example, heroin-dependent Indo-Chinese offenders frequently face rejection by their families and community, and are isolated from the mainstream community as well. Female offenders often come from backgrounds of extensive sexual and physical abuse, their heroin dependency is often supported by prostitution,5 and any interventions need to take account of their responsibilities as parents.10 Treatment and maintenance programs need to be delivered in ways that meet the material, social and cultural needs of those at risk. Overdose risk can be dramatically lowered by behaviour changes, like not using drugs by yourself, being aware of variations in the purity of heroin, and not taking heroin in conjunction with alcohol or benzodiazepines. Again, the problem is partly that those at greatest risk are also the most difficult to communicate with, and tend to be unrealistic in judging risks to themselves. Peer-based education and information dissemination programs have shown they can transmit the key messages about risk reduction to this group (eg, how to avoid overdose and recognise its signs),9 but, again, a range of approaches tailored to the needs of specific groups at risk is required. Such approaches could include maximising the effectiveness of needle and syringe program workers by having them provide standardised, evidence-based messages and materials on safe injecting, overdose prevention and support options.9 The importance of heroin as a cause of unnatural death should not obscure the other dangers that offenders face. Individuals who have the combination of mental disorder and drug and alcohol misuse experience much higher risks of both overdose and suicide and can find it difficult to obtain the kind of treatment and support services that might alleviate their problems. Older offenders are at increased risk of a variety of general health problems, such as diabetes, cancer and liver disease, and there need to be programs that link at-risk offenders with healthcare and support services.11 People who are released from custody are at greatly increased risk, in part because their tolerance for heroin is reduced, and also because return to the community can be a time of great emotional stress. Prisoner release support programs like the Victorian Bridging the Gap program have shown that the period before release can be an important “window of opportunity” when offenders are motivated to plan for their release.12 A key feature of this program is intensive, outreach-based support, with the support agency helping the releasee to identify his or her specific needs and brokering access to material support, healthcare and social services. Releasees who participated in Bridging the Gap had improved outcomes as measured by accommodation stability and engagement in drug-treatment programs, and these in turn translated into lower rates of reoffending.12 Finally, we need to attend to an important lesson from the Royal Commission. Despite real improvements in custodial management, the number of deaths of Indigenous people in custody has continued to increase because there are now more Indigenous people in custody.2 The high rate of unnatural deaths among offenders is a public health problem that requires changes in the way that healthcare services are delivered to this vulnerable population. However, we also need to recognise that the justice system has a key role to play in ensuring that its goals of punishing offenders and preventing crime are properly balanced by a consideration of the health and support needs of the people who are the subjects of its interventions.

Stuart Ross

There is yet no convincing evidence that testosterone therapy is safe or effective in counteracting any effects of ageing One of the most challenging and time-consuming aspects of medical practice is discussing with patients what they have gleaned from the Internet or popular lay publications. One topic of such discussion is the use of testosterone in male ageing, with public interest fuelled by persuasive publications like Maximising manhood,1 The testosterone revolution2 and Male menopause.3 Much of the information gained from these books may seem to be very convincing, but is, at best, “ahead of the evidence”. It is often difficult for doctors not to appear old-fashioned, ignorant or downright contrary when showing scepticism or advising caution in the face of such conviction. . . . beware when entrepreneurial business ventures overtake evidence-based medicine. In this issue of the Journal, Handelsman (page 419) has documented temporal and regional trends in testosterone prescribing in Australia.4 He has shown increases in prescribing corresponding to popular promotion of androgen therapy in ageing. This rise has been particularly marked in Western Australia, coincident with the opening in that state of entrepreneurial clinics aimed at the ageing-male market. There is no doubt that testosterone therapy benefits patients with documented hypogonadism associated with conditions such as Klinefelter’s syndrome and hypopituitarism. Current prescribing guidelines allow for this, regardless of age. However, for the use of testosterone in men of middle age and older with borderline low serum levels of testosterone, the evidence for both efficacy and safety is yet to be established. The original description of the efficacy of testosterone therapy for the vicissitudes of age has been shown to be no more than a powerful placebo effect.5 Nevertheless, it would seem that those who espouse testosterone therapy in this setting have identified an expanding market. The Australian population is ageing: 28% of men are over the age of 50 and 12% over the age of 65 years. It is projected that by 2021, 4.0 million Australians will be over the age of 65, an increase of 1.7 million from today’s estimate.6 Together with a documented fall in testosterone level with age, where it is estimated that 20% of men over the age of 60 will have a testosterone level below the reference range, this predicts a large population of men as potential customers for androgen therapy.7,8 Although most studies have shown a gradual decline in testosterone level with age, the clinical consequences of this are not known. Conditions such as muscular frailty, loss of bone mass, cognitive decline and erectile dysfunction are also age related, but whether testosterone deficiency has a causal role is not clear. More importantly, it has not yet been established that testosterone therapy has any role in correcting these conditions. It has been a widely held belief that androgen deficiency is a common and correctable cause of erectile dysfunction. However, in a cohort of 1455 men presenting with erectile dysfunction, we found that testosterone deficiency constituted a correctable cause in only 3%.9 All of those who responded to testosterone therapy for erectile dysfunction had a testosterone level < 7 nmol/L, well below the reference range of 11–37 nmol/L. The use of testosterone therapy in patients with normal or slightly depressed androgen levels seems to be of little benefit.10 A similar finding has been documented in the response of bone density to testosterone therapy. The largest and longest-term study in this setting examined testosterone treatment in 108 men aged over 65 years with a baseline testosterone level more than 1 standard deviation below the young adult mean (ie, < 16.5 nmol/L).11 Lumbar spine bone density rose significantly only in those with a baseline testosterone level below the reference range (ie, below 10 nmol/L). Another, smaller study has shown a significant increase in lumbar spine density with androgen therapy in men with a baseline testosterone level < 12.1 nmol/L.12 Muscle mass and strength decrease with age, and it is tempting to link this with the decline of testosterone. In hypogonadal men, testosterone therapy improves muscle strength. In men aged over 65 years, testosterone treatment leads to a fall in fat mass and a rise in lean body mass, together with a perception of increased strength. However, although a perception of improved muscle function was reported, no objective change in measured physical function, such as walking or stair climbing, knee flexion or in muscle strength as measured by dynamometer, was demonstrated.13,14 The safety of sex hormone therapy in menopausal women, used widely for the last 60 years, has recently been scrutinised and reassessed.15 Knowledge about the safety of sex hormone replacement in men is, by contrast, in its infancy. No studies have been conducted for long enough to identify the long term risks of androgen therapy in ageing. Because of lack of statistical power in studies, it is not known whether testosterone use will increase the incidence of androgen-dependent disease such as prostate cancer, although a sustained rise in prostate-specific antigen level has been observed.13 Two other side-effects of testosterone treatment have been identified in short term studies, namely an increase in obstructive sleep apnoea and increased haematocrit and polycythaemia, both of which may have implications for cardiovascular risk.13,16 Handelsman has documented the effect on testosterone prescribing of entrepreneurial clinics aimed at the ageing-male market.4 Daily, we see advertisements for similar commercial enterprises which deal in unregistered and/or unproven prescribing, including DHEA (dehydroepiandrosterone) or testosterone to men and women, progesterone cream, and lozenges of variable mixes of oestrogens, progestins and androgens. We should beware when entrepreneurial business ventures overtake evidence-based medicine. What is needed now regarding testosterone therapy in ageing are large, long-term, prospective, randomised, placebo-controlled studies to establish if there is, indeed, benefit for specific symptoms and to identify potential risks.17

Bronwyn GA Stuckey BA, FRACP

Objective: To explore the experiences of carers and families of people with depression.Design and setting: Structured focus groups conducted in six Australian capital cities between February 2002 and July 2002. Thematic analyses were conducted using the QSR NUD*IST software package for qualitative data.Participants: Thirty-seven carers or family members.Results: Thematic analyses highlighted five key themes. Most notably, the carer’s role is made more difficult by the lack of community awareness about depression, and, in some instances, an unwillingness of other family and friends to provide ongoing support. Carers experience a resulting sense of isolation, often exacerbated by adverse experiences with healthcare providers. Carers and family members are frequently excluded when key decisions are made, and report that emergency services are relatively unresponsive to their concerns. By contrast, community support organisations usually provided a sense of inclusion and common purpose.Conclusions: The experiences of carers and families of people with depression highlight the urgent need for more extensive community education about the illness and more productive collaboration within the healthcare system.

Nicole J Highet DPsych · Bernard G McNair GradDip(Nursing Management) · Tracey A Davenport BA(Hons), GCM · Ian B Hickie MD, FRANZCP

Objective: To describe the experiences of people with bipolar disorder with primary care and specialist mental health services.Design and setting: Focus groups and indepth interviews were conducted in seven Australian capital cities between July 2002 and April 2003. Thematic analyses were conducted using the QSR NUD*IST software package for qualitative data.Participants: Forty-nine people with bipolar disorder participated in the focus groups and four participated in the interviews.Results: Thematic analyses highlighted eight key themes. Most notably, respondents identified a lack of awareness and understanding about bipolar disorder within the Australian community, which contributed to apparent delays in seeking medical assessment. The burden of illness was exacerbated by difficulties experienced with obtaining an accurate diagnosis and optimal treatment. The healthcare system responses were described as inadequate and included inappropriate crisis management, difficulties accessing hospital care, inappropriate exclusion of carers and families from management decisions, and frequent discontinuities of medical and psychological care.Conclusions: People with extensive experience of bipolar disorder report barriers to optimal care because of lack of community understanding and healthcare system shortcomings. These barriers exacerbate the social, interpersonal and economic costs of this illness.

Nicole J Highet DPsych · Bernard G McNair GradDip(Nursing Management) · Marie Thompson BSc(Hons) · Tracey A Davenport BA(Hons), GCM · Ian B Hickie MD, FRANZCP

John M N Hilton Associate Professor, Department of Pathology, University of Sydney; and Consultant in Forensic Medicine, PO Box 45, Katoomba, NSW 2780. kornhilATiinet.net.au To the Editor: Byard’s succinct dissertation on the Clark case1 omits one crucial aspect in redressing this miscarriage of justice. Without the vigorous and persistent efforts of a vocal and well directed support group, which included Mrs Clark’s legal team, their scientific and medical advisors, the Law Society of England, and her family, she would still be serving a life sentence in jail. An Australian example of the effectiveness of such a support group in combating injustice is afforded by the Lindy Chamberlain case.2 Historically, Sir Arthur Conan Doyle spearheaded the efforts — sustained over nearly 20 years — to exonerate Oscar Slater,3 an unfortunate German–Jewish immigrant to Glasgow who was condemned to death after a conviction for murder based largely on identification evidence given by one of the probable perpetrators. Slater was granted a reprieve from the death sentence at the last moment, only to serve some 17 years in a grim Scottish penitentiary. Less fortunate was Timothy Evans,4 who was convicted and hanged for murdering his wife and daughter on the evidence of one of London’s infamous mass murderers, John Christie. Evans was eventually pardoned — unfortunately, too late to save his life — largely thanks to a very active support group headed by the journalist Ludovic Kennedy. In contrast, those who lack such a support group are exemplified by Ziggy Pohl,5 who was convicted, despite rather than because of the evidence, of killing his wife in Queanbeyan, NSW. He served more than a decade in prison, only to have the true perpetrator confess after Pohl was released on parole. Byard highlights evidentiary shortcomings in one recent English case. How many other people have suffered the ignominy, distress and dire consequences of unjust convictions because they lacked the support of an individual or a group prepared to question the propriety of the conviction process?

John M N Hilton

Should we do it, is it worthwhile, and who should decide? In the Western world, the number of people living beyond 80 years is increasing. In the United States, it is expected that 43% of the population will reach the age of 80.1 In Australia, men and women who reach 80 years may expect a further 7 and 10 years of life, respectively, the majority being disability free.2 Cardiac surgery in Australia has entered its fifth decade, and is now commonly performed (18 000 cases/year). The total cost (including salaries, equipment, building depreciation, etc) of having coronary artery bypass grafting (CABG) (which constitutes 75% of all cardiac surgery) at Western Australian teaching hospitals is about $12 000 per case (WA Department of Health, 1994, unpublished data). Over the past decade, the proportion of cardiac surgery patients aged 80 years or more has risen from negligible to 7% in selected centres.2-4 Surgical outcomes are encouraging: a 2002–03 report from six Victorian public hospitals revealed mortality rates of 2%–4% for elective CABG and 10%–12% for aortic valve replacement.4 However, follow-up assessment by direct patient contact has not been universal — commonly, outcome analyses rely solely on physicians’ perceptions.2 In a series of 64 octogenarians having cardiac surgery over a 5-year period at three Australian hospitals, our research group prospectively assessed outcomes and directly spoke to patients at several time intervals.2 The need for surgery was compelling — all had class III/IV symptoms of angina and/or dyspnoea. The total in-hospital mortality was 6.3% (nil in those having elective surgery and 10.5% in those requiring urgent surgery). The incidence of significant complications was low (perioperative myocardial infarction, 1.6%; stroke, 1.6%). At a mean follow-up time of 2.8 years, 44 patients were still alive, 42 (95%) were free of cardiovascular symptoms, and 42 remained independent, with a significantly improved quality of life. Kaplan–Meier actuarial survival for hospital survivors at 4 years was 74%. Interestingly, 8 patients (18%) had remarried and 8 had commenced on sildenafil. Not surprisingly, 43 (98%) of the patients said they would recommend cardiac surgery. Despite these favourable outcomes, one in five of the study participants had been originally advised by their general practitioner and/or physician not to proceed with surgery because of their age. Discrimination based on age alone is not uncommon.1,5 Performing surgery in these octogenarians was on a needs basis — other patients on waiting lists were not disadvantaged. If people over a certain age are to be barred access to healthcare, it is for society to debate and for governments to legislate. In Australia, Katrina Bramstedt (a bioethicist at the Department of Community Medicine and General Practice, Monash University) has cogently argued that age discrimination is common. Yet there is no ethical justification for denying cardiac surgery to octogenarians,5,6 particularly as empirical evidence validates the potential benefit of this treatment.5 It has been stated that “survival is not the most important outcome in the elderly”.7 Not so. Of the 102 patients on whom we have now operated, all wished to continue to live independently. So what have we learnt? Firstly, that surgery can be safely performed in octogenarians. The best people to make the decision whether to operate are the surgeon and the cardiologist, working in conjunction with one another. Secondly, that the success of surgery is critically dependent on the quality of anaesthesia and postoperative intensive care. There must be ongoing clinical governance so that expected outcomes match actual results.8 Not only are more and more octogenarians choosing to have cardiac surgery, but the chances of a good outcome are improving. Advances in surgical techniques in recent years mean that the risks of cardiac surgery, for all patients but especially those over 80 years, have been substantially reduced. The availability of “off-pump” technology (ie, doing coronary artery anastomoses without the use of cardiopulmonary bypass [CPB]), including mechanical aortocoronary anastomotic devices, allows CABG to be done not only without CPB, but also without manipulating the aorta, thus reducing atheroembolic risk.9 Furthermore, the duration of CPB and global myocardial ischaemia can be minimised by combining off-pump techniques with CPB (eg, valve replacement with CABG). Also, selective use of ventricular fibrillation (rather than cardioplegic arrest) when repairing a mitral valve avoids global myocardial ischaemia. Surgeons have several options for the technical performance of these operations. While there may be no surgical consensus on the optimal technique for a given patient, in my view a “one shoe fits all” surgical approach may prove hazardous. It is important to prepare the patient optimally before surgery. This includes universal carotid screening and judicious use of prophylactic carotid endarterectomy, together with preoperative optimisation of renal function and maintenance of perioperative enforced diuresis.10 Although none of these innovations has been tested in randomised controlled trials, myocardial, cerebrovascular and renal complication rates are now low. A critical factor determining surgical outcomes is whether the patient is in need of urgent surgery (ie, surgery required as a hospital inpatient because the patient cannot be satisfactorily stabilised with medical treatment).2-4 Delays in referring symptomatic patients are invariably associated with rapid clinical deterioration and poor results. The role of percutaneous coronary intervention (PCI) versus surgery for coronary artery disease requires comment. Neither surgery nor PCI is benign.11 For comparable patients of any age in experienced hands, the risks of inducing death, myocardial infarction, stroke or neurocognitive deficits are the same with either approach.12,13 With surgery, the failure rate is lower and there is less need for repeat interventions. However, surgery requires a sternotomy and graft harvest incisions on the leg. A number of clinical factors are associated with increased risk of PCI failure (eg, left main coronary artery or multivessel disease, diabetes).14 Before PCI is undertaken, it is essential that the cardiologist and the surgeon carefully assess which procedure is optimal for a particular patient. If PCI fails, performing emergency surgery (ie, within 24 hours of hospital admission) is associated with markedly increased risks, particularly in octogenarians. Which octogenarians should be offered cardiac surgery? Many, if not the majority, should be readily identifiable as unsuitable because of advanced comorbidities. However, the 20% of patients in our series who were advised not to proceed with surgery had no clear features distinguishing them from the 80% advised to proceed. It is impossible to provide unambiguous criteria for refusing surgery. Nor am I suggesting that all octogenarians be offered this treatment. What I am advocating is that age alone must not be a barrier to accessing cardiac surgery. We can be heartened that careful evaluation allows us to pick the right patients and that these patients are achieving acceptable outcomes. Patients should be offered a choice. Those who have had cardiac surgery believe it is worthwhile and are very grateful.2

John MP Alvarez FRACS

The NHS was founded on the principle of access to adequate healthcare for all Roman society in Britain was highly classified. At the top were . . . the legions, the provincial administration, the government of towns and the wealthy traders and commercial classes who enjoyed legal privileges not generally accorded to the majority of the population. In 212 AD, the Emperor Caracalla extended citizenship to all free-born inhabitants of the empire, but social and legal distinctions remained rigidly set between the upper rank of citizens known as honestiores and the masses, known as humiliores. At the lowest end of the scale were the slaves . . .1 In the United Kingdom today, the widening gap between upper and lower “social classes” is regularly presented by politicians and health bureaucrats to professional and lay audiences alike, and used to justify the public health agenda. Health inequalities have become the driving force for public health initiatives. The government under Thatcher explored “variations” in health outcomes and in health service provision. Subsequently, the Blair government replaced “variations” with the more class-oriented “inequalities”. All too often, however, attempts to deal with the real and frequently demonstrated social gradient in disease and in health service provision is limited to “hand-wringing epidemiology”. In any case, discussion of a widening gap reflects a failure to understand the difference between relative and absolute risk, as well as demographic change and the type of outcomes amenable to prevention. . . . unless public health programs are based on sound theoretical bases, they will fail. The debate in Australia is rather more sophisticated: for example, in the report of the Chief Health Officer of New South Wales,2 trends over time in the social gradient are presented in terms of absolute risk, as well as for diseases in which social interventions are likely to be effective. Presented in this way, the social gradient persists, but does not necessarily appear to widen over time, and some improvement in the experience of the least affluent may also be apparent. Are we carping and nit-picking to criticise the UK approach? No, because unless public health programs are based on sound theoretical bases they will fail. Implausible and non-achievable targets aimed at “narrowing the gap” have been established. These include: reducing, by 10%, the difference in infant mortality between the children of manual workers and the whole population; and reducing, by 10%, the gap in life expectancy at birth between the quintile of local council areas with the lowest life expectancy and the whole population. Far better would be to aim at the more important goal of improving the health of the whole community, as well as the disadvantaged part. The NHS was founded on the principle of access to adequate healthcare for all. Selectivity, even well intentioned selectivity, not only flies in the face of this ideal, it ignores the late Geoffrey Rose’s astute observation3 that small changes in the average for the whole population can bring great benefits to those at greatest risk, provided the change involves the whole population. People in the UK still talk about, and measure, social class. Although the use of the term “socioeconomic status” may be an example of political correctness, the fact that “class” is still an acceptable form of scientific terminology in the UK reflects the underlying acceptance of its existence. People typically “know their place”. They measure themselves against a social standard. Those who are “working class” stoutly defend their place in the social hierarchy and are proud of it. Expectations of health and of access to healthcare are firmly rooted in the class system. It is “posh” to eat healthy food, and “posh” is a derogatory term. If men (and women) are born into such shackles of social convention, their freedom to improve their health is distinctly limited. The claim that Australian society is classless is oft made but open to challenge. The concept of social class, as developed by Weber and Marx, is a complex one that involves consciousness of social position and sharing of values and outlooks within the group. If Australia has social classes, they are probably blue collar, white collar, “squattocracy” and those on the dole, but ranged against this are the acknowledged rights of all to “have a go” and to “a fair go”. These maxims make attempts to improve everyone’s health possible, as well as socially and politically legitimate. Why should we care if socially entrenched self-denial of the chance for better health exists in the UK? The reason is that attempts to deal with health inequalities are doomed to failure in such a climate. The debate about equity and health is complex and wide-ranging, and has an international component — all countries have inequality and inequity. The ancient Romans introduced a rigid social class structure into Britain, but the current inhabitants of the British Isles have made its perpetuation an art form.

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

Christine B Phillips,* Suzanne Manning† * Senior Lecturer, Academic Unit of General Practice and Community Health, Australian National University Medical School, PO Box 254, Jamison Centre, Jamison, ACT 2614; † Intern, Department of Psychology, Australian National University, Acton, ACT. christine.phillipsATcalvary-act.com.au To the Editor: Since 1999, most asylum seekers in Australia who have been detained and subsequently found to be genuine refugees have been issued temporary protection visas (TPVs). Missing from much of the debate about management of asylum seekers has been the impact of the provisions of TPVs on children. A comparison of the entitlements of refugees on permanent and temporary protection visas is given in Box 1. To estimate the proportion of TPVs issued to children under 18 years of age, we analysed data provided by the Department of Immigration and Multicultural and Indigenous Affairs (DIMIA). The denominator population was drawn from data on numbers of temporary and permanent protection visas issued between June 1999 and June 2002.1,2 Numerator data were drawn from information provided by DIMIA on request.3 As shown in Box 2, we found that between October 1999 and June 2002, 23% of all TPVs were issued to children under the age of 18. Some of these children are now over 18 years of age. However, as children born to TPV holders in Australia are also given TPV status, more children will be recruited into this visa category. Australia is a signatory to the UN Convention on the Rights of the Child, which enshrines key rights for children, such as the right to health and safety.4 However, we believe that several of these basic rights are undermined by the lack of provisions afforded to TPV holders: they are prohibited from sponsoring family members, and they have limited access to settlement services for refugees (Box 1). Withholding of family reunion provisions increases the risks for children, as it makes it more likely that parents will take their children with them when they undertake hazardous travel to seek asylum. This is in contrast to the traditional model of families sending an index person, who then sponsors other family members. The lack of a comprehensive settlement package for TPV holders, and the temporary and indeterminate nature of the visas, is likely to compound the psychological distress experienced by both adult and child refugees. Children who have experienced ongoing adversity are vulnerable to developing psychological disorders.5 The children of TPV holders must also live in families where the parents bear an ongoing burden of fear and destabilisation. The effects of TPVs are borne by large numbers of children. There is a need for concerted advocacy by health professionals to ensure that the health consequences of TPVs for children are recognised and addressed. Addendum 13/07/04. While a recent federal government initiative will allow current Temporary Protection Visa holders to apply for permanent Australian residency, we urge ongoing review of refugee visas. 1 Comparison of entitlements of refugees on permanent and temporary protection visas Services funded by the Australian Government Refugees with permanent visas Refugees with temporary protection visas Settlement services Translating and interpreting service Eligible Not eligible Accommodation support Eligible Not eligible Assistance from Migrant Resource Centre Eligible Not eligible Early health and intervention service Eligible Eligible Torture and trauma counselling Eligible Eligible English language tuition Free tuition for adults and children Adults not eligible. Children eligible from July 2002 Family reunion May apply to sponsor family members Not eligible Employment Access to all assistance programs Not eligible except for most basic services Income support Eligible for full range of social security benefits Restricted entitlements Medicare Eligible Eligible Education Primary and secondary education Eligible Eligible Tertiary education Eligible for HECS Must pay upfront fees Travel Right of return if holder travels overseas No right of return if holder leaves country HECS = Higher Education Contribution Scheme. 2 Proportion of temporary protection visa (TPV) holders who were children when visa was granted (1999–2002) Years* No. of TPVs granted No. (%) < 18 years when TPV granted 1999–2000 871 108 (12.4%) 2000–01 4456 907 (20.3%) 2001–02 3196 952 (29.8%) Total 8523 1967 (23.1%) * Financial years.

Christine B Phillips · Suzanne Manning

Gaston R B Arnolda Honorary Associate, Department of Public Health, University of Sydney, QEII Institute for Mothers and Babies, Building DO2, Sydney, NSW 2006. garnoldaATperinatal.usyd.edu.au To the Editor: O’Grady and Noland, concerned about the consequences of privacy legislation,1 draw attention to “. . . the findings of an Australian survey in which 61% of adults believe that even their de-identified health information should not be used for research purposes without their consent”. Unfortunately, they do not point out that the survey,2 commissioned by the Office of the Federal Privacy Commissioner, had a 20% response rate, making it effectively useless in determining what Australian adults really think about the use of their de-identified health information. Alarmed at the possibility that “evidence” of this quality could be used to aid decision-making that had important implications for rigorous research, I turned to Google (<www.google.com>) for assistance. A Google search using the words “61% de-identified health information roy morgan” generated 21 hits, 15 of them unique, and only five related to the subject. One of the five was the letter by O’Grady and Noland, one was the report of the survey, and three specifically cited this survey result: Privacy Victoria,3 Privacy NSW,4 and the Office of the Federal Privacy Commissioner5 all used the result in formal submissions to reviews of privacy-related issues — without revealing the survey’s appalling response rate. We have privacy commissioners who are powerful advocates of the principles of respect for privacy and autonomy. Perhaps the time has come for Australia to have “public interest commissioners” who can powerfully advocate for the public interest in high-quality health research.

Gaston R B Arnolda

Gary C Morgan Executive Chairman, Roy Morgan Research Pty Ltd, PO Box 2282U, Melbourne, VIC 3001. Gary. MorganATroymorgan.com In reply: In a world in which people are increasingly busy and mobile, increasingly concerned about invasions of privacy and increasingly approached to participate in surveys, survey response rates that could be readily achieved 25 years ago are now very much more difficult to attain. High response rates (ie, 60% and over) are still very desirable and can still be achieved. We have conducted surveys on sensitive issues, such as drug-taking, and achieved response rates that would probably satisfy even Arnolda. But this requires very intensive field activity that is not always justified by the nature of the project. The survey in question was not a health survey. It set out to provide general background information, exploring comparative levels of concern about, and the relationships between, a very wide range of privacy issues on a scale adequate to allow relatively small groups within the population to be examined. It was not intended to yield precise and critical measurements. Measures of “concern” or “reluctance” are highly context-dependent, “soft” measures, subject to interpretation, both by the respondents and by end-users. External validity is therefore not the issue: a response rate of 80% would not have made the figures demonstrably more “accurate”. Given the imprecise nature of the measures obtained, overengineering the sample relative to other components of the survey design would have been a waste of (public) money, better devoted to further research. The survey was part of a wider-ranging project and was planned in close consultation with the Office of the Privacy Commissioner in the light of their needs and priorities. It is appropriate that this issue arose out of a debate on privacy. As privacy constraints bite harder, whether imposed by statute or codes of practice, or arising through increasing resistance from subjects, medical researchers are going to have to come to terms with problems of non-response in the same way that social-survey researchers have. How are researchers going to react when only 20% of potential subjects consent to have their information used? Will they use words like “appalling” and “effectively useless” to dismiss any studies based on such a subset? Or will they perhaps learn to use them, with due caution, for the valuable information they nevertheless contain? One does not have to look very far in the history of medicine or public health to find major advances in knowledge using less than perfect statistics.

Gary C Morgan

Objective: To assess changes in people’s knowledge and beliefs about cancer between 1964 and 2001.Design: Questions in a 1964 survey of beliefs about cancer (randomly selected households) were replicated in a 2001 telephone survey (random-digit dialling).Setting: Perth, Western Australia.Participants: 984 and 491 participants aged 20 years or older in the 1964 and 2001 surveys, respectively (response rates, 86.8% and 47.0%).Main outcome measures: Changes in knowledge and beliefs about cancer.Results: Between 1964 and 2001, there were major improvements in knowledge about the causes of cancer, with several myths dispelled. In 1964, the proportion of Perth residents surveyed who believed that cancer is contagious was 20% (95% CI, 18%–22%), compared with 3% (95% CI, 2%–4%) in 2001. Similarly, the proportion who believed cancer is caused by “a knock” was 25% (95% CI, 22%–28%) in 1964, compared with 1% (95% CI, 0–2%) in 2001. Cancer screening participation rates also greatly improved, from 18% (95% CI, 16%–20%) in 1964 to 77% (95% CI, 73%–81%) in 2001. Changes in participants’ sources of knowledge about cancer were also evident, with family members and television increasing markedly as sources of information.Conclusions: Improved education of the public in health matters over the past four decades appears to have had a major and positive impact on knowledge about cancer.

Robert J Donovan BPsych(Hons), PhD · Owen B J Carter BPsych, DPsych · Geoffrey Jalleh BComm, MPH · Sandra C Jones BA, MPH, PhD

Integrated clinics have already been established in response to community demand. The growing evidence base for complementary and alternative medicine (CAM) and its widespread community use compels doctors to understand complementary therapies and to refer patients to CAM practitioners where appropriate. Most general practitioners have patients with chronic illness who could benefit from the services of CAM practitioners, and virtually all CAM practitioners have patients who require access to mainstream diagnosis and therapy. Collaboration requires shared respect and trust, and education. Dangers of not integrating care include delaying or depriving patients of safe and effective management, and the potential for harmful interactions. Integration is currently being supported by government initiatives such as the new MedicarePlus package, as well as by initiatives from organisations such as the Australian Medical Association, the Royal Australian College of General Practitioners and the Australasian Integrative Medicine Association.

Marc M Cohen MB BS(Hons), PhD, BMedSc(Hons)

Objective: To ascertain patients’ attitudes to embryo donation for research purposes.Design: Anonymous questionnaire survey.Participants and setting: 235 couples who had embryos in storage at Concept Fertility Centre on 30 March 2003 that had been cryopreserved between 1 January 2000 and 30 June 2002.Main outcome measures: Participants’ choices with regard to donating embryos to another couple, to research to improve in-vitro fertilisation (IVF) techniques or to stem-cell research, and the likelihood of couples choosing to use a range of sources to help them with their decision.Results: The response rate was 57%. Twenty-nine per cent of respondents (36/126) reported they would donate their embryos to research that would improve IVF techniques and 27% (34/126) reported they would donate their embryos to stem-cell research. Fifteen per cent (19/126) would donate their embryos to another infertile couple. Willingness to donate to research was not influenced by whether the couple had previous children, or age. Women and men with moderate to strong religious beliefs were less likely to donate to research. Over 90% of respondents indicated they would seek outside help to decide the fate of their embryos.Conclusion: This study suggests that about 30% of couples would donate their embryos to research, and highlights the need to provide support and information to help couples through their decision-making process.

Peter J Burton PGDip(Sci), PhD · Katherine Sanders BSc(Hons), PhD

Major reasons for the growth in the use of complementary and alternative medicine (CAM), in Australia and elsewhere, are general societal changes rather than specific reasons internal to medicine. There are problems of definition of CAM, as well as the extent to which CAM modalities can be considered a unified paradigm. The general changes examined include the consumer and green movements, as well as postmodernism. The movement surrounding evidence-based healthcare may provide some answers, but will not settle the issue of compatibility. CAM is here to stay and will continue to present challenges for conventional medicine on how to respond.

Ian D Coulter PhD · Evan M Willis PhD

Fairness and compassion are the bases for improving Aboriginal health There is no dispute that Aboriginal health in Australia is both poor and very much worse than that of non-Aboriginal people, and their life expectancy at birth is about 21 years less for men and 19 years less for women. Among Aboriginal and Torres Strait Islander males, 6.8% die in infancy, compared with 1% for the rest of the population. For females the figures are 6.7% and 0.8%. A large array of diseases are much more prevalent among Aborigines.1 Institutional racism in Australian healthcare — some examples Funding inequity: Overall funding of Aboriginal healthcare is not commensurate with extra need.8 Different performance criteria for black and white: For example, in Perth, Derbarl Yerrigan Aboriginal Medical Service funding was cut when an “overspend” arose because of success in attracting clients; at the same time the teaching hospitals’ overspend was 120 times as great as that at Derbarl Yerrigan. The teaching hospitals were given an extra $100 million to cover their overspend.9 “Body part” funding: For instance, separate streams of money for conditions such as diabetes and heart disease for a health service which is intended to be holistic — 26 funding streams (and hence 26 separate accounts and 26 demands for accountability) for the Danila Dilba Aboriginal Medical Service in Darwin. Differences in treatment regimens: Aboriginal people in Western Australia born in the 1940s received low-cost nursing care; in contrast, a white cohort of the same age received higher-cost technological care.10 Inequitable Medicare Primary Health Care (Medicare Benefits Schedule plus Pharmaceutical Benefits Scheme): In Katjungka (a remote Aboriginal community), $80 per head per year; in Double Bay (an affluent Sydney suburb), $900 per head per year.11 Cultural barriers to Aboriginal use of healthcare services: Inadequate funding to reduce these barriers (such as language barrier and lack of recognition of different constructs of health) for Aboriginal people. This is not news. The question is how to improve this situation. The argument presented in this article rests on two core and related ideas: that our health services are “institutionally racist” and that such racism stems from Australia being, or at least having become, an uncaring society. The way forward that we propose is recognising and addressing institutional racism. This would provide a framework for improving Aboriginal health. We believe, however, that acceptance of the need to address such racism can only come about through building a more compassionate and decent society. To suggest that healthcare in Australia is institutionally racist may be confronting for some, but we argue not only that it is institutionally racist, but, more importantly, that such racism represents one of the greatest barriers to improving the health of Aboriginal and Torres Strait Islander people. We will also indicate what might be done to overcome this institutional racism and improve Aboriginal health. Defining institutional racismInstitutional racism “refers to the ways in which racist beliefs or values have been built into the operations of social institutions in such a way as to discriminate against, control and oppress various minority groups”.2 It has been claimed that “Institutional racism is embedded in Australian institutions”.3 Often, institutional racism is covert or even unrecognised by the agents involved in it. In recent years, interest in both the concept and practice of institutional racism has increased. In the United Kingdom, it was sparked by the Stephen Lawrence Inquiry,4 published in 1999. This examined the events which followed the completely unprovoked murder in 1993 of Stephen Lawrence, a young black man, which was “unequivocally motivated by racism”. It found that the investigation was marred by a combination of professional incompetence, institutional racism and a failure of leadership by senior officers. It claimed that “officers approached the murder of a black man less energetically than if the victim had been white and the murderers black”. In the context of racial and ethnic disparities, Camara Jones,5 an Assistant Professor at Harvard University School of Public Health, has called for “a growing national conversation on racism”, one key aspect of which is “institutionalized racism”. This she sees as being “often evident as inaction in the face of need”. An increasing focus on institutional racism in Aotearoa (New Zealand) was prompted by a visit there by Camara Jones in 1999.6 In Australia, institutional racism has been an almost constant feature of our history, from the British designation of the continent as terra nullius, through the 1897 Convention on Federation (where the question of whether Aboriginal people should be counted as “people” in the national census was covered in just 195 words7), to the stolen generations and the failure of the federal government to issue an apology. Examples of institutional racism are shown in the Box. Clash of culturesWe believe that any healthcare system is a social institution built on the cultural stance of the population it serves. It follows that cultural values should provide the value base for health services. Between Aboriginal and non-Aboriginal Australians, there is not only a difference in culture, but a clash of cultures. We think some white people are at least dimly aware of this. However, the extent of their understanding of the difference between a culture based on individualism, where the individual ranks above the community in importance, and a communitarian culture, in which each individual is less important than the whole, is limited. One of us, S H,7 a Gungulu man, has written: “Aboriginal Peoples have built a communitarian solidarity that includes an awareness and affirmation of the [cultural] difference [of Aboriginal people]. Such communitarian solidarity is a form of civic friendship between peoples that is distinguishable from other forms of friendship because it unites people who are members of the same particularistic cultural community — persons who share a common worldview and use the same primary moral vocabulary.” Yet that value base is inadequately recognised in the planning of healthcare services in this country. Where societies or social entities have a greater awareness of and concern for mutuality, reciprocity and sharing, trust in institutions will be fostered and racism will diminish. Many Australians have embraced the individualism of neoliberalism. Uniting as a community around little other than the successes of its sporting teams, today’s white Australia lacks these “communitarian” traits. While communitarianism need not always be a force for good (the Nazi vision of the “master race” is a case in point), it can be and has been a beneficial force in Aboriginal culture. Here it is best seen in terms of what the distinguished public servant Coombs12 describes as “the Aboriginal ethic of accountability to others”. This, he writes, “is required by their commitment that autonomy, at a personal and group level, will be exercised so as to ensure that what is done contributes to the care and nurture of others with whom they are related; so that personal behaviour remains socially grounded”. In current health policy there is little attempt to recognise the differences in culture between black and white. The holism of Aboriginal health involves not just a “wholeness”, but a series of mutual obligations. Aboriginal Medical Services attempt to provide culturally “secure” services (ie, services based on Aboriginal preferences where differences in culture do not create additional barriers to use). Their poor funding levels, however, severely restrict them in this. Mainstream services make almost no effort to understand or provide culturally secure services. To deliver such services might increase primary healthcare costs for Aboriginal people by more than 50%.9,13 This is because, for example, questioning with respect to history has to be indirect, and preceded by time spent in building trust and confidence between the doctor and patient. This process, to be done well, can be time consuming. Also, advocacy on behalf of the client with other agencies, such as those providing housing, is often expected by Aboriginal clients as part of a GP’s role. The prospects for creating a cohesive Australian community, advancing social capital, furthering equity and reducing racism are not bright. For example, the Human Rights and Equal Opportunities Commission conducted a series of consultations across Australia which showed racism to be widespread and institutionally based, especially with respect to Aboriginal people.14 We believe that the current Australian federal government puts at risk our social capital in its pursuit of divisive policies. This applies not only to Aboriginal people, but also to other minority groups, defined racially or otherwise. For example, extending upfront fees for universities gives the affluent greater access compared with the poor; and ignoring the principle of universality (which did not rate a mention in the Prime Minister’s media release as one of his three pillars of Medicare15) on Medicareplus creates yet more of a two-tier healthcare system. The government’s policies on immigration have been severely criticised by many, including Father Frank Brennan, the Jesuit priest and lawyer, who concludes his book on the subject with an appeal to re-create social capital in Australia: “Many of us would like to return collectively to being a warm-hearted, decent international citizen.”16 We believe that Aboriginal people have lost their trust in the institutions of government, including healthcare services. Lack of respect by white Australians for Aboriginal values, the discounting of these values by those who have sought, patronisingly and paternalistically, to “do good” to Aboriginal people (according to a “good” defined by white fellas), leads to further erosion of trust. The lack of trust by Aboriginal people in white people and white institutions is obvious. More tellingly, we believe there is a lack of trust by Aboriginal people in themselves as a people — a lack of confidence in their culture. It is this last, a legacy of colonisation and its aftermath, that has wreaked the greatest havoc of all. We also believe that there is a lack of political will and of leadership to deal with inequalities generally in Australian healthcare. The most glaring example in recent times lies in the government’s schemes to promote private health insurance. The cost of increasing spending on primary healthcare for Aboriginal people to a level which would take into account such considerations as greater health problems, cultural-access barriers and equity (ie, increasing it to five times the per-capita level for non-Aboriginal people17) might be measured by the benefit forgone if the government were to halve the rebate (from 30% to 15%) for private health insurance.18 Progressing from institutional racismCurrently, cultural differences and ignorance create racism, and indifference nurtures it. Cultural differences must be celebrated, rather than denigrated. Former Prime Minister Paul Keating’s Redfern Speech on reconciliation pointed the way forward: “I think what we need to do is open our hearts a bit. All of us. Perhaps when we recognise what we have in common we will see the things which must be done . . . If we open one door others will follow.”19 That was 12 years ago. Today, the converse is true. As we have closed one door, others have followed. So many doors on social justice are closing in this society. We closed the door on a Norwegian freighter carrying abandoned refugees. We close the door on children in detention centres, on poor youngsters trying to get a university place. We close the door on opportunities for Aboriginal people and on the richness of an ancient culture which is potentially there for all Australians to learn from and take pride in. What scope is there for building compassion? Not much, it might seem, in this neoliberal society and this globalising world. Yet, as the social commentator Richard Titmuss remarked 30 years ago about the UK National Health Service, altruism and compassionate acts are infectious not only to other people, but to other events and circumstances.20 Compassion is good for us. What to do?Firstly, white Australia must learn to understand Aboriginal culture, particularly with respect to its fundamental philosophy of “communitarian solidarity”. Only then can social institutions, such as healthcare services for Aboriginal people, be built on a genuine understanding followed by accommodation of the hopes and aspirations of Aboriginal people. More directly, only then can Aboriginal people have the chance to have health services delivered to them that are, by right, as accessible (in the broadest sense) as they are to white Australians. Secondly, those white people who were described (above) as patronising and paternalistic would cease to be so when, in their “doing good”, good was defined by Aboriginal preferences. Thirdly, Aboriginal communitarian preferences must drive Aboriginal health services, their funding and their performance indicators. Unless the governance of Aboriginal organisations is based on Aboriginal cultural values, these services will not function effectively or efficiently. Fourthly, public compassion must be built into the Australian social fabric. The “fair go”, if it ever existed, has gone, but Australia needs a leadership that will articulate that fair go. The philosopher Martha Nussbaum argues against “impoverished models of humanity” with “numbers and dots taking the place of women and men”.21 She continues: “. . . when one’s deliberation fails to endow human beings with their full and complex humanity, it becomes very much easier to contemplate doing terrible things towards them . . . if you really vividly experience a concrete human life, imagine what it is like to live that life, and at the same time permit yourself the full range of emotional responses to that concrete life, you will . . . be unable to do certain things to that person. Vividness leads to tenderness, imagination to compassion.”21 Finally, our call is for a more compassionate society. Attitudes to asylum seekers, to Aboriginal people, to people who are in any way disadvantaged, are linked. Social attitudes need to be more compassionate to all who are disadvantaged, and not just to Aboriginal people. ConclusionAboriginal people merit so much more from white Australia. First and foremost, they deserve white Australia’s trust — trust that Aboriginal people know better than white Australians what is good for Aboriginal people. They deserve (and not just in their music and dancing) recognition of their culture. Two things are necessary — first, Australian society needs to listen and hear the calls of the disadvantaged (and there are so many in Australia today, especially Aboriginal people); then, those who have compassionate voices need to use them. Many people working in healthcare and in universities have social consciences and believe in social justice. They need not only to give voice to the voiceless, but to give themselves voice as decent, white Australians. In this Australia — this divided, divisive, racist, socially unjust society that we have built — we now need institutions and policies that will unbuild it. We need to acknowledge that the “fair go” is struggling to survive, if not already dead. Fairness and compassion need to be once again the guiding principles of our leaders and our democracy. Only then can we build a society where decency can become the fundamental in addressing Aboriginal health. There will be no sudden breakthrough; there is no magic pill. Decency, however, is a good place to start.

Barbara R Henry GradDipHE · Shane Houston PhD · Gavin H Mooney MA

Gordon Broderick Executive Director, Distilled Spirits Industry Council of Australia, 1st Floor, 117 Ferrars Street, South Melbourne, VIC 3205. gordonbATdsica.com.au To the Editor: In their article on risk-taking behaviour among young Australian women, Carr-Gregg and colleagues make a number of statements about alcohol consumption among young women.1 Unfortunately, these statements are not supported by the facts. The authors assert, citing a national study of 14 762 women aged 18–23 years,2 that “seventy percent of young women engage in ‘binge drinking’ (5 or more drinks on one occasion) at some time, with 19% doing so on a weekly basis”. The level and frequency of alcohol consumption that constitutes “binge drinking” is a matter of conjecture. The National Health and Medical Research Council (NHMRC), in guidelines released in 2001,3 state that “binge drinking” is “not a preferred term due to its lack of consistent and specific meaning”. The NHMRC guidelines on short term risk specify 5–6 alcoholic drinks for a female on any one day as being “risky” for health, and 7 drinks or more being “high risk”. For long term risk, 3–4 drinks on an average day, or 15–28 drinks a week, is considered “risky”, with any more constituting “high risk”. Applying these guidelines to the Women’s Health Australia dataset shows that 5.1% of young women engage in drinking that is “risky” or “high risk” in the long term. Of the remaining 94.9%, 14.4% drink 5 or more drinks weekly or more, and 51.9% drink five or more drinks monthly or less. This is a more revealing (and accurate) picture than the blanket statement that “70% of young women are ‘binge drinkers’ ”. Carr-Gregg and colleagues also claim that “22% of females aged 14–19 years drink between 9 and 30 alcoholic drinks a day”. The source for this statement is a survey conducted for the Salvation Army.4 The survey has several limitations, not least the small sample size. The survey sampled 614 respondents, of whom 70 were aged 14–19 years. The assertion that 22% of females in this age category were “binge drinkers” is based on just seven respondents. This number is well below what is required for any reliable statistical estimation. Encouraging responsible drinking among younger people is a major goal of health professionals and the alcohol industry. A constructive policy debate on this issue requires sound, objective evidence about alcohol consumption among younger people. The article by Carr-Gregg et al does not represent progress towards providing that evidence.

Gordon Broderick

Addictions and healing in Aboriginal country. Gregory Phillips. Canberra: Aboriginal Studies Press, 2003 (xix + 210 pp). ISBN 085575408. This is not the first book documenting the problems of addiction and healing in Aboriginal communities. It is, however, the first written by an Indigenous academic. It is also important because it puts forward a methodology for an Indigenous science that seeks to provide a theoretical and practical basis for Indigenous ways of knowing and working. The study is based on ethnographic research in an Indigenous community in north Queensland. Phillips first discusses his own role and responsibilities as an Indigenous academic working in an Aboriginal community. He articulates an Indigenous-defined methodological theory and culturally appropriate knowledge production, an issue that has received very little discussion in research among Indigenous Australians. Interweaving the voices of the community of “Big River” with a range of historical, anthropological and medical material, the experience of trauma and substance misuse is explored. Arising from these explanations, the author reflects on some of the ways the Big River community talk about addressing addiction problems. One fascinating chapter explores approaches to treating addictions among Native Canadians, where the author, together with a suicide prevention officer from Big River, made a number of visits to different communities and treatment programs. Through these experiences the author provides a provisional approach to the treatment of addictions, one that acknowledges the importance of culture and spirituality, but which also incorporates a number of other approaches, such as harm reduction, Alcoholics Anonymous and residential treatment. One criticism would be that the approaches to an Indigenous science outlined at the beginning are not clear in the following chapters. How would the Indigenous methodologies be replicated elsewhere? Do they rely on identification as an Indigenous person and in what ways can non-Indigenous academics and health professionals engage with this approach? In order for such important ways of knowing to be transferred elsewhere, it is important that such methodologies be clearly formulated. Nevertheless, this is an important book on a difficult subject, and one that successfully conveys the individual and social traumas of substance misuse and the ways communities are addressing them. Richard D ChenhallResearch Fellow Menzies School of Health Research, Darwin, NT

Richard D Chenhall

Double standards in medical research in developing countries. Ruth Macklin. Cambridge: Cambridge University Press, 2004 (viii + 280 pp). ISBN 0 521 54170 0 Inequity, when looked at steadily, is appalling. Here we see it, like a Dementor straight out of Harry Potter, staring us down and threatening our sanity in the middle of nice, clean drug trials. Increasingly, pharmaceutical companies conduct clinical trials of new drugs in developing countries because, without adequate mechanisms for the protection of human subjects and the interference of busybody ethics committees, they can obtain rapid answers and get on with the business of profiteering. Clinical trials of new medications conducted in developing countries first provoked comment in 1997, when a study of relatively low dose AZT, given late in pregnancy to HIV-positive mothers about to give birth, was compared with treatment with a placebo. By then we knew that high-dose AZT (expensive) given for a longer period during pregnancy had positive consequences for the newborn child. The idea of not treating the controls caused uproar. Why worry? Firstly, the cost of the new treatment under test is often unaffordable for the country in which the trial is being conducted. When the trial ends, questions arise about continued use of the drug in that country. Secondly, trials using placebo controls bother some observers. They feel that the control subjects should be offered best care as provided in the country from whence the drug trial emanates. This is difficult when standard care is well beyond the reach of the country where the trial is running. What a mess! Thirdly, others worry when a trial is conducted, say, in Botswana of a drug of limited relevance there but highly relevant in Germany, where the costs of the trial would be much higher. Rip off? Ruth Macklin is a New York-based bioethicist with a legal background, which makes her a formidable commentator. She has served on many prestigious international bioethics agencies and inside the NIH. She writes compellingly, lucidly, and in deep detail. She examines the three questions mentioned above, and explores the interplay of science with concerns for human rights, justice, equity, and development. This is not a book for anyone in search of a quick fix or a slick answer. It is, however, chock-full of up-to-the-minute, sophisticated, sound and helpful ethical reasoning and reflection in an area that challenges our humanitarian values head-on. Stephen R LeederProfessor of Public Health and Community Medicine University of Sydney, Sydney, NSW

Stephen R Leeder

A recent editorial looked at the way the problems at Camden and Campbelltown hospitals were managed, and has attracted a range of opinions Be very afraid Brad Frankum,* Duane Attree,† Andrew Gatenby,‡ Sandy Eagar,§ Anthony Aouad¶ * Director of Medicine, and Conjoint Associate Professor, University of New South Wales; † Clinical Decision Support Manager; ‡ Chair, Division of Surgery; § Nurse Manager, Professional Development; ¶ Chair, Clinical Advisory Council, and Physician; Macarthur Health Service, PO Box 149, Campbelltown, NSW 2560. Brad.frankumATswsahs.nsw.gov.au To the Editor: In reply to your question as to whether the crassly phrased “Cam Affair” was “an isolated incident or destined to be repeated?”,1 doctors and administrators throughout our healthcare system should be very afraid. They may be next; this was no isolated incident. We who continue to work in Macarthur Health Service (MHS) expect a daily dose of ill-informed and inaccurate “revelations” about our hospitals in the media. Our despair increases, however, when we read similar superficial comments from your esteemed publication. For the record, before the leaking of the draft Health Care Complaints Commission (HCCC) report, some of the following systems and solutions had already been put in place at MHS (implementation date in parenthesis): Performance management of all staff — including 100% of all senior medical staff — with focus on Key Performance Indicators and implementation of the Clinician’s Toolkit (March 2003). Capital development at a cost of over $100 million (ongoing). Appointment of 45 new consultants across a variety of specialties (2000 to September 2003). Appointment of an academic full time Director of Medicine (January 2003). Establishment of new and innovative services in ambulatory care, acute medicine, emergency short stay, paediatric emergency, stroke, palliative care, cancer therapy, rehabilitation/geriatrics, radiology, community maternity and paediatrics, and mental health. A local graduate nurse program with over 85% retention rate (1998–2003). Rigorous identification of all adverse events from acute settings by having dedicated staff and weekly multidisciplinary team review of cases (2001–2003). Weekly multidisciplinary grand rounds (January 2003). An active partnership with members of the community through a Community Council, community review of complaints handling and inclusion in MHS committees (2002). A functional and well represented Allied Health Council and Discipline Seniors Committee. Well attended and widely represented (including community) Clinical Advisory Council (December 2002). Multidisciplinary team meetings and quality review in all specialty departments (July 2003). Increase from one to three Royal Australasian College of Surgeons accredited surgical registrar positions since 2000. Successful Postgraduate Medical Council accreditation (2003) and recruitment of 6 additional Junior Medical Officers. Are these the actions of an “indifferent administration”? Was there any attempt to place these adverse outcomes in the context of an extremely busy health service; one with historically the poorest staffing levels of any metropolitan hospital in New South Wales (Box) and a health service existing in a population with one of the highest growth rates in Australia?7 No one wishes to minimise the impact on the families of those who suffered adverse outcomes. However, anyone who works in a public hospital knows that adverse events occur. The established rate internationally ranges from 3.7%–45.8%.8 Applying the accepted rate in Australia (16%), Camden and Campbelltown hospitals should have had 26 667 adverse events in the years 1998–2003. The number of cases highlighted in the various investigations (71) represents an adverse event rate of 0.043%. The only appropriate way to deal with these events is through a rigorous quality framework making use of the expertise of staff at the coalface. The handling of our hospitals’ adverse events by various bodies has set this quality agenda back many years. In its report, the HCCC showed that it is a completely inappropriate body to be investigating a health service. It investigated and passed judgements on clinician performance without ever consulting individual clinicians. It convened expert panels unsuitable for the nature of the cases reviewed (eg, no Visiting Medical Officer [VMO] involvement on a panel that investigated over 30 cases of patients under the care of VMO physicians). Our State Health Minister shares this opinion.9 In 2003, MHS achieved 2 years’ accreditation with the Australian Council on Healthcare Standards.10 What, then, does this mean? In 2004, significant numbers of senior clinicians have resigned, the administration has been decimated, and there is widespread bewilderment among the hard-working, skilled and dedicated staff. The media and politicians on both sides have behaved poorly. Ironically, staff now fear to speak out publicly, because to do so may jeopardise the assistance and resources we may finally be afforded. Obviously the government and bureaucracy would prefer the general public to believe that MHS is the only “sick hospital(s)” in the healthcare system, find some individuals to blame, play catch-up with resources, and watch the problem evaporate. Furthermore, a new threat is emerging: if you undertake investigation into adverse events, you risk confidential cases being easily identified and passed on to the media and regulatory bodies. If you are a clinician and you treat enough patients, one day you will make a mistake. Be very afraid. The precedent is set — blame is back on the agenda. Occupied bed-days, emergency department presentations and staffing levels at Sydney public hospitals Hospital Bankstown St Vincent’s Macarthur Sutherland Hornsby Admissions in 2002/03 26 2252 29 6813 29 4092 19 3963 16 9644 Emergency department presentations (for November 2003)5 2 710 2 755 3 713 2 590 1 922 Salaried medical officers (FTE)6 128.61 266.7 70.83 93.26 108.87 FTE = Full-time equivalent. Staff goodwill is running out David Rosenfeld Chairman, Liverpool Health Service Medical Staff Council, Liverpool Hospital, Locked Bag 7090 Liverpool, Sydney, NSW 1871. d.rosenfeldATunsw.edu.au To the Editor: In response to your recent editorial,1 I would like to point out the following. The Sydney Metropolitan Area Health Services, comprising Northern Sydney, South Eastern Sydney, Western Sydney, Central Sydney, South Western Sydney and Wentworth, had a budget expenditure for 2001/02 of $4581 million (information from internal Department of Health documents). The combined population of these health service areas was 3 887 142, and dividing this expenditure by the population gives annual expenditure of $1178.66 per person. In 2001, South Western Sydney Area Health Service (SWSAHS) had a population of 797 510,2 making it the most populous of all these health areas. Dividing SWSAHS’s expenditure by its population gives an annual expenditure of only $920 per resident. Population projections (an increase of 14.9% from 2001 to 2006) show SWSAHS to be the fastest growing of all, which means the funding per resident will continue to deteriorate. To spend the 2001 average on SWSAHS residents would require increasing this health service’s budget by $205 million. This is the crux of the whole problem. For far too long, residents of SWSAHS have lagged far behind their metropolitan neighbours in healthcare expenditure. These figures do not even take into account the marked disparity in research funding flowing to other metropolitan areas compared with SWSAHS, nor all the private hospitals and level of privately insured patients in other health areas, which would probably more than double the health expenditures already listed. Further, SWSAHS has the highest ethnic population in the country and is the most socioeconomically disadvantaged; our expenditure on interpreter services and social workers consumes a disproportionate percentage of our funding. The state Department of Health has long recognised this disparity, and has been trying to redress the problem. However, unless significant additional funds can be generated, resources will need to be redistributed from other Area Health Services. This can be extremely difficult — long-established teaching hospitals have very well resourced support networks and links that go back many years. SWSAHS includes Liverpool Hospital, which is a tertiary referral service still funded as a district hospital. Unfortunately, the only real surprise to staff working there is that the recent problems have not happened before, and that they have not happened at more of the hospitals in SWSAHS. Medical research in SWSAHS is extremely limited. We struggle to appoint advanced trainees. We are trying to teach our undergraduates in an environment with shrinking teaching resources, and the promise of $5 million is a couple of zeros short of what is needed. It is only through the goodwill of staff, and their extraordinary commitment, that we have survived this long. Senior medical staff are now leaving in significant numbers because of “burnout” and overwork. The solution is not money alone, and it is certainly not “working smarter”. Colleges need to make rotation compulsory for advanced trainees so that they can be exposed to a wider variety of clinical cases. There need to be inducements locally to attract staff — including not charging them more for parking than any other hospital! There are no simple answers, but blaming inadequately trained and resourced staff, who are placed unwillingly in situations beyond their competence, is severely damaging to all SWSAHS staff. Diagnosis before treatment: don’t blame funding Paddy A Dewan Paediatric Urologist, PO Box 152, Parkville, VIC 3052. Paddy. DewanATwh.org.au To the Editor: In your recent editorial, you make the statement “it is hoped that something more substantial than yet another list of blameworthy individuals will emerge from the inquiry”, and then blame funding shortages for substandard care,1 highlighting how pervasive blame and guilt are! Nonetheless, your suggestion that we have a sick, politically motivated health-care system is accurate. Improvement will occur if we, as medical service providers, take responsibility for the deficiencies and accept that we and our system are inadequate for a whole host of reasons, including less-than-perfect science, and competition rather than collaboration between specialties and specialists, to name just a few. Even more importantly, we are constrained by an unfriendly work environment in much of the public hospital system, for which we blame the budget. Money never made anyone happy! Unfortunately, hospital administrators are usually not “in for the long haul” and often seem poorly focused on the needs of the patients, let alone the emotional needs of staff — an administrator’s career is more dependent on meeting “targets”. The workplace environment is further marred by the limited ability of some of our clinical colleagues who have been “elevated” to management positions, where they manage budgets, complex interpersonal issues and patient complaints. Strategic planning, root-cause analysis and staff satisfaction are terms without real meaning to many of these doctors, who appear to be set up to fail. Once in the clinical administrative position there seems little in the way of “staff caring” performance review. Interpersonal conflict and politics often predominate, and bullying is facilitated by these high-stress environments, exacerbated by the threats of litigation from patients, some of which occur because unhappy staff lash out at consumers. As we tend to view adverse events as something for which families will seek legal solutions rather than seeing such events as opportunities for change, we are frightened. Because we are stuck in a culture of fear and blame, we avoid these patients rather than try to share the hurt that comes from an adverse outcome. Thus, minor imperfections are dismissed as inevitable, and for more major adverse catastrophes we seek qualified privilege to feel protected. However, we are not protected by hiding; we are protected by dealing with a complaint as a challenge to improve rather than a reason to abuse the person who points out a deficiency. At the Royal Children’s Hospital, Melbourne, a senior clinician expressed concern about quality of care, for which he was progressively marginalised, put through an unjust request for resignation, and exposed to a hospital board review conducted with no clinical expertise and little understanding of bullying. The clinician’s appointment was then terminated because he went to the media, and his termination was justified by a clinical review with restrictive terms of reference. The circumstances were similar to those of the “Cam affair” in the Macarthur Health Service. The public and the medical community can only conclude that politics, and not standards, drive the health agenda, a view that was confirmed during a recent Victorian parliamentary inquiry into community advisory committees of hospital boards that did not allow major concerns of selected people to be heard by the public. This lack of transparency, and lack of partnership, at all levels, should be replaced with a more open, trusting culture with greater accountability, less blame and less hollow jargon. When will we ever learn! In support of the HCCC John H T Ellard Psychiatrist, 29A Almora Street, Balmoral Beach, NSW 2088. manstumATtpg.com.au To the Editor: Your recent editorial1 raises some very interesting questions. The Health Minister commented in his press release that the “HCCC [Health Care Complaints Commission] does not go far enough in terms of finding anyone accountable for these failures”.2 He could have set his mind at rest by consulting the relevant articles in the Encyclopaedia Britannica. In essence, in the system of government that we have, with Cabinet responsibility, he is the person with the ultimate responsibility. If his departmental and administrative heads did not keep him properly informed and advised, then surely their heads should roll rather than that of the HCCC Commissioner, whose report demonstrated that there were big problems. I believe that one of your suggestions — that of dismantling the “highly centralised HCCC” and replacing it with regional panels — is very likely to make things worse rather than better. The first question to be answered in an inquiry of this kind is whether or not there was medical error, incompetence or impropriety. This involves a careful and detailed examination of the information available about the event or events in question. There are allegations and responses, and there is often a large body of clinical notes, hospital records and laboratory results to be read most carefully and considered. Sometimes the issues are simple, and sometimes they are complex, requiring the assessor to have considerable experience, detailed specialist knowledge and to make literature searches. Not every local area will have a sufficiently wide range of expert assessors. The capacity to find competent, experienced, unbiased assessors diminishes as the geographical and administrative areas to be considered become smaller. Remember that the HCCC has to deal with all the registrable healthcare professions — not only medical practitioners, but psychologists, nurses, physiotherapists, osteopaths and the like. Consider the amount of time and effort required to set up the panels in all these activities in each local area. I will conclude by indicating what I believe to be the fatal error in your suggestion. Imagine that the preliminary inquiries strongly suggest that the problems in question arose from a lack of resources and that the government of the day is substantially responsible for what happened. I have the greatest difficulty in believing that the area’s state and federal politicians would be capable of coming to an opinion which laid the fundamental blame on the government of the day, if it happened to be that of their party. I believe that the “Cam affair” provides an indication of what would happen. I have been associated with the present system since it began as the Complaints Unit and then became the HCCC. I do not suggest that it has reached perfection, but long observation convinces me that it has played a valuable role and that many errors and improprieties in medical practice have been much diminished because of its good work. No profession has ever welcomed scrutiny from outside its ranks, and there are still those in medicine who hold that position. I am in firm disagreement. The healthcare complaints commission needs reform, and politicians must accept ultimate responsibility Martin B Van Der Weyden Editor, The Medical Journal of Australia, Locked Bag 3030, Strawberry Hills, NSW 2012. editorialATampco.com.au In reply: We at the Journal welcome criticisms as treasures from which we always learn. The recent editorial on the “Cam affair” has certainly provoked responses from a number of our readers. Let me state from the outset that I fully understand the tension so evident in the remarks of Frankum and his colleagues from the Macarthur Health Service. However, I am not sure why our choice of the phrase “Cam affair” has caused so much apparent distress. The Concise Oxford Dictionary defines an affair as: “1 a concern; a business; a matter to be attended to (that is my affair). 2 a a celebrated or notorious happening or sequence of events. b colloq. a noteworthy thing or event (was a puzzling affair). 3 = love affair. 4 (in pl.) a ordinary pursuits of life (current affairs). b business dealings. c public matters.” The unfortunate events within the Macarthur Health Service over the last year certainly constitute “an affair” which will be remembered for some time; whether its use is “crass” is in the eye of the beholder. I am heartened to read the administrative and clinical progress listed by Frankum et al. However, as late as August 2003, the Macarthur Expert Clinical Review Team recommended, among other things, the need for significant leadership in the hospitals’ clinical and administrative spheres, and the involvement of academic institutions and clinical colleges to make the hospitals more professionally attractive for postgraduate training and senior staff. Central to all this is the importance of doctors in training in Sydney’s south- west to be seen to successfully withstand the scrutiny of our clinical colleges, on par with other metropolitan hospitals. This will only come with an enhanced academic presence in all major clinical disciplines of the Macarthur Health Service. Again, I am heartened to read that this is happening, albeit slowly. Rosenfeld’s data reinforce one of my editorial’s contentions, that the Cam affair was a system failure, a “mismatch between clinical capacity and clinical demand — a mismatch exacerbated by the chronic ‘poor country cousin’ status of Sydney’s outer metropolitan hospitals compared with their ‘rich city cousins’, the established inner city hospitals”. However, transfer of resources alone will not solve the problems. Our public hospitals are 19th-century institutions at sea in the 21st century, and they need reform. This will require urgent short-term and long-term solutions to meet the obvious funding and workforce deficiencies, but also fundamental system reform. How long do doctors and other healthcare professionals have to send out SOSs that the public hospital ship is sinking before bureaucrats and their political masters respond? Dewan’s comments are apt; our healthcare culture is not good at confronting criticism. Witness the experiences in Bristol1 and Winnipeg.2 We desperately need an open, blameless and depoliticised environment which allows individuals to speak frankly about individual or systemic shortfalls and failures, and clear pathways for these to be addressed. Finally, Ellard is not certain that dismantling the highly centralised Health Care Complaints Commission is a good idea. Modern management principles eschew top-down, people-insensitive systems as appropriate quality improvement tools, and the HCCC allegedly has all these attributes. Further, the Commission provides politicians, as aptly noted by Ellard, with another means of dodging their responsibilities. It is evident that the healthcare complaints system needs reform. Thus, my suggestion for local complaints panels headed by an ombudsman, and involving local health professionals and politicians, was meant not only to promote debate, but also to engage an inclusive, bottom-up approach. I am not rigidly committed to the local entity, but whatever strategies and recommendations emerge from current parliamentary enquiries they must ensure the integrity of systems and locate these close to where the healthcare action is played out. It is also imperative that local politicians on both sides of politics are involved along with healthcare professionals, and that the current emphasis on investigation of individuals is shifted to investigation of systems. Finally, it is crucial that any reporting undertaken is directed, not to health bureaucrats or the Minister for Health, but to Parliament as a whole. Our politicians must take collective responsibility for healthcare in the communities they purport to represent. Anything else is political bastardy.

Brad Frankum · Duane Attree · Andrew Gatenby · Sandy Eagar · Anthony Aouad

International human rights law affirms that everyone has a right to the enjoyment of the highest attainable standard of physical and mental health. States that are parties to human rights treaties are obliged under international law to observe these rights. Australia has ratified all international human rights law instruments in which the right to health is enshrined, and so is obliged to ensure that its foreign policy, including its development assistance program, contributes towards the progressive realisation of the right to health. International trade regulation should be consonant with the progressive realisation of the right to health globally.

Elizabeth A Reid AO, FASSA