Social determinants of health

Assessing patients' spirituality provides important medical information In this issue of the Journal, Peach examines whether the medical profession in Australia ought to consider patients' religion or spirituality in clinical practice (page 86).1 There is much that Peach writes which I wholeheartedly support. This includes the important role that clergy play in medical settings, the need for further research on the health benefits (and risks) of spirituality in Australian patients, and the need to better understand the costs and benefits of Australian physicians making spiritual inquiries. However, on four points we disagree: Australians are not as religious as Americans and therefore religion is less important for Australian patients; although religion appears associated with health in the United States, there is little evidence for this in secularised Australia; assessing spirituality should probably be deferred to clergy or social workers; and until more is known, including spirituality in medical practice (in addition to addressing it in Australian medical schools) would be premature. Although Australians may be less religious than North Americans, the difference is not that great. Belief in God has decreased in Australia, but it has not gone away. In 1948, 95% believed in God; by 1975, the figure was 80%.2 In 1998, 74% believed in God, a higher spirit or life force,3 and according to the 1996 census only 0.05% of Australians are avowed atheists. When physical or emotional illness strikes, spiritual issues become even more important, as issues of meaning and purpose become relevant. This is particularly true for older adults with chronic illness, a population that will increase as Australians older than 65 years increase from 2.4 million people in 2001 to a projected 5.4 million in 2031.4 Even among younger patients, spiritual practices assume substantial importance. Consider a study of 108 patients (mean age 38 years) from medical practices in Sydney, in which researchers examined patients' experiences concerning the efficacy of 25 coping behaviours.5 Forty-one per cent of subjects indicated they would increase prayer in response to stress, 56% said prayer was helpful and, overall, prayer was ranked seventh in effectiveness, ahead of 18 other traditional coping behaviours, such as discussing the problem, seeking advice, spending time with friends, or socialising. Similar findings emerge among psychiatric patients. A study of 79 psychiatric patients at Broken Hill Base Hospital in New South Wales found that 79% rated spirituality as very important, 82% thought their therapist should be aware of their spiritual beliefs and needs, and 67% indicated that spirituality helped them cope with psychological pain.6 Thus, at least preliminary research suggests spiritual needs are not uncommon among Australian patients. Is religion related to better health in Australia? Although research is less plentiful than in the US, it is not entirely absent.7 Australian studies have found greater marital stability, less alcohol and illicit drug use, lower rates of and more negative attitudes toward suicide, less anxiety and depression, and greater altruism among the religious. Religiosity has also been associated with less cigarette smoking, more conservative sexual practices (reducing risk of sexually transmitted diseases), lower cortisol and catecholamine levels (for meditators), lower blood pressure, lower cholesterol, longer survival (Seventh Day Adventists), and even lower risk for colon cancer.8 Such findings are similar to those in the US,7 and, although more research is needed, these findings cannot be ignored. Because religion relates to health, and spiritual issues are important to many sick patients, deferring assessment of all such issues to clergy or social workers is probably unwise. Although physicians are not trained in this area, brief evaluation and orchestration of resources does not require great skills beyond what physicians already possess. Insufficient time is a problem, but it is not the main reason why physicians don't address spiritual issues. Rather, it is lack of comfort.9 Not knowing why or how to address such issues and feeling worried about imposing their beliefs on patients, not surprisingly they avoid the topic. Nevertheless, a brief spiritual history gathers information that is medically relevant and necessary to practice whole-person medicine.10 Are religious beliefs a source of comfort or stress in coping with illness? Does the patient have religious beliefs that could interfere or conflict with medical treatments? How might religious beliefs influence medical decision-making during serious or terminal illness? Is the patient part of a supportive faith community that can monitor and ensure compliance? Physicians also need to know their limits. If complex spiritual issues come up during assessment, then referral to trained clergy is appropriate and necessary. Physicians should not offer spiritual advice or counselling, or try to solve a patient's spiritual dilemmas. A patient who is not religious or does not wish to talk about such issues should not be pressed. Such inquiries must always be patient-centred, guided by the patient's wishes and religiosity, not the physician's. Nevertheless, taking a moment to listen, validate concerns, and mobilise spiritual resources are actions that physicians can do. Likewise, if the patient is a member of a faith community, then working with a parish nurse after discharge may ensure successful transition from hospital or medical office to home and community life.11 Exposing medical students in Australia to the role that religion plays in coping with illness and the research connecting religion and health should not be delayed. There is ample evidence to support some cautious first steps.12 Certainly, as Peach suggests, ongoing research is necessary. Nevertheless, religion is a powerful factor that can influence health, wellbeing, and medical decisions for better or worse. It should not be ignored or neglected by physicians.

Harold G Koenig M.D.

Greater participation in religious activities is associated with better health outcomes. In the US, most inpatients have religious needs, but physicians address them only occasionally and infrequently refer patients to clergy. US medical students are learning to do spiritual assessments and integrate the findings into patient management, which may reverse this. Religion does not play a central role in the lives of Australians as it does for US citizens. Research is required to better understand the spirituality of Australians, its relationship to health and the benefit, cost and acceptability of doctors enquiring into spirituality compared with spiritual advisers and counsellors.

Hedley G Peach PhD, FFPHM

Disobedience, in the eyes of anyone who had read history, is man’s original virtue. It is through disobedience that progress has been made — Oscar Wilde, 1881 The invitation to contribute this piece to the Journal was disconcerting. I told the Editor I felt previous contributors to the Power of One series were all distinguished retirees. What was he trying to tell me? I have just turned 51, but it seems some believe I have been around forever and should write a retrospective piece. Sinking smokingRecently, I was leaked a staff training CD-ROM from British American Tobacco (Australia). Five senior executives sat in front of the camera blubbing about the inexorable fall in smoking rates and how, as the plug had been pulled, this could only get worse. As the remaining water drained from the pool, they tried to inspire their staff by talking up hopes of snatching profit from brands that smokers were inspired to believe were at the luxury end of the market. Luxurious carcinogens! It was desperate stuff, but heartening all the same. In the early 1960s, nearly 60% of men and 30% of women in Australia smoked.1 Today, daily smoking by adults has fallen to under 20% for the first time,2 and shows no signs of having bottomed out. In NSW, lung cancer in men has been falling for 18 years and female lung cancer has stopped rising.3 National death rates from coronary heart disease fell by 59% in men and 55% in women between 1980–2000, in large part because of changes in risk factors like smoking.4 Along with vaccine uptake, the fall in the road toll and arresting the HIV/AIDS epidemic, the fall in the smoking rate is one of the major public health achievements of the past 40 years. Innocents sometimes introduce me as "the person" who is responsible for the revolution in the way smoking is now regarded. This nonsense derives from their youth, mixed with thoughts of David and Goliath — as if a single individual could ever be said to be responsible for turning around something as complex as community and political perceptions of smoking. The metaphor of being pecked to death by ducks provides a more apposite description of the way things work in public health. Strategic pecks that irritate and distract gradually build to a point where those under attack — in this case, the tobacco industry — develop a debilitating siege mentality. While the public appetite for dragon-slayer mythology demands there should be individuals who stand over public health carcasses, many, often unsung, people have oxygenated the huge changes achieved in smoking in Australia. MOP UP and BUGA UPA BUGA UP refacing, circa 1983. Today, smokers huddle in doorways and excuse themselves from meetings. To smoke with equanimity is increasingly to wear a badge of immaturity, low education or resigned addiction. Thirty years ago, it was very different. The tobacco industry had infected smokers with the thought that they had a monopoly on all that was interesting, convivial and sensual. Epidemiological revelations rather ruined all that; but it was advocacy that ensured the translation and transition of epidemiologists' conclusions into policy and law reform. In the late 1970s, I was bored witless in my first job as a community health educator, employed by the NSW Health Commission. While I gave interminable Rotary Club talks to half-sozzled businessmen about the "drug problem", tobacco advertising adorned every conceivable public space. Drug pushers were very publicly jailed while tobacco industry executives were quietly knighted. So, in 1978, with a few colleagues, I formed MOP UP — Movement Opposed to the Promotion of Unhealthy Products. We put out a precocious press release and in the next week were covered by the Sydney Morning Herald as "the latest pebble in the shoe of sin industries".5 We engineered the removal of Paul Hogan from the Winfield advertising campaign;6 "MOP UP's slingshot cuts down the advertising ogre" read one headline. MOP UP re-energised the debate about tobacco advertising that Nigel Gray (then head of the Anti-Cancer Council of Victoria) and Cotter Harvey (founder of the Australian Council on Smoking and Health) had started in the 1960s. At our first meeting — held in the lecture theatre of the Sydney morgue in Camperdown — someone stood up and declared, impatiently, that our political letter-writing plans were pathetic and that, if we had guts, we would take more direct action. BUGA UP, the graffiti movement, was born and over the next eight years revolutionised ordinary people's understanding of the politics of tobacco control.7 My modest involvement was to take ongoing responsibility for the billboard on a shopfront directly opposite the entrance to News Ltd, but my admiration for the dozens of courageous people who risked much over a decade of civil disobedience is boundless. We held a 20-year reunion in October this year. (For a powerpoint collection of BUGA UP's 'greatest hits' see http://tc.bmjjournals.com/cgi/content/full/11/3/DC1). Truth in advertising: the German brand West shows a smoking Olympic athlete "lighting the fire" of a stick-figure woman in front of Australia's Uluru, about the time of the 2000 Sydney Olympics. When I first started in tobacco control, people at parties would occasionally give me wide berth as a probable teetotal morals crusader who would soon move to turn the music down and pluck sweets from children's mouths. MOP UP, and especially BUGA UP, changed all that. Understanding that the tobacco industry is a pariah of the corporate world rapidly became a litmus test for a whole set of values about the abhorrence of putting profit above all else. Today, one never hears a tobacco industry executive in the media. As my colleague Stan Glantz, professor of medicine at the University of California, San Francisco, has said: "They are like cockroaches; they spread disease and don't like to be seen in the light." No respectable politician would now ever risk public association with these executives, and this change in business community status has facilitated the incremental adoption of a legislative program that puts Australia in the forefront of nations trying to reduce tobacco's health toll. Getting the message outThose heady days and my first degree in media sociology gave me a taste for the nature of news values. They blooded me for a career where I have tried to translate epidemiologists' conclusions into discourses that gel with community concerns, and then needed to truncate them into soundbite-length summations if they were to have any hope of making the news. I have always had enormous respect for the power of the news media to influence the way that communities think about issues. My honours thesis on imagery in advertising for psychotropic drugs in medical journals was tabled into the Senate Hansard by Peter Baume in 1979.8 That lit a fire within me: there were ways in which academic work could climb out of its (mostly) cosseted sanctuary and thus get to influence political debates. A luxurious Sunday for me is an undistracted day of writing. Since 1976, I have published over 370 original articles, editorials, letters and commentaries in peer-reviewed journals and another 105 in throwaways. I have written 10 books and large reports. A few of these have become citation classics in my field,9-11 but if I was to nominate my most influential writing without hesitation I would name some of my 93 newspaper opinion pieces, my 130 letters to newspapers or some of my extended radio and TV interviews during critical periods of advocacy for change, like the tumultuous period of advocacy required after the Port Arthur gun massacre in 1996. Years of watching my citation rate splutter upward and 11 years of editing an international journal (Tobacco Control) have taught me that scholarship, for all its importance, exists in intellectual backwaters and rarely influences practice, public or political opinion. Colleagues boast of a paper being cited a few hundred times or of speaking to 5000 people at an international conference. In my opinion, a gloves-off opinion piece in a morning newspaper, followed by a round of interviews on breakfast radio, on the day that a vital public health political decision is to be made will be read, and often discussed, by incomparably more people than a journal's readership. Outside agentAdvocacy, by its nature, involves contested debates — there are always losers when change occurs; so often, they are determined to resist change, and angry when it happens. Public health advocacy often requires pushing governments to act and being critical of inaction. This can brand advocates as troublemakers, with all that can go along with that. I have known David Hill, now the director of the Anti-Cancer Council of Victoria, since 1978 and count him as a close friend. A few years ago, when I was feeling a little disconsolate at being plainly excluded from some key national committees appointed by a minister for health whom I had occasionally criticised, David counselled me to consider that every cause needs different people to work "inside and outside the political tent". He said that those on the inside greatly appreciated that someone with my judgement and determination was outside helping keep policy agendas alive that would otherwise be at risk of neglect, being largely off-limits to those working on government committees. Magnificent mentorsMayer mailI count three mentors in my life. Henry Mayer (1919–1991), Professor of Political Theory at the University of Sydney, invited me to lunch after reading an analysis I wrote of the use of sexually seductive imagery in a doctor-directed advertisement for a bronchodilator.12 Henry was a Renaissance man who read everything from impenetrable European psychoanalytic theory to debates about radio bandwidths. From that day on, seldom a week passed in the next decade when a bulging packet of eclectic pages torn from his astonishing reading habits did not arrive in the mail. "Read this", he'd have scribbled. To this day, I am compelled to open my mail and email before anything else, so exciting were the contents of the material he often sent me. I found out later that Henry was in the same habit with dozens of other people he favoured. My imagination owes him an enormous debt. Godfather GrayNigel Gray, then head of the Anti Cancer Council of Victoria, invited me to go with him to Papua New Guinea in 1983 to help convince the government to ban tobacco advertising. It did, although the law remains poorly enforced. Nigel quickly burst any preconceptions I had about senior, venerable figures in medicine being aloof, arrogant and irrelevant. Besides being great fun, Nigel has an appetite for energetic people who, like him, were prepared to stay for the long haul, always searching for opportunities to reignite concern about tobacco industry actions or complacency in government. He taught me that public health's successes tend to creep along almost imperceptibly and about the importance of setting 10–20-year windows on achievement. He remains the godfather of tobacco control advocacy for many of us.13 "Fearless" LeederStephen Leeder, then head of Community Medicine at Westmead Hospital, asked me to work with him in 1986 and has been a major influence ever since. While he has written some of the most articulate public health policy analyses, and cuts the mustard with most powerbrokers, it is his incandescent humanity that sets him apart for me as one of Australia's most inspirational figures in public health. Affectionately known to many of us as "Fearless" Leeder, Steve's writing and speeches drip with his values. Working with Steve for 16 years has exposed me not just to his intellect, but to his unerring encouragement of others. Whenever I have had moments of doubt about writing what I think and upsetting someone powerful, he has seldom hesitated to say simply, "You must say this . . . if you won't, who will?". He's been a wonderful role model. Citizen ChapmanWinner of the Lung Slayer Award. This portrait, of a 34-year-old man with emphysema, was a rejected entry in the 1984 John Player Portrait Award, National Portrait Gallery, London. An alternative exhibition was held on the footpath outside the gallery (that's me holding the painting). Most days I pinch myself in disbelief that I get paid to do what I would gladly do for nothing as a citizen. My 20 years (1982–2002) as a director and chair of the Australian Consumers' Association (Choice magazine) count as an experience I value enormously. I have swapped tactics with some of the most tenacious exponents of rat-cunning advocacy that you could ever hope to meet. Today, I have seven researchers working with me on a critical history of the tobacco industry as revealed through their internal documents (see http://tobacco.health.usyd.edu.au/). Each day, I see their growing incredulity at what they are discovering and the way this translates into passion about carrying on this work, using scholarship as an instrument of shame that drives policy change. The other day we found an item that read "Australia is a laboratory for the global anti-smoking network. Both anti-smoking policies and the individuals who promote them are exported from Australia and stimulate anti-smoking activities worldwide."14 It's been a huge privilege to be a part of that.

Simon Chapman PhD

Christmas Eve, a couple of years ago. I was on call for the birth suite until 8 am the next, Christmas, morning but was hoping to be able to stay at home with my family. At 6 pm, I did a festive round with the registrar on duty. Good — only three women in the suite, and two delivered, both delighted with themselves for getting it over before Christmas Day. In the corner room, one woman in early labour — Grace, aged 34. Elderly for a first baby, especially for an Aboriginal woman, the registrar observes. I say hello to Grace, but don't examine her — that's why the midwives and junior staff are here. Surprisingly, no partner or family is with her. Then I realise that I have seen Grace about our town. She is one of the "park people". Virtually homeless, living mostly outdoors, drifting back and forth between town and some of the more remote communities of the region, the park people are frequently subjected to the ire of some of the town's better-heeled residents. Recently, these residents have demanded more stringent "move-on" laws, to keep the park people out of the sight of the tourists and restaurant patrons along the town's seashore. So far, the State's Anti-Discrimination Commissioner has successfully opposed such laws, but for the park people — rather like those people back in Bethlehem whose birth experience we are celebrating tonight — it seems there is no room at the inn. In her time, like other park people, Grace has had many visits to the hospital's emergency department. At every admission, the same comments appeared: "poor historian"; "C2H5OH"; "lacerations"; "bruises". She'd been sutured many times, with the new and old stab wounds noted. A large scar on her throat and another on her left breast were recorded. Unfortunately, no-one noted the scar on her lower abdomen. Longitudinal and midline. A laparotomy scar. Grace hasn't attended any formal antenatal clinics, but thankfully, during one of her visits to casualty a while back, someone did do an ultrasound scan, so we know she is labouring close to term. Routine antenatal blood tests are being done now. She is in established labour, progressing, and all appears well. I leave it to the registrar to check the results, wish everyone a Merry Christmas, and go home. Two hours later, I am rung by an agitated registrar and, on the strength of what I am told, go back to the birth suite. In conversation with one of the midwives on duty, an elderly Aboriginal woman, visiting another patient, remarked of Grace: "Long time since that girl had a baby!". "Oh no," replied the midwife, "this is her first". "No," the woman was firm. "Had the baby when she was 13. A caesarean. At . . . " — and she named a former mission station some hundreds of kilometres away. The midwife hastened to question Grace. Did she ever have a baby before? It was difficult for her to answer; she is indeed a poor historian. For a start, she has no teeth. Those that weren't knocked out in fights have rotted away. Also, chronic middle ear disease since childhood has made her rather deaf. But she does know that, yes, she did have a baby. A girl. Nobody in the hospital had ever asked her before; she didn't know it was important. Did she have a caesarean? Grace is unsure. It was a long time ago. Did the baby come out through that scar on her tummy? Yes, maybe. It was a long time ago. Where is her daughter now? Grace does not know. Obstetric dilemma: is the abdominal scar longitudinal because Grace had a classical caesar, in which case, because of the risk of uterine rupture, caesarean section should be repeated forthwith? Or — and more likely — was the longitudinal incision merely the route to a standard lower-segment operation, allowing Grace the possibility of a successful vaginal birth this time? For the moment, all seems well. Grace is contracting regularly, has accepted pethidine, and is making progress in labour. She now lies in a clean hospital bed, surprised to be — for perhaps the first time in her life — the centre of concerned attention. We try ringing the hospital near the former mission for more information. It's 9.30 pm on Christmas Eve! We're told: "You want records from more than 20 years ago? You must be joking! Ring back next week." An hour later, a further complication arises. Grace's blood has shown unusual antibodies and it will take some hours to find and crossmatch blood if we need it. We decide to ask for the crossmatch and hope that she delivers vaginally soon and that she won't need surgery or blood. Regularly, anxiously, we watch Grace's vital signs and the fetal monitor. Another two hours later, we have blood, Grace's cervix is 8 cm dilated and the fetal heartbeat has been fine. And then, she begins to bleed. Torrentially. Everyone swings into action. After all, this is what we do best. Acute care. Three wise men appear — anaesthetist, paediatrician and theatre porter — bringing not frankincense, myrrh and a manger but ropivacaine, oxygen and a trolley. In five minutes, Grace is on the operating table; another five, and a spinal block is in place. Soon, a rapid repeat caesarean section is under way. The old scar — in fact, a classical — has ruptured and is bleeding profusely, but it's repairable and the baby is alive. On the stroke of midnight, a baby boy arrives. He is small and scrawny, covered in meconium. But when he gives a feeble cry, Grace smiles and reaches out one arm for him (a blood transfusion is running into the other) and she names him, appropriately, Joseph Christopher. Joseph spends that night and the next in the special care unit. He starts to breastfeed. Grace is eating three meals a day, including turkey and plum pudding. But it's Christmas time, the hospital is short of staff and many beds are closed, so even at this inn Grace cannot stay too long. On Day 5 post-op, Grace and Joseph are discharged "home". As Grace has no home, a place is found for her in a hostel, with domiciliary visits planned. On the first visit, the domiciliary midwife finds things are OK; the next day, Grace and her baby have gone. A few days later — in fact, on New Year's Day — Grace presents to the emergency department again, this time with Joseph. He isn't feeding well and is bringing up feeds; and, he has a fever. But we can deal with all that. It's another acute problem, not one of those complicated social issues that, in hospital practice, just have to be put into the "too-hard" basket. The paediatric registrar arrives, Joseph is admitted and a drip is put up. And so the cycle of disadvantage starts all over again — unto a new generation.

Caroline M De Costa FRANZCOG, FRCOG

A case of public policy confusion In recent years, there has been an increasing focus on the mental health of children and adolescents.1 This is part of the broader process of reform of Australian mental health services, which now emphasises mental health promotion, the development of preventive approaches, early detection of mental disorders and early treatment interventions.2 At the same time, there is now clearer recognition that, in a country as culturally and linguistically diverse as Australia, specific attention must be paid to the cultural dimensions of mental disorder and mental health service design and the specific needs of Indigenous people, immigrants and refugees.3 Major national mental health policy statements now recognise these issues, and funding for State-based transcultural mental health units and centres for the treatment and support of torture and trauma survivors is one aspect of implementing this policy. This is consistent with increased attention being paid to the mental health of immigrants and refugees internationally.4 Of the 6.1 million refugees worldwide for whom demographic data are available, 45.6% are aged under 18 years, although the proportion of children and adolescents varies considerably by region (eg, 56% of refugees in Africa, 23% of refugees in Europe).5 In 2001 there were 900 000 asylum applications pending worldwide.5 The article by McKelvey and colleagues6 in this issue of the Journal (page 413) is important for several reasons. Firstly, research data on the mental health of immigrant and refugee children and adolescents are scarce. The study contributes to knowledge about one of the largest immigrant/refugee communities in Australia in a way that cannot be achieved even by large-scale and expensive studies that aim to be representative of the Australian population.1,7 The recent national survey of 4500 children and adolescents "provides only very limited information about the mental health of children and adolescents living in non-English speaking families".1 Secondly, the authors carefully avoided methodological pitfalls commonly seen in cross-cultural mental health research. They used appropriate translation methods for the questionnaire, worked in partnership with community leaders and Vietnamese-speaking mental health professionals, and conducted research interviews in either English or Vietnamese, using bilingual research staff who were trained and supervised in interview administration. Such attention to appropriate cross-cultural research methods is essential to ensure the validity of information obtained. Thirdly, the study is important because of the finding that the prevalence of psychiatric disorders in Vietnamese children and adolescents was not significantly different from that found in a general Western Australian sample8 and in a national sample,1 despite the fact that many of these children and adolescents had been affected by the stresses of migration to a vastly different cultural environment and that many came from families who had lived through the traumas of war. The data of McKelvey and colleagues relate to Vietnamese refugees settling in Western Australia at one point in time. The same rigorous research process is highly desirable when comparing other refugee populations, especially those experiencing different traumas before migration or different experiences of settlement within Australia. A clinical challenge is to identify subgroups who have suffered, or are at risk of developing, adverse psychiatric consequences. In the study by McKelvey et al, the low rates of mental health problems identified by parents highlights but one of the difficulties that young people from migrant families have in accessing mental health services. There may be a range of explanations for the relatively low rate of mental disorders identified in the study. However, if corroborated by studies of other ethnic groups and research in other settings, these data may reflect a feature of Australian society that has been a considerable success. That is, our capacity to accept immigrants and refugees from all over the world; to integrate new arrivals into a generally harmonious and well-functioning multicultural society; to create the conditions necessary for refugees to recover from trauma; and to provide an environment that is conducive to normal development, especially in children and adolescents. Underpinning this success have been legal and policy frameworks for multiculturalism, extensive services that have supported the successful permanent settlement of immigrants and refugees, and the general goodwill shown by the Australian population to immigrants and refugees. Unfortunately, recent years have seen a substantial bipartisan policy shift in Australia's treatment of asylum seekers, particularly of people arriving unauthorised by boat.9 The policy of mandatory detention of unauthorised "boat people" is now the subject of heated debate. One component of the debate has been the question of whether prolonged detention has harmful effects on the mental health of detainees in general,10 and on the mental health and development of children and adolescents in particular.11 On this latter issue, the subject of an inquiry by the Human Rights and Equal Opportunity Commission, there is remarkable unanimity of medical opinion: prolonged detention is causing harm to the mental health and development of children and adolescents.12 Also of concern is the plight of refugees who have been granted temporary protection visas and live within the community. In comparison with refugees who have obtained permanent residency visas, these people have substantially restricted rights, including the preclusion of family reunion and limited access to social services, English-language training and other services. There is concern that such restrictions may contribute to mental health problems in this group.13,14 Children's emotional and social development may be adversely affected if they are living with parents who are functionally impaired because of depression, anxiety or other mental health problems relating to the stresses and uncertainties of being a temporary visa holder. Current immigration policy, in the form of prolonged detention of asylum seekers and the move to temporary visas for some, is resulting in harm to the mental health of already vulnerable children, adolescents and adults. The mental health impact of this aspect of immigration policy appears at odds with national mental health policy and with the successful settlement policies that still apply to authorised immigrants and some refugees. The study by McKelvey and colleagues6 shows that we can do very much better than this.

I Harry Minas FRANZCP · Susan M Sawyer MD FRACP

A more proactive approach by GPs would help to ease the burden on family carers In Australia, up to 2.3 million people are involved in informal care of children, adults and older persons with disabling chronic and terminal conditions.1 Their role includes managing medications, therapies and medical emergencies; providing supervision and emotional support; and assisting with personal care, mobility and household tasks.1-3 While caring can provide considerable satisfaction and strengthen relationships, carers often feel exhausted, isolated and burdened by their responsibilities.1,3,4 In a recent survey of carers, 58% reported their physical health had been adversely affected, a third said they had sustained a physical injury, and over half reported depression, anxiety, high levels of stress and other impacts on their mental health.2 There have been many calls for general practitioners to be more proactive in addressing the support needs of carers,3-6 and carers have identified how this may be accomplished (see Box). A 1998 editorial on family carers in Australia3 called for strategies to raise health professionals' awareness about carers, to keep them abreast of programs available to carers, and to encourage them to be more proactive in helping carers to obtain support. Since then, there has been limited apparent progress in Australia (unlike Britain, where there has been considerable interest in the primary care team's designated responsibility for addressing carer needs7). Projects conducted through Divisions of General Practice to inform and educate doctors, to promote carer self-identification and discussion5-6 and to promote collaborative referral with regional carer respite services5 showed encouraging outcomes, but have failed to attract further funding from government. Carer associations have also acted by providing various resources. The GP information kit, Carer Checklist and Carers Profile assessment tools (trialled in New South Wales) are time-efficient and pave the way for discussion of carer issues.7,8 In Victoria, individual carers are encouraged to raise issues and to give their GPs a tailored service-provider kit, but this approach lacks systematic coverage. In South Australia, a GP working group is seeking to collaboratively explore various approaches, including GP education and involvement of practice managers. Government initiatives have focused on raising GPs' awareness of community services and referral pathways (eg, the Commonwealth CareLinks and Victorian Primary Care Partnership8). Supporting tools initiated by governments include service directories, consumer assessment and service coordination templates, referral mechanisms (both printed and Web-based) and consumer/carer charters. The full potential of information technology has not yet been harnessed. For example, including a "carer status" field in patient records would prompt early identification of care responsibilities. Software could also alert GPs to provide information or follow-up, and could even include (or electronically link to) carer fact sheets and resources, such as those produced by the national carer organisation Carers Australia. Even GPs committed to working with carers can face considerable barriers to implementing a proactive approach. The patient may not agree to the carer participating in the consultation, or the carer may be reluctant to discuss how he or she is managing, especially if the patient is present or the carer perceives the GP to be too "busy" or very medically focused.4,5,7,10 Either the patient or the carer may be reluctant to accept external assistance.5,6,10 The carer may forgo his or her own health checks or treatment plan because of the pressures of caregiving.2 Finally, in addition to lack of training, information and resources,5-7,11 GPs have to cope with increasing demands, time constraints and inadequate remuneration,5,7,9-11 problems that are often difficult to overcome. The Enhanced Primary Care (EPC) Medicare Benefits Schedule items provide an opportunity to focus on carers and partly address the issue of remuneration for GPs.12 With the patient's consent, carers can be formally included in care planning and case-conferencing activities. This enables GPs and other healthcare workers to hear carers' views on how well they and their patients are managing at home. GPs and carers can then jointly consider options for coordinated support. Where carer wellbeing is an issue, staff of regional carer respite services (or other workers assisting the carer) can usefully be involved.6 Health assessments, another EPC item, should also include screening for carer issues. However, GPs may still need to grapple with the thorny issues of consent, conflict and reluctance — interpersonal issues arising in the relationships between patients and carers and between patients/carers and their doctor. Much of the responsibility for monitoring patient records and maintaining information resources can be delegated to the practice manager or an allied health professional. For example, practice nurses have effectively undertaken health assessments13 and are well positioned to provide carer health education, service referral and coordination. A counsellor or carer-support worker attached to a general practice can assist with identifying carer needs and making referrals, as well as helping the carer to develop skills and to work through emotional or relationship issues.6 The Better Outcomes in Mental Health Initiative14 is relevant to assisting carers who are experiencing severe stress, anxiety or depression. The initiative provides incentive payments for mental health needs assessment, planning and review activities to doctors who register interest with their local Division of General Practice and receive training. We believe that including educational material on carer mental health issues in training packages would enhance this initiative. Given the absence of clear strategies and leadership on this issue over the past four years, the development of clinical practice guidelines and policy positions by governments and peak practitioner bodies is needed. The evolving Commonwealth-funded Primary Health Care Research Evaluation and Development Strategy15 provides an ideal opportunity to prioritise collaborative research in this area. The demonstration of the benefits to carers, those they care for, and the community generally, of an overtly aware and interventionist clinical approach is well overdue. What carers would like general practitioners to do6-8 Recognise their carer status and care responsibilities and include them in care planning and decision-making. Avoid assumptions about carer's capacity, confidence and willingness to provide home care. Provide plain-language information to the carer on the patient's condition, prognosis, treatment, care needs and management (including behaviour management). Provide information and referrals relevant to carers (eg, in-home and residential respite care options, counselling, peer support groups, financial entitlements, self-care and coping strategies). Give referrals to carer associations and state-wide condition-specific bodies as a starting point. Discuss and, where appropriate, assess the carer's own physical and psychosocial health needs. Engage other family members in understanding and sharing care responsibilities. Recognise grief and loss on cessation of caring.

Julie M Nankervis MSW MAPS · Peter J Waxman MB BS FRACGP · Denise A O'Hara MB BS MPH FAFPHM · Mary Burbidge MB BS

Objective: To determine the prevalence of psychiatric disorders among Vietnamese children and adolescents living in Perth, Western Australia.Design, participants and setting: A list of Vietnamese households was drawn from Perth telephone directories. A computer program generated a systematic probability sample of households. All children and adolescents aged 9–17 in these households were invited to participate in the study. Children and their parents were interviewed in their home using the Diagnostic Interview Schedule for Children, version 2.3 (DISC-2.3). The child version (DISC-C) was used for children and the parent version (DISC-P) for adults. The study was conducted between July and December 1997.Main outcome measures: The prevalence of psychiatric disorders in children and adolescents, based on DISC-C and DISC-P data.Results: Results were based on the 519 children (89.2%) for whom complete data were available. Twenty-three parents (4.4%) reported that their child had one or more disorders on the DISC-P, 82 children (15.8%) reported one or more disorders on the DISC-C, and 18.3% of children were reported to have a disorder on either the DISC-C or the DISC-P. Parent–child concordance on specific diagnoses was very low (0.6%). The great majority of disorders reported were anxiety disorders, especially simple and social phobias.Conclusions: The combined prevalence of psychiatric disorders among Vietnamese children aged 9–17 was similar to that found among children in Western Australia's general population. Vietnamese children in our study were much more likely to report symptoms of a psychiatric disorder than were their parents.

Robert S McKelvey MD, FRANZCP · David L Sang PhD · Loretta Baldassar PhD · Lisa Davies PhD · Lynne Roberts PhD · Neil Cutler BA

In this issue of the Journal, Loke and colleagues (page 291) present data from an analysis of 174 advertisements for pharmaceuticals appearing in six Australian medical publications.1 The findings are striking enough to be restated. Fewer than 8% of the advertisements contained quantitative data about the outcomes of therapy, and most of these framed the information in relative rather than absolute terms. Only 28% of the therapeutic claims in the advertisements conveyed clinical outcomes in any specific, substantive and unambiguous way. In the United States, pharmaceutical advertising is subject to the Federal Food, Drug, and Cosmetic Act,2 and Loke et al suggest that, in Australia, advertisements for drugs may be less informative than in the US. The pharmaceutical industry has long maintained that drug advertisements are an important vehicle for conveying important information about new drugs to prescribers. Is this how industry believes it should communicate with highly trained healthcare professionals? Should we really be surprised by the results of Loke et al, and, more importantly, should we be concerned? We know that the pharmaceutical industry spends enormous sums on promoting its products (about twice the amount spent on research and development),3 but most data on the effect of advertising on prescribing are unpublished, and have been gathered by advertising companies. The Association of Medical Publishers (AMP), a US-based organisation whose membership includes the publishers of nearly 200 biomedical journals, boasts "advertising in medical publications alone... can generate sales for both new and more-established products" [original emphasis].4 AMP reports a number of studies that have shown a significant increase in market share and retail sales as a result of medical journal advertising, which is reported to provide a return on investment (ROI) of about US$5.00 for every dollar spent, greater than detailing (ROI US$1.72) and direct-to-consumer advertising (ROI US$0.19).5 Most advertisements are for new and expensive drugs, so increased use due to promotion will contribute to the financial pressures on the Pharmaceutical Benefits Scheme (PBS). Does journal advertising also lead to inappropriate practices? Although there is a substantial body of research on the effects of pharmaceutical industry promotion generally, relatively little involves printed advertisements in medical journals. In a landmark study, Avorn and colleagues studied physicians' beliefs about the efficacy of two classes of drugs (propoxyphene analgesics and central/peripheral vasodilators) that were being heavily promoted as effective, despite evidence that they lacked any efficacy and offered no advantages over existing treatments.6 The authors found that, even though doctors reported paying little attention to drug advertisements, most doctors believed that these agents were effective. Do the results reported by Loke and colleagues have other implications? What is their relevance for the development of government policy? The Australian Competition and Consumer Commission (ACCC) is currently examining an application for reauthorisation of the Code of Conduct of the Australian Pharmaceutical Manufacturers' Association (now Medicines Australia). As part of the examination of the relationships between pharmaceutical industry participants, the ACCC is investigating claims in the media about some practices and whether they are in the best interests of the community (Lin Enright, Director, Public Relations, ACCC, personal communication). The ACCC should heed the results reported here. It is only two years since the review of direct-to-consumer advertising of pharmaceutical products in Australia.7 Although the review recommended against direct-to-consumer advertising, the subject is under continuing review, and some within the pharmaceutical industry are still pressing for change, maintaining that such a facility would enable them to provide important educational information about drugs to the public. Similar moves to relax laws relating to direct-to-consumer advertising are also occurring in Europe and Canada.8 The information reported by Loke et al on journal advertisements suggests that direct-to-consumer advertising is likely to be uninformative and promotional rather than educational in nature. Where should we look for guidance on appropriate standards for advertising pharmaceutical products? Medicines Australia polices a voluntary code of conduct that aims to set "standards of conduct for the activities of companies when engaged in the marketing of prescription products".9 This document places more emphasis on what not to do when promoting medicines, rather than offering guidance on how to provide balanced advice to clinicians about the efficacy and safety of medicines. Perhaps we should pay more attention to the advertising standards maintained in other industries. Generally, advertisements for technologically sophisticated products include prominent displays of their specifications, performance and selling price. Is it too much to ask that advertisements for modern drugs provide similar information? In an era of evidence-based medicine this should include data on the absolute effects of therapy, such as the response rates with and without treatment, and the number needed to treat, in order to avoid the ambiguities of relative measures such as the relative risk reduction. It would be best if this information related to comparisons with established therapies, not just placebo. Clinicians should also be told the dispensed price of the drug under the Pharmaceutical Benefits Scheme.

David A Newby BPharm, PhD · David A Henry MRCP, FRCP

In 1990, while the Royal Commission into Aboriginal Deaths in Custody was in progress, a group of Aboriginal women requested a meeting with the Federal Minister for Aboriginal Affairs so they could talk with him about issues of deep concern. They were granted 10 minutes. Two minutes into the meeting, as they told the Minister of the escalating incidence of violence within our communities, the Minister interrupted: "I know the problem. You tell me some solutions."1 Most Indigenous Australians regard research and researchers with cynicism and suspicion. We have good reason. We have been researched to death and beyond. Research does have an important role in helping find solutions. It can uncover what is happening and why. If designed and implemented appropriately, it can navigate a way forward and show what is, or is not, working. An accurate description, analysis and understanding of "problems" determines the actions of activists, workers in the field, policy-makers and service providers. Research therefore has a vital role to help inform both Indigenous peoples in their pursuit of appropriate services and non-Indigenous policy makers as we work together. In this issue of the Journal, Williams et al (page 300), reporting on assault-related admissions to hospital in Central Australia, conclude: ". . . assault-related admissions to hospital in the proportions we describe suggest a significant public health problem that requires attention."2 Their article is important, if only to strengthen the voices of Aboriginal women, who have been saying for some time that violence, in its many forms, is escalating at an alarming rate within our communities.3 But more is needed. Williams et al present their results from a reductionist research focus on morbidity and mortality. These parameters represent only the end-result of a vicious cycle of violence — a cycle that has had profound and lasting impacts on Indigenous families and communities across generations.4 No reference is made to the context, which embraces where, why and how such violence is occurring. A reference is made to "many resources . . . developed to assist healthcare workers, communities and individuals with alcohol and violence", but these are not discussed. Research into the health status of Indigenous peoples must begin to focus beyond statistical data. For research to have value and to be of benefit, we must try to find out if the strategies referred to are working or not, and why. Some researchers have observed that "there is abundant evidence that psychosocial factors have a profound impact on health", but that "little research to date has targeted the possible biopsychosocial pathways by which social, environmental and contextual conditions of living affect health".5 Indeed, the Australian Institute of Health and Welfare, while recognising the multiplicity of factors that might account for poor health status, relies predominantly on biomedical indicators of health.9 This fails to embrace the less easily measured aspects of community living and wellbeing, now deemed to be of prime importance by Indigenous peoples and public health researchers alike.7 The 1986 Ottawa Charter of Health Promotion outlines the fundamental conditions and resources for health: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity, which requires, among other things, equity in housing, education, income, and social power.8 Its principles resonate strongly with punyu. The word punyu, from the language of the Ngaringman of the Northern Territory, explains that concepts and functions of health or wellbeing must be considered from an interdisciplinary and multidisciplinary approach. Punyu encompasses person and country, and is associated with being strong, happy, knowledgeable, socially responsible (to "take a care"), beautiful, clean, and safe — both in the sense of being within the law/lore and in the sense of being cared for.9 Being well would therefore be an "achieved quality, developed through relationships of mutual care".10 We do not have peace in Indigenous communities, and all the other prerequisites listed here for health and wellbeing are also left wanting. The Ottawa Charter and the subsequent Sundsvall Statement bring into sharp focus the connectedness between human beings, their physical and social environments and their health and wellbeing. They emphasise that "Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love. Health is created by caring for oneself and others, by being able to make decisions and have control over one's life circumstances and by ensuring that the society one lives in creates conditions that allow the attainment of health by all its members."11 This view echoes the same beliefs that underpin the quest for equality in health, which ensures all people have a right to be part of the process that impacts on their wellbeing at both personal and professional levels within the health service, education and research industries. As we reflect on this major public health problem, we must also consider our potential for doing things differently. There is an appealing reciprocity about the Indigenous punyu and the Western new public health movement, with its strong ecological framework. There exists an opportunity for strong partnerships between Indigenous and non-Indigenous healthcare professional educators and practitioners in shaping or reshaping the future education of healthcare professionals and meaningful health research, even research that focuses on violence. The Minister was right. We do need to focus on solutions. Some Indigenous Australians have argued for process evaluation research, looking at the application and outcomes of interventions and services within our communities. The search for solutions will have to involve greater discussion between Indigenous and non-Indigenous researchers in consideration of the more ecologically grounded interpretation of health promoted by Indigenous peoples, the Ottawa Charter and the Sundsvall Statement. We must develop ways of thinking about and engaging with problems, such as assault-related injuries, as we work together to find better tools for changing the wellbeing of Indigenous communities.

V Judy Atkinson BA, PhD · Jenny Graham DipOT, MSc(Ed), AFCHSE · Gloria Pettit BA, MA · Liz Lewis BA

Objective: To determine the quality of claims in advertisements published in Australian medical publications, describe how benefits and harms are presented, and examine the level of underpinning evidence.Design and setting: Audit of a consecutive three-month sample of advertisements appearing in six popular Australian medical publications.Main outcome measures: Proportion of advertisements with quantitative information; proportion of claims conveying clinical outcomes; where retrievable, level of underpinning evidence.Results: Of 1504 claims, 855 could be substantiated quantitatively. Of these, 45% were supported by compelling evidence (randomised controlled trials or better). Of 13 claims explicitly reporting quantitative outcomes, none provided the absolute risk reduction or the number needed to treat.Conclusions: Our audit invites greater diligence by pharmaceutical companies in substantiating their claims and greater vigilance among clinicians when reading them.

Tim W Loke MB BS(Hons) · Fong Chee Koh MB BS(Hons) · Jeanette E Ward PhD, FAFPHM

Objective: To determine the number of assault-related admissions to hospital in the Central Australia region of the Northern Territory over a six-year period.Design and setting: Retrospective analysis of all patients admitted to Alice Springs Hospital (ASH) and Tennant Creek Hospital (TCH) from July 1995 to June 2001, where the primary cause of injury was "assault".Main outcome measures: Frequency of assault-related admission to hospital; demographic characteristics of the victims.Results: In the six years, there were 2449 assault-related admissions to ASH and 545 to TCH. Adults aged 25–34 years were most frequently hospitalised for assault, in a proportion greater than their proportion in the NT population. Females represented 59.7% of people admitted to ASH and 54.7% to TCH, greater than their proportion in the NT population. Aboriginals comprised 95.2% of ASH and 89.0% of TCH admissions, and were admitted in a significantly greater proportion than their proportion in the NT population (P < 0.001). The age-adjusted hospital admission rate resulting from assault has increased (P = 0.002) at an average rate of 1.6 (SE, 0.2) per 10 000 people per year. The proportion of assault-related admissions associated with alcohol has also increased significantly (P < 0.001).Conclusion: The frequency of assault-related admissions to hospital, especially among the Aboriginal population, suggests that this major public health issue is escalating.

Ged F Williams RN, FRCNA · Wendy P Chaboyer RN, PhD · Philip J Schluter MSc(Distinction), PhD

Hollywood celebrity Pamela Anderson's announcement that she has hepatitis C was a major talking point at this recent conference. Unlike similar announcements of HIV infection, Ms Anderson has not positioned herself as a celebrity campaigner — there is no princess or pop star championing the rights of people with hepatitis C or demanding extra funding for research or services. Hepatitis C has been characterised as an "epidemic of difference",1 affecting people from a wide variety of ethnic, cultural and class backgrounds, with implications for the ability of people with hepatitis C to organise and advocate for changes in policy to improve their lives. Until recently, a study by Crofts et al (1997) was the only example of academic research to focus on hepatitis C-related discrimination and to highlight the part played by healthcare professionals.2 It is timely that many presentations from the recent Third Australasian Conference on Hepatitis C, held in Melbourne in March 2002, highlighted the discriminatory attitudes and practices of some healthcare workers when treating and working among people with hepatitis C. Presentations discussed both institutional and interpersonal discrimination against people with hepatitis C. The relatively low level of community and government concern regarding this epidemic was alluded to in several presentations, suggesting a form of systemic discrimination. There have been more than 160 000 notified cases of hepatitis C since antibody testing became available in 1990.3 Alex Wodak (Director, Alcohol and Drug Service, St Vincent's Hospital, Sydney) described the estimated incidence of 16 000 new infections in 2001 as one every 33 minutes.4 Given the high prevalence and estimated incidence of the hepatitis C epidemic, Nick Crofts (Head, Epidemiology and Social Research Unit, Macfarlane Burnet Institute for Medical Research and Public Health [Burnet Institute], Melbourne) questioned whether the government response might have been quicker and better funded if hepatitis C primarily affected people other than injecting drug users.5 Similarly, conference presentations from people with hepatitis C, community organisations and researchers challenged the positioning of hepatitis C (in their view) as a "second-class" disease. These presentations indicated that people with hepatitis C are tainted as past or current drug users and suffer attitudes of blame from healthcare professionals, often described as "userphobia". Grant McNally (Chair, United Kingdom Assembly on Hepatitis C) summarised the effects of these negative attitudes on people with hepatitis C: they take for granted and come to expect substandard levels of healthcare.6 Academic presentations documented the effects of discrimination on prevention, testing, living with hepatitis C, quality of life, treatment and prognosis. A paper by Michael Kerger (Manager, Centre for Harm Reduction, Burnet Institute), Campbell Aitken (Research Fellow, Centre for Harm Reduction, Burnet Institute) and Nick Crofts discussed piloting peer-delivered hepatitis C testing and counselling at a needle and syringe program.7 The authors highlighted current injecting drug users' fear of discrimination following disclosure of their injecting status to doctors. This fear meant that users often did not present for hepatitis C testing. Max Hopwood (Senior Research Officer, National Centre in HIV Social Research, University of New South Wales, Sydney) and Erica Southgate (Research Fellow, National Centre in HIV Social Research) reported that people with hepatitis C at times feel pressured by healthcare workers to reveal their hepatitis C status.8 They described how some people with hepatitis C were refused medical treatment and had their positive serostatus disclosed to other healthcare workers without permission. Similarly, in discussing women's experiences of living with hepatitis C while using drugs, Mary O'Brien (Researcher, Australian Centre for Research into Sex, Health and Society, La Trobe University, Melbourne)9 reported that participants in their study who were current injecting drug users were treated less favourably by healthcare professionals than women with hepatitis C who were not currently injecting drugs. Sandy Gifford (Professor, School of Health Sciences, Deakin University, Melbourne) presented a paper noting the harmful impact of hepatitis C-related discrimination on participants' quality-of-life measures, including physical and emotional health scores.10 The participation of people from the affected communities provided opportunity for elaboration and reflection on research from the perspective of those primarily affected by hepatitis C. People with hepatitis C spoke informally of feelings of guilt, shame, low self-esteem and self-worth that arose as a result of their interactions with some healthcare professionals. They claimed that internalising stigma led to missed opportunities for care and support from social networks and had implications for people's access to healthcare services. Deb Warneke (Metropolitan Educator, Hepatitis C Council of South Australia) and Richard Hanssens (Representative, Hepatitis C Resource Centre, Christchurch, New Zealand) provided personal views and case studies of the effect of hepatitis C in other domains of life experience —within family circles and the workplace.11,12 These conference papers support the report of the New South Wales Anti-Discrimination Board Enquiry, which found that hepatitis C is a highly stigmatised condition and discrimination is rife, especially in healthcare settings.13 The report states that discrimination results either from an inadequate knowledge of the virus and how it is transmitted, or from a confounding of injecting drug use with hepatitis C virus infection. Both the conference presentations and the Enquiry report acknowledge that not all healthcare workers discriminate against people with hepatitis C. However, it is time for healthcare professionals to acknowledge and address hepatitis C-related discrimination. No short term practical solutions to healthcare workers' discrimination against hepatitis C-positive injecting drug users were proffered. A paper by Piergiorgio Moro (Education and Community Development Officer, Hepatitis C Council of Victoria) suggested that a long term solution would involve organisation and lobbying by the hepatitis C-positive and injecting drug use communities to effect legislative change.14 As implied in many of the conference papers, marginalising people with hepatitis C will impede measures to prevent the further spread of the virus throughout the community, and will contribute much to the burden borne by people with hepatitis C.

Carla J Treloar BSc(Hons), PhD · Max N Hopwood BA(Hons) · Stuart K Loveday BCom

Research and practice in grief and loss have been undergoing something of a sea-change in recent years. Past research-based models of grief have attracted much criticism, not only from practitioners but also from researchers in the social sciences. There have been persistent calls for greater sensitivity to the contexts of grief and a more balanced understanding of its positive and cultural influences in our lives. Most of our understanding about grief has been drawn from psychoanalytical sources (eg, the work of Freud or Klein) and later from attachment theory (eg, the work of Bowlby).1 These sources have emphasised the role of the emotions and psychological defences. Research commonly focused on particular populations (such as children, the terminally ill, the mentally ill, or victims of disasters), while the research on community samples examining the loss of spouses, parents or children overidentified grief with bereavement. The conceptual emphasis that emerged from this research stressed issues such as "loss", "disengagement" or "resolution".2 There were debates about whether grief was a "state" or a "process", and later, when the process theories became popular, whether these processes had "phases" or "stages". Many practitioners and popular writers working in bereavement care embraced much of this important early work, which still forms the basis of our understanding of personal control and adaptation in the face of loss. But a concentration on the psychodynamics of attachment and defence inadvertently resulted in overattention to professional interventions and an underemphasis on social relationships, contexts and cross-cultural issues.3 The early work by the psychological professions also led to a concentration on the negative experiences of grief. The traumatic, obsessional and socially destructive aspects of grief were stressed and examined. The concern was to reduce the morbidity and mortality associated with grief, particularly to lessen its role in suicide, substance misuse and other psychiatric conditions, such as severe anxiety or depression. Recent research has attempted to restore greater professional and conceptual balance to these early insights and concerns. There are now increasing numbers of sociologists, anthropologists and historians entering the field, and many of these have been critical of the psychological emphasis on attachment, separation and "letting go".4,5 There has been greater attention to the different ways people grieve according to their own social norms, cultural prescriptions and personal styles.6 There is a growing awareness and theoretical interest in the relationship between bereavement and other kinds of loss, such as the dispossession felt by Indigenous people and refugees, or losses associated with adoption.7 There has been growing international acceptance of a theory of "continuing bonds" — a recognition that people do not necessarily "let go", but transform their former relationships by renewing their meanings about them and continuing the relationship in new ways.8 There has been some recognition of the limits to professional help, reflected by the growing interest, worldwide, in support and self-help groups. The growing input of the social sciences has encouraged a parallel interest in the role of social and cultural differences in the expression of grief and its diverse coping styles. There has been a renewed interest in normal and positive aspects of grieving. There is a growing realisation that the dead may be important role models for the grieving; that they may continue to be "significant others" to the bereaved. People continue to relate to their dead as "active and living memories" at times of personal crisis and success.9 Grief can also create a positive social legacy — in advocacy (influencing policy and education), in political activism (giving rise to groups such as Mothers Against Drink Drivers), in foundations (supporting research or service development) and in careers (heightening the personal achievements and ambitions of survivors).10 Grief also creates "social ghosts" in the form of influential memories, dreams, or visions.11 These can be both comforting and disturbing; motivating and hope-giving as well as upsetting. Furthermore, the general experience of grief can enhance personal empathy and social compassion. These previously under-recognised perspectives present new but complementary challenges for research and practice in the care of people suffering grief. We need to return our attention to the diverse expressions of normal and healthy grieving, while continuing to recognise that grief can cause marked health changes in some individuals. The new insights also highlight the limits to professional care and the need to create supportive environments in our communities for people living with loss. There is a major need for government policy development in this area to reflect a broader public health sensitivity towards our diverse national grief and loss needs. Policy and research priorities might address issues such as the social impact of grief on Indigenous health, on the lives of elderly people, or on the desire for suicide. These research directions will assist us to understand public expressions of creativity or personal experiences of resilience. Our referral options for people suffering grief should include community support, such as pastoral care or the National Association for Loss and Grief, as well as specialist medical and psychological services. These issues are only some of the recent practice and research challenges to emerge in the field of grief and loss, but they point to its constructive and positive revival.

Allan Kellehear

Physicians' dual roles — as healer and professional — are linked by codes of ethics governing behaviour and are empowered by science. Being part of a profession entails a societal contract. The profession is granted a monopoly over the use of a body of knowledge and the privilege of self-regulation and, in return, guarantees society professional competence, integrity and the provision of altruistic service. Societal attitudes to professionalism have changed from supportive to increasingly critical — with physicians being criticised for pursuing their own financial interests, and failing to self-regulate in a way that guarantees competence. Professional values are also threatened by many other factors. The most important are the changes in healthcare delivery in the developed world, with control shifting from the profession to the State and/or the corporate sector. For the ideal of professionalism to survive, physicians must understand it and its role in the social contract. They must meet the obligations necessary to sustain professionalism and ensure that healthcare systems support, rather than subvert, behaviour that is compatible with professionalism's values.

Sylvia R Cruess MD · Sharon Johnston LLM · Richard L Cruess MD

South Bank Medical Centre York, UK I needed a change and I got one — more than one, in fact. In July 2000, I resigned as a general practitioner in York, England, to become GP Educator at the Centre for Remote Health in Alice Springs. My remit includes training medical students and GP registrars, and providing professional development for GPs and other health professionals. I do a clinical session at the Aboriginal Medical Service and another in private practice. Squirrels and oak trees have been exchanged for parrots in the pawpaw tree outside my kitchen window. What has it been like? What changes have I encountered, and what cultural adjustments were required? With more "foreigners" being enticed to the bush, my experience may be of interest to those who follow and to those who work with them. The most obvious change is the interaction with Aboriginal culture. It was also a change I expected, as did colleagues, who helped me along, recommending books1 and arranging cultural awareness courses. But to this was added the cultural shift from city to remote area, from clinical service to academic medicine, from England to Australia, and from a National Health Service to private practice. Each change has had its own challenges and rewards. Centre for Remote Health, Alice Springs Remote practiceThe prospect of medical practice in a remote area was frightening. I observed the debate between the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine about the nature of rural and remote practice and wondered how I would cope. In reality, Alice is a regional centre, and I have better access to help than I did in urban York, where patients sometimes waited a year to see specialists. Relationships with patients and communication skills remain the cornerstone of practice. Where I have needed skills retraining has been in aspects of practice that, in England, are performed by practice nurses, such as Pap smears and ear syringing. Although the principles of medicine are similar, some of the practice is inevitably different. Service delivery in private practice is less cohesive than in England, where the registered list system encourages continuity of care and work within multidisciplinary teams. Conversely, the absence of the responsibility brought by the list system means that "extra" patients at the end of the day are seen by choice rather than contractual obligation. Indigenous healthThe high morbidity and mortality among Indigenous Australians is well documented, but the suffering behind those statistics jolts into reality when patients younger than myself shuffle in with the after-effects of a stroke or are semi-incarcerated by renal dialysis. Because of the high incidence of rheumatic fever, practising evidence-based medicine requires that sore throats are treated with penicillin, not just analgesics. Without a first language or health beliefs shared between patients and staff, achieving a common understanding of a problem and its appropriate management takes time. Teamwork between staff of different professions and cultures is essential to reduce "non-compliance" caused by misunderstandings and unallayed fear.2 Academic practiceI often wondered about a career in academic general practice. It would capitalise on my love of books and teaching, as well as my experience of different practices acquired during my husband's ophthalmology rotations. In addition, coursework on organisational change and medical sociology for a Master's degree in primary healthcare was invaluable preparation, revealing that values, behaviours and ideologies are culturally transmitted and relative.3 The good side of academic life is the flexibility and ability to work at home if children are ill; the downside is the halving of income. It took time to escape from the habit of 10-minute consultations and the expectation that colleagues "book with my receptionist". Just as the pressures of academic life are less visible, so are the rewards — the results of teaching may never be seen, while research projects take an age. As a clinician, I believe a patient's story unless compelling contrary evidence forces me not to. The world of medical politics, into which academics are unwittingly propelled, requires a more circumspect approach. Grant applications, teaching schedules and research reports have replaced insurance forms and prescription requests as the bottomless pit of paperwork in my life. Life in AliceMy neighbour on a flight to Sydney asked what it was like living in a remote place. Despite my previous concerns, I struggled to understand the question. I could think only of the privilege of working and living in a friendly community. It takes no more than five minutes to get anywhere, the tourism industry supports a wide range of facilities, and the weather is fantastic. In cities, I now find it stressful working out how to cross the road — it is much easier just to wander over when no "utes" or four-wheel-drives can be heard. BureaucracyThe hardest struggle has been to navigate the path to obtaining registration and visas. Is it a deliberate ploy to enlist human psychology — to inspire doctors to want what they cannot have? The declared need for doctors in rural and remote areas is not matched by Commonwealth action or policy towards overseas doctors. Our visas arrived three weeks before our departure — six months after the application was submitted. As "temporary residents", we had difficulty getting a mortgage, yet buying a house seemed a logical way of ensuring a commitment to the area. While I appreciate the need to maintain standards, I have only just gained conditional registration to work as a GP in the Northern Territory. A letter from the medical board previously advised me either to pass the Australian Medical Council examination or to enter a recognised training program, despite my having an FRACGP. I replied that it was difficult to enter a training program that I had been appointed to assist in running! Surviving and thrivingHow have I survived? Flights, family, friends, faith, keeping fit and the phone, plus knowing my limits and previous experience of work in a cross-cultural environment. We miss friends and extended family, but this also happened in England, as the hours of work and commuting reduced life to a subsistence sandwich of work, shop, eat, sleep and more work. Email, videos and a family website of our latest camping exploits help us keep in touch. The community in Alice has been welcoming and supportive, and the fundamentals of my life have not altered. I am still married with two children and regularly attend church. The children have had their ups and downs but hope that we will be allowed to stay. Knowing one's personal limits seems important for survival. My limit was a desk of my own, and when space became short I offered to bring my tent to work. In the end, it was not needed, but a place to work was an essential anchor. Others will have different needs, which may sound equally odd or difficult. Try to provide the luxury that will keep your colleagues sane. So, if you need a change, it can be done, and life can be richer for it. If not, enjoy your situation, and ensure that you perceive that life is greener on your own side of the fence.

Susan M Wearne MMedSc, FRACGP

To the Editor: Cunningham has shown that in Australian public hospitals patients identified as Indigenous are significantly less likely than other patients to have a principal procedure recorded.1 This finding is based on data collected by the Australian Institute of Health and Welfare using the coding scheme of the International classification of diseases, 9th revision, clinical modification (ICD-9-CM). No information was available about the clinical indications for conducting a principal procedure. Despite this crucial omission, Cunningham speculates about the reasons for the disparity in the rate of procedures between Indigenous and non-Indigenous patients. These speculations include alarming suggestions such as the possibility of systematic discrimination against Indigenous patients of both an institutional and personal nature. She then concludes that "Work is urgently needed to characterise more fully the nature, level, sources and consequences of institutional and interpersonal discrimination so that we can reduce unfair treatment, ensure equitable care and improve outcomes for the most disadvantaged Australians". These speculations and conclusions are simply unjustified by the data. In addition, such comments may cause more harm than good — Indigenous people have become extremely sensitive about medical and social research and may reject future investigations that are essential to their welfare. There are reasons other than adverse discrimination which may explain the data. These include the common rejection by Indigenous patients of medical advice to have a procedure (they may well be adopting the wisest action), and their more frequent admission to hospital (rather than outpatient care), as they may have travelled from remote communities (ie, there are social criteria for admission without the need for medical procedures). Furthermore, the quality of the data must be questioned, as many Indigenous patients are admitted to hospitals where the data forms are completed by unskilled personnel who do not understand the meaning of a "principal procedure". Cunningham J. Diagnostic and therapeutic procedures among Australian hospital patients identified as Indigenous. Med J Aust 2002; 176: 58-62. <eMJA Full text> <PubMed> (Received 1 Mar 2002, accepted 25 Mar 2002)

James S Lawson

In reply: Lawson suggests that my conclusions1 are not justified, and that they may "cause more harm than good". I strongly disagree. He suggests a number of alternative explanations, including "social" admissions for remote patients, and poor coding, but these do not account for the differences observed. Over half of the separations identified as Indigenous were of urban (19%) or rural (33%), rather than remote, area residents. Disparities in procedures for Indigenous and other patients were evident for each area. Almost half (46%) the separations identified as Indigenous were in principal referral or major hospitals, where coding should be of a high standard. Indigenous–non-Indigenous disparities existed within each hospital category. The results presented in my report1 were adjusted for area of residence, hospital category, as well as several other factors, and large differences in procedures remained. Lawson also suggests that rejection of medical advice by Indigenous patients may play an important role. Rejection of advice certainly occurs on occasion, by both Indigenous and non-Indigenous patients. I question whether it is "common", as Lawson suggests, but that is not really the point. It would be far more productive to ask why and how this occurs, and how interactions between healthcare providers and Indigenous patients can be improved. Lawson takes exception to my raising the possibility of systematic discrimination in the Australian healthcare system, referring to it as "alarming". In that we are in complete agreement. I, too, find it alarming. However, unlike Lawson, I choose not to deny it, but to accept it as an important challenge. My aim is not to make medical practitioners defensive, but to invite them to participate in finding ways to reduce disparities. Systematic discrimination can occur even when well-meaning people are trying to do the right thing. The systems in which we work can defeat our best intentions, even when we don't realise it. The reasons why a procedure was not performed on a particular patient may be perfectly sound given the circumstances. What we must ask ourselves is how those circumstances came to be, and what we can do to change them. I agree with Lawson that some Indigenous people are sensitive about research, but I do not accept that they will "reject future investigations that are essential to their welfare". On the contrary, I expect that many Indigenous people would be happy to participate with healthcare providers in the development and implementation of creative solutions to improve the healthcare system. Cunningham J. Diagnostic and therapeutic procedures among Australian hospital patients identified as Indigenous. Med J Aust 2002; 176: 58-62. <eMJA full text> <PubMed> (Received 21 Mar 2002, accepted 25 Mar 2002)

Joan Cunningham

We are well aware of the excess mortality of Australian Aboriginals and Torres Strait Islanders, their higher hospital admission rates and their longer duration of hospital stay.1,2 However, despite this, relative to their need, Aboriginals and Torres Strait Islanders underutilise specialist healthcare, both as inpatients3 and outside hospitals.4 This situation is exacerbated by demonstrable underfunding of primary care services for Indigenous Australians.4 In this issue of the Journal, Cunningham (page 58)5 reports an analysis of Australian hospital separation data which documents significantly fewer diagnostic and therapeutic procedures performed on patients identified as Indigenous. Cunningham took into account variables possibly affecting use of procedures, including diagnosis, age, sex and place of residence, and acknowledged the problem of incomplete identification of hospital patients as Indigenous. The adjusted data still show fewer recorded procedures in Indigenous compared with non-Indigenous inpatients. These differences are significant within certain disease and diagnostic groups, and of a magnitude which cannot be ignored. Cunningham's study is also consistent with a large body of research from other countries showing disparities according to ethnic group and gender in the use of procedures.6,7 Are the reasons for these disparities in use of procedures related to disease characteristics (including severity), the patient (including preferences and comorbidities), the clinician or the institutional setting? Are they appropriate? And what exactly do these findings indicate? Ideally, decisions regarding medical care are based on evidence, or at least consensus opinion as reflected in a range of standard practices or options. Patient goals and values are then factored in, together with provider and institutional preferences and consideration of available resources. The end-result should be an individualised decision for each patient. Cunningham's findings suggest that, somewhere along this chain within hospitals, different decisions about use of procedures are being made that correlate with, but may not be caused by, ethnic origin. It seems implausible that such significant and Australia-wide differences could implicate large numbers of individual clinicians and result from purely personal biases based on race. The disparities are more likely a result of subtler systemic practices, not ill-intentioned but still discriminatory, and almost invisible within an individual patient–provider encounter. The challenge for clinicians is to further dissect the available information and identify the true cause from the many possible contributory factors. For example, it is likely that in some disease conditions where aetiology is well identified in a population and where the disease is endemic that fewer investigations (and therefore procedures) are needed. Renal biopsy may be performed less frequently to investigate renal disease in Indigenous patients, in whom identified antecedent chronic diseases are endemic. Iron-deficiency anaemia may be treated with anthelmintic drugs rather than first confirming the cause. Alternatively, there may be situations in which a population is genuinely underserviced relative to need (eg, some forms of elective or semi-elective surgery). Possible patient factors should also be identified and dealt with. These include stage of presentation, comorbidities, consent and anticipated postprocedural compliance. All may be reasons why a procedure is not performed, but all these factors can be ultimately overcome, in particular with greater recognition of the importance of primary care. The Royal Australasian College of Physicians has emphasised that adequate primary care is a prerequisite for effective specialist care.8 The uptake of services is more than "patient related" and cannot be separated from the provision of services; societal and institutional factors also structure the doctor–patient encounter within which decisions are made.9 Compliance is likely to improve when a patient's understanding and ownership of his or her disease is matched by a commitment (in the broadest sense) to providing high quality communication and a range of treatment options. The national underdevelopment of key services — Aboriginal Health Workers, Liaison Officers, and particularly interpreter services — shows a lack of appreciation by health institutions of the importance of involvement of Indigenous patients in decision making. Finally, could clinician factors be a major issue in this disparity in the use of procedures? Do we try hard enough and devote sufficient resources to the early diagnosis of serious conditions, to ensuring stabilisation of comorbidities, to obtaining meaningful consent, and to ensuring good postprocedural care and compliance? Do we have preconceived and incorrect perceptions of cultural appropriateness? Are the expectations we factor into our decision making, often derived from our knowledge of group outcomes, appropriate for this individual patient? It is certainly interesting that for trauma and infectious diseases, in which the decision-making process may be less subjective, Cunningham found no difference overall in the likelihood of having a procedure. However, even within these groups, large differences could be seen at an individual "principal diagnosis" level. To improve and structure our medical decision making, we need to continue to develop standardised protocols based on best evidence. Subsequent careful recording of consent processes, together with documentation of the decisions reached and the reasons behind them, will shed further light on the issues raised by Cunningham's data. Cunningham's article shows why clinicians need to contribute to the interpretation of population health information. As presented, these data do not identify the specific clinical procedures possibly denied to Aboriginal and Torres Strait Islander inpatients, and, although the findings have flagged the disparity in procedures, more information is needed for clinicians to take these concerns to the next level of analysis. Specifically, these findings should prompt us to review the decision-making processes determining use of diagnostic and therapeutic procedures in Aboriginal and Torres Strait Islander inpatients. Specialist colleges, societies, hospital units and individual clinicians now have a responsibility to review their own data and establish whether the trend in differential use of procedures applies to their area and, if so, what is driving this difference. The next chapter in this story needs to tease out the connections between healthcare need, use of procedures and health outcomes. If healthcare services are to foster equity rather than further institutionalise inequity, inappropriate reasons for different use of procedures need to be identified and the problems rectified.

Dale A Fisher FRACP, DTM · Tarun S Weeramanthri PhD, FRACP, FAFPHM

Objectives: To determine whether hospital patients identified as Indigenous are less likely than other inpatients to have a principal procedure recorded, and the extent to which any disparity in procedure use can be explained by differences in patient, episode and hospital characteristics. Design: Retrospective analysis of routinely collected administrative data from the National Hospital Morbidity Database (NHMD). Setting: Australian public and private hospitals. Patients: All patients included in the NHMD whose episode type was recorded as acute and whose separation occurred between 1 July 1997 and 30 June 1998. Patients admitted for routine dialysis treatment were excluded. Main outcome measure: Whether a principal procedure was recorded. Results: In public hospitals, patients identified as Indigenous were significantly less likely than other patients to have a principal procedure recorded, even after adjusting for patient, episode and hospital characteristics (adjusted odds ratio [OR], 0.67; 95% CI, 0.66–0.68). This disparity was apparent for most diseases and conditions. In private hospitals, no significant difference was observed (adjusted OR, 0.94; 95% CI, 0.83–1.06). Conclusions: The disparity in procedure use after adjustment for relevant factors indicates that in Australian public hospitals there may be systematic differences in the treatment of patients identified as Indigenous.

Joan Cunningham ScD (Epidemiol)

To the Editor: The article by Sultan and O'Sullivan on detention of asylum seekers in Australia in the 3/17 December issue of the Journal1 contains several errors of fact and distortions that I believe you have an obligation to address. While I am not addressing medical issues, this nevertheless goes to the issue of credibility. The article made several claims that are factually wrong and would not have withstood even cursory examination had you sought verification. I will not attempt to deal with all distortions and factual errors, but your readers should be made aware of at least some elements. Detention is not arbitrary. It is humane and is not designed to be punitive. Staff are provided with cultural-awareness training and are expected to interact with detainees in an appropriate manner. Further, the level and range of medical services available to detainees exceed those available in many regional areas of Australia. It is true some people have been detained for some years. However, Sultan and O'Sullivan neglected to mention that these cases are ones where people have been found to have no lawful right to remain in Australia, but have been pursuing all legal avenues or have been refusing to cooperate with departure arrangements. Another distortion and half-truth relates to a hunger strike where "power and water supplies were cut to the cell block . . . affecting uninvolved women and children". Firstly, there are no cells at Villawood and the alleged cell block was actually a recreation room. The water supplies were cut when earth-moving equipment outside the centre accidentally cut the mains supply to the area, affecting surrounding homes and the centre. Water containers were provided for the detainees until the water supplies were restored. What Sultan and O'Sullivan do not tell you about the power supply was that it was cut when detainees ripped wires out of electrical equipment and threatened to use them to electrocute staff. This action obviously also posed a risk to the children who were moving in and out of the room. A small number of protesting detainees were denied access to the visitors' area because of the disruption their actions would cause to the majority of detainees who were not involved in the protest. Head counts have taken place at 2 am, but what you were not told was that these followed escapes and are not routine. The claim that there has been a dearth of educational and resource material is a factual error. It is disappointing that a publication of your standing did not make even cursory enquiries on simple factual issues.

Aamer Sultan MB ChB · Kevin O'Sullivan BSc, PhL, DipClinPsychol · Debra Graves MB BS, MHA, FRACMA

In reply: The Minister for Immigration and Multicultural and Indigenous Affairs, Mr Philip Ruddock, claims that our article contains several errors of fact and distortions. He does not comment on the substantive concerns of the article, but implies that the errors undermine the credibility of our finding — that prolonged detention of asylum seekers appears to cause serious psychological harm. In response, we will address the alleged errors of fact and then the credibility of the observations made in our article. The Minister states that we failed to identify the factors leading to long periods of detention for some asylum seekers. It is clearly stated in the article that "lengthier detention is particularly common for detainees who appeal against adverse decisions about their refugee status". The Minister's response adds nothing of substance to this and fails to identify the other major factor accounting for prolonged detention, namely the difficulties in removing individuals who are stateless or from countries such as Iraq and Afghanistan. The Minister states that nightly head counts at Villawood occur only after escapes. Unfortunately, the Minister has not been accurately briefed on this matter. Nightly head counts have been a regular practice at Villawood. One of us (A S) has documented proof from the minutes of both the Community Reference Committee and the Centre Manager's detainee meetings held at Villawood, which record the concerns of the detainees and the refusal of management to discontinue the practice. Moreover, this practice was openly acknowledged by the operators of Villawood to the Parliamentary Joint Standing Committee which visited the centre in February 2001.1 It is pleasing to note that, after the publication of our article, nightly head counts have been discontinued in the Stage Two section of Villawood. There are conflicting accounts between detainees and management regarding the events surrounding the hunger strike referred to by the Minister. One of us (A S) sent a complaint about this incident to the Commonwealth Ombudsman. In his reply, the Ombudsman quoted a letter from the Department of Immigration and Multicultural Affairs dated 27 October 2000, which states: "I can confirm that power to the recreation room was cut-off for a short period of time to ensure the safety of the detainees participating in the protest action who had been threatening self harm". There is no mention of attempts by detainees to electrocute staff, as suggested by the Minister, and one of us (A S) has spoken to some of the detainees involved in the protest, who have categorically denied this. Many detainees remain highly sceptical of the official explanation offered regarding the lack of water to the block where the hunger strikers were being held. The very existence of the mass hunger strike and the conflicting accounts of the incident all attest to the emotionally charged environment that has at times existed at Villawood, which was the major point of discussing this incident in our article. We made it quite clear that there have been recent improvements in recreational resources at Villawood. However, as stated in our article, there had been a long history of neglect of this issue. This was confirmed by the statement of the Human Rights and Equal Opportunity Commission in 1998 that "the recreation facilities at Villawood are inadequate for the number of detainees being held there".2 Moreover, despite recent improvements, our statement that detainees face long periods of unstructured time remains true. Although we did not discuss the issue of whether mandatory detention was arbitrary, it is worth noting in response to the Minister's claim that the Human Rights and Equal Opportunity Commission concluded that "In some instances, individuals . . . have been held for more than five years. This is arbitrary detention and cannot be justified on any grounds".2 The failure of the Minister to consider the substantive issues we raised, namely the negative psychological effects that long-term detention appears to be having on asylum seekers, was disappointing. As we stated, we attempted to report our observations in what we consider to be an objective and truthful manner. Nothing in the Minister's response suggests that we have failed to do this. Even if the findings in our report were to be entirely dismissed, Steel and Silove (in the same issue of the Journal)1 document compelling evidence of the serious psychological symptoms observed among long-term detainees. In conclusion, we can only offer a continued exhortation for the Minister to attend to the collective weight of evidence indicating a mental health crisis within Australian detention centres.

Philip Ruddock MP · Derrick M Silove · Zachary Steel · George Halasz MRCPsych, FRANZCP · Michael Block · Leon Petchkovsky · Howard Cooper · Martin B Van Der Weyden · Ruth M Armstrong · Helen M Randall

In reply: Several aspects of Mr Ruddock's letter concern us. The tendency to evade the substance of the message and instead to attack the messenger, in this case the MJA, is unwarranted. Fortunately, the Journal's reputation rests secure with its more usual, considered readership, but the accusation that the MJA has acted in a cursory manner is particularly jarring — the media response by the Minister to the publication of the relevant articles occurred within hours, hardly sufficient time to subject them to a considered analysis. The haste of the response is also evident in the substance of the letter, with its focus on largely irrelevant technical aspects rather than on the key issue — the legitimate concerns raised about the impact of detention on the mental health of inmates. Are we to assume from the Minister's silence on this core matter that he acknowledges that the majority of long-term detainees are suffering from severe depression and other disabling emotional disturbances, as described in the article by Sultan and O'Sullivan and supported by other data we cite? The rates of depression reported by Sultan and O'Sullivan represent a roughly eightfold greater prevalence than is found in the general Australian population — if correct, this reflects an epidemic of mental illness among long-term detainees. Until proven otherwise, there is every reason to assume that the mental disorders identified are a direct outgrowth of the conditions of detention. One of the key findings of research in this area is that asylum seekers in detention report similar patterns of abuse and trauma as their refugee counterparts authorised to resettle in Australia. It is paradoxical and contradictory that we provide authorised refugees some of the best rehabilitative services in the world through our national network of services for survivors of torture and trauma, while at the same time creating conditions in detention centres that exacerbate the effects of past trauma in their compatriots. The claim that detention is humane is extraordinary. From a medical perspective, the obvious test of such a claim is in the health outcomes. Instead of the steady improvement in psychosocial status witnessed in authorised refugee populations after resettlement, there appears to be a progressive deterioration in the mental health of similarly traumatised persons in detention. A policy that in its implementation directly undermines the capacity of displaced persons to recover from the effects of past stresses cannot, by any stretch of the imagination, be humane. If detention is not punishment, then what is it? We are told repeatedly that detention is a deterrent aimed at discouraging the arrival of asylum seekers. How then does detention act as a deterrent if not by punishing the few to deter the many? Interestingly, punishment, according to many criminologists, is not a good deterrent. This makes the situation even worse — punishing those whose only "crime" is to seek asylum from persecution for a presumed greater benefit that remains unattainable. The practical failure of the "punishment as deterrence" approach is evident in the recent, desperate policy shift to the costly and unsustainable "Pacific solution". What next? In short, detention is not humane — prolonged detention, in particular, exacts severe costs by undermining the mental health of detainees. The stark reality is that political policy is creating a preventable public health tragedy. If doubts remain about this conclusion, then we should turn to science as the final arbiter. It is now pressing that an independent group of researchers undertake a comprehensive survey of detention centres in Australia and the Pacific to establish once and for all the impact of current policies on the mental health of the detainees.

Philip Ruddock

To the Editor: We wish to acknowledge Dr Aamer Sultan's courage in carrying out his research as a "participant–observer" into the impact of long-term detention on psychological health of asylum seekers1 at the Villawood Detention Centre, Sydney. In response to the article, Dr Louise Newman, Fellow of the Royal Australian and New Zealand College of Psychiatrists, called for an urgent assessment of the mental and physical health of asylum seekers in detention. As well, The Australian2 reported that Dr Newman advised members of the College not to accept appointments in detention centres because of serious concerns about how they were run by Australasian Correctional Management. Dr Sultan inspires the medical profession, at considerable risk to himself, in order to fulfil the obligation of the first aphorism of Hippocrates: "The physician must not only be prepared to do what is right himself, but also to make the patient, the attendants, and externals cooperate."

Philip Ruddock

To the Editor: I am writing as a member of the Australian Medical Association, and hence a subscriber to the MJA, to express my concern over the recent publication of the participant–observer account of psychological disturbances in asylum seekers,1 and the subsequent media reporting of the issue as a consequence of the publication. I would like to say at the outset my views are personal. Like most healthcare professionals, I consider access to basic medical care, including care for those with mental illness, is a human right. However, I do not support the use of a peer-reviewed journal such as the MJA for political purposes. The right of freedom of speech is fundamental in a democratic society; however, if the AMA wishes to push a political issue then such articles should be published not in the MJA but in Australian Medicine, with appropriate recognition that the issue is medicopolitical and not scientific. My concerns relate to the responsibility I consider peer-reviewed journals such as the MJA have in ensuring that articles, which include reports of alleged research, are scientifically valid. As can be seen by the media coverage on this issue, the fact that the "research study" was published in the MJA gave the impression to the general public that it was a valid scientific study and should be taken seriously. I have a number of specific issues of concern in relation to the article. Firstly, there is the fact that the principal author and researcher, in being a detainee with serious concerns over his treatment by the democratically elected government of this country, obviously has considerable potential bias in reporting observational research of this kind. Secondly, there is no attempt to assess the baseline mental health of the detainees before coming to Australia, but an assumption that all the symptoms observed are a result of detention. Thirdly, it would appear that there was no attempt to validate the observational research using more rigorous psychological testing. Finally, the methodology of the survey is not outlined, nor is the sample size discussed from the point of view of statistical validity. Admittedly, there was an acknowledgement of the survey's limitations; however, I do not consider that this article should have been published in the MJA. It does the Editorial Committee no credit and the Journal less so.

Philip Ruddock

In reply: The Hon. Philip Ruddock, the Minister for Immigration and Multicultural and Indigenous Affairs, believes that the article by Sultan and O'Sullivan1 makes "several claims that are factually wrong and would not have withstood even cursory examination". When assessing whether contributions are suitable for publication in the Journal, the editors of the MJA submit them to peer review, which has been defined as "independent assessment of the scientific merit of research by experts having knowledge of the research area equal to that of the performers of the work".2 The article referred to by the Minister posed a dilemma. Those with "equal knowledge of the research area" — representatives of the Department of Immigration and Multicultural Affairs or the Department's provider of security services (Australasian Correctional Management) — would have a patent conflict of interest. The Journal did, however, seek advice as to the accuracy of the article from a person with knowledge of the situation at Villawood, who did not advise as to "errors of fact and distortions", as alleged by the Minister. The discrepancy between the truth according to the Minister and according to Sultan and O'Sullivan may reflect differing interpretations and perceptions of information conveyed by intermediaries. Graves implies that detained asylum seekers' mental health and access to healthcare is a medicopolitical issue and that the forum for this debate should be the Australian Medical Association. So it should be! But the MJA has complete editorial independence from the AMA, and we believe that the mental health of asylum seekers transcends medicopolitics and goes to the very core of the ideals of medicine. Finally, it was very clear from the title of the article, and its authorship, that it represented the perspectives of a detained doctor (one of Graves' concerns) and a former visiting psychologist. However, we believe that our readership is sophisticated enough to interpret the content of such articles. We also believe, contrary to Ruddock and Graves, that the standing of the Journal remains solid, as does its policy of "providing a forum for . . . commentary and informed debate on standards of clinical practice, ethics, social, legal and other issues related to health care in Australia".3 To our knowledge, the information conveyed by Sultan and O'Sullivan's article is the best available data on the mental health of detained asylum seekers in Australia. We look forward to a more rigorous and independent assessment, hopefully initiated by the Minister. The opportunity is his.

Philip Ruddock