Social determinants of health

Crisis The place of infamy Charles Guest MJA 2001; 175: 580-582 Immediate responses to the attacks - Bioterrorism and the new security - Communication, protection and mitigation - We can not be everywhere - "No-regrets" measures - War - Conclusion - Acknowledgement - References - Authors' details - - More articles on Social issues Boston, 18 September Seven days ago, I heard on National Public Radio's 9 AM news that planes had just struck the towers of the World Trade Center. We had only recently arrived in the United States via Honolulu, so I thought of Pearl Harbor. In the week since, many others have recalled the attack of 7 December 1941, living on — in the definitive diction of Franklin Roosevelt preserved in newsreels — as "the day of infamy". The Oxford Dictionary defines "infamy" as the "reputation earned by an extreme, publicly known evil act; public reproach, shame or disgrace". It adds a legal consequence — the loss of rights of a citizen after being convicted of certain crimes. What are the implications of this new infamy for security and public health in the present and near future? Immediate responses to the attacks From one of the doomed jets, passengers had told their families by mobile phone that they would die fighting. So there was communication, but not enough time for intervention by the US Air Force. Yet, there was calm appraisal of the disaster at ground level. US Secretary of Health and Human Services Thompson ordered the activation of the National Disaster Medical Assistance Teams and Disaster Mortuary Operation Response Teams. "It is not down on any map: the true places never are." Herman Melville Heroism took many forms, such as the deaths of fire fighters and police officers during their efforts to save others, and the detailed attention paid to the logistics of rescue efforts by Mayor Giuliani of New York. The disaster immediately promoted a sense of unity among the survivors, those who came to help them, and other people across the United States and many other parts of the world. As people donated blood or money or time in the week following the attacks, compassion became almost competitive. Advertisers in the New York Times vied to "outdo" each other with expressions of sympathy, solidarity and nationalism. Fundraising scams were also reported. The counterterrorist inquiry started immediately, involving thousands of FBI agents and support staff — probably the most intensive investigation of this kind ever conducted in the United States. Osama bin Laden was soon named as the prime suspect. Just as soon, retaliation was on President Bush's agenda, gaining the support of all but one representative in Congress. The feared reprisal attacks and harassment of Arab-Americans in New York and elsewhere began to occur, but perhaps to a lesser extent than was expected. Local environmental investigations were largely unrevealing. The high temperature of the fires that razed the towers of the World Trade Center could have converted the refrigerant freon to phosgene, a highly poisonous gas, but this was not found. Stray sources of radiation among the rubble, another potential hazard, were also not detected. Days of black smoke, much thicker than the air pollution caused by industry, caused some respiratory distress, while many rescue workers, at least in the early urgency of the disaster, failed to wear safety masks, and so may have been exposed to asbestos. (Later, engineers wondered whether the towers would have stood for longer if the ban on use of asbestos had come in after, rather than during, construction of the Center.) Trauma takes its toll, but most of us will be able to put these events into a corner of our lives. A few will experience post-traumatic stress disorder, so, in New York, the world capital of psychotherapy, a surge in that industry may be expected. The trauma, physical and psychological, was exhaustively documented, and there were countless analyses of the way forward. How should the medical community respond to the death and destruction caused by terrorism? Can we move from the infamy of 11 September to constructive action for human health worldwide? Bioterrorism and the new security As a result of the events of 11 September, far stricter guidelines for airports are now in place in the United States. Doubt had been expressed on many previous occasions about the effectiveness of security checks, partly because security is typically run by contractors working for the airlines. This outsourcing of security functions carries a risk that has been widely recognised as intolerable: security and surveillance must be strengthened. This may include more attention to a small proportion of passengers in a "high-suspicion" category, as well as measures that will be applied to the entire travelling public. Some types of security, previously considered unacceptable for reasons of privacy protection, practicality, or expense, will emerge, at least in New York.1 In highly vulnerable and densely populated areas of the city, such as Times Square, options include the widespread use of surveillance cameras, connected to computers with software for face recognition. There will be more police and security officers, with dogs to detect explosives in suspicious bags or packages. Buildings will be reinforced, while heating, ventilation and air-conditioning systems will be secured to prevent the introduction of chemical or biological agents. Traffic and parking will be restricted. The possibility of biological warfare is the chief health concern in plans for the management of catastrophic terrorism. After the events of 11 September, the Centers for Disease Control and Prevention mounted special surveillance programs at New York healthcare facilities for unusual skin lesions that might be indicative of anthrax, plague or smallpox. (Later events showed that this localised approach was not enough.) The establishment of disaster surveillance is not new, following widespread concern about bioterrorism in the 1990s, but how far and how fast should we pursue safety measures? Ideally, the public health approach would focus on prevention of contamination episodes, but terrorism specialists warn that mass screening methods to detect the carriage of chemical or biological agents are not yet available. That leaves the collection and review of information about possible sources, the prevention of acquisition of hazardous material, and the early detection of cases and outbreaks of disease as the principal counterterrorism measures. Communication, protection and mitigation Governments should know where and why scientific equipment (such as that required for microbiology) is used, to reduce the chances of mischief. Public health authorities, including all healthcare facilities, require clear channels of communication with the police and other security agencies. Compliance with the Biological Weapons and Chemical Conventions should be verified worldwide. In Australia, security should be improved at the many places that could be raided by terrorists to obtain biological weapons.2 Existing public health infrastructure (including electronic information systems) should be upgraded, probably without requiring a new bureaucracy, for case and epidemic surveillance. All other aspects of the healthcare system should be reviewed now from the point of view of security. Education and training in the medical aspects of bioterrorism should be a priority. This has started with the development, in 1999, of a training program by the Australian Medical Disaster Coordination Group. Security issues surrounding the 2000 Sydney Olympic Games have also increased our awareness of bioterrorism. However, no country can yet claim to be well prepared. The Clinton administration's campaign to build civil defences against terrorism included the stockpiling of drugs and vaccines. (For example, 40 million doses of smallpox vaccine were to be prepared by 2004.3) The adequacy of these measures is under urgent review. We can not be everywhere The hijacked planes departed from Boston, Dulles and Newark airports, with the mayhem occurring in New York and Washington DC. Soon after the attacks, investigators, following any available leads, searched businesses and homes in New Jersey, Massachusetts, Florida and other states. Follow-up investigations spread to countries where Osama bin Laden's allies in the jihad are known: Egypt, Saudi Arabia, Yemen, Somalia, Eritrea, Afghanistan and Pakistan (to name but a few). As the list gets longer, the likelihood of finding the "true place" (in Melville's phrase) — the base of the terrorists or the trace to their next attack — gets smaller. How far will technology allow the improved tracing of terrorists — or, in the public health sphere, the mapping of diseases and their risk factors? Modern mapping techniques, enhanced by computer-generated imaging, can provide highly sophisticated representations of the distribution of people or diseases. Yet maps yield only partial truths, as Melville suggested. Comprehensive security and public health measures simply can not be implemented everywhere. "No-regrets" measures The technical difficulties of trying to root out terrorists or pinpoint the sources of all disease outbreaks make it essential to work on other fronts, to make more effort with responses that would be worthwhile regardless of whether or not terrorism was involved. Such "no-regrets" measures would have much in common with policies aimed at reducing the health burden caused by degradation of the global environment. For example, climate change threatens the livelihoods of people in poor countries; yet, in rich countries, governments do little to curb the environmentally harmful behaviours (such as the widespread use of private cars and sports utility vehicles) that contribute to global warming. This is but one reflection of the environmental injustice between rich and poor nations. Such inequalities have in turn fuelled a suicidal terrorist anger towards Western success and the hegemony of the United States in particular. The Hippocratic ideal requires that the medical community promote a positive program with a focus on the fundamental causes of terrorism, including such environmental concerns. War War is not the answer to the atrocities of 11 September. "Infamy" seems a fair description, but otherwise the analogy with the attack on Pearl Harbor fails. The identity of the "enemy" was rapidly declared by President Bush, but the retalictory action has not been properly targeted. The population of Afghanistan is not the enemy: most have been oppressed by the Taliban, not in league with it. Afghanistan needs support, not indiscriminate bombing. Bringing the terrorists to justice is the only acceptable form of retaliation. There may be a role for military intervention, but there must be at least as much digging in the civilian trenches to create peace. "The enemy of my enemy is my friend" is an inadequate basis for allegiance in a renewed "war" on terrorism; it will only serve to enlarge a war of hate. ("Wanted dead or alive" was an even more inflammatory phrase, but probably just a Wild West lapse of concentration from President Bush.) Instead of war, international unity, with genuinely shared strategic interests, must be developed. Stronger US support for the United Nations should be a good start. The term "war" is best avoided, even as a metaphor. In the medical arena, as elsewhere, "wars" are rarely won. Consider what has still to be achieved, 30 years after President Nixon's declaration of a "war against cancer". The "wars" on drugs and tobacco will also drag on throughout the new century. Conclusion Building global cooperative strategies to counteract catastrophic terrorism may take decades. The public health system must play its part in the scale-up of disease surveillance systems now, while recognising that we can not be everywhere. Medicine and healthcare represent a locus of vulnerability that should be covered. Removing the causes of terrorism — including an extremism that arises from poverty, hate and envy — will be harder. And increasing our information and security without unjust reductions in the freedom of some populations may be harder still.4We can not predict the time or place of the next strike, but it will happen. We must prepare. Public health surveillance must now have a global network, promoting not only the peaceful purpose of epidemiology, but also the warning, prevention and deterrence of bioterrorism. The epidemiologist classifies health problems according to time, place and person. I have argued here that the place for modern surveillance — not only of terrorism, but also of the risk factors and occurrence of disease — must be expanded, and now is the time. As for the people, government health authorities are necessary but not sufficient: "they" cannot do something about everything. We are all responsible. Postscript, 29 October Bioterrorism in the United States is now a fact: anthrax has been transmitted by mail. After criticism of the failure of intelligence services to prevent the hijackings on 11 September, blame is now cast on health authorities for underestimating the danger to postal workers.5 Will anyone now take bets against the re-introduction of smallpox? Vaccine production has been accelerated. War is also now a fact, but that does not make it right. Our response to this new infamy of terrorism requires, as the Oxford Dictionary noted, a criminal conviction. There has not yet been one. Unilateral declarations of war have been illegal since the adoption of the United Nations Charter in 1945, except under very limited conditions that constitute self-defence.6 The attack on Afghanistan by the United States has exceeded the legitimate use of force. Objections to this war derive not only from the hope for the sustainable, international rule of law, but also from the effect of retaliation, likely to increase the authority of Osama bin Laden and his supporters in some places. Will the US government — now working with the advertising agencies of Madison Avenue on ways to improve the US image abroad — consider that? Acknowledgement Many of the facts recorded above derive from media reports, mainly National Public Radio (WBUR Boston) and the New York Times, September 12-18. References Barstow D. Envisioning an expensive future in the brave new world of Fortress New York. New York Times 2001; 16 September: A16. Robertson AG. Bioterrorism and Australia: where to from here? Aust Mil Med 1999; 8: 18-23. Broad WJ, Petersen M. Nation's civil defense could prove to be inadequate against a germ or toxic attack. New York Times 2001; 23 September: B12. Ignatieff M. Paying for security with liberty. Financial Times 2001; 12 September: 14. Miller J, Stolberg SG. Anthrax: US officials acknowledge underestimating mail risks. New York Times 2001; 25 October: A1. Charter of the United Nations, 1945. Articles 2(4) and 51. Authors' details Department of Population and International Health, Harvard School of Public Health, Boston, MA, USA. Charles Guest, PhD, FAFPHM, Visiting Scholar. Reprints will not be available from the author. Correspondence: Dr C Guest, Department of Population and International Health, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115. cguestAThsph.harvard.edu Make a comment

Charles Guest

Asylum seekers and healthcare Asylum seekers in Australia The medical profession can assist by reinforcing the principle of healthcare as a right, and opposing policies that contribute to poor health MJA 2001; 175: 587-589

Mitchell M Smith

table { width: 100%; table-layout: fixed; } table tr td { width: 70%; } table tr td:first-child { width: 30%; } Asylum seekers and healthcare The health needs of asylum seekers living in the community Mark F Harris and Barbara L Telfer MJA 2001; 175: 589-592 Abstract - Health needs of asylum seekers - Access of asylum seekers to healthcare - Caring for refugee patients - The role of healthcare workers - Competing interests - References - Authors' details - - More articles on Social issues Abstract Asylum seekers living in the Australian community, and awaiting the outcome of applications for protection visas, may require medical treatment for a range of illnesses, and are likely to have psychological or musculoskeletal problems as a consequence of traumatic experiences in their own countries. Many require specialist treatment. Some asylum seekers living in the community are denied access to Medicare and can not afford basic medical treatment. This creates suffering in the short term and complications in the long term. Healthcare professionals have an ethical responsibility to provide basic medical care for asylum seekers in Australia. Under the offshore component of its Humanitarian Program, Australia offers 4000 places for refugees each year. In addition, Australia offers places under its Special Humanitarian Program for people in refugee-like situations who have links to Australia. There is also provision for granting refugee status to applicants who apply from within Australia (onshore asylum seekers). In total, the program assists 12 000 people per annum.1 In 1999-2000, the Department of Immigration and Multicultural Affairs (DIMA) received 12 713 applications for refugee status from people onshore.1 In that year, 2458 onshore asylum seekers were granted protection visas: 1684 of these were granted at the completion of the primary stage of processing (which is handled by a DIMA staff member).1 More than 70% of those unsuccessful at the primary stage appealed to the Refugee Review Tribunal, but, in 1999-2000, only 679 protection visas were granted after this second stage of processing.1 The number of protection visas granted as outcomes of successful appeal to the Federal or High Court is not specified on the DIMA website. In the year 1999-2000, 76 protection visas were granted through ministerial discretion, the final stage of appeal.1 (Because of the time delay involved in the various stages of the visa process these figures do not all apply to the same group of applicants.) According to DIMA, at 30 June 2000 there were 6500 applications for protection visas at the primary stage and 7828 at the Refugee Review Tribunal stage.1 With 3622 asylum seekers in mandatory detention at 23 March 2000,2 we estimate that there were over 10 000 asylum seekers living in the community in Australia in 1999-2000. While embroiled in the multistage application and appeal process (which can take from three months to over three years) community-based asylum seekers must remain in Australia. During this period, however, many must survive with no right to work, and no Medicare cover, no pharmaceutical benefits and no welfare support.3,4 Health needs of asylum seekers Several studies have assessed the health needs of refugees. In the United Kingdom, one in six refugees have a physical health problem severe enough to prevent them from going about their daily life and two-thirds have experienced anxiety or depression.5 Not surprisingly, a past history of torture, or the feelings of insecurity experienced by refugees, amplify and extend the duration of their illnesses.6 In addition, postmigration factors such as discrimination, lack of social support and unemployment have been identified as major contributors to anxiety and depression in refugees.7 Children, in particular, appear to suffer prolonged psychological distress after resettlement.8Some asylum seekers present with the physical sequelae of torture or other violent trauma which may not have received adequate medical attention in their countries of origin. These sequelae include malunited fractures, osteomyelitis, epilepsy or deafness from head injuries, or non-specific musculoskeletal pain or weakness.9 In rape victims, in addition to the psychological sequelae of rape, there may be a risk of HIV or other sexually transmitted diseases. The incidence of infectious and nutritional diseases varies between refugee groups according to their country of origin.10 The presence of HIV, hepatitis A and B, tuberculosis or immunisable diseases is of major public health concern.11 However, severe parasitic and intestinal infections are also common. Helicobacter pylori infection is particularly common in refugees from developing countries or those who have spent time in refugee camps.12 In Sydney, a study in 1994 of 40 asylum seekers attending the Asylum Seekers Centre, a charitable organisation which provides education and support for asylum seekers, suggested that most were suffering from psychological and physical symptoms sufficiently serious to warrant medical assessment.13 Thirty reported exposure to premigration trauma, 10 had been subjected to torture, 10 reported gastrointestinal disease, nine musculoskeletal complaints, six gynaecological problems and one had an infectious disease (hepatitis). Smith has described the similarity between the health of asylum seekers and that of refugees resettled in Australia from overseas.4 Their general health problems are complex and compounded by the socioeconomic disadvantage they experience in Australia. Likewise, in the United Kingdom, studies have found that many of the diverse and manifold health needs of asylum seekers overlap with those of "deprived or excluded groups, ethnic minorities or new entrants to the country".14 Access of asylum seekers to healthcare UK and Europe In the United Kingdom, asylum seekers have free access to the National Health Service. They can register with a general practitioner and are exempted from charges for prescriptions and dental and optical care.15 However, many refugees encounter problems registering with a GP,16 with GPs' concerns ranging from the demands on their time to communication difficulties.17 Low consultation rates with primary care doctors have also been reported in Switzerland.18 Apart from GPs' attitudes, other barriers to healthcare access for asylum seekers in the UK include practitioner inexperience with uncommon and complicated health problems; a lack of relevant cultural, health and health service educational material for both asylum seekers and healthcare staff; language difficulties; misunderstandings; and inadequately resourced interpreter and advocacy services. Importantly, a scarcity of government-funded health services for asylum seekers is overburdening non-governmental and voluntary organisations and community groups.16,19 In the words of the Chairman of the British Medical Association Medical Ethics Committee: There has been no real NHS planning for the health needs of asylum seekers . . . No thought has been given to their health needs or the social infrastructure around them and it is possible to see the whole process as an abuse of human rights in itself.20 The outcome of these "system based" shortcomings is "false economy", where many asylum seekers "end up requiring hospitalisation for conditions which could have been easily treated at an earlier stage".21 Australia In Australia, to be eligible for essential medical services through Medicare and the Pharmaceutical Benefits Scheme, asylum seekers with a valid visa must apply for asylum within 45 days of their arrival in Australia. As a result of this "45-day rule" and other governmental restrictions, about 40% of asylum seekers are denied Medicare and work rights.3 If they appeal their case to the Refugee Review Tribunal or the courts (as most asylum seekers do who are unsuccessful), these restrictions can persist for many months to years. Asylum seekers experience a greater burden of ill health, lower socioeconomic status and greater problems accessing affordable and appropriate healthcare.4,13In exceptional circumstances asylum seekers who are denied Medicare and work rights can receive help from the Asylum Seekers Assistance Scheme (ASAS). ASAS is a Commonwealth Government scheme administered by the Red Cross which provides financial assistance and healthcare to a small proportion of eligible asylum seekers.22 In 2000-2001, the scheme assisted 2641 ASAS-eligible asylum seekers. However, the number of community-based asylum seekers "unable to meet their most basic needs" exceeds the scope of the scheme. For example, in 2000-2001, the Red Cross assisted an additional 1475 asylum seekers who were officially ineligible for the ASAS scheme, but unable to meet their most basic needs (ASAS, National Office of the Red Cross, Melbourne). The NSW Health Department charges patients who are ineligible for Medicare for inpatient and outpatient care. At a metropolitan referral hospital, these charges are $695 per day for inpatient care and $80 for outpatient care.23 An assurance of payment is required before treatment is provided (cash, credit card or guarantee from an Australian citizen) (Box 1). When such an assurance of payment is not forthcoming, the patient is to be informed that he or she will receive only the minimum and necessary medical care to stabilise their condition. Persons admitted to a public hospital under ASAS are exempt from paying these fees, but this does not apply to the many asylum seekers who do not qualify for this scheme or fee exemption. In Australia, there have been few studies of access to healthcare of asylum seekers. In the 1994 study of 40 asylum seekers,13 27 expressed concerns about not obtaining treatment for general health problems over the previous 12 months, with 25 citing lack of access to Medicare as the main reason; 21 reported poor access to emergency care and 19 to long term medical care; and 27 reported difficulty accessing dental care. Caring for refugee patients The Victorian Foundation for Survivors of Torture and the West Melbourne Division of General Practice have produced a guide to the care of refugee patients in general practice.24 This emphasises the importance of engaging a professional interpreter and providing adequate education and information to refugee patients, including the cost of prescriptions, investigations and referrals. Key issues to be considered in the assessment include preventive care, chronic conditions for which management may have been delayed or inadequate, dental care, developmental problems, mental health problems, injuries and infectious diseases. The aims in managing refugee patients who may be survivors of torture or other trauma associated with refugee status are:25 To identify patients who may have experienced torture and/or traumatic experiences. To understand the context in which torture and refugee trauma may have occurred, and the impact on the individual, family and community. To assess the physical and mental health problems of torture and refugee trauma survivors. To work with patients to develop a management plan. To be aware of and confident in referring patients to appropriate services. To be aware of the impact of these issues on health professionals. For many refugee patients who were tortured, the torturing was done by medical practitioners, who were forced to do so by the authorities. Not surprisingly, these patients often find it difficult to trust practitioners, especially when there are also language and cultural barriers. The role of healthcare workers Healthcare workers have an ethical responsibility to provide life-saving care for asylum seekers in Australia. However, this responsibility is not always clear cut, and clinicians, in their attempts to provide care in a timely way, are often frustrated by State and Commonwealth health department policies. Patients with physical conditions requiring investigations (such as possible malignancy), subacute conditions (such as extrapulmonary tuberculosis), or those with chronic conditions which may result in acute complications (such as diabetes), face significant barriers to accessing healthcare (Box 2). Very often they rely on charitable organisations and the ingenuity of volunteer healthcare workers to "bend the system". This is becoming increasingly difficult. A case study illustrating the problems of access to healthcare is given in Box 3. Competing interests None declared. References Department of Immigration and Multicultural Affairs. Humanitarian Program http://www.immi.gov.au/statistics/publications/popflows/c2_4.pdf (accessed September 2001). Department of Immigration and Multicultural Affairs. DIMA Fact Sheet 82: Immigration detention. http://www.immi.gov.au/facts/82detain.htm (accessed September 2001)] Mares P. Borderline: Australia's treatment of refugees and asylum seekers. Sydney: UNSW Press, 2000. Smith M. Desperately seeking asylum: The plight of asylum seekers in Australia. New Doctor Summer 2000-2001; 74: 21-23. Carey Wood J, Duke K, Karn V, Marshall T. The settlement of refugees in Britain. London: HMSO, 1995. (Home Office research study 141.) Sundquist J, Johansson SE. The influence of exile and repatriation on mental and physical health. A population-based study. Soc Psychiatry Psychiatr Epidemiol 1996; 31: 21-28. Pernice R, Brook J. Refugees' and immigrants' mental health: association of demographic and post-immigration factors. J Soc Psychol 1996; 136: 511-520. Hjern A, Angel B, Jeppson O. Political violence, family stress and mental health of refugee children in exile. Scand J Soc Med 1998; 26: 18-25. Burnett A, Peel M. The health of survivors of torture and organised violence. BMJ 2001; 322: 606-609. Jones D, Gill PS. Refugees and primary care: tackling the inequalities. BMJ 1998; 317: 1444-1446. Burnett A, Peel M. Asylum seekers and refugees in Britain. BMJ 2001; 322: 544-547. Walker PF, Jaranson J. Refugee and immigrant health care. Med Clin North Am 1999; 83: 1103-1120. Sinnerbrink I, Silove DM, Manicavasagar VL, et al. Asylum seekers: general health status and problems with access to health care. Med J Aust 1996; 165: 634-637. Bardsley M, Storkey M. Estimating the numbers of refugees in London. J Public Health Med 2000; 22: 406-412. Connelly J, Schweiger M. The health risks of the UK's new Asylum Act: The health of asylum seekers must be closely monitored by service providers. BMJ 2000; 321: 5-6. Islington Refugee Working Party. Report on questionnaire survey. London: Islington Voluntary Action Council, 1992. Ramsey R, Turner S. Refugees' health needs. Br J Gen Pract 1993; 43: 480-481. Blochliger C, Junghanss T, Weiss R, et al. Asylum seekers and refugees in general practice: problems and possible developments. Soz Praventivmed 1998; 42: 18-28. Woodhead D. The health and wellbeing of asylum seekers and refugees. 2000, London: King's Fund. Available at: http://www.kingsfund.org.uk/ePublicHealth/assets/applets/asar.pdf (accessed October 2001, no longer available). Wilks M. Chairman of the BMA Medical Ethics Committee. The Observer 2001; Sunday June 24. Available at: http://www.observer.co.uk/life/story/ 0,6903,511637,00.html (accessed September 2001). Murshali H. Refugee Council, UK. Australian Red Cross. Asylum Seeker Assistance Scheme. http://www.redcross.org.au/ourservices_acrossaustralia_asas_default.htm (accessed October 2001, updated February 2006). NSW Health Department. Health Services Act 1997. Scale of fees for hospital and other health services. Circular No 99/64. Caring for refugee patients in general practice. Victorian Foundation for Survivors of Torture, on behalf of the Western Melbourne Division of General Practice, 2000. Canberra: Department of Health and Aged Care, 2000. ISBN 0 9585657 4 0. Available at: http://www.racgp.org.au/downloads/20000831refugeevic.pdf (accessed November 2001). Managing survivors of torture and refugee trauma. Guidelines for general practitioners. NSW Service for Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS), General Practice Unit, South West Sydney Area Health Service, Centre for Health, Equity, Research and Evaluation (CHETRE), NSW. Sydney: Refugee Health Service, 2000. ISBN 1 876056 12 6. Authors' details University of New South Wales, Sydney, NSW. Mark F Harris, FRACGP, MD, Professor of General Practice, School of Community Medicine. Barbara L Telfer, BPhysiotherapy, MPH Student. Reprints: Professor M F Harris, School of Community Medicine, University of New South Wales, Sydney, NSW 2052. m.f.harrisATunsw.edu.au Make a comment 1: A Medicare card is required for all hospital attendances Back to text 2: An audit of primary care needs of asylum seekers at the Asylum Seekers Centre, Sydney, 2001 Objective and methods: To describe the health problems and access to health services of community-based asylum seekers, we audited the records of 102 consecutive asylum seekers attending the general practice clinic at the Asylum Seekers Centre in Sydney over a 12-month period in 2000-2001. These asylum seekers, whose mean age was 33.5 years (SD, 15.9; range, infancy to 68 years), did not have access to Medicare. Sixty-one per cent were men. Results: Most patients were from Africa, the Middle East and South America. Their diagnoses, in order of frequency, are listed below. There was a history of torture or trauma in 45 of these patients. Psychological, musculoskeletal and cardiovascular problems were the most common. Sixty-seven were prescribed medication, 32 required a pathology test and 20 were investigated by imaging. Twenty-eight patients were referred (most frequently to physiotherapy, eye clinic, gynaecologist, psychologist, diabetes centre, gastroenterologist, urologist, breast clinic or family planning). For several patients there were problems with providing care because of cost or access. This resulted in a significant delay in care over and above what would normally be expected, or in the care not being provided. This included patients requiring hospital admission (5), complex investigation including magnetic resonance imaging, bone scan, angiography (3), subacute or elective surgery (5), dental care (3), referral to allied health (3), specialist medical care (6) and drugs on the Pharmaceutical Benefits Scheme, which are expensive to purchase at full price (6). Arranging bookings for confinement was difficult in most cases — especially so in two. Conclusions: This pattern of morbidity is not surprising given their frequently reported history of torture and trauma. A significant proportion required specialist care and experienced problems accessing hospital-based services, especially inpatient care, as well as difficulty paying for expensive drugs (such as triple therapy for Helicobacter pylori infection, and antipsychotic drugs). Psychological and medical conditions of asylum seekers Psychological, including depression, anxiety, post-traumatic stress disorder 26% Musculoskeletal, including previous injuries/trauma 24% Circulatory, including hypertension, heart disease 18% Digestive, including peptic ulcer 16% Infectious diseases, including TB, HIV, hepatitis B 12% Urological, including urinary tract infections, prostatitis 9% Neurological, including headache, epilepsy 8% Endocrine, including diabetes 7% Pregnancy 6% Female genital conditions 6% Ophthalmological conditions 6% Skin conditions 5% Dental problems, including dental abscess, gum disease 3% Anaemia 2% Ear problems 2% Back to text 3: Case study A 27-year-old man whose case was before the Refugee Review Tribunal had experienced trauma during imprisonment in his country of origin and had sleep problems as a result. He had had abdominal pain, diarrhoea and fever for 3-4 months. He felt constantly tired and lethargic and had lost 9 kg (down to 43 kg). He had been unable to get medical attention because he was not eligible for Medicare. On examination, his right abdomen was very tender and he had an enlarged liver. His haemoglobin level had fallen to 86 g/L (normal range, 120-160 g/L), and he had a lowered white cell count and a raised erythrocyte sedimentation rate of 60 mm/h (normal range, 5-15 mm/h). The provisional diagnosis was tuberculosis or malignancy. He was referred to a senior gastroenterologist, who tried to admit him to hospital for further investigation. However, the hospital would not authorise his admission as he did not have a Medicare card. After multiple entreaties by the doctors involved, the Red Cross lodged an application with the Department of Immigration and Multicultural Affairs for financial coverage of his health costs in a public hospital. This took 5 days to organise, during which time he suffered repeated blackouts at home. He was eventually admitted to hospital a week after the original recommended urgent admission date and investigations confirmed a diagnosis of tuberculosis. He was treated with antituberculosis chemotherapy and has made a slow recovery over 6 months. Back to text

Mark F Harris · Barbara L Telfer

Asylum seekers and healthcare Psychological disturbances in asylum seekers held in long term detention: a participant-observer account Confinement in immigration detention centres for extended periods of time can have severe, psychologically disabling effects on asylum seekers. Aamer Sultan is a medical practitioner who fled persecution in Iraq after providing casualty medical care to Shiite Muslim rebels. He has been detained in the Villawood Detention Centre, Sydney, since May 1999, as his claim for protection under the United Nations Convention has not been endorsed by Australian authorities. He can not be returned to Iraq because Australia currently has no diplomatic ties with Iraq and no international flights go to Iraq. As a health professional and a bilingual Arabic/English speaker, he has acted as a confidant for many detainees. His observations are supplemented by those of clinical psychologist Kevin O'Sullivan, who provided psychological treatment for over 50 asylum seekers during a recent 12-month contract with the same detention centre. Aamer Sultan and Kevin O'Sullivan MJA 2001; 175: 593-596 For editorial comment, see Steel and Silove Abstract - The environment of detention - Refugee assessment process - Cumulative effects on the mental state of asylum seekers - Effect on children - Survey of detainees at Villawood - Conclusions - Authors' details - - More articles on Social issues Abstract The process of applying for refugee status in Australia is complex, lengthy and often poorly understood by asylum seekers. The psychological reaction patterns of detainees whose claims for asylum are unsuccessful are characterised by stages of increasing depression, punctuated by periods of protest, as feelings of injustice overwhelm them. These reactions have a marked secondary impact on their children in detention. The prolonged detention of asylum seekers appears to cause serious psychological harm. Even if many of those who spend long periods of time are not deemed to have proven their refugee claims, this administrative decision should not be grounds for inflicting grave ongoing psychological injury on the applicants. Most of the asylum seekers detained at Villawood Detention Centre come from developing countries ruled by oppressive regimes with poor human rights records. Many have been victims of State-organised violence, including torture and other forms of inhuman or degrading treatment or punishment, or have family members who have suffered such abuses. Thus, they are at high risk of the range of post-traumatic psychological reactions widely documented among victims of mass trauma and organised violence. These background issues are relevant to the understanding of the impact of detention on asylum seekers' psychological state. The environment of detention On arrival in Australia, most asylum seekers hold strongly to the belief that their applications for protection are legitimate and most are confident that a just society such as Australia will accept the veracity of their claims for refugee status. After transfer to a detention centre, several factors converge to undermine this faith and hence the psychological stability of the asylum seeker. The most threatening aspect is loss of liberty for an indeterminate period of time — detention without trial imposed on people fleeing injustice in a context where no crime has been committed. The average length of detention in Villawood in February 2001 was six months, although the duration varies from individual to individual and, for some, may extend for longer periods of time, with no maximum limit on the period of detention. Lengthier detention is particularly common for detainees who appeal against adverse decisions about their refugee status, or those who are unable to be deported from Australia (because they are stateless or from countries with no diplomatic ties with Australia, particularly Afghanistan and Iraq). The physical environment at Villawood is intimidating in a number of respects. Each compound is surrounded by multiple layers of high fencing topped and grounded by razor wire. All visitors must pass through high security checkpoints. Within the detention centre, there are multiple daily musters and nightly head counts, which may occur at 2 AM and 5.30 AM. The public address system, which operates almost continuously from 7 AM to 9 PM, is also disturbing. For most of the previous two years, there has been a general dearth of activities, resources, or educational materials, leaving detainees with long periods of unstructured time. Despite recent improvements, boredom, aimlessness and apathy are widespread, particularly among those who have been detained for longer periods of time. At times, we have observed harsh and uncompassionate handling of asylum seekers by staff. Detainees are routinely handcuffed during transportation to and from the facility for medical or legal appointments. Access to medical services sometimes has to be negotiated through correctional centre staff, especially after hours or during security incidents. Detainees may then perceive medical practitioners as being aligned with the detaining authorities and are concerned that this may hinder them in acting in their best interests. Concerns have been raised about doctors authorising sedative medication for containment and removal of detainees rather than for genuine medical reasons. Multiple complaints have been lodged by detainees with the Commonwealth Ombudsman, the Human Rights and Equal Opportunity Commission, and the NSW Health Care Complaints Commission about inadequacies in medical and dental care. Apart from official hearings and interviews, interpreter services are not generally available, leaving detainees with poor English isolated and unable to communicate. During crisis periods, such as when hunger strikes or breakouts occur, detainees have been confined for long periods in their rooms, and denied access to phones, faxes, postal services, and visitors. The rules governing daily life seem arbitrary, changing from time to time, and from one detention officer to another. Some detainees have suffered intimidation and reprisals after acts of advocacy, protest or revolt. Authorities have instituted room searches, confinement in solitary cells, restrictions in receiving visitors, and obstacles to accessing legal representation or medical care. During a hunger strike in July 2000, all electrical power and water supplies to the cell block where the hunger strikers were residing were cut-off, affecting uninvolved women and children. As a consequence of these inhumane actions, the atmosphere at Villawood leads to fear, despondency and frustration. It is within this context that the refugee determination process is undertaken. It is soon apparent to all detainees that their future depends on the procedures established to test their refugee claims, but the complex mechanisms and the legal processes applied are poorly understood by most asylum seekers. Given the context and conditions of their detention, asylum seekers find it difficult to distinguish between the authority of the company managing the detention centre (Australasian Correctional Management) and that of the Department of Immigration and Multicultural Affairs in reaching decisions about their refugee claims. It is a widely held belief by detainees that every action within the detention centre may be observed and may critically influence the outcome of refugee claims. This belief appears to be covertly encouraged by those operating the facility to increase their control over the detainees. Refugee assessment process In their testimonies and at interviews, asylum seekers have to recount in detail the most distressing moments of their lives, testimony that may be treated with doubt, suspicion and incredulity. It is little wonder that memories for details become blurred under such pressure, yet inconsistencies in accounts are often cited as the reason for rejecting a claim. Those people whose claims are rejected at this primary (Department of Immigration and Multicultural Affairs — DIMA) stage can appeal to the Refugee Review Tribunal (RRT). If the claim is rejected by the Tribunal, recent legislation has removed any right of judicial review. The final resort is to appeal to the Minister for Immigration and Multicultural Affairs for humanitarian consideration. Few of these appeals receive compassionate outcomes. (For a summary of the stages of application for protection visas, see Smith.) As the period of detention continues, life is increasingly punctuated by feelings of loss and grief arising from the release of compatriots who have been successful in their refugee claims or the forcible removal from Australia of those who have been unsuccessful. These stresses are combined with the ever-present anxiety about the wellbeing of family members left behind. Some may experience guilt for having left their family to secure their own survival and protection, for not yet being able to work and send money home to assist their family, and for not being able to sponsor them to the safety of Australia. Cumulative effects on the mental state of asylum seekers Our observations suggest that there may be some common themes in the psychological reaction patterns of detainees over time. Each successive stage is associated with increasing levels of distress and psychological disability. Non-symptomatic stage: During the early months of detention, before the primary refugee determination decision, the detainee is shocked and dismayed at being detained, but these feelings are mitigated by an unwavering hope that confinement will be short-lived and that their claim will be upheld. Primary depressive stage: This follows the receipt of a negative decision by DIMA and the realisation by detainees that they face a serious threat of forcible repatriation or detention for an indeterminate period, or both. The clinical presentation is consistent with a major depressive disorder, with the severity closely related to pre-existing risk factors, such as premigration exposure to trauma or personal predisposition to depression. There may also be a reactivation or exacerbation of any pre-existing post-traumatic stress reactions from past abuses (eg, torture, incarceration in political prisons and other forms of persecution). The sense of injustice overwhelms many detainees, who enter a "primary revolt stage" of non-compliance and non-conformity. The nature of the revolt varies: some become protesters (engaging in hunger strikes and other non-violent demonstrations); others become advocates (attempting to raise public awareness about the realities of detention); and some become aggressors (engaging in confrontations, riots, detainee-guard conflict and interdetainee violence). Secondary depressive stage: This typically follows the rejection of the asylum seeker's application by the Refugee Review Tribunal, the ultimate administrative level. The timing of this final rejection may vary, but generally occurs between six and 18 months after first being detained. This stage is associated with a more severe and debilitating depressive reaction, with a greater level of psychomotor retardation and/or agitation. There is a marked narrowing of focus to issues of self-preservation and survival and an overwhelming feeling of impending doom. Whereas before most asylum seekers confided in others about their personal lives and their concerns for family left behind, communication about these issues ceases almost entirely. Some asylum seekers will also enter into a secondary revolt stage that is less aggressive and largely associated with passive, non-compliant resistance and attempts to escape. Many asylum seekers will remain in this secondary depressive stage for the duration of their detention, but a significant number appear to progress to an even more serious state of debilitation. Tertiary depressive stage: At this stage the detainee's mental state is dominated by hopelessness, passive acceptance and an overwhelming fear of being targeted or punished by the managing authorities. Affected detainees become self-obsessed and trapped in their predicament. Ties to other detainees that were once strong become fragmentary and in some cases disintegrate. There is a significant and chronic impairment in concentration, with detainees being unable to perform even simple tasks. The detainee's life can become dominated by paranoid tendencies, leaving them in a chronic state of fear and apprehension and a feeling that no one, including other detainees, can be trusted. Long periods of time are spent alone and some develop frankly psychotic symptoms, such as delusions, ideas of reference and auditory hallucinations. Chronic rage and resentment are directed at the detaining country and the host government. The most disturbed engage in self-stimulatory, stereotypic behaviours, such as repetitive rocking or aimless wandering. Postures and facial expression are consistently downcast and affected detainees may appear to be disengaged or dissociated from their physical environment. Some engage in repeated acts of self-harm or self-mutilation leading to acute hospital admissions. Effect on children Between 10 and 50 children are held at Villawood at any one time. The detention environment, exposure to actions such as hunger strikes, demonstrations, episodes of self-harm and suicide attempts, and forcible-removal procedures, all impact on a child's sense of security and stability. A secondary effect is mediated via the parents, whose ability to provide a caring and nurturing environment is progressively undermined as they pass through the stages outlined above, with risk of neglect and physical abuse of dependent children increasing across the course of detention. Following allegations of child sexual abuse at the Woomera centre, detaining authorities have increased their monitoring of parents at Villawood for evidence of negligence and abuse, leading to parental fears of their children being removed, which has further increased family insecurity. At times, children have also become negotiating pawns in attempts to contain protests within the detention centre. For example, on a number of occasions, the authorities have separated children from their parents to pressure adults to cease their hunger strikes. A wide range of psychological disturbances are commonly observed among children in the detention centre, including separation anxiety, disruptive conduct, nocturnal enuresis, sleep disturbances, nightmares and night terrors, sleepwalking, and impaired cognitive development. At the most severe end of the spectrum, a number of children have displayed profound symptoms of psychological distress, including mutism, stereotypic behaviours, and refusal to eat or drink. Children of parents who reach the tertiary depressive stage appear to be particularly vulnerable to developing a range of psychological disorders. Survey of detainees at Villawood To support some of our participant-observer accounts, in August 2001 one of us (A S) conducted a survey of detainees who had been held for over nine months. Of the 37 people meeting this criterion, 33 agreed verbally to participate in the survey and to allow the results to be reported. The survey consisted of a semi-structured interview based on previous observations. As most of these detainees had been held in Villawood since their arrival in Australia, A S was able to corroborate much of the information from his own longitudinal observations of each participant. The detainees originated from 10 countries, with most being from Afghanistan, Iraq, Iran and the former Yugoslavia. The average period of continuous detention was two years, with the longest period being three years and 10 months. Most were men (85%), and over half were married (55%), with most of these being separated from their spouses on fleeing to Australia. Despite rejection of their refugee claims, over half reported being victims of gross human rights violations before arriving in Australia, enduring abuses such as physical torture (58%) and the murder or disappearance of immediate family members (30%). All but one of the detained asylum seekers displayed symptoms of psychological distress at some time. At the time of the survey, 85% acknowledged chronic depressive symptoms, with 65% having pronounced suicidal ideation. Close to half the group had reached the more severe tertiary depressive stage. Seven individuals exhibited signs of psychosis, including delusional beliefs of a persecutory nature, ideas of reference and auditory hallucinations. Due to the severity of their psychological symptoms, hospitalisation has been recommended for some of these people by the centre health staff, but authorities have not approved this, except in medical emergencies after incidents involving self-harm. A few have been deported without receiving any appropriate care. Conclusions In drawing conclusions, we acknowledge the limitations of our report. A S is faced with the same challenges that other detainees encounter and it might be claimed that he is motivated to advocate not only for others but also for himself. The only counterargument we can offer is our commitment to reporting our observations in what we consider to be as objective and truthful a manner as possible. The observations are broadly consistent with those of other health and mental health professionals who work with detainees, either within the detention environment or on their release from detention. It is therefore difficult to avoid the conclusion that the policy of mandatory detention of asylum seekers is leading to serious psychological harm. Even if many of those who spend long periods of time in detention are not deemed by the strict criteria enforced to have proven their refugee claims, this administrative decision should not be grounds for inflicting grave ongoing psychological injury on the applicants. Authors' details Aamer Sultan, MB ChB, Immigration Detainee, Villawood Detention Centre. Kevin O'Sullivan, BSc, PhL, DipClinPsychol, Former Visiting Clinical Psycologist, Villawood Detention Centre. Reprints will not be available from the authors. Correspondence: Dr A Sultan, Villawood Detention Centre, Villawood, NSW 2163. Make a comment Survey of 33 detainees at Villawood Detention Centre Questionnaire items No. of detainees Demographic Information Average period of detention in Australia, 2.1 years Males Females Married Single 28 5 18 15 Premigration trauma exposure History of physical torture Murder or disappearance of immediate family member(s) 19 9 Symptoms during first six months of detention Sleep problems Regular nightmares Loss of libido Anhedonia Feelings of intense bitterness Adoption of a non-conforming approach to detaining authorities Psychological symptoms, requiring psychotropic medication (primarily, antidepressants) 32 32 32 31 26 22 19 Current mental state Chronic feelings of helplessness Bitterness towards authorities Chronic depressive symptoms Chronic headache Impaired memory and concentration Suicidal ideation Stuttering Delusions of a paranoid nature Psychosis 31 30 28 27 25 23 13 13 7 Stage of observed functioning Not symptomatic Primary depressive stage Secondary depressive stage Tertiary depressive stage 1 4 12 16 Back to text

Aamer Sultan · Kevin O'Sullivan

Asylum seekers and healthcare The mental health implications of detaining asylum seekers In the year when we should be celebrating the 50th anniversary of the United Nations Refugee Convention, we appear instead to be ignoring the lessons of history Zachary Steel and Derrick M Silove MJA 2001; 175: 596-599 Abstract - Recent independent inquiries into detention - Research studies - Discussion - After September 11 - References - Authors' details - - More articles on Social issues - More articles on Psychiatry Abstract The possible mental health impact on asylum seekers of Australia's policy of mandatory detention is an issue of special relevance to health professionals and the public. Independent commissions of inquiry in Australia have found varying degrees of mental distress to be common in detained asylum seekers. Research studies in Australia and elsewhere suggest that detained asylum seekers may have suffered greater levels of past trauma than other refugees, and this may contribute to their mental health problems, with their detention providing a retraumatising environment. Studies are urgently required to examine the mental health consequences of detention, and to determine the effect of detention on acculturation and adaptation for asylum seekers subsequently released into the community. Australia is the only Western country that enforces a policy of mandatory detention for asylum seekers arriving without entry documents. This policy is noteworthy given the fact that Australia receives only a small number of asylum applications (12 700 in 1999-20001) compared with most European countries (Germany, 117 650; the Netherlands, 43 900; Belgium, 42 690; France, 39 780; Switzerland, 32 430 in 2000), the United Kingdom (75 680 in 2000), the United States (91 600 in 2000) and Canada (34 250 in 2000).2 On a per capita basis, Australia was ranked 17th out of 21 industrialised countries in terms of the absolute number of asylum applications received during 1999.3 Because of Australia's policy, the possible mental health impact of mandatory detention on asylum seekers is an issue of special relevance to Australian health professionals and the wider public. Sultan and O'Sullivan,4 provide a picture of the daily difficulties and mental reactions experienced by detained asylum seekers in Australia. Their documentation represents a unique convergence between the observations of an "insider" — a medical practitioner detained at Villawood Detention Centre, Sydney, since May 1999 — and those of a mental health professional who has worked in the same facility. We focus here on several key areas raised by Sultan and O'Sullivan: the mental health implications of detaining people who have previously been exposed to trauma including torture; the patterns of mental and behavioural responses manifested by detainees; and the possibility that conditions of detention may act to retraumatise those who are held for indeterminate periods. In assessing these issues, we will draw on the findings of recent inquiries into the policy of detention and also on the small number of empirical studies investigating the mental status of detainees. Recent independent inquiries into detention A comprehensive inquiry undertaken by the Human Rights and Equal Opportunity Commission5 found that mental distress in varying degrees is a common manifestation in detained asylum seekers, with "a large number of detainees experiencing mental health problems". Factors regarded as increasing the risk of mental distress included prior experiences of torture or other forms of persecution in the country of origin, the stresses created by the length and conditions of detention, and the feelings of anxiety and desperation in those whose refugee claims are rejected. The report noted that suicide attempts by asylum seekers are not infrequent, with "numerous examples of detainees attempting suicide or serious self-harm" being cited in incident reports. This inquiry also found "evidence of violence between detainees, especially within families, as well as between detainees and custodial officers", and concluded that there was "considerable tension created by the regime of control necessary to implement the policy of mandatory detention". The evidence suggested that the indeterminate nature of the detention made it considerably more difficult to endure. Of particular concern to the Commission was that there were no formal procedures to identify people who needed specialist care, such as survivors of torture and other forms of extreme trauma, or people at risk of suicide. In a subsequent report, the Commission concluded that the "balance between security and care is undermined by the contractual arrangements between DIMA [the Department of Immigration and Multicultural Affairs] and ACM [Australasian Correctional Management — the private contractor]", and the increasing emphasis on security ("multiple musters, night curfews") can be traced to this imbalance.6 An independent inquiry by the Commonwealth Ombudsman found evidence from credible witnesses about "the inappropriate use of force, unnecessary "trashing" of rooms for no apparent reason and the alleged harassment of detainees by some [ACM] staff".7 The report concluded that "long-term detention of immigration detainees is a source of frustration, despondency and depression often resulting in drastic action being taken by the detainees". Evidence of self-harm, damage to property, as well as fights and assaults, suggested "systematic deficiencies in the management of the detainees".7 A similar set of concerns emerged from a report by members of the Parliamentary Human Rights Sub-Committee.8 According to the report most committee members were shocked by what they saw during their visits to the centres: "the physical impact . . . the double fences, [the] barbed wire". Inside the centres, committee members were struck by the despair and depression of some of the detainees, and "their inability to understand why they were being kept in detention in isolated places, in harsh physical conditions with nothing to do". The Committee found that medical treatment was not always satisfactory, educational facilities were limited and the range of activities was inadequate for the number of detainees. The report also highlighted the negative psychological impact of prolonged detention, pointing out that "those who had been at Woomera [detention centre] for three or four weeks, for example, were notably less tense and depressed than those who had been at Curtin or Port Hedland [detention centres] for a year or more".8 Research studies Several clinical observations have been published about the general plight of asylum seekers in detention in Australia,9,10 with some focusing on specific issues such as hunger strikes.11 More systematic studies are relatively scant, largely because of problems of access to the centres by researchers. A survey in mid-1995 of 17 East Timorese held at the Curtin Detention Centre, in Victoria, for 1-3 months found substantial levels of premigration trauma, including random and unprovoked harassment, torture and physical assaults, and being arrested and/or detained under harsh conditions.12 All 17 East Timorese were found to be suffering from posttraumatic stress disorder (PTSD), 16 were depressed and 11 suffered from severe anxiety. Thompson and colleagues reported a survey of 25 detained Tamil asylum seekers held at Maribyrnong Detention Centre, Victoria, during 1997 and 1998.13 The results were compared with those of a parallel community-based study of Tamil asylum seekers, immigrants and resettled refugees living in New South Wales.14 Detained asylum seekers reported extensive trauma histories: 18 were victims of torture; 23 had witnessed the murder of family or friends; and 22 had been threatened with death at some time. Detained asylum seekers reported exposure to an average of 12.4 (of a possible 16) major trauma categories, compared with 4.8 for asylum-seeker compatriots residing in the community. Compared with the community group, the detainees were more depressed, suicidal, and suffered more extreme post-traumatic panic and physical symptoms. Levels of past trauma exposure did not account entirely for the symptomatic differences across comparison groups, suggesting, albeit indirectly, that the immediate conditions of detention might be contributing to the mental health problems of detainees. Although Australia is the only country that has adopted a policy of mandatory detention, a number of other countries, including the United States and the United Kingdom, detain asylum seekers considered at high risk of absconding or asylum seekers at various stages of the asylum-seeking process.15 In the United Kingdom, a group of 10 detained asylum seekers, six of whom had been tortured previously, were all found to be clinically depressed, manifesting appetite loss and multiple somatic complaints. Four were suicidal, with two having made suicide attempts while in detention.16 Another UK study found high levels of past trauma, including systematic torture, and ubiquitous depressive, posttraumatic stress, as well as suicidal symptoms, in 15 detained asylum seekers.17 The investigators observed that "a profound sense of injustice characterises detainees' views of their reception and treatment . . . detention is seen as punitive, hostile and unfair". Discussion In recording trauma histories, there is always a risk of retrospective bias, particularly when there is potential for gain, for example to advance a refugee claim. However, exposure to past trauma does not, in itself, provide grounds for claiming asylum. The key criterion is proving threat of future persecution. In addition, consistency in reports of trauma across various samples of asylum detainees, corroborated by the indepth investigations of successive commissions of inquiry, makes it difficult to avoid the conclusion that at least a portion of the detained population have been subjected to extreme forms of previous persecution, including incarceration in political prisons and torture. One study found that detainees may have suffered greater levels of threat and trauma than other refugees,13 suggesting that those under most threat tend to leave their home countries in haste, often without documents, thereby increasing the risk of being detained on arrival in Australia. (This conclusion is supported indirectly by statistics provided by the Department of Immigration and Multicultural Affairs which show that over 85% of recent detainees have been found to be genuine refugees fleeing from persecution, an endorsement rate that is higher than that for refugee applicants living in the community.18) Sultan and O'Sullivan's account of past trauma among detainees thus appears to be credible.4 Their observations need to be considered in the light of conclusive evidence that extreme trauma associated with human rights violations constitutes a potent risk factor for a variety of mental disturbances, including PTSD, depression and anxiety.19,20 A consistent dose-effect relationship has emerged from epidemiological studies of refugees, with greater levels of trauma exposure incrementally increasing the risk of mental disturbance.19 In refugees with comorbid disorders, particularly major depression and PTSD, the impact on psychosocial functioning is particularly severe.21 Furthermore, certain forms of trauma, particularly torture and incarceration in political prisons or concentration camps, appear to be particularly injurious to subsequent mental health.20,21 Yet, according to successive commissions of inquiry into detention in Australia, there is no policy in place to systematically assess the psychological needs of detainees who have suffered trauma or to offer them special consideration in relation to early release. The mental suffering of detainees identified by Sultan and O'Sullivan is not only consistent with the findings of recent research studies, but also paints a more complete picture of the way asylum seekers react at particular milestones in the asylum-seeking process.4 The close association between administrative procedures and psychological reactions is particularly worrisome, as it endorses the concern that these procedures, in themselves, act to undermine the psychological well-being of detainees. Although symptoms of depression and PTSD loom large in all recorded accounts, Sultan and O'Sullivan highlight additional features, such as extreme anger and resentment, self-destructive urges, profound social withdrawal, bitterness and alienation, and interpersonal conflict. These accounts of the wider adaptive difficulties triggered by conditions of threat, frustration, dehumanisation and confinement are reminiscent of those observed in survivors of concentration camps after World War II.22 A critical issue is therefore the extent to which the detention environment itself is a direct contributor to psychological distress, either de novo or as a retraumatising influence. There is growing evidence that refugees rendered psychologically vulnerable by past trauma are at greater risk of PTSD if they are exposed to further trauma or adverse conditions.23 For clinicians, there is little doubt that exacerbations of PTSD occur under stress, especially when people are exposed to salient triggers that remind them of the conditions of past trauma. Conversely, it is well accepted that the provision of a safe, supportive and predictable environment is instrumental to recovery for those suffering early psychological reactions to mass trauma.24 Early recovery is important, as there is some evidence that the longer PTSD symptoms persist, the less potential there is for remission.25 These more general observations in the field of traumatology support the contention raised by Sultan and O'Sullivan4 and others10 that environmental, procedural, and legal stressors associated with detention may converge to undermine the mental well-being of detainees, particularly those who have suffered past persecution and trauma. Longitudinal studies are urgently needed to examine more definitively the possible mental health consequences of detention, an imperative supported by a recent public statement by the Australian Medical Association (for a summary of the AMA's statement, see Smith). Of particular concern is the possibility that detention may leave long term psychological scars that may impede the process of acculturation and adaptation when asylum seekers are released into the community — the outcome for a majority of cases. After September 11 We have focused here on the mental health implications associated with the detention of asylum seekers. Elsewhere, we have considered some of the broader human rights concerns associated with detention, and the social and political implications of contemporary refugee policies.26,27 The paradox of contemporary refugee policies has been thrown into stark relief by the world crisis precipitated by the terrorist attack on September 11. On the one hand, there is bipartisan political support in Australia for an international war against terrorism. At the same time, those fleeing from terrorist States are treated as criminals when they reach our shores. Also, in supporting war, we should not forget that one of the most certain outcomes is a large flow of refugees seeking asylum. Yet, our leaders have gone to unprecedented lengths in recent times to deter asylum seekers by confining them in detention centres in economically poor island countries to our north, thereby incurring criticism from the United Nations and other international agencies. Australia is a signatory to the Refugee Convention, a landmark international instrument committing ratifying countries to providing humane protection to persons fleeing persecution worldwide. In the year when we should be celebrating the 50th anniversary of the Convention, we appear instead to be ignoring the lessons of history. In so doing, we risk travelling full circle to the pre-Holocaust era. At an international meeting on the refugee crisis in Europe in 1938, Australia expressed its vociferous opposition to resettling Jews and others fleeing the Nazi terror — all in the name of defending our racial homogeneity and our "way of life". The outcome was the most destructive genocide of all time. Socrates once proclaimed that an unexamined life is not worth living. Are we examining closely enough a national "way of life" that requires, as its cornerstone, the exclusion, punishment and confinement of those fleeing persecution? References Department of Immigration and Multicultural Affairs. Humanitarian Program http://www.immi.gov.au/statistics/publications/popflows/c2_4.pdf (accessed November 2001). United Nations High Commissioner for Refugees. 2000 global refugee trends: analysis of the 2000 provisional UNHCR population statistics. Geneva: UNHCR, 2001. United Nations High Commissioner for Refugees The state of the world's refugees: fifty years of humanitarian protection. New York, NY: Oxford University Press, 2000. Sultan A, O'Sullivan K. Psychological disturbances in asylum seekers held in long-term detention: a participant-observer account. Med J Aust 2001; 175: 593-596. Human Rights and Equal Opportunity Commission. Those who've come across the seas: The report of the Commission's Inquiry into the detention of unauthorised arrivals. Canberra: HREOC, 1998: 167, 153, 154, 218. Available at: http://www.hreoc.gov.au/pdf/human_rights/asylum_seekers/h5_2_2.pdf (accessed November 2001). Human Rights and Equal Opportunity Commission. 1998-99 Review of immigration detention centres. Canberra: HREOC, 1999: 12. Available at: http://www.hreoc.gov.au/pdf/human_rights/asylum_seekers/idc_review.pdf (accessed November 2001). Commonwealth Ombudsman. Report of an own motion investigation into the Department of Immigration and Multicultural Affairs' immigration detention centres. Canberra: Commonwealth Ombudsman, 2001: 26, 20, 2. Available at: http://www.comb.gov.au/publications_information/Special_Reports/IDCMarch.pdf (accessed November 2001). Joint Standing Committee on Foreign Affairs, Defence & Trade, Human Rights Sub-Committee. A report on visits to immigration detention centres. Canberra: Parliament of the Commonwealth of Australia: 2001: 65-67, 104. Silove D, McIntosh P, Becker R. Risk of retraumatisation of asylum-seekers in Australia. Aust N Z J Psychiatry 1993; 27: 606-612. Becker R, Silove D. Psychiatric and psychosocial effects of prolonged detention on asylum-seekers. In: Crock M, editor. Protection or punishment: the detention of asylum-seekers in Australia. Sydney: The Federation Press, 1993. Silove D, Curtis J, Mason C, et al. Ethical considerations in the management of asylum seekers on hunger strike. JAMA 1996; 276: 410-415. Victorian Foundation for Survivors of Torture. The East Timorese: clinical and social assessments of applicants for asylum. In: Silove D, Steel Z, editors. The mental health and well-being of on-shore asylum seekers in Australia. Sydney: University of New South Wales, Psychiatry Research & Teaching Unit, 1998: 23-27. Thompson M, McGorry P. Maribyrnong Detention Centre Tamil Survey. In: Silove D, Steel Z, editors. The mental health and well-being of on-shore asylum seekers in Australia. Sydney: University of New South Wales, Psychiatry Research & Teaching Unit, 1998: 27-31. Silove D, Steel Z, McGorry P, et al. Trauma exposure, postmigration stressors, and symptoms of anxiety, depression and posttraumatic stress in Tamil asylum seekers: comparisons with refugees and immigrants. Acta Psychiatr Scand 1998; 97: 175-181. Silove D, Steel Z, Watters C. Policies of deterrence and the mental health of asylum seekers in Western countries. JAMA 2000; 284: 604-611. Bracken P, Gorst-Unsworth C. The mental state of detained asylum seekers. Psychiatr Bull 1991; 15: 657-659. Pourgourides C, Sashidharan S, Bracken P. A second exile: the mental health implications of detention of asylum seekers in the United Kingdom. Birmingham, UK: North Birmingham Mental Health, NHS Trust, 1995: 96. Edmund Rice Centre. Just comment: debunking more myths about asylum seekers. Sydney: Edmund Rice Centre for Justice and Community Education. October 2000. Available at: http://www.erc.org.au/issues/text/se01.htm (accessed November 2001). Mollica R, Donelan K, Tor S, et al. The effect of trauma and confinement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps. JAMA 1993; 270: 581-586. Van Ommeren M, de Jong Joop T, Sharma B, et al. Psychiatric disorders among tortured Bhutanese refugees in Nepal. Arch Gen Psychiatry 2001; 58: 475-482. Mollica R, McInnes K, Pham T, et al. The dose-effect relationships between torture and psychiatric symptoms in Vietnamese ex-political detainees and a comparison group. J Nerv Ment Dis 1998; 186: 543-553. Bergmann M, Jucovy M. Prelude. In: Bergmann M, Jucovy M, editors. Generations of the Holocaust. New York: Basic Books, 1982: 3-29. Steel Z, Silove D, Bird K, et al. Pathways from war trauma to posttraumatic stress symptoms amongst Tamil asylum seekers, refugees and immigrants. J Traumatic Stress 1999; 12: 421-435. Silove D. The psychosocial effects of torture, mass human rights violations and refugee trauma: Towards an integrated conceptual framework. J Nerv Ment Dis 1999; 187: 200-207. Kessler R, Sonnega A, Bromet E, et al. Posttraumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 1995; 52: 1048-1060. Silove D, Steel Z, Watters C. Policies of deterrence and the mental health of asylum seekers in Western countries. JAMA 2000; 284: 604-611. Silove D, Steel Z, Mollica R. Detention of asylum seekers: assault on health, human rights and social development. Lancet 2001; 357: 1436-1437. Authors' details School of Psychiatry, University of New South Wales, Sydney, NSW. Zachary Steel, MPsychol, Adjunct Lecturer; Derrick M Silove, MD, Professor. Reprints will not be available from the authors. Correspondence: Mr Zachary Steel, Psychiatry Research and Teaching Unit, School of Psychiatry, University of New South Wales, Level 4, Health Services Building, Liverpool Hospital, Sydney, NSW. z.steelATunsw.edu.au Make a comment

Zachary Steel · Derrick M Silove

Although responsibility for health is national, the means to fulfil that responsibility are increasingly global. MJA 2001; 175: 648-651 3 AM. The phone falls to the floor as I grope around in the dark. "We have another one for you, boss", the voice says, with the schadenfreude that the night doctors feel when summoning the on-call staff. "What, another snakebite ?" I wonder what the poor man was doing getting bitten at that hour. It has been a tough night for the emergency doctors. Patients look up hopefully at the first sign of a doctor, while others complain to triage. There is some blood on the floor in the main room; the smell of sweat hangs thick in the air. The interns gesture tiredly in the direction of the resuscitation room. "There is a transfer letter somewhere," they tell me. It is a pithy statement of fact, even for Papua New Guinea. "Thank you for taking K, who is 12 years old. He was bitten by a snake at 6 PM. We have no tet tox or penicillin. We have no antivenom. Yours truly." I'm not sure if they mean to tell me that they have thought of these things, or they are hoping we will provide some for them. Although Australian snakebite mortality rates have fallen more than tenfold since the introduction of the first antivenom 70 years ago1(see Box 1), our nearest neighbour, Papua New Guinea (PNG), has not been so fortunate. Not only do they share with us snakes that are among the most toxic known, but in some areas the snakebite rate is one of the highest in the world.2 Moreover, the consequences of snakebite in PNG are particularly severe; 36% of envenomed patients seen at Port Moresby General Hospital (PMGH) will require ventilation3(see Box 2). In an ironic twist, Gajdusek, whose work on kuru among the Fore people underlies contemporary understanding of "mad cow disease" (which has received much funding and international attention), also reported that snakebite was the commonest cause of death in some of these villages.4 At the same time, the cost of a single ampoule of Australian polyvalent antivenom (CSL Limited), the type most frequently used in PNG,5 at over A$1200, represents approximately half the per capita annual gross domestic product (Anna Leina, Officer in Charge, Pharmacy Department, Port Moresby General Hospital, personal communication). Consequently, even the nation's premier medical institution, Port Moresby General Hospital (PMGH), is frequently without antivenom.6 This situation, unthinkable in Australia, has forced some healthcare centres into managing death adder bites with prolonged pressure bandaging to save scarce antivenom supplies.7The child is not well. Held up by his tired parents, his eyes are heavy from fatigue and from the neurotoxin that is taking over. He is still breathing, with some effort. He does not care that saliva spills from his chin onto his T-shirt. He will need to be ventilated soon, but not yet. His blood does not clot. I have learned not to ask the lab to tell me how long it takes; once I called for missing results only to be told that they couldn't give me a clotting time, as they were still waiting. It has been a steep learning curve for me. The refrigerator in the emergency department has contained two ampoules of sea snake antivenom for a few years now. No-one at the hospital has ever heard of anyone being bitten by a sea snake. The paediatric ward staff tell me they do not have any polyvalent antivenom, but I run across to make sure. It would not be the first time they have tried to save some antivenom. Pharmacy is locked, but I checked there earlier in the day. The nurses in intensive care eye me suspiciously. "We are full, boss." It has been just over a hundred years since Calmette successfully developed the first antivenom, using cobra venom from Indo-China, now Vietnam.8Unfortunately, little has changed regarding antivenom availability for snakebite victims in this region during the past century. The global burden of this eminently treatable condition is estimated at approximately 100 000 deaths each year,9 about a tenth the mortality attributable to malaria. Most of these deaths are concentrated in the Indo-Pacific region,10 where the poor (or absent) access to antivenom for most people results in snakebite mortality orders of magnitude greater than that in Australia (see Box 3). Indeed, tragically, although the burden of snakebite on the local people stimulated Calmette's original studies at the Vaccine Institute in Saigon (now Ho Chi Minh City),11 no snake antivenom was made in Vietnam for the next 100 years. There were five snakebites today and two yesterday — unusual even here. There are over 100 snakebite victims seen each year at Port Moresby General Hospital and we had received 20 ampoules of antivenom in the year 2000. There are seven ventilators. I try again to wrest an ampoule of antivenom from the intensive care ward by telling the staff that this patient might not need to come up to their ward if he had some. They honestly do not have any. I try all the tricks. Neostigmine sometimes helps if the snake was a death adder. I know that over 90% of bites are from taipans, but it is worth a try. I wonder if the scientists who theorised about cholinergic neurotoxins ever thought that it would come to this. It has been said that as the horses used to produce antivenoms for other snake venoms were the same ones used for the taipan antivenom, the antivenoms might have some activity against other snakes. Perhaps the sea snake antivenom might yet be useful. . . We recently proposed a global strategy for snakebite control and procurement of funding to overcome the inequality of antivenom supply.12 This comes amid an acute crisis in antivenom availability for Africa13 and a long-standing undersupply in the Asia-Pacific region14-16(see Box 3). Echoing Nossal's call to awaken the global conscience to the resource constraints facing childhood vaccination,17 we note that the greatest barrier to the widespread availability of antivenoms is not technical, but rather the mobilisation of enough resources. Fortunately for childhood vaccination, the establishment of the Global Fund for Childhood Vaccines by the William H Gates Foundation represents an unprecedented opportunity for infectious disease control by a systematic change in vaccine procurement methods.18 This change recognises that while "responsibility for health is national . . . the determinants of health and the means to fulfil that responsibility are increasingly global".18,19 A similarly coordinated international strategy is required to tackle the neglected issue of snakebite. We propose a comprehensive program that builds on the resources and relationships acquired by the Children's Vaccine Initiative20 and on World Health Organization (WHO) policy initiatives towards securing global access to essential drugs.21 It would employ strategies such as that adopted by the Pan American Health Organization's revolving fund, which emphasises sustainability by long-term government commitment before donor-supported expansion.22 This International Snakebite Initiative (ISI) would recognise that antivenoms are, like vaccines, international public commodities usually manufactured by the same companies facing the same pressures of economics.18 This is already recognised implicitly by the inclusion of antivenoms in the WHO's essential drug list.23 The ISI would require an interdisciplinary and multisectoral partnership maintaining national responsibility and aiming, where possible, for antivenom self-sufficiency. In addition to procurement, it would facilitate the development of new antivenom technology and adjuvant therapies. It would also encourage sustained primary-prevention programs, sponsor research and implement appropriate first-aid methods, ongoing snakebite injury surveillance and improved clinical education tools such as regional snakebite management guidelines. I intubate the boy, leave the intern with the bag, and go back to intensive care and give the staff the bad news. They tell me again that there are no ventilators. I ask which patients' wantoks (relatives) are staying with them. I tell them that we need the ventilator for a child and that they will have to help. I disconnect a patient's ventilator and attach the bag to his tube, explaining to his relatives,"This is how you breathe for him. If you stop, he does not breathe." The lesson is easily understood. We transfer the boy from emergency to intensive care and the other patients' relatives look at us impassively. As highlighted by the reduction in Australian snakebite mortality over the past century, dedicated venom and antivenom research and production saves lives and alleviates suffering. Unfortunately, the global tendency to privatise government-owned antivenom manufacturers,13,24 unleashing free market forces in countries with poor pharmaceutical regulation, threatens the humanitarian task of international snakebite control.13,14,16,25 For example, fake antivenoms are widely sold in Nigeria, and in many countries only charlatans or traditional healers are available to manage snakebite.13,14 These difficulties, combined with the cessation or reduction in antivenom production by traditional manufacturers, such as Aventis Pasteur, have precipitated escalating snakebite mortality in Africa.13Locally, efforts to enhance antivenom availability in PNG through calls for direct or indirect price subsidies16,25 have been ineffective.12,16,25,26 This reflects the general difficulty of facilitating access to essential drugs by appeals to charity or corporate social responsibility.21 Commercial disinterest in this class of pharmaceuticals is clearly evident in the apparent recent withdrawal of the incumbent snake antivenom manufacturer from the United States market.27 This has handed a monopoly to the new producer, which is now selling the most expensive antivenom in the world.14 We therefore argue that a new and more sustainable approach to antivenom procurement is required. Our proposal places antivenoms within global initiatives to secure access to essential drugs, particularly immunotherapeutics, in partnership with donors, the public sector and the pharmaceutical industry.21 Despite these challenges there is room for optimism. The chosen theme of PNG's 25th anniversary of Independence last September was "Walking together", or Raka hebou in Motu and Wokabaut wantaim in Tok Pigin. This theme resonates strongly with our aspirations for regional and global partnerships for snakebite control. Australia, with its distinguished record in antivenom research and development as well as in the Children's Vaccine Initiative, has the potential to play a leading role in the ISI. Countries with a high burden of snakebite, such as PNG and Vietnam, have well-organised national health systems effectively participating in global vaccination programs and disease eradication.28 Australian medical staff assist with snakebite management in regular regional toxinology teaching workshops and courses,29 and by international hospital-based, exchanges, sponsored by Australian institutions.30 Indeed, in the very week of PNG's Silver Jubilee celebrations, two such snakebite workshops were held at PMGH by one of us (K D W). Nevertheless, the need for global snakebite control is urgent and "action plans express no outrage".31 Unless affluent nations like Australia rise to this challenge, variations on our tragic scene will be replayed daily throughout the Asia-Pacific region for want of a 19th-century therapy. Acknowledgements We thank Professor Emeritus Sir Gustav Nossal, Professor Graham Brown and Dr Gabrielle Hawdon of the University of Melbourne, Dr Gertrude Didei of the Port Moresby General Hospital, Dr John Reeder of the Papua New Guinea Institute of Medical Research, and Professor David Warrell, University of Oxford, for their critical review of the manuscript. We are grateful to Dr Forbes McGain for the use of his photograph. Thanks also to CSL Limited and Boucher and Muir for sponsoring K W's trip to Port Moresby and to the ongoing Medical Officer, Nursing and Allied Health Training Project, for its support of A C's part in the registrar exchange program with PMGH. We acknowledge the continuing support of the Victorian Department of Human Services for the work of the Australian Venom Research Unit. Competing interests None declared. The preparation of this article received no specific funding from any organisation. References Winkel KD. Strychine, ammonia and gunpowder for snake bite — the end of an era. Med J Aust 2001; 174: 607. Lalloo DG, Trevett AJ, Saweri A, et al. The epidemiology of snake bite in the Central Province and National Capital District, Papua New Guinea. Trans R Soc Trop Med Hyg 1995; 89: 178-182. Warrell DA, Lalloo DG. Snake bite and its treatment in Papua New Guinea. In: O'Shea M, editor. A guide to the snakes of Papua New Guinea. Madang, Papua New Guinea: Christensen Research Institute, 1996. Gajdusek DC. Urgent opportunistic observations: the study of changing, transient and disappearing phenomena of interest in disrupted primitive human communities. In: Ciba Foundation Symposium 49 (new series), editors. Health and diseases in tribal societies. Amsterdam: Elsevier, 1977. Trevett AJ, Lalloo DG, Nwokolo NC, et al. Venom detection kits in the management of snakebite in Central Province, Papua New Guinea. Toxicon 1995; 33: 703-705. Dyke T. In the tail of the taipan. A personal view of snakebite and serum sickness. Med J Aust 1995; 163: 614-615. Oakley J. Managing death adder bite with prolonged pressure bandaging. In: Handbook, Millennium 2000, the 36th PNG Medical Society Symposium. Port Moresby, Papua New Guinea: PNG Medical Society, 2000: 24. Calmette A. Propriétés du sérum des animaux immunisés contre le venin des serpents; thérapeutique de l'envenimation. C r hebd Seanc Acad Sci Paris 1894; 118: 720-722. Chippaux J-P. Snake bites: appraisal of the global situation. Bull World Health Organ 1998; 76: 515-524. WHO/SEARO guidelines for the clinical management of snake bites in the Southeast Asian region. Southeast Asian J Trop Med Public Health 1999; 30 (Suppl 1): 1-85. Calmette A. étude éxperimentale du venin de Naja tripudians or cobra capel. Ann l'Institute Pasteur 1892; 6: 160-183. Cheng AC, Winkel KD. Call for global snakebite control and procurement funding [letter]. Lancet 2001; 357:1132. Theakston RD, Warrell DA. Crisis in snake antivenom supply for Africa [letter]. Lancet 2000; 356: 2104. McNamee D. Tackling venomous snake bites worldwide [news]. Lancet 2001; 357: 1680. Currie B, Vince J, Naraqi S. Snake bite in Papua New Guinea. PNG Med J 1988; 31: 195-198. Currie B. Medicine in tropical Australia: the quality and price of snake antivenoms [letter]. Med J Aust 1993; 159: 284. Nossal GJV. Awakening the global conscience: Who will benefit from new vaccines in the 21st century? Immunol Cell Biol 1997; 75: 584-586. Mahoney RT, Ramachandran S, Xu Z-Y. The introduction of new vaccines into developing countries II. Vaccine financing. Vaccine 2000; 18: 2625-2635. Jamison DT, Frenk J, Knaul F. International collective action in health: objectives, functions and rationale. Lancet 1998; 351: 514-517. Muraskin WA. The politics of international health. Albany: State University of New York, 1998. Scholtz M. WHO's role in ensuring access to essential drugs. WHO Drug Infor 1999; 13: 217-220. Freeman P. The PAHO revolving fund: history, operations and contribution to speeding vaccine introductions. Geneva: Children's Vaccine Initiative, 1999. Essential drugs: WHO Model list, 11th revision. WHO Drug Infor 1999; 13: 245-258. Sutherland SK. The sale of Commonwealth Serum Laboratories: wither antivenom research? Med J Aust 1992; 157: 731-732. Cheng AC, Ratcliff A, Adhikari P. Snake anti-venom in Papua New Guinea. Fellowship Affairs 2000; 19: 26. Sutherland SK. Medicine in tropical Australia: the quality and price of snake antivenoms. Med J Aust 1993; 159: 284. Galli R. The antivenin is safe, but its future is uncertain. West J Med 2001; 175: 91-92. Temu P. Health Secretary's message to the 2000 medical symposium. In: Handbook, Millennium 2000, the 36th PNG Medical Society Symposium. Port Moresby, Papua New Guinea: PNG Medical Society, 2000: 6-9. White J, editor. Clinical toxinology short course. 2001 handbook. Adelaide: University of Adelaide Faculty of Health Sciences, 2001. AusAID. Papua New Guinea program profiles, 1999-2000. Canberra: Australian Agency for International Development, 2001. Einternz EM. International aid and medical practice in the less-developed world: doing it right. Lancet 2001; 357: 1524-1525.(Received 19 Jul, accepted 1 Nov, 2001) Authors' details Duke University Medical Center, Durham, NC, USA. Allen C Cheng, MB BS, Fellow in Infectious Diseases. Department of Pharmacology, University of Melbourne, VIC. Kenneth D Winkel, MB BS, PhD, Director, Australian Venom Research Unit. Reprints: Dr K D Winkel, AVRU, Department of Pharmacology, University of Melbourne, VIC 3010. kdwATunimelb.edu.au Make a comment 1: Snakebite fatalities in Austrlia, 1910-1989 Back to text 2: A young snakebite victim requiring assisted ventilation in the Intensive Care Unit, Port Moresby General Hospital, in September 2001. This patient recovered after receiving two ampoules of Australia-New Guinea polyvalent snake antivenom (CSL Limited). Photograph by Dr Forbes McGain, Fellow, Australian Venom Research Unit. Back to text 3: Reported or derived snakebite mortality rates and the quality and status of antivenom supply, by country, in the Asia-Pacific region, excluding the Indian subcontinent9,10 Country Estimated snakebite mortality* Antivenom quality and supply Burma 100 Reasonable quality, limited supply Vietnam 80 Good quality, very limited supply Papua New Guinea 20 Imported high quality, limited supply Taiwan 2.5 Good quality, uncertain supply Australia 0.2 High quality, excellent supply Thailand 0.2 Good quality, excellent supply Japan No data Good quality, good supply East Timor No data Imported reasonable quality, little supply Malaysia No data Imported from Thailand China No data Quality and supply uncertain Indonesia No data Low quality, very limited supply Philippines No data Low quality, uncertain supply * Per million population per year. No data available for Cambodia and Laos. Many of the data reflect historic patterns and are subject to significant reporting bias. Where it is likely that the rate is an underestimate, such as for Myanmar (Burma), the figures presented here incorporate appropriate adjustments. The comparative assessment of quality combines measures of potency, clinical efficacy, pyrogenicity and acute allergic reaction rates. Back to text

Allen C Cheng · Kenneth D Winkel

Medicine and the Community The physical, sexual and emotional violence history of middle-aged women: a community-based prevalence study Danielle Mazza, Lorraine Dennerstein, Corrine V Garamszegi and Emma C Dudley MJA 2001; 175: 199-201 Abstract - Methods - Questionnaire - Study participants - Statistical analysis - Results - Domestic violence - Unwanted sexual experiences with someone other than a husband or partner - Childhood abuse - Discussion - Acknowledgement - Reference - Authors' details - - More articles on Obstetrics & gynaecology and women's health - More articles on Social issues Abstract Objectives: To determine current and lifetime rates of the experience of partner abuse and sexual violence in a community-based sample of middle-aged women and compare these to figures obtained in a general practice setting. Design and methods: This research was part of the Melbourne Women's Midlife Health Project (MWMHP), an observational, longitudinal, population-based study of 438 Australian-born women conducted over nine years. In 1996, during the sixth year of the study, we asked the MWMHP participants to complete a self-administered "violence questionnaire", incorporating a modified Conflict Tactics Scale and questions on sexual abuse experienced during childhood and adult life. Results: Of the 395 women remaining in the sixth year of follow-up of the MWMHP, 362 (92%) completed the questionnaire. Overall, 28.5% (n = 101) of the women had experienced some form of domestic violence (physical, sexual or emotional) during their lifetime; 5.5% (n = 15) of women had experienced severe physical abuse in the past year at the hands of a partner; and 11.8% (n = 42) of the women had experienced rape or attempted rape between the age of 16 and the time of our survey. Regarding abuse in childhood, 8.9% (n = 32) of women had experienced physical abuse, 42.3% (n = 152) had experienced non-contact sexual abuse, and 35.7% (n = 128) contact sexual abuse. Compared with the general-practice-based study, rates of childhood physical abuse and penetrative sexual abuse were similar, but rates of less intrusive child sexual abuse were significantly higher in our study. Conclusions: Doctors in all areas of medicine who are dealing with middle-aged women need to be aware of the levels of violence sustained by women throughout their lives. Such experiences may have a substantial impact on women's physical and mental wellbeing. Over the past 20 years, the high prevalence of violence against women has been exposed by rigorous research. Women's Safety Australia,1 a large community-based survey of 6300 women undertaken by the Australian Bureau of Statistics, found that 2.6% of women who currently had partners had experienced an incident of physical violence in the previous 12-month period; 8.0% reported an incident of physical violence at some time during their current relationship; and 1.9% of women had experienced an incident of sexual violence during the 12 months prior to the survey. Mazza and colleagues2 examined the prevalence of physical, sexual and emotional violence experienced by women attending general practitioners in metropolitan Melbourne. Their study found that, of women aged 18 years and over who were in relationships, more than a quarter had been victims of physical or emotional abuse by a partner in the previous year, with one in 10 experiencing severe physical violence. In two Australian studies undertaken in hospital emergency departments,3,4 about 19% of female attendees disclosed histories of domestic violence. It is now recognised that domestic violence has an important influence on the morbidity and mortality of women. Increased utilisation of healthcare facilities,5 chronic pain (particularly pelvic pain),6,7 functional gastrointestinal disorders,8 drug and alcohol dependence or misuse,9-11 attempted suicide11 and psychopathology12-14 are all strongly associated with the experience of violence. The aims of our study were to determine current and lifetime rates of the experience of partner abuse and sexual violence in a community-based sample of middle-aged women and to compare these to figures obtained in a general practice setting in a previous study.2 Methods Questionnaire The "violence questionnaire" that was handed to participants for self-completion was the same as that used in a prevalence study of domestic violence experienced by women attending general practices in Melbourne,2 with which we wanted to compare our study data. The questionnaire incorporated the Conflict Tactics Scale,15 with the modification that respondents were asked whether the tactic had occurred never, once or more than once in the past year, and with the addition of questions on emotional abuse. Physical violence was classified as minor or severe.2 Questions about sexual abuse were derived from the studies of Wyatt16 and Russell,17 both of which used multiple screening questions to allow time for the respondent to become accustomed to the nature of the questions. Childhood sexual abuse was classified as "contact" abuse (involving physical contact) or "non-contact" abuse. (For the purposes of our study, a "child" was defined as a person under 16 years of age.) Study participants The subjects of our study were participants in the sixth year of the Melbourne Women's Midlife Health Project (MWMHP),18 a longitudinal study of a community-based cohort of Australian-born women aged 45-55 years at the beginning of the study. An initial cross-sectional study undertaken in 1991 of a randomly selected community-based sample of 2001 women gathered baseline information regarding women's health experiences and variables related to these experiences.19 The MWMHP study was approved by the Human Research Ethics Committee of the University of Melbourne. Eligibility for the longitudinal phase of the study included women who at baseline were premenopausal, were not taking the oral contraceptive pill or hormone therapy, and had an intact uterus. Of the 779 women eligible to enter the longitudinal study, 56% (n=438) chose to do so. Volunteers for the longitudinal study were more likely than non-participants to report better self-rated health, paid employment, more than 12 years of education, having ever had a Pap smear, exercising at least once a week, and having undergone dilatation and curettage.19 In the MWMHP study, women were interviewed annually face-to-face in their own homes by trained interviewers. Information was collected on a range of variables, including sociodemographic factors, health status, lifestyle behaviours, menopausal status and hormone therapy use. By 1996, when our study was conducted, the retention rate of MWMHP participants was 90% (n = 395). Of these women, 23 who had experienced surgical menopause were not given the violence questionnaire, and a further 10 women refused to complete the questionnaire, leaving 362 women who took part in our study. Statistical analysis The Statistical Package for the Social Sciences (SPSS)20 was used to analyse the sample and determine the prevalence of different forms of violence reported by the women. A statistical comparison was made between the results of our study and the data (previously unpublished) for the subset of women aged 50-69 years (n = 411) from an earlier, general-practice-based study of violence2(Box 1). Ninety-five per cent approximate confidence intervals were used. Results Of the 362 questionnaires available, there were missing data for eight women who did not answer questions on adult violence, four who did not complete the adult sexual abuse questions, and four who did not answer either one or more questions on childhood violence. At the time of completing the violence questionnaire the women were between 51 and 62 years of age (mean, 54.6; SD, 2.42). Sixty-six per cent (238/362) were in paid employment and 77% (277/362) were married or living with a partner. The median parity was 3 (range, 0-9), and 35% of the women had had more than 12 years' education. Domestic violence Overall, 28.5% (101/354) of the women in our study had experienced some form of physical or emotional violence over their lifetime (Box 2). A comparison between our sample and the general-practice-based sample with regard to prevalence of violence experienced in the past year is shown in Box 1. Unwanted sexual experiences with someone other than a husband or partner Overall, 40.8% (146/358) of respondents had, between the age of 16 years and the present, experienced either unwanted sexual advances or been in a situation in which the threat of sexual assault was associated with violence or threat of violence. This included one or more of the following: experiencing rape or attempted rape; encountering sexual advances from someone in authority; or narrowly missing being sexually assaulted. A comparison between the responses in our study and the general practice study is shown in Box 1. Childhood abuse Childhood physical abuse had been experienced by 8.9% (32/358) of the women in our study, and more than one in three women had experienced some form of childhood sexual abuse. Our study showed similar levels of physical abuse and penetrative sexual abuse in childhood, but significantly higher levels of less intrusive child sexual abuse, compared with the general practice sample (Box 1). Discussion Using a longitudinal cohort study such as the MWMHP provides many benefits in a prevalence study. Principal among these is that the women surveyed have been interacting with the research staff for over six years and have therefore built up a degree of trust and comfort with these people. This may facilitate disclosure of sensitive issues such as domestic violence and sexual abuse. A limitation of the study is that in order to obtain some comparative value with other work the questions were delivered by self-administered questionnaire, allowing no opportunity for clarification or exploration of the issues being recorded. Also, the additional questions about emotional abuse had not previously been validated. Of interest is the fact that, despite the participants being a self-selected group of relatively well-educated and health-conscious women, there is a considerable lifetime prevalence of domestic violence among them. The fact that our community-based survey results were similar to those of the general-practice-based survey2 confirms that violence affects the lives of all kinds of women and that it may be a very important contributor to concurrent morbidity occurring at the menopause. In the area of child abuse, our data show similar levels of physical abuse and penetrative abuse but significantly greater levels of less intrusive sexual abuse than those found in the general practice sample. This is surprising given that prevalence rates of most forms of abuse are usually lower in community-based settings than in general practice.2 The greater levels in our sample may reflect a cohort effect or may be owing to the long-term relationship developed over six years of follow-up that may have led to more disclosures. Many studies have demonstrated a relationship between experience of violence and long-term morbidity. Our findings of a high prevalence of violence experienced by women over their lifetime suggest that doctors practising in all areas of medicine need to recognise and explore violence issues when considering middle-aged women's reasons for presenting with ill health. Acknowledgement This study was funded by the National Health and Medical Research Council, the Victorian Health Promotion Foundation, and the Australasian Menopause Society. References Australian Bureau of Statistics. Women's Safety Australia 1996, Canberra: ABS, 1996. (Catalogue No. 4128.0.) Mazza D, Dennerstein L, Ryan V. Physical, sexual and emotional violence against women: a general practice-based prevalence study. Med J Aust 1996; 164: 14-17. de Vries Robbe M, March L, Vinen J, et al. Prevalence of domestic violence among patients attending a hospital emergency department. Aust N Z J Public Health 1996; 20(4): 364-368. Roberts GL, O'Toole BI, Lawrence JM, Raphael B. Domestic violence victims in a hospital emergency department. Med J Aust 1993; 159: 307-310. Stark E, Flitcraft A, Zuckerman D, et al. Wife abuse in the medical setting: an introduction for health personnel. Monograph No. 7. Rockville, Maryland: National Clearinghouse on Domestic Violence, 1981. Schei B. Psycho-social factors in pelvic pain. A controlled study of women living in physically abusive relationships. Acta Obstet Gynecol Scand 1990; 69(1): 67-71. Walling MK, Recter RC, O'Hara MW, et al. Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstet Gynecol 1994; 84(2): 193-199. Drossman DA, Leserman J, Nachman G, et al. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Ann Intern Med 1990; 113(11): 828-833. Burnam MA, Stein JA, Golding JM, et al. Sexual assault and mental disorders in a community population. J Consult Clin Psychol 1988; 56: 843-850. Winfield I, George LK, Swartz M, Blazer DG. Sexual assault and psychiatric disorders among a community sample of women. Am J Psychol 1990; 147: 335-341. McCauley J, Kern DE, Kolodner K, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995; 123(10): 737-746. Gleason WJ. Mental disorders in battered women: an empirical study. Violence Vict 1993; 8(1): 53-68. Mullen PE, Romans-Clarkson SE, Walton VA, Herbison GP. Impact of sexual and physical abuse on women's mental health. Lancet 1988; 1: 841-845. Beitchman JH, Zucker KJ, Hood JE, et al. A review of the long-term effects of child sexual abuse. Child Abuse Negl 1992; 16: 101-118. Straus MA. Measuring intrafamily conflict and violence: the conflict tactics (CT) scales. J Marriage Fam 1979; 41(1): 75-88. Wyatt GE. The sexual abuse of Afro-American and white-American women in childhood. Child Abuse Negl 1985; 9: 507-519. Russell DEH. The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse Negl 1983; 7: 133-146. Dennerstein L, Smith A, Morse C, et al. Menopausal symptoms in Australian women. Med J Aust 1993; 159: 232-236. Burger HG, Dudley EC, Hopper JL, et al. The endocrinology of the menopausal transition: a cross-sectional study of a population-based sample. J Clin Endocrinol Metab 1995; 80(12): 3537-3545. SPSS for Windows. Statistical package for social sciences. Version 9.0. Chicago, Ill: SPSS Inc, 1999. (Received 2 Mar 2000, accepted 29 Mar 2001) Authors' details Office for Gender and Health, Department of Psychiatry, University of Melbourne, VIC. Danielle Mazza, MD, FRACGP, Research Fellow; Lorraine Dennerstein, AO, PhD, FRANZCP, Director; Corrine V Garamszegi, MWH, SRN, Research Assistant; Emma C Dudley, BSc(Hons), GradDip Epidemiol, Research Fellow. Reprints will not be available from the authors. Correspondence: Professor L Dennerstein, Office for Gender and Health, Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Charles Connibere Building, Parkville, VIC 3050. ldennATunimelb.edu.au Make a comment 1: Number of women experiencing various types of violence among MWMHP* participants compared with the number of women aged 50-69 years reporting these experiences in a general practice setting† Type of abuse MWMHP study (%) General practice study (%) Difference in prevalence between the 2 studies (95% CI) P Adult experience of violence Overall physical and/or emotional abuse by partner in the past year 57 (20.9%) 80 (29.6%) -8.7% (-16.0%, -1.4%) Minor physical abuse by partner in the past year 46 (16.9%) 61 (22.8%) -5.9% (-12.6%, +0.8%) 0.088 Severe physical abuse by partner in the past year 15 (5.5%) 18 (6.7%) -1.2% (-5.2%, +2.8%) 0.550 Emotional abuse by partner in the past year 31 (11.3%) 54 (20.0%) -8.7% (-14.8%, -2.6%) All forms of sexual assault between 16 years of age and the present 146 (40.8%) 135 (33.3%) +7.5% (+0.6%, +14.4%) Unwanted sexual experience between 16 years of age and the present 85 (23.7%) 79 (19.8%) +3.9% (-2.0%, +9.8%) 0.189 Rape or attempted rape between 16 years of age and the present 42 (11.8%) 43 (10.7%) +1.1% (-3.4%, +5.6%) 0.640 Childhood experience of violence Physical abuse 32 (8.9%) 34 (8.6%) +0.3% (-3.7%, +4.3%) 0.856 Non-contact sexual abuse 152 (42.3%) 103 (25.5%) +16.8% (+10.2%, +23.4%) Contact sexual abuse 128 (35.7%) 110 (27.2%) +8.5% (+1.9%, +15.1%) Penetrative sexual abuse 24 (6.7%) 17 (4.2%) +2.5% (-0.8%, +5.8%) 0.129 * MWMHP = Melbourne Women's Midlife Health Project (our study was based on the cohort of women participating in the MWMHP study18 in its sixth year). † The group of women aged 50-69 years was a subset (previously unpublished data, n=411) of the 2181 women aged over 18 years who took part in a general-practice-based study of violence against women.2 ‡ Missing data from incomplete questionnaires were excluded when calculating prevalences. Back to text 2: Lifetime prevalence of domestic violence among middle-aged women (MWMHP* participants) Type of abuse Number of women Prevalence† (95% CI) Overall physical 101 28.5% and/or emotional (23.8%-33.2%) abuse Minor physical 79 22.4% abuse (18.4%-26.2%) Severe physical 31 8.8% abuse (5.9%-11.8%) Emotional abuse 60 17.0% (13.1%-20.9%) * MWMHP = Melbourne Women's Midlife Health Project (our study was based on the cohort of women participating in the MWMHP study18 in its sixth year). † Missing data from incomplete questionnaires were excluded when calculating prevalences. Back to text

Danielle Mazza · Lorraine Dennerstein

Viewpoint Heroin addiction: the science and ethics of the new treatment pluralism As approaches to treating heroin addiction grow in number, their ethics and their meaningful contribution to the science in this field need more careful consideration Matt D Gaughwin and Philip Ryan MJA 1999; 170: 129-130 Introduction - Questions of ethics - Questions of science - Ways forward - References - Authors' details - - More articles on Drugs and alcohol Introduction There is a new pluralism of approaches to treating heroin addiction. Many trials are concerned with relatively small populations of heroin users, among whom researchers hope to demonstrate, by various methods, that one drug or treatment is effective and safe, and perhaps better than, another. At the other extreme are clinics which offer treatments -- such as ultrarapid opiate detoxification (UROD), in which heroin addicts are given opiate antagonists while anaesthetised so that they do not consciously experience withdrawal symptoms -- at a price, and not necessarily with a special interest in evaluation and research. Such approaches have their place, but they can never address the question of how much of what treatments we need to help stem the tide of heroin problems in the community. That question has scientific and ethical implications about the design of trials and treatments and the application of the results of trials to communities. Questions of ethics There are two categories of ethical issues associated with the new treatment pluralism. Firstly, ethics as they relate to individuals and, secondly, ethics as they relate to populations. The proponents of trials, and perhaps the ethics committees that consider these trials, are more concerned with ethics in relation to the individual trial participants. The ethical obligations of treating clinicians, whether they are working in franchised clinics or research institutions, are clear. They must adequately inform patients about the treatments, which must be as safe as they can be. Whether a procedure such as anaesthesia should be used at all for a clinical condition that is not life threatening was raised by Hall and Mattick,1 and countered by Seivewright and Greenwood,2 who said that the same argument is not used for childbirth or dental treatment. There is an important ethical discussion yet to be had about the extent to which we should introduce new elective procedures which require anaesthesia. Importantly, the risk -- perhaps increased risk -- of death from heroin overdose (as a consequence of reduced opiate tolerance) that can accompany poor compliance with naltrexone means that there is a great responsibility to inform patients being treated with naltrexone about that specific risk. There is also an urgent ethical responsibility to decide whether that risk is too great for some or all participants, and thus to act to reduce or eliminate the risk even if that means stopping or modifying trials and treatments. Also, there is yet to be a comprehensive ethical discussion about the allocation of resources for these new treatments. We do not deny that there is a place for new treatments. Rather, in the face of inadequate resources for existing proven treatments (such as methadone), the effect of introducing new treatments or trials on the ability of heroin addicts seeking help to actually obtain that help needs to be considered. Addiction to opiates is a multifaceted problem which may require multifaceted solutions. If we accept a humanitarian view of treatment, including treatment within trials, we must accept our ethical obligation to offer a treatment that we know works if a trial participant or a patient in a UROD clinic "drops out" of a new treatment. Some heroin users, desperate for help, hardly have a choice, and will enrol in a trial of an unknown treatment because standard treatments (such as methadone maintenance) are relatively unavailable. The other, often neglected, dimension is that of public health ethics. Trials which are publicly funded have special ethical obligations to ensure, as far as possible, that the questions being asked, and the design and evaluation of trials, are in the public's best interest -- that is, what a public given the chance to deliberate adequately about the issue would choose. Because there are no standards for deliberation about public health issues such as heroin addiction,3 propsals for trials may be approved or denied at the discretion of those who hold the relevant power. Thus, the ACT heroin trial was halted by the Prime Minister and Cabinet, while State governments, such as the South Australian government, announced trials of rapid opiate detoxification4 without comprehensive consultation and deliberation with the public, heroin addicts or the clinicians who treat them. The idiosyncrasy of such approaches must militate against sustainable solutions to the problem of heroin addiction, and raises the ethical question of how rational and reasonable approaches to this problem can be given a "fair go". If there has not been meaningful public deliberation about proposals, we believe their proponents can not claim that they are ethical trials in a public sense. Questions of science This emergence of a pluralism of approaches to heroin problems brings with it scientific difficulties. As more and more treatments are trialled, we increase the difficulty and the cost of designing studies that can determine which collection or combinations of treatments are better than others. This does not negate the value of small trials, but it does raise the question of the relationship between trials and evaluation of treatments as a whole. The diversity of treatments and trials is wide, ranging from uncontrolled small case series through modest-sized randomised trials to modest treatment programs. It is the view of one researcher that ". . . we are likely to get poorly designed, incompatible trials . . . which produce inconclusive results, ie a null effect in a study lacking adequate power".5 Indeed, a pilot study of naltrexone treatment in New South Wales6 concluded that about 450 participants would be needed for a randomised trial of adequate power -- considerably more than the 100-200 participants proposed for the randomised trials in SA and NSW. Many trials are of short duration, whereas the problem of addiction often occurs over many years. Thus, deciding when to measure outcomes becomes an important issue. Trials risk being irrelevant to the real world of addiction if they ask questions or evaluate outcomes relevant to the short term only. As in cancer epidemiology, we should develop standards for evaluating endpoints in heroin addiction trials so that we might, as with cancer, agree that after a certain period someone is "cured" of their addiction. Or, if we consider addiction to be a chronic relapsing condition, we might perhaps model trials for heroin addiction on those for treating diseases such as epilepsy or diabetes. Moreover, we must never forget that there can be a vast gulf between efficacy demonstrated in clinical trials and meaningful control of a public health problem. Ways forward The new pluralism in treatments for heroin addiction is fragmented and uncoordinated, with no particular strategic direction. This is not surprising given the lack of an agreed strategic framework on which to design treatments and trials in the area of drug addiction. However, a strategic framework will be successful only if all those with an interest in the problem -- experts and non-experts alike -- are justly and fairly engaged in ways which consider and account for the diversity of views about heroin. It is encouraging that the National Drug and Alcohol Research Centre has recently been contracted to coordinate the trials of new pharmacological treatments (Associate Professor Richard Mattick, Director of Research, National Drug and Alcohol Research Centre, University of New South Wales, personal communication). Perhaps this Centre might take on the wider role of considering the ethical and scientific questions we have raised here. In summary, the new pluralism in treatments for heroin addiction poses some dilemmas. We should welcome the opportunities they may offer, but approach them cautiously and comprehensively so that we avoid the traps of ill-considered science and ill-considered ethics. References Mattick R, Hall R. Are detoxification programs effective? Lancet 1996; 347: 97-100. Seivewright N, Greenwood J. What is important in drug misuse treatment? Lancet 1996; 347: 373-376. Gaughwin M. Why Australia needs minimum standards of deliberation for public health. Med J Aust 1998; 168: 228-229. Minister for Human Services, South Australia. Rapid heroin withdrawal treatment trial [media release]. Adelaide: Department of Human Services, March 2 1998. Caplehorn J. Reply to Hall et al: on ROD, UROD and ODs. Drug Alcohol Rev 1998; 17: 222-223. Foy A, Sadler C, Taylor A. An open trial of naltrexone for opiate dependence. Drug Alcohol Rev 1998; 17: 167-174. Authors' details Department of Public Health, University of Adelaide, Adelaide, SA. Matt D Gaughwin, PhD, FAFPHM, Senior Clinical Lecturer; Philip Ryan, MB BS, FAFPHM, Lecturer. Reprints will not be available from the authors. Correspondence: Dr M D Gaughwin, Drug and Alcohol Resource Unit, Level 5, Services and Teaching Wing, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000. Email: mgaughwin@medicine.adelaide.edu.au

Matt D Gaughwin · Philip Ryan

Should research ethics change at the border? The use of placebos in HIV drug trials has raised concerns about research ethics in developing countries MJA 1998; 169: 509-510 Research on mothers with HIV in poor countries has attracted vehement criticism. The researchers (largely funded from the West) are accused of changing their ethics "at the customs desk."1 In defence of their own position researchers (and their sponsoring bodies) claim that ethical standards are unrealistic and that local conditions require studies "that might not be found ethically acceptable in developed countries."2 They argue for achievable standards that depend on local circumstances.2-4 The controversy concerns the use of placebos in zidovudine drug trials on mothers with HIV in Thailand, Africa and the Caribbean. The trials aimed to test the effectiveness of a short course of low-dose zidovudine in preventing transmission of HIV from mothers to infants by comparing transmission rates of mothers given zidovudine with those offered only a placebo. The short course is an alternative to a more expensive regimen of treatment with zidovudine for both mother and infant previously demonstrated to be effective in the trial known as ACTG 076.5 Although the ACTG 076 regimen has been effective in reducing transmission rates by almost 70%, it is not available in resource-poor countries because of the cost and lack of necessary facilities and support.3 Placebo trials in Thailand have recently shown that a simplified regimen of zidovudine was effective in reducing the transmission of HIV between infected mothers and their infants by 51%. This finding is from studies with women who did not breastfeed and who were given zidovudine orally for three to four weeks before birth. No zidovudine was given to their infants.6 This result now makes it clear that placebo comparisons are no longer ethical in mother-to-child HIV transmission studies, even in poorer countries. However, it does not answer the charge that they were unethical in the first place. It is an issue that is still current because there are other diseases for which treatments are available in the West, but not in resource-poor countries. Could placebo trials be justified to test cheaper alternative treatments for these diseases? Furthermore, to continue the logic of the Thai HIV transmission trials, is it ethical to test an even cheaper (shorter course and lower dose) zidovudine regimen? In broad terms the issue is whether ethical standards in research apply across borders, irrespective of poverty and lack of supporting health care systems. The concern with "ethical relativism" in HIV research1,7 is an instance of a long-standing debate between universalism and relativity in ethics, with the universalists arguing for an "irreducible set of ethical standards" that apply internationally.8 These include requirements that the interests of participants in research be given priority over potential benefits for science and society;9 that there be "genuine doubt" as to whether an alternative is as good as standard accepted treatment;10 that studies be approved by an independent committee;9 and that no study be conducted in a foreign country unless it meets the standards of the sponsoring country.11 Failure to accept these minimal conditions, it is argued, is an invitation to unscrupulous researchers and companies to exploit poorer countries.11 Lurie and Wolfe ask ". . . why not select the approach that minimizes loss of life?"11 Although these authors opposed the placebo studies, the answer to their question may well support the placebo trials in Thailand, in that they were quicker and their results support immediate implementation of an effective treatment program (albeit one not as effective as the ACTG 076 regimen). The indications are that in the long run these particular placebo trials will save more lives. Does this end result justify research that withheld effective treatment from HIV-infected mothers and their infants? I admit to being caught between the arguments: on the one hand it is abhorrent to accept that mothers were recruited for studies in which some of them were deprived of a treatment that might have protected their child from contracting HIV. On the other hand, a great many more (future) lives may have been saved. The pragmatic argument is that we must do what we can to test and find effective treatments which can be made available in conditions of poverty. The inequity lies, not in researchers withholding effective treatment, but in a callous world that tolerates gross disparities between rich and poor countries. Researchers are trying to reduce (where they can) some of those inequities. Could there be a middle way between the extremes of universalism and relativity? Nussbaum, while supporting a universalist approach to ethics, argued for "a delicate balancing between general rules and a keen awareness of particulars, in which process . . . the particular takes priority . . . in the sense that a good rule is a good summary of wise particular choices, and not a court of last resort."12 From this perspective, the rule that research must meet the standards of the sponsoring country may need "modification in the light of new circumstances".12 If we take this lead, there may be no simple answer. Each situation would require a careful analysis, guided by internationally accepted rules, and applied with a keen sense for the most humane decision in those circumstances. Certainly, we should be on our guard and block research which simply exploits those in poverty. However, the "wise choice"12 that most benefits people in poor countries may not always conform to Western standards. In this issue of the MJA Studdert and Brennan13 call for "dialogue about whether a universal standard of care is applicable." Although this debate may no longer be relevant to studies of mother-to-child HIV transmission, it remains an important ethical question in responding to dire health needs of those in poor countries. Paul M McNeill Associate Professor in Ethics and Law Faculty of Medicine, University of New South Wales Sydney, NSW Acknowledgement: My thanks to Gregory J Dore, National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, for information on recent developments and his many helpful comments. Cohen J. Ethics of AZT studies in poorer countries attacked. Science 1997; 276: 1022. Varmus H, Satcher D. Ethical complexities of conducting research in developing countries. N Engl J Med 1997; 337: 1003-1005. Levine RJ. The "best proven therapeutic method" standard in clinical trials in technologically developing countries. IRB -- A Review of Human Subjects Research 1998; 20(1): 5-9. Merson MH. Ethics of placebo-controlled trials of zidovudine to prevent the perinatal transmission of HIV in the third world [letter]. N Engl J Med 1998; 338: 836. Centers for Disease Control and Prevention. Administration of zidovudine during late pregnancy and delivery to prevent perinatal HIV transmission -- Thailand, 1996-1998. JAMA 1998; 279: 1061-1062; also in MMWR - Morbid Mortal Wkly Rep 1998; 47(8):151-154. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med 1994; 331: 1173-1180. Angell M. The ethics of clinical research in the third world. N Engl J Med 1997; 337: 847-849. Angell M. Ethical imperialism? Ethics in international collaborative clinical research. N Engl J Med 1988; 319: 1081-1083. McNeill PM. The ethics and politics of human experimentation. Sydney and London: Cambridge University Press, 1993: 165-183. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med 1987; 317: 141-145. Lurie P, Wolfe SM. Unethical trials of interventions to reduce perinatal transmission of the human immunodeficiency virus in developing countries. N Engl J Med 1997; 337: 853-856. Nussbaum N. Non-relative virtues: an Aristotelian approach. In: Nussbaum N, Sen A, editors. The quality of life, Oxford University Press, 1993: 242-269, at 257. Studdert DM, Brennan TA. Clinical trials in developing countries: scientific and ethical issues. Med J Aust 1998; 169: 545-547. - Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Paul M McNeill

Improving the mental and physical health of unemployed people: why and how? Strategies that reduce the negative effects of joblessness are likely to benefit us all MJA 1998; 168: 177-178 Unemployment has been a recurring social problem throughout this century, and a permanent feature of economic life in Australia and other industrialised countries since the early to mid 1970s. Our current unemployment rate hovers between 8% and 9%,1 although the Australian Council of Social Services estimates that there could be just as many "hidden unemployed", who do not feature in official statistics.2 The "hidden unemployed" comprise two main groups: those who do not register for work because of illness or for personal reasons or who have given up job-seeking (discouraged workers), and those who hold part-time and casual jobs but would prefer full-time work (the underemployed).3 The official unemployment rate equates to some 800,000 people out of work, with about a third of these being long-term unemployed (ie, out of work for 12 months or more).1 It is now well documented that for many the experience of unemployment brings with it physical and mental health problems. Furthermore, longitudinal studies have shown that the negative effects of unemployment have largely resulted from people moving from being employed to being unemployed, and are not associated with workers with few skills or inadequate personal resources "drifting" into joblessness.4 Not all groups in our community are equally affected by unemployment. Australian Aboriginals, people from non-English-speaking backgrounds, especially recent migrants, and people with disabilities are especially vulnerable. Young people are another seriously disadvantaged group. Three articles in consecutive issues of the Journal will highlight the health problems faced by unemployed people. The first will review the evidence for the detrimental effects of unemployment on health (see Mathers and Schofield in this issue of the Journal);5 the second will address the particular problems of young unemployed people (Morrell et al, MJA 1998; 2 March);6 and the third will look at how the health system can respond to the health problems of unemployed people (Harris et al, MJA 1998; 16 March).7 Satisfactory employment has many benefits that unemployed people are denied. These benefits are firstly financial, but equally important are the assignment of identity and status, the increased social contact, being part of a collective purpose and joint effort, and being able to engage in regular activity.8 The substantial cuts to income that most unemployed people face are associated with real and relative deprivation that, in itself, can be psychologically destructive. Poverty clearly affects physical and psychological well-being. It also reduces confidence and restricts personal agency and empowerment.9 Loss of income and resulting poverty can be especially psychologically destructive for adults, as they are likely to have financial and family commitments. For young people, failure to find satisfactory employment may adversely affect their psychological development and have negative long term consequences. The lowered self-confidence associated with unemployment10 can reduce the number and types of jobs applied for, restrict the uptake of training, and inhibit engagement in self-employment or cottage/craft industries. Furthermore, lack of confidence also means that low levels of commitment, motivation and effort will be brought to bear, perseverance will be low, and, in particular, the capacity to persist with an activity in the face of setbacks or adversity will be greatly reduced. Unemployed people with poor self-confidence will timidly pursue occupational possibilities, and are likely to desist altogether in the face of repeated failures. This pattern will repeat itself in other areas of these people's lives, impinging on their ability to cope with their financial commitments and their social and family life. Not only does unemployment reach beyond those who are jobless, and put at risk the well-being of their partners and children,11,12 but there is also growing evidence that high levels of unemployment have an adverse effect on those in the workforce, with job insecurity being associated with elevated stress levels.13 The picture is further complicated by increasing numbers of people who, on the one hand, are underemployed, and those who, on the other hand, are in full-time employment but are required to work ever-longer hours to maintain their jobs. Little is known about the health effects on these two groups. Despite the evidence of the detrimental effects of unemployment on health, there is little debate in the community about these issues. The assumption remains that it is a temporary problem and that the emphasis should be on encouraging people to enter training or to find work. This is despite the fact that unemployment and underemployment are now long-standing and near-universal problems. This assumption has resulted in too few resources being expended on the development and evaluation of interventions to reduce the adverse effects of unemployment. Harris et al, in the final article in this series, document the few interventions that have been tried, and outline possible strategies to address this problem.7 It is important to reduce the negative effects of unemployment to minimise individual misery of unemployed people, as well as to benefit their families and the commun ity in general. While this task does include the development and implementation of individual health and well-being programs, the solution also lies in our responses to the changing nature of work and how we will structure our major institutions in the next century. We need to develop policies and strategies to reduce the stigma of joblessness. The right of all to be able to engage in meaningful and community-sanctioned activities that bring with them opportunities for financial security is central to reducing the debilitating effects of unemployment. Unemployment is a long-standing problem. It is not likely to disappear in the short to medium term. Income support from government sources will inevitably continue, and could do so without the stigma with which it is currently associated and at levels that ensure that unemployed people do not live in poverty. This, together with an expansion of reciprocal relationships between the community and unemployed people (as is currently being tested under the "work-for-the-dole scheme" which commenced in December 1997), offer some scope for setting a new agenda in this area. Peter A Creed Lecturer, School of Applied Psychology Griffith University, Gold Coast, QLD Australian Bureau of Statistics. 1997 Year Book Australia. No 97. Canberra: AGPS; 1997 (Catalogue No. 1301.0.). Spiers R. Growing problem of long term unemployed. Financial Review (Sydney) 1991; 11 Mar: 6. Canadian Public Health Association. 1996 Discussion paper on the health impact of unemployment. Winefield AH, Tiggemann M, Winefield HR. Growing up with unemployment: longitudinal study of its psychological impact. London: Routledge, 1993. Mathers CD, Schofield DJ. Health consequences of unemployment: the evidence. Med J Aust 1998; 168: 178-182. Morrell S, Taylor R, Kerr C. Unemployment and young people's health. Med J Aust 1998; 168. In press. Harris E, Webster I, Harris M, Lee P. Unemployment and health -- the healthcare system's role. Med J Aust 1998; 168. In press. Jahoda M. Work, employment and unemployment: values theories and approaches in social research. Am Psychol 1981; 36: 184-191. Fryer D. Benefit agency? Labour market disadvantage, deprivation and mental health. Psychologist 1995; 8: 265-272. Bandura A. Self efficacy: the exercise of control. New York: Freeman, 1997. McLoyd VC. Socialization and development in a changing economy: the effects of paternal job loss on children. Am Psychol 1989; 44: 293-302. McKee L, Bell C. His unemployment, her problem: the domestic and marital consequences of male unemployment. In: Allen S, Watson S, Purcell K, Wood S, editors. The experience of unemployment. Basingstoke: Macmillan 1986: 134-149. Winefield AH. Unemployment, occupational stress and psychological distress. In: Hicks R, Creed P, Patton W, Tomlinson J, editors. Unemployment: developments and transitions. Brisbane: Australian Academic Press, 1995: 77-88. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/>

Peter A Creed

Driving and dementia: balancing personal independence and public safety Drivers with dementia require standardised on-road assessment of their driving safety MJA 1997; 167: 406-407 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - ©MJA1997 In this issue of the Journal, Lipski addresses the important topic of driving by people with dementia.1 Although older drivers drive fewer kilometres than younger drivers, and are less likely to drive at night or in heavy traffic, their crash rate per kilometre driven may be the highest of any age group, and they are more likely to be killed when involved in a crash.2 Several retrospective studies have found that people with dementia are involved in more accidents than age-matched control subjects, and that many drivers with dementia continue to drive despite having had crashes.3-5 Notably, these studies do not agree on issues such as whether the duration of the dementia is an accurate predictor of driving ability, and many rely on reports by caregivers of driving history and crashes, the reliability of which are uncertain. Recent neuropathological findings in 98 older drivers killed in traffic accidents showed that 33% had neuritic plaque scores indicating certain Alzheimer's disease (AD) and, in a further 20%, findings were suggestive of AD.6 This raises the possibility that more accidents are attributable to AD than previously thought. In contrast, another study of Michigan State records showed that road crash and violation rates among AD patients did not differ significantly from those of matched controls;7 this study did not control for mileage driven, and reduced driving exposure of AD patients may have kept their crash rate equal to that of control subjects. Drachman and Swearer investigated crash rates for patients with AD over a 10-year period.8 They also did not control for mileage driven, but found that, although the AD patients had fewer reported crashes than 16-24 year old drivers, they had more than twice as many in the years after the onset of their AD, than matched control subjects. Doctors cannot reliably predict driving competence or increased crash risk in drivers with AD on the basis of a clinical examination There are few reports on actual driving performance of people with dementia. Fitten and colleagues examined the performance of patients with mild AD and patients with mild vascular dementia.9 Compared with control groups, the groups with AD and vascular dementia had lower mean scores on the driving test and made more errors in the complex stages of the course. In addition, a retrospective analysis of crashes and driving violations for these patients was consistent with road test results. However, Hunt and colleagues found that, while 40% of drivers with mild dementia of the Alzheimer type (DAT) were unsafe, some others may drive safely. The driving competency of individuals with DAT could not be determined reliably from self report.10 Fox and colleagues found that 63% of licensed drivers diagnosed with probable AD failed a standardised on-road evaluation.11 Conversely, 37% passed this evaluation, suggesting that a diagnosis of AD alone may be insufficient justification for stopping people from driving. These studies of on-road driving behaviour of patients with dementia indicate that older drivers with a range of cognitive abilities can be safely and reliably evaluated by a road test, with validity equal to that of driver licence tests. As noted by Lipski,1 while data increasingly show risks to individuals and the community associated with driving by people with dementia, there are few guidelines for helping doctors determine who can or cannot drive. This assessment may be further complicated if any of the new drugs currently undergoing clinical trial for AD are found to enhance performance on cognitive or driving tasks. Doctors cannot reliably predict driving competence or increased crash risk in drivers with AD on the basis of a clinical examination.10 There is also a lack of consensus about the predictive validity of neuropsychological assessment for driving competence among patients with dementia, partly because of the different neuropsychological tests employed in different studies. While the Mini Mental State Examination has been proved to significantly predict driving competence in studies of patients with dementia, its specificity and sensitivity were not sufficient for efficient prediction of driving safety.11 In the light of recent empirical data, we recommend that if a doctor learns that an older patient gets lost while driving or has been involved in a crash, the possibility of a progress ive dementing illness as a cause of their driving difficulties should be investigated. In many cases, licence cancellation may be indicated without on-road assessment. If licence cancellation threatens a general practitioner's long term relationship with a patient and his or her family, referral to an appropriate specialist may be preferable. In cases of disagreement, an on-road driving test may help the family, and possibly the patient, accept that the patient is incompetent to drive. In patients for whom unsafe driving behaviours have not been reported, an on-road assessment is currently the most valid means of determining driver competence and safety. The driving test should be standardised, designed for neurologically impaired people, include some complex traffic situations, and, ideally, should be available in both urban and rural areas. It has been suggested that patients with dementia who drive with the assistance of a passenger or "copilot" should be assessed with, and subsequently permitted to drive with, the "copilot".12 However, several logistic and legal problems (surrounding such questions as: Who is licensed to drive? How can the presence of the "copilot" be ensured? Can the cognitive status of the "copilot" be monitored?) render this proposal impractical. For patients whose driving tests indicate safe and competent driving, driving performance must be reviewed regu larly (e.g., six-monthly), or after a noticeable increase in dementia severity. Criteria for driving competence and licence cancellation should be discussed with the patient and family. If assessment indicates that the patient should stop driving, the patient and family should be involved in discussion of transport alternatives which may be available from family or friends, or through community transport options. Counselling of the patient and family about lifestyle changes and future planning of transportation may be critical to compliance as well as to psychological wellbeing, as driving cessation may be associated with depressive symptoms. As a society, we need to devote more planning and resources to provision of safe, convenient and affordable transportation alternatives for those unable to drive. Gillian K Fox Clinical Neuropsychologist, Rehabilitation Studies Unit, University of Sydney, NSW. Guy M Bashford Staff Specialist, Department of Rehabilitation and Geriatrics, Illawarra Area Health Service, Warrawong, NSW Lipski PS. Driving and dementia: a cause for concern. Med J Aust 1997; 167: 453-454. Waller PF. Renewal licensing of older drivers. Transportation in an aging society. Vol. 2. Washington, D. C.: Transportation Research Board, 1988: 72-100. Friedland RP, Koss E, Kumar A, et al. Motor vehicle crashes in dementia of the Alzheimer type. Ann Neurol 1988; 24: 782-786. Lucas-Blaustein MJ, Filipp L, Dungan C, Tune L. Driving in patients with dementia. J Am Geriatr Soc 1988; 36: 1087-1091. Gilley DW, Wilson RS, Bennett DA, et al. Cessation of driving and unsafe motor vehicle operation by dementia patients. Arch Intern Med 1991; 151: 941-946. Johansson K, Bogdanovic H, Kalimo H, et al. Alzheimer's disease and apolipo- protein E e 4 allele in older drivers who died in automobile accidents. Lancet 1997; 349: 1143-1144. Trobe JD, Waller PF, Cook-Flanagan CA, et al. Crashes and violations among drivers with Alzheimer disease. Arch Neurol 1996; 53: 411-416. Drachman DA, Swearer JM. Driving and Alzheimer's disease: the risk of crashes. Neurology 1993; 43: 2448-2456. Fitten LJ, Perryman KM, Wilkinson CJ, et al. Alzheimer and vascular dementias and driving. JAMA 1995; 272: 1360-1365. Hunt L, Morris JC, Edwards D, Wilson BS. Driving performance in persons with mild senile dementia of the Alzheimer type. J Am Geriatr Soc 1993; 41: 747-53. Fox GK, Bowden SC, Bashford GM, Smith DS. Alzheimer's disease and driving: prediction and assessment of driving performance. J Am Geriatr Soc 1997; 45: 949-953. Shua-Haim JR, Gross JS. The "co-pilot" driver syndrome. J Am Geriatr Soc 1996; 44: 815-817. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Gillian K Fox · Guy M Bashford

Passive smoking and respiratory function in very low birthweight children Lex W Doyle, Geoffrey W Ford, Anthony Olinsky, Annette M L Knoches and Catherine Callanan For editorial comment see Woodward & Jamrozik Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - Acknowledgement - References - Authors' details - ©MJA1997 Abstract Aim: To determine if an adverse relationship exists between passive smoking and respiratory function in very low birthweight (VLBW) children at 11 years of age. Setting: The Royal Women's Hospital, Melbourne. Patients: 154 consecutive surviving children of less than 1501 g birthweight born during the 18 months from 1 October 1980. Methods: Respiratory function of 120 of the 154 children (77.9%) at 11 years of age was measured. Exposure to passive smoking was established by history; no children were known to be actively smoking. The relationships between various respiratory function variables and the estimated number of cigarettes smoked by household members per day were analysed by linear regression. Results: Most respiratory function variables reflecting airflow were significantly diminished with increasing exposure to passive smoking. In addition, variables indicative of air-trapping rose significantly with increasing exposure to passive smoking. Conclusions: Passive smoking is associated with adverse respiratory function in surviving VLBW children at 11 years of age. Continued exposure to passive smoking, or active smoking, beyond 11 years may lead to further deterioration in respiratory function in these children. MJA 1996; 164: 266-269 Introduction Passive smoking is associated with several adverse health outcomes in children, including higher rates of asthma,1 and infections of the upper2 and lower3 respiratory tract. Further, respiratory function is reduced with passive smoking in children who have no lung disease,4 as well as those with lung diseases such as asthma5 and cystic fibrosis.6 To survive the neonatal period, many very low birthweight (VLBW) children (less than 1500 g at birth) require prolonged periods of assisted ventilation, and some may develop bronchopulmonary dysplasia (BPD) and suffer from ongoing respiratory problems as a consequence. We have previously reported the respiratory health to eight years of age of cohorts of children of birthweight 500-999 g (n = 83), 1000-1500 g (n = 114) and > > 2500 g (n = 51).7 Passive smoking was significantly related to the duration of hospitalisation for respiratory problems up to two years of age for all children in that study, but was not associated with changes in respiratory function at eight years of age. In contrast, in another recent cohort study of respiratory function at seven years of age in children of birthweight less than 2000 g Chan et al.8 reported reduced air-flow rates with maternal smoking, but not with smoking by other household members. Because the effects of passive smoking could increase with increasing duration of exposure, the aim of this study was to determine if an adverse relationship exists between passive smoking and respiratory function at 11 years of age in VLBW children. Methods We studied 154 consecutive surviving children of less than 1501 g birthweight born during the 18 months from 1 October 1980 at the Royal Women's Hospital, Melbourne, the largest of the three tertiary-level perinatal centres in Victoria. Details of the survival rate and early neonatal care of this cohort have been described.9,10 Bronchopulmonary dysplasia (BPD) was diagnosed in children who had required intermittent positive pressure ventilation in the neonatal period, who had respiratory distress and were still having oxygen therapy at 28 days of age, and who had an abnormal chest x-ray consistent with stage III or IV disease (as defined by Northway et al.11 ) at or after 28 days. A previous report of the respiratory function of this cohort at eight years of age7 included data for some children with birthweights of less than 1000 g born before 1 October 1980. We did not have the resources to measure respiratory function at 11 years of age of the children born before October 1980. Respiratory health was determined by history and examination, and measurement of respiratory function. Children who had required bronchodilators within the previous year for attacks of wheezing were considered to have asthma. Data on passive smoking were obtained by asking the parents about the daily consumption of cigarettes by members of the household. We did not distinguish between mothers and other smokers, or between smoking inside or outside the home. Some data on maternal smoking in pregnancy had been collected in the perinatal period, but were obtained for only one-third of mothers. Children were questioned about active smoking in their parents' absence. As some children had changed households in their lifetimes, we considered those who had lived in any household with smokers over the 11-year period to have been passively smoking during childhood. Two categories of social class were determined -- unskilled or unemployed, and other (professional, skilled or semi-skilled) -- based on the occupation of the family breadwinner. Respiratory function was measured in the Department of Thoracic Medicine at the Royal Children's Hospital, Melbourne, as described previously,7 by personnel blinded to the exposure of individual children to passive smoking. Maximum expiratory flow rates were recorded with a pneumotachograph (Fleisch No. 3, Switzerland) and plotted against volume by integrating flow on an X-Y recorder to obtain flow-volume loops. Maximum flow rates at 75% (VEmax75%), 50% (VEmax50%) and 25% (VEmax25%) of forced vital capacity (FVC), and forced expiratory flow between 25% and 75% of FVC (FEF25%-75%), were measured from the loops. Flow rates were corrected for body size by dividing by vital capacity (VC). Vital capacity, FVC and forced expiratory volume in one second (FEV1) were measured with a water-filled spirometer (Godart Expirograph, Bilthoven, Netherlands) in accordance with standard guidelines, and results at body temperature and pressure saturated with water vapour were expressed as a percentage of the predicted value for age, height and sex.12 Total lung capacity (TLC) and residual volume (RV) were measured in a body plethysmograph (Jaeger Bodyscreen 2, Wurzburg, Germany). Children were not subjected to bronchial provocation tests as these are poorly tolerated, and we were eager to maintain a high degree of cooperation with these and with future respiratory function tests. Not all children could complete all respiratory function tests, either because of poor cooperation, or unavailability or malfunction of equipment on the day of testing. Data were edited and analysed using SPSS.13 Dichotomous variables were contrasted by chi-squared analysis, and continuous variables by t test, or Mann-Whitney U test if the data were skewed. The dose-response relationship between the estimated daily number of cigarettes consumed by members of the household and various respiratory function variables was established by linear regression; linear and quadratic relationships were tested. Data were then analysed by linear regression to adjust for the potentially confounding variables of birthweight, gestational age, birthweight ratio (child's birthweight divided by median birthweight for gestational age14 ), sex, BPD, and asthma; all variables were entered simultaneously, even if they were not statistically significant. Durations of intermittent positive pressure ventilation and oxygen therapy were not included as they were strongly related to BPD. For all analyses, P values of less than 0.05 for any test were regarded as statistically significant. Results We measured the respiratory function of 120 of the 154 (77.9%) children at 11 years of age. Of the 34 children not tested, 15 lived in another State, four lived in another country, 10 refused the tests, three were lost to follow-up, and two were too disabled to complete the tests. There were no substantial differences in perinatal variables between children who did and did not have respiratory function tests at 11 years of age. Eighty of the 120 children (66.7%) had been exposed to passive smoking in the household. The only substantial differences in perinatal or subsequent variables between children who were and were not exposed to passive smoking were a significantly longer duration of oxygen therapy and a lower proportion of unskilled or unemployed families in the group not exposed (Table 1). For children exposed to passive smoking, the median number of cigarettes consumed in the household per day was 21 (interquartile range, 15-25). Of the 15 children tested who had developed BPD in the newborn period, three (20%) had asthma at 11 years of age; this proportion was similar for children with asthma at 11 who did not have BPD (22 of 105; 21%). For variables expressed as a percentage of predicted values (FEV1, FVC, RV, TLC), the means of the measured values were all close to their expected values of 100% (Table 2). For all respiratory function variables significantly associated with the dose of passive smoking, a quadratic relationship was more significant than a linear relationship (Table 2, Figures 1 and 2). Most respiratory function variables reflecting airflow (VEmax75%/VC, VEmax50%/VC, FEF25%-75%/VC, FEV1 and FEV1/FVC) were significantly diminished by increasing exposure to passive smoking (Table 2 [below], Figures 1a and 1b). In addition, RV, TLC and RV/TLC rose significantly (consistent with progressive air trapping) with increasing exposure to passive smoking (Table 2 [below], Figure 1c). One child was exposed to 115 cigarettes per day, and the next highest exposure was only 70 cigarettes per day. When the child exposed to 115 cigarettes per day was excluded, most of the statistically significant relationships disappeared, except for the increases in RV and RV/TLC (Figure 2). From the multiple linear regression analyses, some variables reflecting flow (VEmax75%/VC, VEmax50%/VC, VEmax25%/VC, FEF25%-75%/VC and FEV1/FVC) were significantly higher in girls. BPD was significantly associated with reductions in some variables reflecting air-flow (VEmax50%/VC, FEF25%-75%/VC, FEV1 and FEV1/FVC), as was asthma (with significant reductions in FEF25%-75%/VC, FEV1 and FEV1/FVC). FVC was significantly lower and VEmax25%/VC significantly higher with lower social class. Birthweight ratio, birthweight and gestational age were not significantly associated with any lung function variable. None of the statistical conclusions relating respiratory function variables with passive smoking were altered by adjusting for all potentially confounding variables, except that the reduction in VEmax50%/VC was no longer statistically significant. Discussion Passive smoking was associated with reduced airflow and air-trapping in VLBW children at 11 years of age, which is consistent with observations in non-preterm children free of lung disease.4 However, this finding was different from our observations of these children at eight years of age,7 when passive smoking was unassociated with any lung function variable. Chan et al.8 reported reduced flow rates with smoking by mothers in children of less than 2000 g birthweight at seven years of age, but they did not measure variables reflecting air-trapping. We did not distinguish between mothers and other smokers in the household. The association between passive smoking and adverse respiratory function in our VLBW children at 11, but not at eight, years of age suggests that the harmful effects of passive smoking take time to become obvious in VLBW children. Moreover, the adverse response seems to accelerate with increasing dose of passive smoking (Figures 1 and 2). We are concerned that continued exposure to passive smoking, or, even worse, active smoking, beyond 11 years will lead to not only further, but also to an accelerating rate of, deterioration in respiratory function. Our results should not be overinterpreted. They were not substantially altered by adjusting for potentially confounding perinatal or other variables, but we did not have data on a wide range of confounding variables. Moreover, they were heavily influenced by one child who lived in a household whose members consumed 115 cigarettes per day. Excluding this child from the analysis, the only remaining statistically significant associations indicated air-trapping with increasing exposure to passive smoking. However, we consider that this child's data should not be excluded just on the basis of heavier-than-average exposure to passive smoking. To remove any doubt about the association between passive smoking and adverse lung function in VLBW children, lung function could be measured in another cohort of VLBW children, or the same cohort when they are older. Parents of VLBW children, particularly those of children who have received assisted ventilation, frequently ask about long-term lung problems. Many variables, such as family history or duration of assisted ventilation and oxygen therapy, may be related to long-term lung problems, but most cannot be altered by the parents. Exposure to passive smoking is one variable associated with poorer respiratory function in VLBW children they can influence. Until there is evidence to the contrary, families of VLBW children should be encouraged to stop exposing their children to cigarette smoke in the household. As there appears to be a dose-response relationship, those who cannot stop smoking should at least reduce their children's exposure to passive smoking. Acknowledgement This study was supported in part by a grant from the Royal Women's Hospital-3AW Community Services Trust. References Landau L. Smoking and childhood asthma. Med J Aust 1991; 154: 715-716. Wright AL, Holberg C, Martinez FD, et al. Relationship of parental smoking to wheezing and nonwheezing lower respiratory tract illnesses in infancy. J Pediatr 1991; 118: 207-214. Etzel RA, Pattishall EN, Haley NJ, et al. Passive smoking and middle ear effusion among children in day care. Pediatrics 1992; 90: 228-232. Cook DG, Whincup PH, Papacosta O, et al. Relation of passive smoking as assessed by salivary cotinine concentration and questionnaire to spirometric indices in children. Thorax 1993; 48: 14-20. Chilmonczyk BA, Salmon LM, Megathlin KN, et al. Association between exposure to environmental tobacco smoke and exacerbations of asthma in children. N Engl J Med 1993; 328: 1665-1669. Smyth A, O'Hea U, Williams G, et al. Passive smoking and impaired lung function in cystic fibrosis. Arch Dis Child 1994; 71: 353-354. Kitchen WH, Olinsky A, Doyle LW, et al. Respiratory health and lung function in 8-year-old children of very low birth weight: a cohort study. Pediatrics 1992; 89: 1151-1158. Chan KN, Noble-Jamieson CM, Elliman A, et al. Lung function in children of low birth weight. Arch Dis Child 1989; 64: 1284-1293. Kitchen WH, Ford GW, Murton LJ, et al. Mortality and two year outcome of infants of birthweight 500-1500 g: relationship with neonatal cerebral ultrasound data. Aust Paediatr J 1985; 21: 253-259. Kitchen WH, Yu VYH, Lissenden JV, Bajuk B. Collaborative study of very-low-birthweight infants: techniques of perinatal care and mortality. Lancet 1982; i: 1 454-1457. Northway WH Jr, Rosan RC, Porter DY. Pulmonary disease following respirator therapy of hyaline-membrane disease: bronchopulmonary dysplasia. N Engl J Med 1967; 276: 357-368. Hibbert ME, Lanigan A, Landau LI, Phelan PD. Lung function values from a longitudinal study of healthy children and adolescents. Pediatr Pulmonol 1989; 7: 101-109. SPSS for Windows [computer program]. Version 6.1. Chicago, Ill: SPSS Inc, 1994. Kitchen WH, Robinson H, Dickinson AJ. Revised intrauterine growth curves for an Australian hospital population. Aust Paediatr J 1983; 19: 157-161. (Received 8 Jun, accepted 18 Nov 1995) Authors' details Division of Paediatrics, the Royal Women's Hospital, Melbourne, VIC. Lex W Doyle, MD, FRACP, Paediatrician; and Associate Professor, Departments of Obstetrics and Gynaecology, and Paediatrics, the University of Melbourne. Geoffrey W Ford, MB BS, FRACP, Paediatrician. Annette M L Knoches, MB BS, FRCP(C), Paediatrician. Catherine Callanan, RN, Research Nurse. Department of Thoracic Medicine, the Royal Children's Hospital, Melbourne, VIC. Anthony Olinsky, FRACP, Respiratory Physician. No reprints will be available. Correspondence: Associate Professor L W Doyle, Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC 3052. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Lex W Doyle · Geoffery W Ford · Anthony Olinsky · Catherine Callanan

Viewpoint Caring for a vulnerable population Who will take responsibility for those getting a raw deal from the health care system? Helen P Beange MJA 1996; 164: 159-160 Introduction - References - Author's details - - More articles on General practice and primary care Introduction In Australia, there is a minority population of about 70 000 people. Their mortality rate is at least 10 times that of the general population. They attend doctors twice as often, are admitted to hospital at twice the average rate, and have many more operations. More than half take prescription drugs daily, a third are taking multiple drugs, and 5% take more than four drugs. As 30% of this group have epilepsy, the commonest medications are anticonvulsants. On physical examination, they have an average of five serious medical disorders, but, astonishingly, only half of these conditions have been detected or treated. Although people in this minority group attend general practitioners frequently, they rarely see specialists, despite the fact that most of their disorders need specialist care. Blindness affects 4.4% (20 times the usual rate in Australia) and deafness affects 25% (compared with the average 2%) of people in this group, yet there are no special services for those who are blind or deaf. Although 9% have a psychiatric disability (compared with 2% of the general population), there are no special psychiatric services for them. Dental disease is the most frequent problem, affecting 86% of this group, but there are few special dental services. With such a gross difference in health when compared with the general population, it would be very reasonable to ask whether there are any modifiable risk factors for these diseases. The answer is yes -- surveys show that, while people in the group smoke very little and drink less than the general population, this minority group is generally unfit, obese and often hypertensive. So at least with exercise and better nutrition, it is likely they could avoid developing some diseases. Exercise opportunities improve the quality of life for people with an intellectual disability. (Reproduced with permission of the Stockton Centre, Newcastle, NSW.) How can this apparently disgraceful situation exist? Is Australia a Third World country? Is this a neglected and persecuted ethnic minority? No, not at all -- but this minority group does have problems accessing health care when compared with their fellow citizens. They are poorer and nearly all are dependent on social security. They tend not to marry or have children, and live mainly in public housing. Educational levels are low and illiteracy is the rule rather than the exception. They do not drive cars and many do not have an occupation. They are less mobile; 10% either need assistance to walk or use a wheelchair. One of the greatest barriers to health care is that many cannot speak at all and only half can communicate in complete sentences. The non-ideal social conduct of some of the group is such that doctors are nervous about keeping them waiting and reluctant to expose them to their other patients for fear of losing customers. Another barrier is that members of this group usually have to negotiate health care through another person, which only works successfully if their agent is trained and empathic and does not underestimate their complaints. Unfortunately, Australia has few doctors specially trained to understand this minority group. Australian doctors, although a decent lot, are (as a group) a bit impatient, are seldom able to fathom the language or unique culture of this group, and may not even recognise the names of most of the rare conditions from which they suffer. These conditions include fragile X syndrome, Rett syndrome and Angelman's syndrome. Further, because many of these patients take at least twice as long in consultation as the average patient, the more minority patients a doctor sees, the less the doctor's income. By now, you will have realised that the minority population I am concerned about is composed of people with an intellectual disability, which is defined as an IQ below 70. The figures given above are from a population study of adults between the ages of 20 to 50 in the lower North Shore of Sydney.1 All intellectually disabled adults living in a population of about 200 000 were identified and a random sample of 202 adults was examined. The lower North Shore is regarded as an affluent area of Sydney with good health services; it is thus reasonable to assume that conditions elsewhere in Sydney (and Australia) were either similar or worse. Studies on mortality and morbidity in people with intellectual disabilities in other parts of the world show similar results to the Sydney study.2,3,4 How can we improve the medical care of people with intellectual disabilities? I believe it is simplistic to think we can solve the problem by changing medical undergraduate training alone. Doctors currently treat intellectually disabled patients fairly well, but they are mainly dealing with minor illnesses and injuries. Serious problems are rarely recognised because these patients are used to suffering and cannot articulate their symptoms, and thus seldom complain. The woman with a slowly developing breast tumour, the man with anaemia as a result of a bleeding peptic ulcer, the child with Down's syndrome who is going deaf, the disturbed person having fluphenazine injections who is developing parkinsonism all depend on someone else to take them to a doctor. Young disabled people living at home are in less danger because there is a greater chance that their parents will badger the health system until something is done to help the child. But when a grown child leaves home, who will arrange medical care? Most Australian adults can be responsible for their own health, but we can rarely expect this of people with an intellectual disability. In the heyday of mental institutions, the medical superintendent was responsible for the health of people with an intellectual disability. Now, there is a question mark over just who is responsible. Local general practitioners, group home managers, area health service managers, heads of the Departments of Health and Community Services, perhaps even the Ministers, all disclaim responsibility. After all, the person is intellectually disabled, not sick. People with disabilities need access to the health system (a system which is becoming exceedingly complex). Once within the system, they need interpreters and advocates, and more time and resources than the average patient. General practitioners should obtain additional remuneration for the extra time spent with each patient. The health system needs to follow guidelines for improving the medical care of people with intellectual disabilities (see Box). The medical care of people with an intellectual disability should be set up in the mainstream of hospital medicine, not in academic backwaters. We need additional information about special health risks among people with disabilities and management protocols for the commonest syndromes. Preventive health services and health promotion would save enough money to make other special services available, such as dental clinics, psychiatric and neurological services and eye clinics. In the meantime, we are neglecting the health of people with developmental disabilities and, as a result, they are dying earlier and spending more time with doctors and more time in hospital than is necessary. If we valued the health of people with disabilities their lives would be longer and happier. References Beange H, McElduff A, Baker W. Medical disorders in adults with intellectual disability: a population study. Am J Ment Retard 1995; 99(7): 595-604. Fryers T. Mortality and cause of death. In: The epidemiology of severe intellectual impairment. The dynamics of prevalence. London: Academic Press, 1984: 139-141. Asberg KH. The need for medical care among mentally retarded adults. A five year follow up and comparison with a general population of the same age. Br J Ment Subnormality 1989; 35: 50-57. Howells G. Are the medical needs of mentally handicapped adults being met? J R Coll Gen Pract 1986; 36: 449-453. This article is based on a paper presented at the conference of the Australian Society for the Study of Intellectual Disability (NSW), Sydney, 12 May 1995. Author's details Stockton Centre, Developmental Disability Service, Hunter Area Health Service, Newcastle, NSW. Helen P Beange, MPH, FAFPHM, Visiting Medical Officer. No reprints will be available. Correspondence: Dr H P Beange, 23 Alpha Road, Willoughby, NSW 2068. Guidelines for improving medical care of people with intellectual disabilities Each patient with an intellectual disability should receive comprehensive and continuous health care, with primary care shared between clinical nurse specialists and general practitioners. They should have access to medical specialists and receive adequate attention in hospital. Clinical nurse specialists should be attached to the local group homes that are replacing institutional care. (Group homes usually house four people and are staffed either part-time or full-time.) These nurses would be responsible for health maintenance, preventive health care, arranging vaccinations and checking drugs. They would also make appointments for patients with acute and chronic health problems and maintain the medical records. General practitioners should be encouraged to review their disabled patients' drugs every three months and perform annual physical examinations. Full medical and genetic histories should be made available to these doctors. Health promotion clinics for people with disabilities should be established at teaching hospitals to provide back-up for the general practitioners in the area. These clinics should have formal links with genetic, paediatric and psychiatric departments and provide access to specialists who have expertise and empathy with disabled people. Clinics should offer medical, dietary and exercise advice, and opportunities for exercise after fitness testing. Protocols for dealing with particular syndromes should be developed (e.g., regular hearing and thyroid function tests for people with Down's syndrome, and regular surveillance for hip dislocation and urinary tract infections in people with cerebral palsy). All residential staff should be trained in basic health care, first aid, pharmaceutical treatment and nutrition. Staff should know how to treat fits and choking episodes. Courses in developmental disability medicine for medical students and interested family practitioners should be provided, utilising the skills of doctors who have experience in the field. A medical specialty in developmental disability medicine should be developed, so that these specialists could act as generalists in the same way as geriatricians care for the elderly. Back to text

Helen P Beange

Vaccine-preventable childhood diseases in Australia Too much disease, not enough vaccination: what more can we do? MJA 1996; 164: 61 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". - ©MJA1997 In 1994, there were 17 442 notifications of vaccine- preventable diseases in Australia.1 This disgraceful situation exists despite the ready availability of free, safe and effective vaccines. Particularly damning were the 8661 cases of pertussis, measles, mumps, rubella and Haemophilus influenzae type b notified in children up to school leaving age (19 years old) -- all diseases for which a national immunisation program has been in place for many years! Why do we still have so much disease despite good vaccines and good delivery systems? While there is a lack of uniform reliable data on vaccination coverage, it would seem our national childhood vaccination rates are inadequate. The Australian Bureau of Statistics' 1989-90 National Health Survey reported that, according to parental recall, 53% of children up to six years of age had been vaccinated in accord with the National Health and Medical Research Council (NHMRC) vaccination schedules.2 Unpublished data from State health departments include the report of a 1991 cluster survey in Victoria of 630 children aged 18 months to 3 years which found that 88% were fully vaccinated against diphtheria, pertussis, tetanus, polio and measles (John Carnie, Manager, Infectious Diseases Unit, Victorian Department of Health and Community Services, Melbourne, personal communication); a 1994 ACT report found that only 67% of 236 children at school entry (aged about five years) were fully vaccinated (Ms Ann Kempe, Immunisation Coordinator, ACT Department of Health and Community Care, Canberra, personal communication). Whatever the true vaccination coverage, continuing notifications (in the thousands) of cases of measles, with its well-known risks of encephalitis, bronchopneumonia and subacute sclerosing panencephalitis (SSPE), highlight how much still needs to be done. In the United Kingdom a recent national measles-rubella immunisation program has successfully terminated measles virus circulation in schools; in March and April 1995, there were four confirmed cases of measles in England and Wales; three cases had recently arrived in the country, and the other occurred in an unvaccinated 15-month-old child.3 In Australia there were 229 measles notifications for the same period (National Notifiable Diseases Surveillance System, personal communication). there is still a lack of awareness on the part of parents and even some health practitioners of the benefit-risk equation for vaccination On the other hand, notifications of invasive Haemophilus influenzae type b have decreased from at least 3.5 cases per 100 000 population in 19911 to 1 case per 100 000 in 1994.1 Within three years we may see less than a quarter the number of cases of childhood bacterial meningitis recorded in 1990 -- evidence of the benefit of effective vaccination. The National Childhood Immunisation Committee has implemented a number of initiatives over the past two years to increase vaccination coverage rates in line with the goals of the 1993 NHMRC National Childhood Immunisation Strategy.4 More than 30 000 copies of a kit, which included the fifth edition of the Australian immunisation procedures handbook,5 were distributed to general practitioners and other vaccination service providers. A parents' guide to immunisation, Understanding childhood immunisation,6 was also produced and widely distributed; a recent mass media awareness campaign offers this booklet free to enquirers through a toll-free telephone number (1800 671 811). Such initiatives have received broad professional and community support from organisations such as the Australian Medical Assocation, the Royal Australian College of General Practitioners, the Australian College of Paediatrics, the Australian Institute of Environmental Health, the Sudden Infant Death Association and the NHMRC. Technical considerations also play a role in ensuring the optimal efficacy of vaccines: guidelines and systems for cold-chain maintenance have been implemented (some local studies have suggested that some vaccine providers have difficulty maintaining vaccines at between 2-81/4C7,8 ); knowledge of the thermolability of reconstituted measles-mumps- rubella vaccines and of oral polio vaccine at room temp erature is another important consideration. The safety and efficacy of vaccines are apparent to all but a few. A scheme to record, follow-up and regularly publish significant adverse events following vaccination has been under way since March 1995 (general practitioners and other providers notifying respective State or Territory health authorities by telephone). The data are collated, reviewed and published monthly in Communicable Diseases Intelligence. Adverse event rates of less than 1% have been recorded, although the data are as yet incomplete. Nevertheless, there is still a lack of awareness on the part of parents and even some health practitioners of the benefit-risk equation for vaccination, at least for some vaccines. A few individuals who propagate tired myths of exaggerated vaccination harm, however sincerely, make it more difficult to provide concerned parents with balanced benefit-risk information. To address this problem Commonwealth funding of $24 million has been allocated towards childhood vaccination during 1995-96 and 1996-97. Most of this outlay is provided to the States and Territories to purchase NHMRC standard childhood immunisation schedule vaccines in return for their undertaking to provide a coordinated program. Some of this funding will be used to obtain better information about vaccination coverage via the Australian Childhood Immunisation Register, which commenced on 1 January 1996. Information from the Register will enable resources to be targeted effectively to assist areas with the lowest coverage rates. Combination 4-in-1 (tetravalent) and 5-in-1 (pentavalent) vaccines (e.g., against diphtheria, tetanus, polio, Haemophilus influenzae type b and hepatitis B), less reactogenic acellular pertussis vaccines, as well as a varicella vaccine, are soon to appear on local markets. On the eve of the third millennium, once again we as a nation will need to debate the cost-benefit of disease prevention. In this debate we must acknowledge how far we have come in the two hundred years since Jenner's successful inoculations against smallpox, and how far we have yet to go. Gavin W Frost Senior Medical Adviser, AIDS/Communicable Diseases Branch Commonwealth Department of Human Services and Health, Canberra, ACT Monica Johns Senior Project Officer, National Childhood Immunisation Program Commonwealth Department of Human Services and Health, Canberra, ACT Hargreaves J, Longbottom H, Myint H, et al. Annual Report of the National Notifiable Diseases Surveillance System 1994. Commun Dis Intell 1995; 19: 542-574. Australian Bureau of Statistics. 1989-90 National Health Survey Children's Immunisation Survey, Australia. Canberra: ABS, 1992. (Catalogue No. 4379.0.) Interruption of measles transmission in school schildren, 1995. Wkly Epidemiol Rec 1995; 70: 215-216. National Health and Medical Research Council. National Immunisation Strategy. Canberra: NHMRC/AGPS, 1993. National Health and Medical Research Council. The Australian immunisation procedures handbook. 5th ed. Canberra: AGPS, 1995. Herceg A, Shelley S. Understanding childhood immunisation. Canberra: Commonwealth Department of Human Services and Health, 1995. Liddle JL, Harris MF. How general practitioners store vaccines. A survey in south-western Sydney. Med J Aust 1995; 162: 366-368. Herceg A, Longbottom H. A national immunisation provider survey. Canberra: Commonwealth Department of Human Services and Health, 1995. ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Gavin W Frost · Monica Johns