Social determinants of health

There is little legal recourse in Australia for someone who is denied care on resource grounds, particularly in the context of a pandemic

Michelle A Gunn · Fiona J McDonald

Objectives: To describe patterns of care in New South Wales for men with prostate cancer, and to ascertain factors associated with receiving different types of treatment. Design: Individual patient data record linkage study. Setting, participants: 4003 New South Wales men aged 45 years or more enrolled in the population‐based 45 and Up Study in whom prostate cancer was first diagnosed during 2006–2013. Main outcome measures: Prostate cancer treatment type received; factors statistically associated with treatment received; proportions of patients who consulted radiation oncologists prior to treatment. Results: In total, 1619 of 4003 patients underwent radical prostatectomy (40%), 893 external beam radiotherapy (EBRT) (22%), 183 brachytherapy (5%), 87 chemotherapy (2%), 373 androgen deprivation therapy alone (9%), and 848 no active treatment (21%). 205 of 1628 patients who had radical prostatectomies (13%) had radiation oncology consultations prior to surgery. Radical prostatectomy was more likely for patients aged 45–59 years, with regional stage disease, living 100 km or more from the nearest radiotherapy centre, having partners, or having private health insurance, while lower physical functioning, obesity, and living in areas of greater socio‐economic disadvantage reduced the likelihood. EBRT was more likely for patients aged 70–79 years, with non‐localised or unknown stage disease, living less than 100 km from the nearest radiotherapy centre, or not having private health insurance, while the likelihood was lower for patients aged 45–59 years or more than 80 years and for those who had several comorbid conditions. Conclusions: Men with prostate cancer were twice as likely to have radical prostatectomy as to receive EBRT, and fewer than one in seven had consulted radiation oncologists prior to prostatectomy. The treatment received was influenced by several socio‐demographic factors. Given the treatment‐specific side effects and costs, policies that affect access to different treatments for prostate cancer should be reviewed.

Mei Ling Yap · Dianne L O'Connell · David E Goldsbury · Marianne F Weber · David P Smith · Michael B Barton

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has raised multiple health challenges for Australian society. In addition to the direct impacts of infection, there will be broader health impacts caused by physical and social distancing and the collapse in economic activity leading to the loss of employment and income. Interventions by the federal government, including JobKeeper, increased JobSeeker payments, the introduction of telehealth, and increased mental health spending, have made an important initial contribution to addressing the health impacts for individuals, families, and communities.1,2 A by‐product of these interventions, however, has been a rapid increase in government debt.3 We are now seeing increased calls to enact austerity policies. Such policies prioritise rapid reductions in government debt usually through cuts to health and social services. These calls should cause concern. Economic crises can damage mental health, increase the misuse of alcohol and other drugs, and increase suicidal behaviour.4 Austerity policies are likely to worsen these effects.4 Such concerns are illustrated by the effects of austerity policies in Europe and the United Kingdom made in response to the global financial crisis, which had serious health‐related consequences.5 For example, a study on the impact of austerity measures on health reported that austerity policies were implicated in worsening mental health, increased suicide rates, heightened mortality in older age groups, and greater unmet health care needs.6 Indeed, despite relatively progressive government interventions during the global financial crisis in Australia, we still had a rise in suicide rates among employed and unemployed Australians.7 If enacted in Australia, austerity policies have the potential to lead to health‐damaging effects. It is important not to compound the health impacts of the pandemic with austerity programs focused on short term reductions in government debt. Health and social services are critical buffers against economic shocks,8 and austerity is likely to undermine these buffers. Policies that prioritise economic and social supports as well as increasing access to care are likely to reduce the health impacts of economic crises.4 In particular, European countries that invested most in social protections during the global financial crisis suffered the least harms to their populations’ wellbeing.5,6 It is also crucial to recognise that austerity policies are a choice. There are alternatives for managing high levels of government debt to cutting public spending on services,6 and austerity policies are not widely endorsed by economists.9 Government spending on health, education, and social supports has the potential to increase economic growth.10 Taking a longer term view and avoiding austerity measures will better serve the health of Australia’s population, and indeed the health of the nation.

Shane A Kavanagh · Anthony D LaMontagne · Sharon Brennan‐Olsen

To the Editor: The coronavirus disease 2019 (COVID‐19) pandemic has highlighted the need for accessible information for people with disability during public health crises. Accessible information — including Easy Read, Auslan, large print, Braille and audiovisual formats — is a human right.1 Such information is critical for people with disability to understand public health crises and know how to remain safe and access support. These needs are important, particularly given that people with disability commonly have underlying health conditions that may make them vulnerable to public health risks,2 are subject to service systems that may enhance their exposure to infection,3 and often face entrenched system‐driven inequalities, such as being excluded from health prevention and response actions.4 In Australia, accessible information is provided by governments, specialist information access agencies, disability advocacy groups, and service providers. As these groups have provided information about COVID‐19, lessons have emerged for informing better practice during future crises.5 To be appropriate for a public health crisis, accessible information must be: Accurate and of high quality — the information needs to be correct and sufficiently accessible. This requires collaboration between medical professionals and information specialists. Timely — delays in producing accessible information are common, but dangerous. Kept up‐to-date — producing accessible information that is never revised is inappropriate when the details of a crisis are constantly changing. Provided in sufficient detail and breadth — just as the rest of the population needs to know about many different aspects of a crisis, so do people with disability. Resources with a range of subtopics are required. Produced with people with disability — including people with disability in producing the information will ensure it is useful to and accepted by them. Disseminated appropriately — people with disability need to be able to access information through agencies they trust, as well as news media and governments. Where applicable, hard copies should be available, not only online.

Ariella Meltzer

The pandemic is a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses The coronavirus disease 2019 (COVID‐19) pandemic has been a once‐in‐100‐years event. The scale of the disaster overshadows all others in living memory. Most disasters are focal and time‐limited. This one will span a considerable period of time and the economic impact will last years. This means the mental health effects will be deeper and more sustained than in other disasters. A survey during the first month of the pandemic in Australia assessed the nation's “temperature” early, as reported in this issue of the Journal.1 This survey and other information2,3 confirm that the initial mental health impact has been severe, and worse may be coming. Scientific models predicted that Australia would face a second curve of mental ill health and suicide,4,5 and this has now clearly arrived. We have been willing to turn our society and lives upside down to flatten the COVID‐19 curve. The same commitment is now required to flatten the mental health curve. After acute disasters, most people experience a transitory wave of distress that is considered normal and they do not generally require professional care. COVID‐19 is fundamentally different. It is not a single shock, but a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses, and many of the usual mitigation strategies are banned or unavailable. Modelling and earlier recessions show that it is the economic consequences, especially financial stress, unemployment, and educational failure, that fuel mental ill health and suicide risk.4,6 This impact is anything but short lived, and will produce a long, deep second wave of mental ill health and suicide. The impact is not uniform and there are groups at especial risk: notably, the already marginalised and disadvantaged, young people, women, those living alone and those already unemployed. Young people are especially disproportionately affected, and face a generation‐defining disruption that will have a multifaceted, long term impact on their lives. Socio‐economic inequality is a major risk factor for an array of negative health and social outcomes, including mental illness,7 and the potency of this risk factor will be magnified by a pandemic followed by a recession. We may all be in this together, but some are further in than others. The response so far has been based upon thinking from earlier crises and disasters. The focus is on the general public and aims to stress the normative aspect, that “it is OK to not be OK”, that simple coping mechanisms will get people through the crisis, and wishful thinking that professional help is available if needed. Crisis lines have been bolstered, but there has been no major effort to increase the capacity of the system, although the pivot to telehealth has sought to maintain access. These steps are welcome, but they will be inadequate on their own. The scale and sustained nature of the stress, the undermining effect of the containment measures, especially second lockdowns, and economic collapse mean that a much larger proportion of the population may need mental health care and be at risk for suicide than in more focal disasters. The capacity of the mental health system, even before COVID‐19, had been inadequate for responding to the demand.8,9 The system is now expected to respond to the surge in need for mental health care. It has been admirable how single‐mindedly governments and the health system have responded with public health measures and a boost to intensive care capacity10 in order to flatten the infection curve and to treat infected patients. At the time of writing, 886 people have died of COVID‐19 in Australia. During the same time period (February to October), more than 2000 Australians will have died from suicide,11 let down by an inadequate health and social system response. Most suffered from clear‐cut mental ill health, although only a minority had accessed mental health care.12 It is predicted that the number of suicides will rise in parallel with the COVID‐19 crisis and associated recession.4 These lives are surely just as precious as the ones directly lost to and threatened by COVID‐19. They have not yet been lost, and many, if not all, can be saved. What can be done? Firstly, policymakers must accept that this is not a routine disaster and that the times call for a very different approach. I believe the Prime Minister and some premiers are engaged with resolving this problem. Economic measures to soften the impact of the recession are the paramount preventive strategy, and the federal government has acted promptly with the JobKeeper and JobSeeker schemes, which have been partially extended while being reduced in stages. The global financial crisis showed how destructive austerity policies are, increasing inequality and social determinants of mental ill health, as well as weakening the social fabric and democracy itself. Secondly, the crisis provides a unique opportunity to create the “new mental health care” by dramatically reforming and strengthening the current system. An international position paper13 has been published, but Australia is ahead of the curve with key innovations, such as home‐based care and hospital in the home, assertive outreach models, and a national youth mental health platform (headspace), supported by digital and telehealth, which not only suit the times but are evidence‐based and strongly preferred by patients and families to emergency and inpatient care. Shifting the centre of gravity of mental health care to local communities via integrated care hubs linked closely with primary care is an innovation strongly supported by the federal government and Health Minister Hunt, not only through headspace, but also through the adult mental health hub model announced in 2019.14 Integrated care hubs with deeper capacity and expertise in helping people (young and older) with more complex needs could easily be fast tracked in the shadow of COVID‐19, initially as pop‐ups boosted by digital technology and outreach. State governments should consider releasing the governance of community mental health care from large hospital‐centric health networks so that it is embraced and can be accessed by local communities. And federal commissioning of community mental health care should be more coherent, guided by national evidence‐based standards, with the goal of regional integration of services, reversing the fragmentation produced by the competitive tendering policies of the excessively devolved primary health network model. The coming months will reveal whether we are really all in this together or whether the 5 million15 Australians (and rapidly growing) who confront mental ill health each year will continue to be treated as second class citizens.

Patrick McGorry

Objective: To assess long term graft and patient survival after donor liver retransplantation in children in Australia and New Zealand during 1986–2017; to determine the factors that influence survival. Design: Retrospective cohort analysis (registry data). Setting, participants: Australia and New Zealand Liver Transplant Registry data for all liver retransplantations in children (under 18 years of age), 1986–2017, in all four paediatric and six adult liver transplantation centres in the two countries. Main outcome measures: Graft and patient survival at one, 5, 10 and 15 years. Results: 142 liver retransplantations were undertaken in children (59 during 1986–2000, 83 during 2001–2017). Kaplan–Meier survival analysis indicated that survival was significantly greater during 2001–2017 than 1986–2000 (P < 0.001). During 2001–2017, graft survival one year after retransplantation was 84%, at 5 years 75%, at 10 years 70%, and at 15 years 54%; patient survival was 89% at one year, 87% at 5 years, 87% at 10 years, and 71% at 15 years. Median time between transplantations was 0.2 years (IQR, 0.03–1.4 years) during 1986–2000, and 1.8 years (IQR, 0.1–6.8 years) during 2001–2017 (P = 0.002). The proportion of graft failures that involved split grafts was larger during 2001–2017 (35 of 83, 42%) than 1986–2000 (10 of 59, 17%). Graft type, cause of graft failure, and number of transplants did not influence survival following retransplantation. Conclusion: Survival for children following retransplantation is excellent. Graft survival is similar for split and whole grafts. Children on the liver waiting list requiring retransplantation should have the same access to donor grafts as children requiring a first transplant.

Angus W Jeffrey · Gary P Jeffrey · Michael Stormon · Gordon Thomas · Edward O'Loughlin · Albert Shun · Winita Hardikar · Robert Jones · John McCall · Helen Evans · Graham Starkey · Peter Hodgkinson · Looi C Ee · David Moore · Catherine Mews · Geoff W McCaughan · Peter W Angus · Alan J Wigg · Michael Crawford · Jonathan Fawcett

A recent High Court decision directs and reassures medical and other practitioners in clinical and community settings that no parent or individual can compel this unlawful procedure

Ben Mathews · Elizabeth Dallaston

Objectives: To assess catch‐up vaccination of older children and adolescents during the first two years of the “No jab, no pay” policy linking eligibility for federal family assistance payments with childhood vaccination status. Design, setting, participants: Cross‐sectional analysis of Australian Immunisation Register data on catch‐up vaccination of children aged 5 to less than 7 years before (January 2013 – December 2014; baseline) and during the first two years of “No jab, no pay” (December 2015 – December 2017), and of children aged 7 to less than 10 years and young people aged 10 to less than 20 years (“No jab, no pay” period only). Main outcomes: Catch‐up vaccination rates for measles–mumps–rubella vaccine second dose (MMR2), by age group, Indigenous status, and socio‐economic status; catch‐up vaccination of children aged 5 to less than 7 years (third dose of diphtheria–tetanus–pertussis vaccine [DTPa3], MMR1), before and after introduction of “No jab, no pay”. Results: The proportion of incompletely vaccinated children aged 5 to less than 7 years who received catch‐up DTPa3 was higher under “No jab, no pay” than during the baseline period (15.5% v 9.4%). Of 407 332 incompletely vaccinated people aged 10 to less than 20 years, 71 502 (17.6%) received catch‐up MMR2 during the first two years of “No jab, no pay”, increasing overall coverage for this age group from 86.6% to 89.0%. MMR2 catch‐up activity in this age group was greater in the lowest socio‐economic status areas than in the highest status areas (29.1% v 7.6%), and also for Indigenous than for non‐Indigenous Australians (35.8% v 17.1%). MMR2 catch‐up activity in 2016 and 2017 peaked mid‐year. Conclusions: Linking family assistance payments with childhood vaccination status and associated program improvements were followed by substantial catch‐up vaccination activity, particularly in young people from families of lower socio‐economic status.

Brynley P Hull · Frank H Beard · Alexandra J Hendry · Aditi Dey · Kristine Macartney

Air pollution poses global health, equity, and environmental problems with short and long term consequences

Julie M Marchant · Anne B Chang

To the Editor: In Australia, 2020 began with raging bushfires, and we now confront the coronavirus disease 2019 (COVID‐19) pandemic. While health protection is currently at the top of the public policy agenda, can we rise from these huge ruptures and “build back better”? The full health costs of the bushfires, including the mental health toll, are yet to be quantified. No sooner had the bushfires abated than the battle against the COVID‐19 pandemic began. The immediate public health response has been well managed in Australia.1 Although Victoria is currently grappling with a second wave of infections, by international comparisons the number of cases and deaths around the country has remained low.2 Government leaders have listened to health experts and acted on evidence, including the need for strict physical distancing in the absence of a vaccine, supplemented by universal masking in Victoria. As governments move to revitalise the economy with financial stimulus, what guidance can health experts provide to inform this stimulus? One clear priority is that stimulus accelerates the decarbonisation of the Australian economy. Climate change is a recognised health issue. Published as the bushfires erupted, the 2019 MJA–Lancet Countdown on health and climate change report3 found that Australia is extremely vulnerable to the impacts of climate change on health. There are also health co‐benefits from action on climate change. The clearest example is the transition to renewable energy generation. Globally, in 2015 alone, more than 460 000 preventable deaths were attributable to coal burning.4 An urgent transition to renewable energy would be an evidence‐based public policy response to these deaths and assist a global green recovery from the pandemic which is called for by the World Health Organization.5 Australia is well placed to lead such a recovery as indicated in a recent report by ClimateWorks Australia,6 which provides a blueprint to achieve net zero emissions by 2050 through accelerated uptake of mature zero emission technologies and the rapid development and commercialisation of emerging zero emission technologies in harder to abate sectors (Box). Beyond stimulus for decarbonisation, investments in affordable housing, mass transit infrastructure, safe routes for walking and cycling, regeneration of degraded ecosystems and infrastructure to support working from home would also benefit health through reduced homelessness, improved levels of physical activity, and improved urban air quality. Australia has, thus far, avoided the high COVID‐19 case numbers and death rates seen in some other countries because of evidence‐based decision making. It is essential that decisions about the stimulus for economic recovery are similarly grounded in evidence. The health and wellbeing of current and future generations of Australians depend on it. Box – Summary table of key emissions‐reduction solutions by sector CCS = carbon capture and storage.

Selina N Lo · Anna Skarbek · Anthony Capon

“Now we say Black Lives Matter but … the fact of the matter is, we just Black matter to them”1

If Black lives matter we need to be prepared to examine and address racial violence within the Australian health system My name is Kevin Yow Yeh and today I march for every Black death in custody but I especially march for my grandfather Kevin Yow Yeh Sr. At the age of 34 this man apparently had a heart attack at a Mackay watch house … This last month we've seen plenty of stats, 430 plus Black deaths in custody … and that's only since the Royal Commission, but what about all those deaths that led to that. My grandfather was one of them. Let's humanise these stories. When this man had a heart attack, he left his wife and he left five young children. My grandmother was still having his children when she had to put this man in the ground. That's why we march! Of course we stand in solidarity with our brothers in America. And, of course we stand in solidarity with our sisters in West Papua … but today we stand for our lives here, on stolen land.2 The statistical story of Indigenous health and death, despite how stark, fails to do justice to the violence of racialised health inequities that Aboriginal and Torres Strait Islander peoples continue to experience. This story has been reported on unremarkably in federal parliament for over a decade, as an annual account‐keeping exercise of policy failure and statistical targets not met.3 This story of failure and failing health has been told countless times in health and medical journal publications, and despite growing more frequent in number, these contributions to new knowledge never seem to translate to improved health outcomes. This story of failure does not do justice to the trauma and loss that Aboriginal and Torres Strait Islander communities experience. This story of failure does not do justice to the pain of never meeting the grandfather that you are named after. Tragically, despite the parlous state of Indigenous health, we have not been met here with the kind of urgency that the global Black Lives Matter movement has spurred elsewhere. What we have been presented with, aside from the Health Minister admonishing Black Lives Matter protestors for putting the health of the public at risk,4 has been the triumphal announcement of “research projects”,5 the release of a “landmark report”,6 and a drafting of “refreshed” and “historic targets”.7 All of these supposedly fresh responses were on track before the Black Lives Matter movement hit our shore. Rather than the “new normal” which the threat of coronavirus disease 2019 (COVID‐19) inspired, the Australian health system's Black Lives Matter moment is best characterised as indifferent; a “business as usual” approach that we know from experience betokens failure. When the threat of COVID‐19 loomed, action was swift and the Aboriginal and Torres Strait Islander leadership within and outside of the health system was even swifter in establishing taskforces, lobbying for additional resources for the community controlled sector, instituting special border control measures for remote Indigenous communities, and the development of emergency response plans to protect their communities.8,9 The effective response to the COVID‐19 pandemic sits in sharp contrast to the ongoing pandemic of racism that Indigenous peoples have been fighting since 1788 and which has taken far more Black lives in Australia. Sweet points out: “To date, there is very little sign that senior health policy makers, from the Chief Medical Officer to Health Minister Greg Hunt, will use their authority to name and address the system racism that contributes to poorer healthcare, as it does to overincarceration”.10 While broad attention is often focused on Black deaths in custody, the premature deaths of Indigenous peoples from supposed natural causes inside and outside of custody tell a consistent story of failure and violence that marks the Australian health system and society more broadly. Against the quietude of the Australian health system on racism are the powerful voices of Aboriginal and Torres Strait Islander peoples, on television screens, on public streets and in our spreadsheets, speaking the truth about how little Black lives seem to matter. Both Indigenous clients and clinicians have stories to tell of the violence of racism in the health system, of being cast in the category of less capable, less compliant, less deserving of care and less worthy of the category of human. This then brings us to the coronial inquiry, the endgame of not caring; of neglect. Here, never let us forget the mothers, the children, the cousins and the spouses weeping outside coroner's courts, bearing photos of their loved ones in their hands and on their clothing, simultaneously appealing for care and for justice.11 Moreover, let us not for a second dismiss the anguish of having to fight for the release of recorded footage of your loved one's final moments, to be replayed over and over, in which they too plead vainly, “I can't breathe”.12 So many grieving Indigenous families continue to appeal to the state for care and for justice via coronial inquiries in the hope that their tragedy will not befall another. But the awful truth is that the recommendations of coronial inquiries are not enforceable because the inquest is meant to discover what happened rather than determine responsibility. So again, regardless of the findings, the resulting outcome is business as usual. The coronial inquiry represents a theatre of power where, in the presence of an avoidable Indigenous death, the state declares its benevolence; duly recording the steps taken and policies and procedures adhered to or those requiring review, and the best efforts of police, medical officers or first responders, to deem the death another “unavoidable” tragedy. Gomeroi scholar Whittaker11 notes how the discourse of “natural causes” in coronial inquiries works to render Indigenous peoples as “fated to die” and beyond care because they were “already dead”. The coronial inquiry represents a moment of confluence of the health and legal systems and the state that seek to erase Indigenous existence and affirm the settler trope of a dying race. It represents the theatre of Indigenous health policy writ large. The story of Indigenous health failure, of persisting and alarming health statistics that are routinely attributed to a complex web of social, cultural and economic factors, sustains the notion of the inevitability of Indigenous ill health, of a race destined to die out, despite the best of efforts and intentions. How do we explain an unwavering commitment to a failed Indigenous health policy framework amid a global movement centred around the importance of Black lives, and a National Aboriginal and Torres Strait Islander Health Plan vision of a health system “free of racism” with no strategy for addressing systemic racism?13 How do we further explain the focus on the individual health behaviours or “choices” of Aboriginal and Torres Strait Islander peoples when we know “incessant racial health inequities across nearly every major health index reveal less about what patients have failed to feel and more about what systems have failed to do”.14 As Boyd and colleagues point out, “The solution to racial health inequities is to address racism and its attendant harms and erect a new health care infrastructure that no longer profits from the persistence of inequitable disease”.14 Earlier this year, the National Registration and Accreditation Scheme demonstrated the type of Black Lives Matter moment that the Closing the Gap refresh missed, by launching the Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020‐2025.15 The strategy sets clear directions for the Australian Health Practitioner Regulation Agency, the national boards and accreditation authorities, which regulate Australia's 740 000 registered health practitioners to ensure that patient safety for Aboriginal and Torres Strait Islander peoples is the norm. The landmark strategy embodies ambition and partnership to address racism and culturally safe care; shifting the blame of failure for good health from Black bodies and instead demanding structural and individual health reform of health practitioners and the systems that regulate them. It is this shift of focus that has been central to the calls from Aboriginal and Torres Strait Islander peoples. Black wounds have been laid bare, to reveal the violence of health and legal systems upon Aboriginal and Torres Strait Islander peoples in a desperate appeal for those same systems to care. At 34 years of age my grandfather died, where's his justice? … what about all the other families, what about all the other fathers, brothers, sisters, nephews and nieces …? What about all the other mob? Where's their justice? My name's Kevin Yow Yeh, f*** the system, if you're not with us you're against us! What is needed is an Australian health system that has a steadfast commitment to Black lives: not as in need of saving, but as deserving of care; one that matches the staunchness of grieving Black families marching the streets of our capital cities in the midst of a pandemic. Such a commitment demands that we abandon the failed Indigenous health policy of Closing the Gap16 in favour of a health justice framework,17 which would include, but not be limited to: A foregrounding of Indigenous sovereignty rendering visible the strength, capability and humanity of Aboriginal and Torres Strait Islander peoples, services and communities in all processes of health policy formation and implementation, not as partners but as architects. State and federal government commitment to the recommendations of the coronial inquiries into the deaths of Aboriginal and Torres Strait Islander peoples who have died of preventable or avoidable conditions in the health system, and the establishment of an Indigenous taskforce to oversee implementation. An explicit financial commitment from the National Health and Medical Research Council and the South Australian Health and Medical Research Institute (via the Indigenous Medical Research Future Fund) and the Australian Research Council for research that attends to the nature and function of race in producing the conditions that allow racialised health inequalities to persist, from birth to death, including the embodied consequences of racism. The establishment of awareness‐raising campaigns that make clear the various ways in which Aboriginal and Torres Strait Islander peoples may seek justice when experiencing discrimination within the health system, and commeasurable resourcing of legal services to support Indigenous peoples to take action. Introduction of publication guidelines for health and medical journals requiring research relating to racialised health disparities to foreground institutional racism in its analysis, rather than socio‐economic disadvantage and other social and cultural factors. Development of an interdisciplinary Indigenous health workforce agenda that centres the care of Indigenous people beyond capacity building to include attending to racial violence within workplaces across the Australian health system. We offer these strategies not as a solution, but as some small steps towards a radical reimagining of the Black body within the Australian health system; one which demonstrates a more genuine commitment to the cries of “Black Lives Matter” from Blackfullas in this place right now.

Chelsea J Bond · Lisa J Whop · David Singh · Helena Kajlich

Objectives: To assess the numbers of notifications to health regulators alleging sexual misconduct by registered health practitioners in Australia, by health care profession. Design, setting: Retrospective cohort study; analysis of Australian Health Practitioner Regulation Agency and NSW Health Professional Councils Authority data on notifications of sexual misconduct during 2011–2016. Participants: All registered practitioners in 15 health professions. Main outcome measures: Notification rates (per 10 000 practitioner‐years) and adjusted rate ratios (aRRs) by age, sex, profession, medical specialty, and practice location. Results: Regulators received 1507 sexual misconduct notifications for 1167 of 724 649 registered health practitioners (0.2%), including 208 practitioners (18%) who were the subjects of more than one report during 2011–2016; 381 notifications (25%) alleged sexual relationships, 1126 (75%) sexual harassment or assault. Notifications regarding sexual relationships were more frequent for psychiatrists (15.2 notifications per 10 000 practitioner‐years), psychologists (5.0 per 10 000 practitioner‐years), and general practitioners (6.4 per 10 000 practitioner‐years); the rate was higher for regional/rural than metropolitan practitioners (aRR, 1.73; 95% CI, 1.31–2.30). Notifications of sexual harassment or assault more frequently named male than female practitioners (aRR, 37.1; 95% CI, 26.7–51.5). A larger proportion of notifications of sexual misconduct than of other forms of misconduct led to regulatory sanctions (242 of 709 closed cases [34%] v 5727 of 23 855 [24%]). Conclusions: While notifications alleging sexual misconduct by health practitioners are rare, such misconduct has serious consequences for patients, practitioners, and the community. Further efforts are needed to prevent sexual misconduct in health care and to ensure thorough investigation of alleged misconduct.

Marie M Bismark · David M Studdert · Katinka Morton · Ron Paterson · Matthew J Spittal · Yamna Taouk

COVID‐19‐related unemployment may significantly increase suicide rates; implementation of appropriate preventive measures is critical In response to the coronavirus disease 2019 (COVID‐19) pandemic, the imposition of social distancing policies and related labour market impacts have resulted in extensive job losses. Globally, the International Monetary Fund has predicted the steepest economic downturn since the Great Depression.1 In May 2020, 2.3 million Australians (one in five employed people) were either unemployed or had work hours reduced for economic reasons, resulting in the steepest rise in rates of unemployment on record — a change from 5.2% in March to 7.1%2 — with Treasury predicting a rate of 8% by September 2020. Unemployment alone is associated with a two‐ to threefold increased relative risk of death by suicide compared with being employed,3 and sudden spikes in unemployment are associated with corresponding surges in the population rates of suicide.4 The global financial crisis, which led to the deepest recession since the 1930s and the loss of 30 million jobs worldwide, is estimated to have resulted in at least 10 000 additional economic suicides between 2008 and 2010 in Europe and North America.5 Projections using historical data suggest suicide rates may increase by 3.3–8.4% over the 2020–2021 period in the United States6 and up to 27% in Canada.7 Of course, all this is speculative and although the links between economic recessions and suicide are well documented, what is less clear is how the relationship plays out in the context of larger sociocultural and health events such as COVID‐19. The 1918–1920 influenza pandemic caused around 39 million deaths worldwide and resulted in governments implementing quarantine, public hygiene and social distancing policies, but evidence regarding its impact on world economies and suicide is limited. The severe acute respiratory syndrome (SARS) epidemic of 2003 came at the height of the Asian financial crisis, so disentangling the two is difficult. However, during this period, suicide rates in a number of Asian nations increased in tandem with unemployment, reaching historical peaks in 2003.8 As the situation continues to change daily, an accurate estimate of likely unemployment resulting from the COVID‐19 pandemic is difficult. Even current estimates under‐represent the impact, as individuals who are still employed but at significantly reduced hours are discounted. This is of particular concern when considering the global financial crisis, which saw Australian unemployment take a comparatively minor increase from 4.0% to 5.8% and coincided with an increase in suicide rates of 22% and 12% for unemployed men and women respectively.9 As the present crisis may potentially double the current unemployment rate, one can extrapolate to alarming conclusions, with some (albeit unpublished) modelling reflecting this projection.10 Despite this grim speculative forecast, this is not the whole story. There are marked differences between the present crisis and those that have come before. For instance, the current recession is supply (rather than demand) driven, and the prospect of recovery, although slow, is conceivable and may bolter optimism. Although major industries will be severely affected, there is potential for increased local spending as the borders remain closed. In addition, some hope may be found in the resilience shown by civilians in times of global unrest — for instance, the often cited “Blitz spirit”11 — and the possibility that the shared experience of the pandemic might bring a sense of social cohesion, which may prove life‐preserving. Notwithstanding considerable evidence of the psychosocial impacts of mass unemployment, we argue that the impact of the COVID‐19 pandemic on suicide rates is far from predetermined, and that early and sustained action can prevent many suicides and other adverse mental health outcomes. During prior recessions, Austria, Sweden and Finland have each displayed resilience in the face of substantially increased unemployment.5 In fact, despite sizeable rises in unemployment rates in Sweden and Finland in the early 1990s, the rate of suicide decreased.4 We suggest that, based on the available literature, there are several factors that may moderate the impacts of widespread unemployment. These include both early prevention measures and crisis care: sustained welfare spending; labour market programs and protections; and adequate funding of, and access to, mental health services, including prevention programs and engaging new technologies in the reporting and care response. Firstly, countries with sustained welfare spending during recessions have less marked increases in suicide rates than those that cut spending on welfare and job search initiatives for the unemployed.12 Robust social policies to ensure adequate welfare benefits for people with low or sudden loss of income are thought to be central to offsetting the impact of the recession on suicide.13 Where governments expand public welfare spending in the wake of disasters, there is good evidence for a reduction in suicide. The federal government's introduction of the JobKeeper and JobSeeker payment schemes are likely to mitigate suicide risk while simultaneously stimulating the economy and require long term investment. Secondly, countries with active labour market programs, which assist the unemployed to find work or retrain, and those with labour market protections have lower rates of unemployment‐related suicide than countries that do not.12 It has been estimated that, during European recession periods in the past 50 years, each US$100 per capita of investment in active labour market programs reduced the association of unemployment with suicide by 0.4%.4 Thirdly, it is critical that investment is made immediately in mental health, not just in terms of treatment but also in evidence‐based prevention programs. Different approaches are required to reduce attempts, and deaths, involving both public health and clinical services. In terms of direct suicide prevention interventions, there is increasing evidence for multilevel systems approaches — using components ranging from individual‐level (eg, assertive aftercare, psychosocial interventions) to public health interventions (eg, general practitioner and gatekeeper training),14 in addition to indirect interventions (targeting risk factors). Critical to effectiveness is the degree of penetration of these services, based on early population modelling, and the types of factors likely to differentially affect communities, including indigenous communities. Improving quality, availability and access to programs and crisis support services is vital to preventing suicide,14 with the current crisis both creating new challenges and compounding pre‐existing systemic issues. While the mental health sector is rapidly mobilising to improve access and the government has been quick to revise the Medicare rebate in this regard, it is vital that resource allocation and innovation continues beyond the span of the physical distancing measures. While increasing telehealth services is critical, the health professionals available to support them are unlikely to increase to meet need, and blended services that include automatised digital components may be a more efficient solution. The additional $48.1 million in mental health funding announced in May 2020 is a positive step; however, further funding for evidence‐based prevention initiatives is more important than ever to alleviate demand on treatment services. In terms of suicide prevention, digital interventions may hold some utility for both at‐risk and actively suicidal individuals, especially where other health services are lacking.15 Of course, economies undergoing recessions by their very nature have significant financial constraints, and governments will inevitably have to review spending across all services. It is critical that these limited funds are directed toward the most viable and cost‐effective services. Importantly, not all groups are affected equally, and subgroup consideration is vital. In crisis periods, it can be the most disadvantaged groups that are disproportionately affected, and marginalised and at‐risk populations require specific attention. It is also important to consider that many of the adverse consequences of job loss, including house repossession, mounting debt, mental health problems and relationship strain, are delayed and, therefore, long term investment is required.16 Finally, engaging new technologies in the fight against suicide may present a valuable new tool. This includes information technology‐enabled coordinated care and the dynamic reporting of suicide risk using immediate and real‐time data so that developing hotspots can be identified and shut down and local services can be mobilised. Although this field of study is in its infancy, the potential for concepts such as integrated, geospatial mapping, hotspot surveillance, and real‐time reporting could lead to significant advancements in predicting and intervening in suicidal behaviour.17 Ultimately, the economic fallout resulting from the COVID‐19 pandemic represents a threat, requiring urgent mobilisation and planning. There are certain steps required to moderate the mental health impacts of widespread unemployment, including sustained welfare spending; labour market programs; adequate investment in, and access to, mental health treatment and prevention services; and the dynamic reporting of suicide risk to aid regional responses and means restriction. The current economic crisis presents an opportunity to implement policies that would not only mitigate the impact of the recession on suicide but may incidentally reduce the national health and economic burden presented by emotional distress in any economic cycle. In doing so, there may be the ability to emerge from the current crisis stronger and more resilient as a nation.

Mark Deady · Leona Tan · Nathasha Kugenthiran · Daniel Collins · Helen Christensen · Samuel B Harvey

Objective: To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas. Study design: Systematic review and meta‐analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas. Data sources: MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature. Data synthesis: Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta‐analysis. Study quality, assessed with the Newcastle–Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta‐analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12–3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48–2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80–7.46; eight studies). Conclusion: GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government‐led initiatives to support an adequate rural GP workforce. Protocol registration: PROSPERO, CRD42017074943 (updated 1 February 2018).

Jessica Ogden · Scott Preston · Riitta L Partanen · Remo Ostini · Peter Coxeter

The incidence of paediatric type 2 diabetes has increased in Australasia parallel to paediatric obesity and international guidelines available do not address the specifics for high risk ethnic groups

Alexia S Peña · Jacqueline A Curran · Michelle Fuery · Catherine George · Craig A Jefferies · Kristine Lobley · Karissa Ludwig · Ann M Maguire · Emily Papadimos · Aimee Peters · Fiona Sellars · Jane Speight · Angela Titmuss · Dyanne Wilson · Jencia Wong · Caroline Worth · Rachana Dahiya

The current reduced capacity of post‐release services may compound offender vulnerabilities, increasing their risk of harm to themselves and others The coronavirus disease 2019 (COVID‐19) pandemic has affected many countries internationally and has been implicated in more than 445 000 deaths worldwide.1 The speed at which this infectious disease is transmitted has led to calls to immediately release prisoners from custody in some countries, including Australia, and has already led to the release of some prisoners in others. The reasons for these calls to action are intuitively rational. Custodial environments are susceptible to a COVID‐19 outbreak given the confined conditions and potential for overcrowding.2 Moreover, prison populations are often vulnerable, having poorer physical and mental health and other social challenges (eg, substance misuse, homelessness) compared with the general population.3 At the time of writing, Australian governments have yet to immediately release select prisoners into the community as part of efforts to mitigate the spread of COVID‐19, despite recent advocacy to do so. Experts across a number of sectors have recommended the early release of prisoners from vulnerable groups if possible, including Indigenous Australians, women, children, older prisoners, victims of domestic violence, and those with chronic health issues.4 However, the proposed early release strategy requires a nuanced assessment of its potential societal consequences and, most importantly, its immediate impact on the health and wellbeing of candidate prisoners for release. Victoria and New South Wales — Australia's most populous states — provide a useful case in point. Stage 3 restrictions — home confinement except for restricted essential activities5 — have been in effect for approximately 2 months. Some restrictions were eased in late May, although limits on public and private gatherings remain in place. Prisons in both Victoria and NSW have yet to record a single case of COVID‐19 within the inmate population. In Victoria, a number of safety mechanisms have been introduced by correctional centres to help manage the potential transmission of the virus.6 These include: temperature testing of all staff before entry to the facility; sending staff home who present with high temperatures and other flu‐like symptoms, and requiring them to undertake a COVID‐19 test before returning; isolating all new prison admissions for up to 14 days; isolating prisoners who display cold or flu‐like symptoms; adjusting programs to abide by physical distancing; and enabling prisoners to connect with family members via video calls on tablet devices (“video visits”) as an alternative to in‐prison visitation. Moreover, conventional medical, psychological and cultural support services continue to be available to prisoners. Similar precautions have been implemented in NSW correctional centres,7 which hold the largest proportion of prisoners in Australia. With no confirmed cases in both Victorian and NSW correctional centres and ongoing efforts to restrict the materialisation of COVID‐19 in custodial settings, the potential costs of releasing vulnerable prisoners into the community necessitates scrutiny. Any prisoners released under anti‐COVID‐19 preventive measures will return to a general community enduring social restrictions and society‐wide economic contraction. The post‐release community support services ordinarily available to released offenders are currently compromised or are experiencing significant delays.8,9,10,11 Moreover, government social security services (ie, Centrelink), which are heavily relied upon by individuals after release, are currently overwhelmed as they service thousands of newly unemployed clients.12 Mental health and crisis support services are also strained as they adjust to remote service delivery and contend with an elevated spike in community‐wide help seeking.13 The reduced capacity for intensive case management, monitoring and re‐entry assistance for released prisoners is a serious concern given their higher levels of complex mental and physical health needs, as well as histories of unemployment, addiction, social disadvantage and homelessness.3 Australian research points to high rates of mortality and self‐harm shortly after release from custody.14 Key predictors of post‐release mortality include mental disorder, suicide and substance misuse — concerns that transitional support programs and other post‐release interventions will be unable to optimally manage during the national lockdown. This scenario poses an increased health risk for released prisoners, compounding their vulnerability and increasing the likelihood of problem behaviour and recidivism. Without readily available coping strategies and assistance with pro‐social functioning, released prisoners with histories of violence, aggression, impulsivity and serious mental illness may put themselves and others (particularly cohabitants) at risk. Calls to release prisoners who are survivors of domestic violence must also consider the heightened risk of revictimisation after release. The social isolation, economic stress and reduced options for support during stage 3 restrictions may exacerbate unhealthy relationship dynamics, especially among those with complex needs. Moreover, physical distancing may not be adhered to by those whose behavioural and psychological needs are untreated. Proposals to immediately release vulnerable prisoners to avert the ostensible threat of COVID‐19 in Australian custodial environments warrant consideration. The potential for a COVID‐19 outbreak in custody is a genuine concern, notwithstanding proactive measures employed in Victorian and NSW correctional centres. However, this advocacy must consider the broader social context. A focus on early release cannot be uncoupled from the current compromised community environment prisoners will face after detainment. Community support services are increasingly strained at a time when released prisoners will have a greater need for them. As such, it is important to balance the relative health and safety trade‐offs of remaining in custody — in Victorian and NSW prisons, there are no confirmed cases of COVID‐19 and health supports remain available — with early release into a resource‐depleted community. The real prospect of harmful outcomes for immediately released vulnerable prisoners must be weighed heavily during this challenging period.

Stephane Shepherd · Benjamin L Spivak

Editor’s note: This is an update of a Letter to the editor originally published as a preprint on 16 March 2020 (https://www.mja.com.au/journal/2020/212/8/covid-19-precautions-easier-said-done-when-patients-are-homeless). To the Editor: Implementation of advice to the public and general practitioners on minimising the risk of COVID‐19 exposure and transmission is immensely difficult for people experiencing homelessness and for the health services working with them. Yet this is a population group more vulnerable to infection than most.1 The elevated risk factors for COVID‐19 are substantial, as people experiencing homelessness have a much higher prevalence of comorbidity and chronic disease compared with people of the same age who are housed.2 To illustrate further, among the 4000 active patients seen by Homeless Healthcare (Australia's largest specialist homelessness GP practice based in Perth), nearly all patients have comorbidities, 13% have chronic respiratory conditions, 79% smoke (associated with poorer lung health and risk) and 8% have diabetes (associated with supressed immunity). There are parallel calls in Australia and the United Kingdom for clearer government guidance as to how the precautionary measures can be applied in homeless populations. There are a myriad of challenges to this, both for people who are homeless themselves and for those providing health care to this vulnerable population group. These challenges include: Regular hand washing and hygiene (and accessing soap or sanitiser and bathrooms in order to do this) is extremely problematic if living on the street. Self‐isolation by staying at home if you feel unwell and suspect having symptoms is impossible if you do not have a home to live in. Reducing face‐to‐face health service contact is being advocated to GPs and health services in Australia and the UK. The Australian Government has just announced Medicare rebates for bulk‐billed telephone consultations,3 but this is problematic for people who are homeless without a phone. Similarly, technological solutions such as video or virtual consultations are digitally prohibitive for people without a home let alone a computer. Outreach health services are among the most effective ways of enabling people who are rough sleeping to access health care.4 Homeless Healthcare, for example, runs clinics at drop‐in centres and crisis accommodation settings and has nurses out on the streets each day and doing home visits to those recently housed. However, implementing the use of personal protective equipment is difficult in these settings, and in the absence of primary care outreach, emergency department presentations are likely to escalate. Cancelling outreach GP clinics and other outreach services for this population to reduce exposure risks would have severe unintended consequences. If risk factors for COVID‐19 or patients with COVID‐19 are untreated in this highly susceptible population, the mortality risk is high.1 Moreover, many people will not receive critical treatment for other medical conditions, such as depot medications for psychotic illness and, as articulated in a recently published article, “lockdowns and disease containment procedures might also be deleterious to the mental health of people experiencing homelessness, many of whom have fears around involuntary hospitalisation and incarceration”.1 The higher risks of COVID‐19 for people experiencing homelessness and, consequently, for those working closely with them present an enormous challenge that has no easy answers. As new precautionary measures are being announced daily, it is critical that further marginalisation for this group is not an unintended consequence.

Lisa J Wood · Andrew P Davies · Zana Khan

To the Editor: Nearly all industries profit from today's 25 million slaves and 150 million child labourers.1 The results of their work, including medical disposables, are sold worldwide. Unfortunately, there is not a comprehensive analysis identifying exactly where slaves are involved in the medical products supply chain. From the hazardous work forging surgical instruments in Pakistan to the manufacture of gloves in Malaysia,2 slavery permeates the manufacture and supply chains of medical products. Slaves are involved in the direct manufacture of medical products and in the generation of raw materials used to make medical devices, including cotton, rubber and metals.3 Some companies, have made a public effort to review their supply chains;4 however, many organisations are failing to monitor human rights abuses in their supply chains.5 As countries legislate Modern Day Slavery Acts, a few companies are moving to eliminate slavery. As an act of radical transparency in the long‐discussed issue of child labour in the cocoa industry, in 2017, Nestlé published the number of child labourers aged 5–17 years known to be working on cocoa farms that supply their cocoa.6 Nothing similar to Nestlé's effort has been done in the medical industry. However, notable efforts to regulate procurement have been demonstrated in the United Kingdom and Sweden.2 Few health professionals are responsible for the direct sourcing of medical products. Nonetheless, when speaking with managers, executives, and representatives of medical suppliers, we have the opportunity to share our concerns for the origins of the products we use. While a conversation with a medical representative on this topic may demonstrate scant knowledge of the manufacturing processes of the goods they are selling, that initial conversation is an important first step towards transparency, and we know that the influence of health professionals on industry is significant.7 Modern slaves are forced to work under threat of harm or by coercion or deception. Unable to refuse or leave, they earn little to no pay for extensive working hours in unsafe conditions, which may cause injury, sickness and, at times, death. Reports of harassment are common. In the medical industry, we must do all we can to address modern slavery because, above all, we should “first do no harm”.

Sharon Sitters

If we are committed to closing the gap, we should be committed to transforming relationships of power between Indigenous and non-Indigenous people

Chelsea J Bond · David Singh

Misgendering negatively affects the mental and physical health of trans individuals

Irene J Dolan · Penelope Strauss · Sam Winter · Ashleigh Lin

The automatic assumption that sexually transmissible infections in young people means sexual abuse further stigmatises them and discourages them from presenting to health services

James S Ward · Belinda Hengel · Donna Ah Chee · Olga Havnen · John D Boffa

Blood lead levels in the pre-school children in our sample were lower than in previous surveys

Christos Symeonides · Peter Vuillermin · Peter D Sly · Fiona Collier · Victoria Lynch · Sandra Falconer · Angela Pezic · Nicole Wardrop · Terence Dwyer · Sarath Ranganathan · Anne‐Louise B Ponsonby

Australia needs to develop and implement policies to ensure that data are disaggregated, analysed and presented by sex and gender

The Sex and Gender Sensitive Research Call to Action Group

To the Editor: The editorial by Murnion and Conigrave1 and the article by Crossin and colleagues2 on the dangers of misuse of pregabalin are a timely warning to all prescribers. The black market utility (based on testimonies) and frequent misuse of pregabalin is well known both academically and to prescribers in prison environments.3,4 Harm relating to gabapentinoid use is noted to be increasing globally. A 2017 case–control study showed a dramatic increase in relative risk of death with opioid and gabapentinoid versus opioid alone.5 People leaving prison are at a higher risk of opioid overdose death, partly because of loss of tolerance.6,7 This will likely be compounded by inappropriate gabapentinoid prescribing. In New South Wales prisons, the Justice Health and Forensic Mental Health Network sees many patients who present seeking pregabalin and other prescription drugs in our health clinics. Patients often enter custody using high doses of medications prescribed in the community, including gabapentinoids, benzodiazepines and opiates. The Network applies a multidisciplinary team approach between primary care, pharmacy, and drug, alcohol and mental health services for these complex patients. Furthermore, clinicians undertake regular medication reviews of patients; medications that are not indicated are deprescribed to reduce potential harm to patients.8,9 The Network has developed management guidelines around gabapentinoid use, including regular review of prescriptions by general practitioners and the clinical director. Off‐label use is discouraged. Pregabalin is always a supervised medication, and dose limits and deprescribing programs are in place to limit availability if not indicated. Alternate medications for the management of diagnosed neuropathic pain are effective and may pose less risk in prison environments.8,9 Gabapentinoid drugs are not used as an alternative to opiate pain medications in NSW prisons. Patients are assessed and given appropriate medications according to the quality and safe use of medicines approach, and medication charts are regularly audited to ensure safe prescription of medications. There has been an overall reduction in actual gabapentinoid prescribing in NSW prisons in recent years. We encourage all Australian prescribers to ensure care around prescribing of gabapentinoid and other medications, especially for complex patients with drug and alcohol misuse and polypharmacy issues.

Gary Nicholls · Peter Samios · Stephen Hampton

To the Editor: Last month, the Medical Journal of Australia called for manuscript submissions on the topic of “Women in medicine and medical leadership in Australia — is there gender equity?” We answer with a resounding no. Indeed, we believe the question itself perpetuates gender disparity by suggesting that the answer is up for debate. There is overwhelming evidence to demonstrate that gender equity in medicine and medical leadership in Australia has not been achieved. Women have had gender parity in Australian medical schools for decades; however, they represent only 28% of medical deans and 12.5% of hospital chief executive officers.1 In February 2019, The Lancet dedicated an entire issue on advancing women in science, medicine and global health.2 The MJA has also reported on capacity, capability and credibility barriers for women in health leadership.3 These disparities are even greater for Aboriginal and Torres Strait Islander women, women of colour and women with disabilities. There is an urgent need to shift our focus from asking whether gender inequity exists to implementing and evaluating sustainable strategies to change the status quo. This year, the Australian Medical Association of Victoria changed its constitution to include a 40% gender quota for its board.4 The Royal Australasian College of Surgeons has established a business plan with tangible indicators to promote leadership and flexible training for its female surgeons.5 Both the Women in Tropical Health Catalyse Program6 in Australia and Wāhine Connect (www.wahineconnect.nz) in New Zealand offer mentoring for women in medicine and medical leadership. We need to bolster current strategies aimed at improving the number of women in medical leadership. Moreover, we need to keep our workplaces, colleges, committees, professional associations and academic journals accountable for the role they play in the persistent gender inequities in medicine and medical leadership in Australia. We invite the MJA to follow The Lancet's example and dedicate an entire issue to strategies that advance women in medicine and medical leadership. We implore it not to ask “is there gender equity?” when the answer to this question is patently clear. The answer is no.

Allison Hempenstall · Jillian Tomlinson · Marie M Bismark