Social determinants of health

Public health messages recognising the significant burden of severe asthma on quality of life are needed

Vanessa M McDonald · Sarah A Hiles · Kimberley A Jones · Vanessa L Clark · Janelle Yorke

To the Editor:There are some populations for whom unequal health cannot be overcome and a preoccupation with preserving health detrimentally affects their quality of life.1 Imagine you live in residential aged care, your health is irreversibly poor and you have days left to live. You want to go for a walk in the sunshine, but are prevented from doing so in case you fall and harm yourself. Your health cannot improve; yet, you are denied the opportunity to enjoy life. Quality of life is influenced by health, as well as social support, autonomy and spiritual fulfilment.2 Society encourages younger people to take risks to fulfil their potential and enjoy life; however, we prevent older people from doing the same. By denying this population the “dignity of risk”,3 we are denying them an opportunity to optimise their quality of life. This optimisation requires recognising that focusing on inequality in health will not always overcome an unequal quality of life, especially for vulnerable older people. Most residents of aged care facilities have multiple comorbidities contributing to poorer health, but this need not equate to a suboptimal quality of life. The goal should be to enable older people to enjoy their life by supporting them to fulfil their potential. People with a similar stage of dementia who live at home report a higher quality of life than those in residential aged care.4 Living at home provides greater independence, illustrating the importance of considering a multifaceted quality of life. If professionals focus only on improving health and not all factors contributing to quality of life, then inadvertently, neither health nor quality of life will improve. Enabling individuals to make choices, even those with a risk of harm, is a pathway to improving quality of life for everyone, including people with irreversible poor health.

Alice L Holmes · Marta H Woolford · Joseph E Ibrahim

Textbook of global health, 4th edition

Mieke L van Driel

The rates of RHD are among the highest in the world, particularly in girls and young women

Kimberly Davis · Bo Remenyi · Anthony DK Draper · Januario Dos Santos · Noel Bayley · Elizabeth Paratz · Benjamin Reeves · Alan Appelbe · Andrew Cochrane · Timothy D Johnson · Laura M Korte · Ivonia M Do Rosario · Inez T Da Silva Almeida · Kathryn V Roberts · Jonathan R Carapetis · Joshua R Francis

To the Editor:In October 2016, we achieved the eradication and control of hepatitis C virus (HCV) in a New South Wales correctional centre, which we believe to be a first of its kind in NSW. HCV prevalence in NSW prisons is 30–40 times higher than in the community, where prevalence is about 1%.1,2 Elevated risk of HCV infection is associated with the high proportion of prisoners who have injected drugs, the rate of injecting in prison, and restricted or limited access to bleach and needle and syringe programs.3 The Justice Health and Forensic Mental Health Network (the Network) is responsible for health care in the NSW forensic mental health and criminal justice systems. The availability of direct-acting antivirals on the Pharmaceutical Benefits Scheme in March 20164 created an opportunity for the Network to cure all patients with HCV infection in one prison. The Compulsory Drug Treatment Program (CDTP) is run at the Compulsory Drug Treatment Correctional Centre — a stand-alone prison with a stable sentenced inmate population, where patients with repeat drug-related charges participate in comprehensive drug treatment and rehabilitation. Patients at this correctional centre have longer sentences than those in other centres, which allowed for the full course of treatment. The Network, Corrective Services NSW and Hepatitis NSW formed a partnership to ensure that patients were able to access health centres, have their medication scripted and administered, could undertake monitoring and were supported through the Network’s established nurse-led model of care.5 All 58 patients in the CDTP were offered screening, and 54 patients with risk factors were screened; of these, 18 patients had chronic HCV infection. After further work-up, including liver elastography to measure fibrosis, all patients were concurrently commenced on treatment. Of the remaining four patients who were not screened, all had recent negative HCV pathology results. Three months after the treatment, 15 patients achieved sustained virological response equating to cure of their chronic HCV infection, and three patients were released before final assessment.6 Concurrent treatment commencement with the direct-acting antivirals was recognised as an innovative measure in reducing re-infection, in conjunction with the more common practices of harm minimisation education and use of the hospital-grade disinfectant for general cleaning purposes offered by Corrective Services NSW to all incarcerated people. Throughout the course of the project, two new patients were admitted, screened, and returned negative HCV pathology results. A proactive screening approach with patient consent was adopted to ensure that new cases were able to be identified and treated to maintain elimination. Maintaining a prison HCV-free may mean that patients have to take some responsibility with regard to sharing needles with new inmates. A peer education approach is being developed to increase patients’ ownership of a prison’s HCV-free status. The CDTP treatment model, combined with ongoing screening of new admissions, is an innovative approach for eliminating HCV, and is considered suitable for adoption in similar-sized prisons across Australia. The Network is currently rolling out this approach within NSW.

James Blogg · James Wood · Colette McGrath · Camilla Lobo

To the Editor:Your publication of a review on global approaches to antimicrobial resistance is timely.1 We especially note that antibiotic-resistant pathogens are not limited by borders, have greater impact on disadvantaged communities, and will require coordinated, high level government commitment to minimise their threat.1 In Australia, Indigenous communities bear a disproportionate burden of infectious diseases. This burden arises on a background of overcrowding, poorly built and maintained water and sanitation infrastructure, and colonisation of companion animals by human pathogens. The delivery of biomedically oriented health services leads to frequent use of broad spectrum antibiotics, promoting the development of multiresistant pathogens.2 The prominent multiresistant pathogen methicillin-resistant Staphylococcus aureus first emerged in hospitals, but, in Australia, it was soon identified in remote Indigenous communities.2 Health services have been unable to control its development and spread. As a consequence, community-acquired methicillin-resistant S. aureus is now the dominant strain of this bacterium in Central Australia, where Indigenous people are one-quarter of the population, but bear three-quarters of the S. aureus disease burden in Alice Springs Hospital.3 Primary health care is founded on full community participation and an intersectoral approach, incorporating education, housing and other sectors to complement health services.4 Housing for Indigenous communities remains inadequate, and government responses deficient, particularly in remote regions.5 As a result, even high quality health services have limited impact on Indigenous people’s health and wellbeing. Safe, secure, functioning housing that is appropriate for its occupants is a building block to manage other areas of Indigenous disadvantage.5 The deficit in appropriate housing contributes to bacterial colonisation, infection and development of antimicrobial resistance among Indigenous Australians.2 “Illness is a weapon” was intended as a metaphor for the resistance of Indigenous people to their ongoing colonisation.6 However, the threat of antibiotic resistance evolving through the neglected conditions in which some communities find themselves could make this metaphor more real than was likely intended. The spread of antibiotic-resistant pathogens in Indigenous communities and elsewhere is a global threat, which highlights the need to transform services for Indigenous people using approaches driven by communities and focused on their strengths.

Rosalie Schultz

To the Editor: We read with interest the recent article by Bonevski and colleagues1 calling for targeting of tobacco cessation interventions to high-risk populations, including prisoners. People who cycle through prisons in Australia smoke tobacco at a rate five times that of the general population,2 and suffer disproportionately from smoking-related morbidity and mortality.3 However, the suggestion by Bonevski and colleagues1 that smoke-free policies in prisons “impact on reducing smoking” is unfortunately a case of misplaced optimism: although these policies reduce smoking in prisons, they have almost no effect on long term smoking behaviour in people who cycle through prisons. Research in the United States shows that about 60% of people released from smoke-free prisons resume smoking on the day of release,4 and 97% relapse within 6 months of release.5 Preliminary findings from a cross-sectional survey we have conducted with 114 ex-smokers released from smoke-free prisons in Queensland paint a similar picture, with 72% of participants reporting relapse on the day of release. Smoke-free policies in Australian prisons are an important public health initiative and should be supported. However, alone they are insufficient to reduce the remarkably high rates of smoking, and of related morbidity and mortality, in the vulnerable populations who cycle through these institutions. There is an urgent need for development and rigorous evaluation of smoking cessation and relapse prevention interventions targeting people released from prison in Australia. Building on the findings of a recent trial in the United States,4 we have recently been awarded funding from the Victorian Health Promotion Foundation to undertake a double-blinded, randomised controlled trial of an intervention designed to reduce relapse to smoking among people released from smoke-free prisons in Victoria. We hope that our study will provide new evidence to guide future efforts to reduce tobacco-related harm in this population. We echo Bonevski and colleagues’1 call for a comprehensive policy shift aimed at reducing tobacco use among disadvantaged populations in Australia. However, prison smoking bans alone are insufficient. Investment in evidence-based efforts to prevent smoking relapse after release from prison will be critical to reduce tobacco-related health disparities in this profoundly vulnerable, marginalised population and realise this important public health opportunity.

Cheneal Puljević · Stuart A Kinner

In reply

Billie Bonevski · David P Thomas · Robyn L Richmond