Improving the health of First Nations children in Australia

Regular monitoring and supportive federal and state public policy are critical to closing the gap in child health

Health and wellbeing of children and young people are the keys to human capability of future generations. Human capability includes the capacity to participate in economic, social and civil activities and be a valued contributor to society;1 it means that not only can you usefully live, work and vote, but you can be a good parent to your children. Thus there is no better investment that the state can make than to influence factors that will enhance the health and wellbeing of children and youth.

There were an estimated 200 245 First Nations2 children aged 0–14 years in Australia in 2011, comprising 4.9% of the total child population and 35% of the total First Nations population.3 With such a high proportion of children compared with the non-Aboriginal population, the First Nations population is much younger, with fewer adults per child to care for them. An Australian Research Alliance for Children and Youth report adds to evidence from the most recent Australian Institute of Health and Welfare report on the health of Australia’s children to document the growing divide between the health of First Nations and other Australian children.3,4

Child health indicators include mortality rates (Box, A), prevalence of chronic conditions, indicators of early development (including rates of dental decay [Box, B]), promotion of early learning (eg, adults reading to children in preschool years) and school readiness assessed with the Australian Early Development Index (Box, C).3 Risk factors for poor child health include: teenage pregnancies; smoking and alcohol exposure during pregnancy; pregnancy outcomes such as stillbirths, low birthweight and preterm births; the proportion of children aged 5–14 years who are overweight or obese; and the proportion of children aged 12–15 years who are current smokers. In addition, indicators of the level of safety and security of children — including rates of accidental injury, substantiated reports of child abuse and neglect, evidence of children as victims of violence, and indicators of homelessness and crime — further highlight how poorly Aboriginal children fare during childhood.

Owing to significant gaps in available data, Australia is not included in UNICEF reports relevant to First Nations children, including The children left behind: a league table of inequality in child well-being in the world’s rich countries.5 This report is important for many First Nations children who experience conditions near the bottom because it focuses on closing the gap between the bottom and the middle:

We should focus on closing the gap between the bottom and the middle not because that is the easy thing to do, but because focusing on those who do not have the chance of a good life is the most important thing to do.5

While there has been progress, particularly in educational outcomes, the gap in healthy child development in safe and secure environments is disturbing. It has resulted from of a variety of complex social circumstances, due to colonisation, marginalisation and forced removals. To effectively and successfully interrupt and reverse these generational traumas on today’s children, careful and sensitive First Nations-led programs are required. Programs in Canada and Australia have shown that the major protective and healing effects of strong culture are immensely powerful, even in urban situations, which highlights the value of strong government support for such programs in Australia. For example, putting First Nations children and youth into cultural programs is more effective than incarceration for preventing recidivism, and increased recognition of Aboriginal cultures in school curricula increases rates of high school completion by First Nations students.6

Drawing on our own and overseas data,7 we believe that Australian services have failed to close the gap in child health because they have been developed without involving or engaging First Nations people. When participatory action research methods are used, as has been done with Inuit communities in Nunavut in Canada,8 the use and success of services are dramatic. Such strategies lead to higher levels of local employment, higher self-esteem, and reduced mental illness and substance misuse among First Nations people. British Columbian data on First Nations youth suicide rates have shown that the lowest rates in Canada were in communities with strong culture and Aboriginal control of services (eg, health, education and community safety).9 This means that a major rethink of services for First Nations people is needed, and that centralised policy applied to multiple diverse communities is unlikely to work. Although the policy content of what needs to be done can be developed centrally based on existing evidence (eg, alcohol in pregnancy causes brain damage, early childhood environments are vital to help children to be ready for school, complete immunisation prevents infections, and avoiding sweet drinks prevents obesity and dental decay), development and implementation of services need to be done locally and with community involvement. A great example of this is the strategy to overcome fetal alcohol spectrum disorders (FASD) that was developed by Aboriginal women June Oscar and Emily Carter and the First Nations people of Fitzroy Valley. This comprehensive and effective strategy has enabled the community to think and act beyond the stigma of FASD — community members drove the design and implementation of programs to prevent FASD, and they created opportunities and support mechanisms to enable the best possible treatment for children with FASD.10

Building on the Australian Research Alliance for Children and Youth report,4 we need a consistent national framework for monitoring health status and an understanding of the impact of federal and state policies on First Nations children. Recent policies with the potential to affect First Nations children include: the Northern Territory intervention, the loosening of alcohol restrictions in the Northern Territory, policies aimed at addressing overrepresentation of Aboriginal children in child protection reporting, housing policies (including evictions and the transfer of public housing properties to ownership and management by non-government organisations), policies that have changed financial support for single parents, education policies aimed at assessing school readiness and other policies aimed at closing the gap in health. The effects of these policies on First Nations children need to be considered in regular assessments of public policy, with the needs of children prioritised over competing interests.

The exciting thing is that we now have a growing number of Aboriginal health care providers and other university-trained professionals to employ to make services effective. We have equity in medical student intakes which augurs well for future progress in this critical area. The dream of having appropriate, culturally safe policies, programs and services for our First Nations children can become a reality if it is supported and promoted by all levels of government.

Child health indicators that show a divide between First Nations and other Australian children*

SES = socioeconomic status. LBOTE = language background other than English. * Adapted with permission from A picture of Australia’s children 2012.3 † Developmentally vulnerable on one or more Australian Early Development Index domains.

History of the LIME Network and the development of Indigenous health in medical education

The Leaders in Indigenous Medical Education (LIME) Network has developed over time as an avenue for sharing, developing and improving upon the emerging discipline of Indigenous health in medical education

The Leaders in Indigenous Medical Education (LIME) Network (a program of Medical Deans Australia and New Zealand, funded by the Australian Government Department of Health and Ageing [DoHA]) has an 800-strong membership of Indigenous and non-Indigenous medical educators, health educators, university leaders, health practitioners, policymakers and community members concerned with improving health outcomes for Indigenous people. The Network encourages and supports collaboration within and between medical schools in Australia and Aotearoa/New Zealand to enhance the quality and effectiveness of Indigenous health curricula in medical education and to enable best practice in the recruitment and retention of Indigenous medical students. Over time, it has developed a portfolio of work that provides quality review, professional development, capacity-building, research and advocacy functions for Network members, and has developed links with specialist medical colleges and educators from other health disciplines. The Network is founded on Indigenous leadership and celebrates the many successes that are occurring in the field of Indigenous health and medical education.

Background

Historically, the relationship between Indigenous peoples and the medical fraternity has had its challenges. In Australia, doctors were involved in implementing segregation policies and played a role in the removal of Aboriginal children from their families.1 Over time, and in recognition of the role of Aboriginal and Torres Strait Islanders in informing government policies and initiatives, researchers and medical practitioners began to acknowledge the special place of Aboriginal and Torres Strait Islander people in the health system.1–6

The status of Indigenous peoples’ health in Australia and Aotearoa/New Zealand remains well below that of their non-Indigenous counterparts.7–9 While there is a range of historical, social and economic factors that influence these figures, the quality of care provided to Indigenous peoples is also an important factor requiring attention.10 The institutions that educate future medical professionals, therefore, have an important responsibility in developing a workforce that is responsive to the needs of Indigenous people.11–13

Joining forces: an informal network for Indigenous health

While formally recognised in 2005, the collaborative effort that underpins the LIME Network has a longer history. In the 1980s, the need for specific training in Indigenous health in medical education was formally submitted for the first time in Australia as part of the Inquiry into Medical Education and Medical Workforce (Ian Anderson, Professor and Foundation Chair of Indigenous Higher Education, University of Melbourne, personal communication).14 Publications on the importance of acknowledging the place of Aboriginal people in the Australian health care system were increasing15,16 and the first Aboriginal and Torres Strait Islander medical student recruitment programs were being implemented at sites across Australia (Shannon C, Leon D, Report on the LIME Workshop, 8–10 June 2005, Freemantle).17,18 Recommendations from health conferences increasingly emphasised the need to build an appropriate health workforce and include Indigenous health in education and training.1,19,20

Importantly, in March 1997, the Inaugural Indigenous Graduate and Undergraduate Medical Conference was held at Salamander Bay, New South Wales, followed closely by the Second Indigenous Medical Conference in July that same year (Garvey G, Smith S, Proceedings of the Inaugural Indigenous Graduate and Undergraduate Medical Conference, 31 March – 3 April 1997, Salamander Shores; Garvey G, Smith S, Proceedings of the Second Indigenous Medical Conference, 14–16 July 1997, Salamander Shores).

Convened by the University of Newcastle, and funded by the Australian Government’s Office for Aboriginal and Torres Strait Islander Health (OATSIH), these conferences led to the establishment of the Australian Indigenous Doctors’ Association (AIDA), which was formalised in 1998. Further goals and recommendations of these conferences that are pertinent to the LIME Network objectives today included that:

the deans of medical schools make a commitment to increasing content on and awareness of Indigenous issues in medical curricula;
teaching of Indigenous health be embedded throughout medical curricula;
consultation with and participation of Indigenous academics and people in the teaching process is essential; and
the number of Indigenous students entering medicine should increase (University of Newcastle, Recommendations to the Medical Deans meeting arising from the Second Indigenous Medical Conference, 29 August 1997, Perth).

These and other recommendations were presented by Aboriginal and Torres Strait Islander doctors, academics and medical students to a Committee of Deans of Australian Medical Schools (CDAMS, now Medical Deans Australia and New Zealand) meeting in Perth in August 1997, and were subsequently endorsed. The need for significant and effective Indigenous consultation and leadership as a fundamental element of any successful policy or program in Indigenous health was also acknowledged.21

A national curriculum and formalisation of the LIME Network

Following the CDAMS endorsement of the recommendations described above, two national reviews of Indigenous health in medical education were conducted — one by the Australian National Audit Office on behalf of the Department of Health and Aged Care,22 and one by Gail Garvey and Ngiare Brown from the University of Newcastle.21 Both reviews identified a lack of consistency and a scattered approach to the inclusion of Indigenous health in the core medical curriculum and the methods used to recruit Indigenous Australians to study medicine.

As a response to the review findings, in November 1999, representatives from CDAMS and OATSIH and Indigenous medical educators from a number of universities came together to develop a strategy for Indigenous medical education with a twofold focus: workforce (recruitment and retention of Aboriginal people) and curriculum (Ian Anderson, personal communication). A series of meetings was initiated to develop core Indigenous health curricula and a collaborative process for ongoing national oversight to ensure that Indigenous health became a meaningful and sustainable component of medical education.23,24

In 2003, the Indigenous Health Curriculum Project was formalised through a partnership between CDAMS and OATSIH. The Project was hosted by the University of Melbourne’s VicHealth Koori Health Research and Community Development Unit (which was later renamed the Onemda VicHealth Koori Health Unit) under the leadership of Ian Anderson, and Gregory Phillips was employed the National Program Manager. The National Curricula Workshop, held in August 2003 in Victor Harbor, South Australia, brought together leaders engaged in Indigenous health and medical education from around the country to engage in the Project’s objectives:

[The] meeting . . . in Victor Harbor . . . helped the leadership in medical schools, giving them a sense that “this is a safe place”.

— Ian Anderson

James Angus OA (Professor and Dean, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne), who attended the meeting on behalf of CDAMS, reflected:

I knew there was a possibility of this taking off, because there was leadership, there was interest, there was passion.

An audit of all existing Indigenous health curricula in Australian medical schools followed25 and, in the process,
the formal cooperation and collaboration between medical schools, CDAMS and the Project team began:

The audit was the first thing. That’s how we engaged the people. Basically, people needed to be heard. They were struggling all by themselves in these institutions, often one Aboriginal worker or part-time worker expected to do everything themselves, and they were struggling. So the first thing was just being there and talking to them all and giving voice to their concerns.

— Gregory Phillips

The audit findings led to and informed the development of The CDAMS Indigenous Health Curriculum Framework.26 The Framework was officially launched in August 2004, with the endorsement of CDAMS representing deans from every medical school in Australia:

We had this wonderful ceremony where we launched the curriculum . . . Sir William [Deane] made the point that he found it truly amazing that all the deans could agree on this core piece of curriculum that would be taught in every medical school in the country because, in his experience, academic professional groups can never agree on what is core.

— James Angus

The Framework provided medical schools with guidelines for developing and delivering Indigenous health content in core medical curricula. Following a determined effort by those involved in the Project, the Framework was included in the Australian Medical Council’s guidelines for medical school accreditation in 2006.27 Gregory Phillips wrote:

This curriculum framework [is] an investment in the future of not only the health and well-being of Aboriginal and Torres Strait Islander peoples and communities, but the training of a more competent medical workforce, and an improvement in the health status of all Australians.26

The Project also sought to establish a “sustainable, functional and effective network” of Indigenous and non-Indigenous medical educators who could collaborate and support each other in the delivery of Indigenous health curricula.28 To support this objective, a meeting was convened at Clear Mountain, Queensland, toward the end of 2004, which led to the establishment of the LIME Network and plans for the first LIME Connection conference.

The LIME Network program

The first official meeting of the LIME Network was at the inaugural LIME Connection conference in Fremantle, Western Australia, in June 2005, with 74 delegates in attendance. Gregory Phillips presented the LIME Network discussion paper, including the Network’s draft objectives and the LIMElight Awards concept (Shannon C, Leon D, Report on the LIME Workshop, 8–10 June 2005, Freemantle).28 The objectives were endorsed by CDAMS in October that year and, with funding from DoHA, the LIME Network was established as a program in its own right. Gregory Phillips wrote:

The LIME Network should ultimately be about empowering its members and participants to achieve the highest quality possible in implementing Indigenous health in medical education and curricula.28

The Network has operated as a bi-national program since 2008, and the quality of its processes and program outputs has been acknowledged by several higher education awards (Melbourne School of Population Health Knowledge Exchange Award, University of Melbourne, 2010).29,30

The overarching objectives of the Network are:

internal quality review;
professional development, capacity building and support;
promoting best practice and building an evidence base through research and evaluation;
professionalising the discipline;
multidisciplinary and multisectoral networking;
advocacy and reform; and
hosting the LIME Connection conferences.

At the heart of the Network is the LIME Reference Group of medical educators, comprising Indigenous and non-Indigenous representatives from every medical school in Australia and Aotearoa/New Zealand. The LIME Steering Committee — made up of medical school deans and representatives from AIDA, Te ORA (Maori Medical Practitioners Association), the National Aboriginal Community Controlled Health Organisation, Indigenous Allied Health Australia, the Committee of Presidents of Medical Colleges and DoHA — ensures input, communication and partnerships with key representative bodies.

The LIME Network has been pivotal, over a sustained period, in strengthening the connections within and between universities and individuals dedicated to ensuring the quality and effectiveness of teaching and learning of Indigenous health in medical education and best practice in the recruitment and retention of Indigenous medical students:

LIME gives us a language in which to speak with one another. It is about us and what we do collectively to grow. It provides a beautiful, strong and congruent environment that supports communication and brings a focus to the bigger picture.

— Lisa Jackson Pulver AM, Professor and Director of the Muru Marri Indigenous Health Unit, University of New South Wales, and LIME Network Reference Group Member

The materials and resources developed as part of the Network’s program of work contribute to the quality and rigour of Indigenous health teaching and learning and provide a forum for peer mentoring and participant support.

[W]e are learning from other people’s lessons and talking to others who totally understand the hard decisions that we have to make. Also more and more now, we are collaborating on research in areas of teaching and learning, Indigenous health and growing the workforce — it has become part of improving each other’s academic practice.

— Papaarangi Reid, Associate Professor, Tumuaki/Deputy Dean and Head of the Department of Maori Health, Faculty of Medical and Health Sciences, University of Auckland, and LIME Network Steering Committee Member

The LIME Connection conferences have become a flagship of the Network’s activities and have been held biennially since 2005. Attracting educators, students and professionals, primarily from the field of medicine, they provide opportunities to share innovations, make connections and gather evidence on best-practice approaches from around the world. Importantly, outstanding work by medical educators is celebrated through the LIMElight Awards.

Coming to the first LIME conference helped me understand that there were other Indigenous/non-Indigenous colleagues facing the same challenges as me. It was like an awakening to go from feeling so isolated to understanding you had a place in a community. LIME Connection gives us the opportunity to learn and further develop our work in a supportive environment.

— Suzanne Pitama, Associate Dean of the Maori/Indigenous Health Institute, University of Otago, Christchurch, and LIME Network Reference Group Member

Conclusion

The LIME Network has developed over time to be a significant avenue through which information about Indigenous health and medical education can be shared, developed and improved upon.

It is not just one or two schools. It’s old, new, rural and urban schools. There is a non-competitive nature to the sharing. We are working hard to support each other’s work. The buy in from so many schools across both countries over a long period of time is exceptional.

— Shaun Ewen

The CDAMS Indigenous Health Curriculum Framework is being widely utilised (not only in medicine, but in other health disciplines) and the quality review tools and evidence-based materials developed as part of the LIME Network program31,32 are ensuring that Indigenous health is developing as a discipline in its own right.

[The] Network is a wonderful enabler. It allows not only the connection, but it’s a two way street, so that we’ve got a repository of the resources . . . [and] the outreach . . . the knowledge gets shared and continues to advance. It’s done in a very exciting, personally empowering, respectful and safe environment.

— James Angus

The leadership and support of Medical Deans Australia and New Zealand, AIDA and Te ORA, and the commitment and collegiality of medical educators involved, has been integral to the ongoing development of the LIME Network. We now see record numbers of Indigenous students enrolled in medicine33 and increased consistency and quality of Indigenous health teaching and learning in medicine.34

As an emerging field, Indigenous health is forging new approaches to education and training that will affect the way health care is understood and delivered. This will have implications not only for Indigenous patients, but for the community more broadly.

The goal of the network, the overall goal should be to empower people to make change, and to give voice to their concerns and to help them get the change they need. So to give voice but also to professionalise Aboriginal health as a discipline, that’s what it’s really about, and to give broader support so that it’s not just Aboriginal people doing Aboriginal health.

— Gregory Phillips

Launch of the CDAMS Indigenous Health Curriculum Framework, Melbourne, 2004 — (left to right) Professor S Bruce Dowton, Professor James Angus, Sir Willam Deane, Dr Lowitja O’Donoghue,
Mr Gregory Phillips, Aunty Joy Murphy Wandin and Professor Ian Anderson).

Associate Professor Kelvin Kong, Dr Tom Calma, Associate Professor Papaarangi Reid, Dr Mark Wenitong, at LIME Connection II, Sydney, 2007.

LIME Reference Group meeting, Gold Coast, 2012.

Planned homebirth in Australia

Time to reconsider what is safe for mother and baby, and what is not

Debates about homebirth have a long tradition of producing more heat than light.1 This is not because people on opposite sides of the fence have a lack of reasonable arguments. Those opposing homebirth rightly argue that, irrespective of how well selection processes work, unexpected complications can and do arise and that several of these cannot be remedied within the home environment. Proponents, on the other hand, argue that complications are rare and that the home environment protects against undue interference in what is basically a natural process. They assert that hospital births lead to interventions that are not risk-free and are disproportionately frequent compared with the benefit that can be derived from them. Undeniably, there is truth to both sides of the debate. Both arguments boil down to an issue of numerators and denominators. As risk is everywhere, the issues are what and how much risk is acceptable and how much action is warranted to avoid that risk. Having both mother and baby to consider does not simplify matters. Essentially, this is what fuels the debate and produces the heat, because there is little light that can be shed on any of these questions.

The article by Catling-Paull and colleagues2 in this issue of the Journal is a commendable attempt to throw some light on the subject in the same way that recent studies in Canada,3 England4 and the Netherlands5 have done. Although widely different in size, they have two unifying features. The first is that they provide some useful numerators on what the major risks to the baby might be. The second is that their denominators relate to homebirths attended by qualified professionals within well regulated systems of governance. Interpreting the findings outside that realm is clearly unjustified, as previous Australian studies have shown.6,7 Assuming that similar findings might apply outside the governance of the public health care system is certainly a few leaps too far.

When drawing conclusions, it is good to realise that there is some debate on what is or is not a planned homebirth.1 Everyone agrees that a woman giving birth at home accidentally or unintentionally is not having a planned homebirth — but that is where consensus ends. Australian perinatal data collections exemplify this. In the Northern Territory, South Australia, Tasmania and Victoria, “planned” refers to the intended place of birth at the time of booking during pregnancy. In the Australian Capital Territory, New South Wales, Queensland and Western Australia, it refers to the intended place of birth at the onset of labour.8 Studies limited to what was planned at the onset of labour tend to overlook that labour constitutes at best only 0.5 per cent of the duration of a pregnancy. It is reasonable to consider only the end of pregnancy if one wishes to examine the effect of the birth locality and what is available within it. It is also fair to acknowledge that women may change their mind during pregnancy about where to give birth. It is not fair, though, to assume that the choice of birth locality is independent of other choices made throughout pregnancy. The high waterbirth and breastfeeding rates in the current study actually testify to that effect.2 When virtually no woman waits for the onset of labour to choose her preferred birthing place, why should we consider outcomes only from that point onwards? Perhaps it may embellish intervention and transfer rates, but there is nothing wrong with timely referral from home to hospital when the need arises either in pregnancy or in labour. If anything, it may add strength to the vast difference between properly governed homebirth programs and the homebirths that create newspaper headlines from time to time.

The low intervention rates reported in the study2 are commendable and commensurate with data elsewhere.3,4 What is less commendable is the low rate of oxytocic prophylaxis to prevent postpartum haemorrhage.2 Admittedly, and despite this, there was a low frequency of postpartum haemorrhage;2 however, its frequency is usually underestimated. It is a major cause of the most devastating pregnancy outcome, maternal death,9 and little can be done about it at home. Oxytocic prophylaxis is a very small price to pay for increased safety.10

In the final analysis, many may wonder why there should be publicly funded homebirth programs when data suggest that only 0.5 per cent of pregnant women in Australia opt for a homebirth.8 It is everyone’s prerogative to have an opinion on homebirth. However, it is a woman’s prerogative and her fundamental human right to determine her reproductive behaviour, and this includes how and where to give birth. The issue is how to accommodate the autonomy of pregnant women in as safe a manner as possible for both mother and baby. The study by Catling-Paull et al2 is a worthwhile contribution to that question.

The sum is more complex than its parts

Western medicine is very good at identifying single factors contributing to disease, with undoubted health benefits for individuals and communities. It is easy to cite from the extensive list of individual factors associated either positively or negatively with disease — cholesterol, smoking, asbestos, micronutrients, antibiotics. But to what extent can this approach improve overall health, prevent disease, and help us manage complex conditions? Articles in this issue of the MJA illustrate emphatically that no single factor affecting our health should be seen in isolation.

Stanton (doi: 10.5694/mja13.10297) welcomes the revised National Health and Medical Research Council dietary guidelines that refocus on foods rather than isolated nutrients, and on patterns of eating as well as total intake. She argues that focusing on single nutrients leads to distorted food choices, and taking nutrients as supplements does not allow for the complex interaction between nutrients in whole food, which may lead to adverse consequences.

These issues are reflected in Brimblecombe and colleagues’ survey of diets in remote Northern Territory Indigenous communities (doi: 10.5694/mja12.11407). They note high intakes of sugary drinks and processed foods fortified with nutrients, alongside low fruit and vegetable intakes. How does this relate to the high burden of chronic disease in these communities? We need to look further than body mass index and total kilojoule and nutrient intake to fully explain the connections between diet and health.

An overly reductionist approach to disease assumes that tinkering with single environmental factors or isolated physiological and biochemical processes will substantially affect wellness or illness. A large section of the food industry and the entire pharmaceutical industry are built on this assumption, which is often justified. But according to complex-systems science, altering one factor can change a system in unpredictable ways. In health terms, this can manifest as either increased risk of other diseases or adverse events. Studying single factors makes for clearly defined research but neglects the complexity of the human body in its environment.

Such complexity has been recognised in other areas. Our understanding of communicable illness has moved well beyond “microbe A causes disease X”; earlier, the “father of pathology” Rudolf Virchow was, unsurprisingly, inexorably led to investigate connections between causative agents, illness and the social environment (Am J Pub Health 2006; 96: 2104-2105). Larney and colleagues’ cross-sectional study of susceptibility to vaccine-preventable diseases in prison inmates (doi: 10.5694/mja12.11110) exemplifies the complexity of communicable diseases: the socioeconomic and cultural backgrounds and the lifestyles of inmates, modes of disease transmission in correctional facilities, and opportunities for intervention all need to be considered when devising health strategies for this vulnerable population who are “racked, stacked and packed” in the wider community’s mindset. Kirby (doi: 10.5694/mja13.10178) highlights the complex social and administrative issues in Papua New Guinea (PNG) that have led to doctors in Australia having to confront extensively drug-resistant tuberculosis, which is difficult to manage, requiring prolonged treatment and expensive resources. A PNG national died in Queensland this year after lengthy treatment for this disease.

Even assessing the therapeutic benefit and safety profile of pharmacological agents — the archetypal single-agent intervention — is often complex and controversial. Attia and Pearce (doi: 10.5694/mja12.10729) and Eikelboom and Hankey (doi: 10.5694/mja12.11642) dissect the results of the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) clinical trial of the anticoagulant dabigatran and come to somewhat different conclusions. The interaction of selection bias and confounding effects from co-interventions and comorbidities are prominent, as they often are when considering drugs used for chronic diseases.

In future, to promote wellness and devise lasting solutions to disease, we will need to better understand the complexity underpinning both. The challenge is for medicine and medical research to put aside single-factor thinking and regard humans as the complex systems we are, recognising that we are not merely a collection of parts that can be targets for silver bullets.

Closing the global gender gap

Education is the key to not only better health outcomes but also less global conflict

Today, sex-based inequalities and inequities shape how individuals are disproportionately exposed to adverse determinants of health. Our sex can determine how well or ill we become, and if or how our health care needs are acknowledged and met.1 The underlying reasons for this disparity are complex and diverse, shaped by how sex and sexual customs interact within varying political and social contexts. Discriminatory values, norms and behaviours, different exposures and disease vulnerability, and health system and health research biases all interact to result in sex-based inequities in health outcomes.1 Conversely, ill health, in and of itself, can also negatively influence social and economic outcomes.

The World Economic Forum has developed a framework, the Global Gender Gap Index, to measure sex-based disparities among countries and to track these disparities over time.2 The framework outlines and examines inequities between men and women in four broad categories: economic participation and opportunity; educational attainment; health and survival; and political empowerment. These four “pillars” are considered essential in recognising the importance of the role of women in society and in diminishing the gaps between the sexes. According to this framework, no country has, as yet, achieved sex equity in all of these four categories, although some countries (eg, Scandinavian countries) are getting close to achieving this goal.

The framework also highlights that high-income countries often have fewer sex-based inequities than low-income countries.2 It is well known that, generally speaking, women in low-income countries fare far worse in terms of health outcomes, and are more likely to experience death during youth and adolescence than those in high-income countries. Maternal mortality exemplifies this, with the vast majority of maternal mortality occurring in low-income countries with weak institutional (including health) structures.

Why has no country in the world achieved sex-based equity? Is inequity between the sexes not an abuse of human rights? It is imperative that action be taken, and I would argue that the most fundamental action required is to provide all women with the opportunity of education.

Educating women has been shown not only to improve health, but also to decrease population growth, decrease child mortality, decrease child marriages and increase the participation of women in the labour force — all of which lead to faster economic growth and decreased poverty. Education is the key to building community capacity, as it provides individuals with the knowledge to participate in society.3 Education is also the key to resolving conflict, locally, regionally and globally, as it has also been shown that less conflict occurs in societies where women have higher economic and social status.4

Globally, there have been strong efforts to ensure access to primary education for all children. World Bank Group data show that, in 1999, 105.6 million children were identified as out-of-school children (ie, not enrolled in primary school); 58% of these were girls and 42% were boys. By 2009, the number of out-of-school children had decreased to 67 million; 52% of these were girls.5 Education is lacking in many regions in the world,3 so this global gap is much larger in specific regions of conflict or low-income countries.

For example, in Afghanistan, 2009 data from the World Bank Group show that the expected years of schooling for a child vary greatly by sex. Boys are in school for an average of 11.2 years; girls, 6.8 years.5 From a global perspective, sub-Saharan Africa is home to half of the world’s out-of-school girls, and South Asia to a quarter.6 Nigeria, Pakistan and India, the three countries with the most out-of-school children, are recognised for their poor treatment of women.6

We need to ask why women are treated as second-class citizens in terms of access to health care and education in developing countries. A global effort is needed to change this pattern, to change the societal view of women, with the goal of promoting equal access to education for girls. Our path forward, as men and women, is to complement each other, not to compete; to create a balance and harmony in relations, not to strengthen one over the other; for all to be strong, and to eradicate domination. Collective efforts are needed from us all, because no one person or group can do everything. Men’s participation, awareness and engagement in this goal will be vital. A global society of freedom, justice and peace will not be achieved unless all human needs are met.7

German doctors apologise for the crimes perpetrated by Nazi doctors

The recent apology from the German Medical Association is commendable, but it fails to mention many of the victims of Nazi medicine

On 23 May 2012, the German Medical Association (Bundesärztekammer [BAK]) issued a declaration — significantly, in Nuremberg — acknowledging the crimes perpetrated by their predecessors during World War II and asking for forgiveness. Several leading medical journals have responded with commentaries or editorials.1–4 My present reflections expand on those in a previous article,4 by providing further historical background to the BAK declaration and considering it in the context of Australian medicine.

It is perhaps appropriate that comment should appear in the journal of the medical community in Australia, the country with the third largest intake of survivors of World War II. Indeed, many refugee doctors underwent recertification or requalified in Australia and have descendants currently practising medicine here.
I am doubly entitled to comment. As a child, I was a displaced person whose father had been deported to
a forced labour camp for 3.5 years; and I have been a practising Sydney surgeon for the past 37 years.

The BAK declaration is important in several respects.
It is a significant acknowledgement of past crimes perpetrated by German physicians in the name of eugenics, the philosophy that aimed to eliminate any “threat to the purity of the Aryan race”. Eugenics, with its subsequent sterilisation and euthanasia debate, had started long before the Nazis established a state based on the rule of the Führer, who was empowered to authorise murderous policies, including those involving “medical experimentation”. The debate in Germany had commenced in 1871 — with the formation of the German Reich and in the wake of the emergence
of eugenics, the “racial science”, in 1865. Health professionals were familiar with the demand to sterilise and euthanase those labelled as “unfit”, “unworthy for life”, “useless eaters”, “burdens on society”, or “threats” to the “purity” and “strength” of the Aryan (ie, Germanic, in their interpretation) master race.

It is worth mentioning that it was in the German parliament that the demand for a code of ethics had originated with a Jewish physician–parliamentarian.
In 1932, Julius Moses had raised the need for a law protecting against experimentation. This followed a disastrous experiment in which 90 children had died as
a result of a tuberculosis (TB) immunisation program in Lübeck. But no such law emerged.5 The proposal was permanently shelved in January 1933, when the National Socialist German Workers’ Party took power. The politicisation of Nazi medicine led to what I have previously referred to as “the darkest page in the history of medicine”6 — the implementation of the “quadruple-E” program of eugenics, euthanasia, experimentation and extermination, to eliminate the “unfit” or “inferior”.7

To justify this, the Nazis needed little scientific rationalisation. The Führer turned to the medical community for assistance, stating: “Doctors, I cannot live without you for a day, not for a moment”. The reply was enthusiastic, with 44% of the medical profession joining the Nazi Party and 7% joining the SS.8 My first presentation on this topic was an exhibition, Nazi Medicine 1933–1945, originally held at the Sydney Jewish Museum, and later that year at the University of New South Wales and the Jewish Holocaust Centre in Melbourne. I also presented accompanying lectures
at the University of New England, the University of Newcastle and Monash University.7 The exhibition exposed the crimes, the active contribution of the doctors, the paucity of doctors taken to trial, and the support they obtained in restarting their practices after the war. For example, Herta Oberheuser, responsible for hundreds of amputations in the Ravensbrück women’s concentration camp, was sentenced to 20 years’ imprisonment, but was released in 1952. Returning
to her home town, she was warmly embraced by the local medical association and received an interest-free
bank loan to restart her practice. Two years after being recognised in 1956 by a Ravensbrück survivor, she was deprived of her licence to practise.9

The first aspect of the recent BAK declaration, for which the organisation must be commended, is its acknowledgement of atrocities: “doctors were not forced by politicians to kill and experiment on prisoners, but became enthusiastic Nazi supporters”. One should be aware that no physician was ever punished or demoted for refusing to collaborate; they were simply transferred to other duties.

The major role of a number of doctors is noteworthy: Irmfried Eberl, an Austrian doctor who was the commandant of the Treblinka extermination camp, which had the second-largest gas chamber; Josef Mengele (with a group of associated physicians),
who selected for gassing some 1.5 million people at Auschwitz; and Karl Brandt, the chief medical officer
of the Reich and private physician to the Führer, who performed the very first “mercy killing” of a German newborn.

The apology notes, “outstanding representatives of renowned academic medical and research institutions were involved in organising and carrying out mass extermination of millions”. Indeed, numerous world renowned medical authorities were among the experimenting “scientists”. Of note was the neurologist Julius Hallervorden, who examined children before and after their euthanasia, and accumulated hundreds of brains for histological examination. He described Hallervorden–Spatz syndrome, more recently renamed pantothenate kinase-associated neurodegeneration.

The most heinous crimes were the Neuengamme TB experiments conducted at the Bullenhusser Damm school in Hamburg in 1945. Twenty emaciated children under the age of 12 years, transferred from Auschwitz
to Hamburg, were injected intravenously with Mycobacterium tuberculosis or it was instilled into their tracheas. Soon, the cachectic children developed haemoptysis. When the Allies were closing in, the children were given morphine and hanged until death on hooks in a changeroom (one child, being too thin, had to be manually strangled as the noose did not catch), and then all of the experimental “material” was cremated. The “scientific” conclusion drawn by these doctors was that Jewish children, being from an “inferior race”, were more susceptible to TB.

The BAK declaration issued apologies to “the victims of sterilisation, of euthanasia of 200 000 psychiatric and disabled people, of non-consented human experiments, as well as of 360 000 forced sterilisations”. All these experiments had been suggested by the doctors themselves and must have obtained approval from the Reichsführer of the SS, Heinrich Himmler. However, although well intended, the declaration is only a half measure. There is no mention of many of the victims, such as the thousands of German children with intellectual disabilities and treatable diseases who were euthanased in six “children’s hospitals”; the Roma (Gypsies) in Auschwitz who were infected with a rare facial gangrene (noma) and then gassed; and the Polish, Russian and British prisoners who were infected with malaria, hepatitis or anaerobic gangrene. Finally, there
is no mention of the word “Holocaust”.

The second aspect of the declaration is that, apart from being an acceptance of guilt, it is also a request for forgiveness. It states that Nazi doctors were “guilty, contrary to their mission to heal, of scores of human rights violations and we ask for forgiveness of their victims, living or deceased and of their descendants”.

Reflecting on the apology, one can ask: how can forgiveness be accorded for the fatal “freezing” or
“high-altitude” experiments?7 One can ask: how can forgiveness even be asked for the children who suffered and perished in Neuengamme?

The prerogative of offering forgiveness belongs only to people like the twin sisters, now aged 85 and living in Melbourne, who were experimented on by Mengele.

My personal view is that the present generation of German doctors is guiltless, but in no circumstances should any forgiveness be accorded to their Nazi predecessors. Now, with a generational change — with the old guard no more — today’s German physicians are trying to “master the past”, which probably prompted this apology.

Why now, so long after the war? What do today’s German doctors hope to achieve? We need to remember that, after the war, German doctors, regardless of
their complicity in heinous crimes, mostly continued undisturbed in their practices. This belated, but novel, declaration by the BAK is commendable. One can but hope that it will soon be followed by an apology from the Austrian Medical Association, which has, I believe, sheltered under the pretext that Austria was the first victim of the invading Third Reich.

This declaration should alert physicians in all other countries. Following the Doctors’ Trial in 1947 of Brandt and others, the Counsel for War Crimes adopted the Nuremberg Code of ethics on the need for consent for treatment and experimentation.10 The essential points
in the Nuremberg Code concern the seeking of consent, doing no harm and the right of each person to cease the process at any time. This excellent first step was later improved upon in Helsinki and then in Tokyo, but in general, all are valid with individual local variants.

The Code of Ethics of the Australian Medical Association and the Code of Conduct of the Royal Australasian College of Surgeons, rigorously respected today, are protection against any such ethical deviation in this country.