The global challenge of women’s health

Sierra Leone, a West African state of 6 million, saw 11 000 cases and over 3000 deaths during last year’s Ebola outbreak. A bitter civil war from 1991 to 2002, fuelled largely by fierce factions from neighbouring countries, led to 50 000 deaths and degradation of the country’s infrastructure and social fabric. Sierra Leone’s exports of diamonds and bauxite notwithstanding, the lack of a socially responsive polity and a largely agrarian population set the scene for the epidemic. Over 70% of its population live in extreme poverty.1

Sierra Leone also tops the 2013 chart when it comes to maternal deaths — 1100 per 100 000 live births.2 The comparable figure for Australia is six. UNICEF estimates that 88% of the women have been subject to genital mutilation.3

Improving maternal health

The Millennium Development Goals, promulgated by the United Nations in September 2000 and endorsed by 189 countries, sought to halve desperate poverty, defined as living on less than a dollar a day, by 2015. The metrics suggest that this goal has been achieved, and it is a remarkable tribute to international efforts. Among the eight goals, five concern health, and most have been achieved, including huge reductions in infant mortality.

Improving maternal health is one of the health-related goals that has proved harder to reach. Under Goal 5, countries committed to reducing maternal mortality by three-quarters between 1990 and 2015. Since 1990, maternal deaths worldwide have dropped by 45%.4

Maternal mortality — often due to blood loss and infection — has proved more resistant to efforts to substantially reduce it as a global health problem. It has been intractable in areas of poverty and social turmoil. There were 289 000 maternal deaths worldwide reported in 2013.4

The explanation for these disturbing figures has much to do with social attitudes and investment. When we encounter health disparities, the explanation is most often found outside the clinic, in society and politics. In preventing maternal death, strong investment in education for women is fundamental. Provision of the basic infrastructure necessary for safe childbirth comes next. But even more basic is a pathological view of women — that they are not a priority and that public resources should be invested elsewhere.

Broadening the focus

The World Health Organization draws our attention in 2015 to food security. Its importance is great for women’s health, before and during reproduction and throughout all adulthood, to reduce the risk of nutritional deficiencies, diabetes and heart disease.

When, in 2003–2004, my colleagues at Columbia University and I were examining cardiovascular disease in emerging economies, I was amazed to discover that it far outweighed obstetric and perinatal disorders, HIV and malaria as causes of death of women in the years of family formation and support. In seven out of nine developing countries that we studied, chronic diseases caused over 20% of deaths among women aged 15–34 years, while reproductive causes and HIV together accounted for about 10% of deaths.5 We questioned why the traditional conceptualisation of women’s health has more to do with disorders that impair their performance as reproductive machines than with the real threats to their wellbeing, including the precursors of cardiovascular catastrophe. Those who work on global programs to abate the scourge of diabetes make a major contribution to reducing deaths among women from cardiovascular disease.

Shaking stereotypic thinking

Even if our view of women’s health is restricted to an understanding of causes of death, it is clear we have a task to shake the stereotypic thinking and social relegation of women that foster a completely inadequate global response to their health needs.

There are tasks aplenty for those with advocacy in their blood at governmental, educational and individual levels. Heroic clinicians such as 91-year-old Dr Catherine Hamlin AC and her co-workers at the Addis Ababa Fistula Hospital, its five regional hospitals and the Hamlin College of Midwives set outstanding examples of other pathways.

New strains force late start for flu vaccination program

Doctors and patients will for the first time have access to single-dose vaccines covering the four most common flu viruses amid concerns a mutated strain that wreaked havoc in the northern hemisphere could take hold in Australia.

The Therapeutic Goods Administration has approved nine vaccines, including, for the first time, three quadrivalent formulations, as preparations advance for the roll-out of National Seasonal Influenza Immunisation Program from 20 April.

The TGA said the vaccines approved for the program provided coverage for two new strains following expert advice about the prevalence of different types of infections in the last 12 months.

The World Health Organisation and the Australian Influenza Vaccine Committee have recommended that vaccines this year cover one existing and two new strains – the California H1N1-like virus that has been in circulation since 2010, the Switzerland H3N2-like virus and the Phuket 2013-like virus.

In addition, the quadrivalent vaccines, FluQuadri, FluQuadri Junior, and Fluarix Tetra, will cover the Brisbane 2008-like virus.

Drug company Sanofi Pasteur, which manufactures two of the quadrivalent vaccines, said they were well tolerated and provided additional protection because they covered both B strains of the influenza virus as well as the two A strains – compared with trivalent vaccines that covered both A strains but only one B strain.

The national immunisation program, which usually commences in March, had been held back a month as manufacturers have scrambled to produce sufficient stocks of the vaccines.

“The double-strain change has resulted in manufacturing delays due to the time it takes to develop, test and distribute the reagents needed to make the vaccine,” a Health Department spokesperson said. “The commencement of the program is being delayed to ensure sufficient supplies of influenza vaccine are available from at least two suppliers in order to mitigate the risk of administration of bioCSL’s Fluvax to children under five years of age.”

The AMA and other health groups expressed alarm last year over revelations that 43 infants and toddlers were injected with Fluvax in 2013 despite warnings it could trigger fever and convulsions.

The TGA has repeated its advice that Fluvax is not registered for use on children younger than five years, and that it should only be used on children between five and nine years following “careful consideration of potential benefits and risks in the individual child”.

Fluvax will be supplied with prominent warning signs and labels to remind practitioners that it should not be administered to young children.

In a stroke of good fortune, the delay in the vaccination program has coincided with a relatively quiet start to the flu season, with reports that influenza activity has so far been weaker than that experienced at the same time last year.

The Health Department and the TGA said that, despite the delay, they do not expect any flu vaccine shortages, and the Government has committed $4.5 million over the next five years to provide free flu vaccination for Indigenous children aged between six months and five years.

The Government has also renewed the contract of the Australian Sentinel Practices Research Network, based at the University of Adelaide, to undertake national surveillance of flu-like illnesses.

The network, which has been operating for more than a decade, collates information from more than 200 GPs and medical practices across the nation to provide health authorities with an early warning of developing outbreaks. Its information is used in conjunction with data from hospitals.

Adrian Rollins

Abolishing the world’s worst weapons

Nuclear weapons abolition — a medical imperative

One could be forgiven for not noticing, but there has been groundbreaking activity going on that is headed in the direction of a ban on the world’s most destructive weapons. This year, 2015, could see the start of negotiations for a treaty to eliminate nuclear weapons, which were first used 70 years ago on the Japanese cities of Hiroshima and Nagasaki. The medical profession, including in Australia, has a history of extremely important advocacy on this issue that must be continued.

The recent developments are a series of international conferences focusing on the humanitarian impact of nuclear weapons, hosted by the governments of Norway (March 2013),1 Mexico (February 2014)2 and Austria (December 2014);3 the Vienna conference attracted 158 governments. Each of these conferences has concluded unequivocally that the humanitarian impacts of nuclear weapons are so catastrophic that no government or non-government organisation would have the capacity to respond to either the short-term or long-term effects of their use.3 Many government delegations at the conferences noted that the risk of nuclear weapons use is higher than is commonly understood. (As an indication of this risk, on 22 January this year, the hands of the Doomsday Clock of the Bulletin of the Atomic Scientists, which warns of our proximity to nuclear and other catastrophic perils, were moved from 5 minutes to midnight to 3 minutes to midnight4). The risk is increasing and there is an urgent need for nuclear disarmament.

These international fact-based gatherings have reaffirmed the central message of International Physicians for the Prevention of Nuclear War (IPPNW):5 if nuclear weapons are used again, health services will be unable to respond in any significant way.6 Whatever health care facilities survived the attack would be overwhelmed to the point of collapse, offering little more than primitive first aid.7

Recent research has added a further dimension and risk. The report, Nuclear famine: two billion people at risk?, released by IPPNW in December 2013 and based on research by climate scientists, concluded that, in the event of even a limited nuclear exchange, the particulate matter and smoke from burning cities would block sunlight and cause agricultural collapse, placing more than two billion people globally at risk of starvation.8

IPPNW’s Australian affiliate is the Medical Association for Prevention of War, which, in 2007, launched ICAN, the International Campaign to Abolish Nuclear Weapons. ICAN has played a key role in advocating a nuclear weapons ban treaty, and was the chosen civil society partner in Norway, Mexico and Austria.

The Australian Red Cross has also played a pivotal and leading role by helping secure the passage of a resolution of the International Red Cross and Red Crescent Movement in November 2011. The resolution stated that “the existence of nuclear weapons raises profound questions about the extent of suffering that humans are willing to inflict, or to permit, in warfare”, and urged laws to prohibit their use and eliminate them.9

As momentum builds unmistakeably towards a ban treaty, there is a renewed call to action for our profession. At the World Medical Association General Assembly in South Africa in October 2014, the Association referred to its International Council a new resolution calling for a ban on nuclear weapons, and urging national medical associations to educate the public and policymakers about this overwhelming public health threat. The resolution will be voted on at the next meeting of the Council in Oslo in April 2015 and at the General Assembly later in the year; it deserves the strongest possible support.

Although Australia does not own any of the world’s 16 300 nuclear weapons, successive Australian governments support “deterrence” by United States nuclear weapons — that is, a threat to use the weapons — and pay mere lip service to the goal of abolition.

Medical and humanitarian professionals have already played a crucial role in advocating for the removal of the global nuclear weapons threat. The emergence now of a strong majority of the world’s governments committed to the same goal represents unprecedented progress and opportunity. Medical voices are needed now as much as ever, to seize the opportunity while it lasts, and to help delegitimise and stigmatise these horrific devices. The elimination of the worst of all weapons of mass destruction, each one of which represents a medical and humanitarian disaster of nightmare proportions, is both necessary and possible.

New strains force late start for flu vaccination program

The TGA said the vaccines approved for the program provided coverage for two new strains following expert advice about the prevalence of different types of infections in the last 12 months.

In addition, the quadrivalent vaccines, FluQuadri, FluQuadri Junior, and Fluarix Tetra, will cover the Brisbane 2008-like virus.

The national immunisation program, which usually commences in March, had been held back a month as manufacturers have scrambled to produce sufficient stocks of the vaccines.

The AMA and other health groups expressed alarm last year over revelations that 43 infants and toddlers were injected with Fluvax in 2013 despite warnings it could trigger fever and convulsions.

Fluvax will be supplied with prominent warning signs and labels to remind practitioners that it should not be administered to young children.

The Government has also renewed the contract of the Australian Sentinel Practices Research Network, based at the University of Adelaide, to undertake national surveillance of flu-like illnesses.

Adrian Rollins

The world we live in

Among the great mysteries of human existence, our uncertain relationship with our environment has been a constant source of puzzlement. In the days of the flat earth, when gods and planets needed constant placation and sacrifice lest the food supply fail and fertility fall, surging infections were thought to be a further manifestation of divine displeasure — something that the deities inflicted upon the people (demos) from above (epi) to chasten and punish. Yet the Old Testament book of Leviticus shows that, thousands of years ago, the need to quarantine people with rashes or swellings “like the plague of leprosy” was recognised (Leviticus 13: 2–5), implying that humans understood from early on that they had a measure of control over infective afflictions.

The path from primitive ignorance and fear to the understanding of the microbiological cause of infection is, as the cliche runs, history. Nevertheless, we continue to fear uncontrolled epidemics, despite our heavy investment in technology to hold them at bay.

Battling the threats

At the beginning of 2003, during the early phases of the severe acute respiratory syndrome (SARS) epidemic, I saw lights burning in the windows of Ian Lipkin’s microbiology laboratory at Columbia University, close to where I was working at the time, for 24 hours every day during the race to sequence the genome of the virus responsible. By May, the 29 751-base genome of the Tor2 isolate had been sequenced in British Columbia and published in Science.1 Fortunately, although SARS was a serious illness, as classical epidemiological data were assembled we recognised that it had low infectivity. We had come to know the enemy — quickly and in fastidious detail — yet we still needed traditional methods to prevent its spread.

Infection retains its character of surprise. Who would have guessed the story of Helicobacter pylori and peptic ulcers? As an intern in 1966–1967, peptic ulcer meant antacids, stress and socioeconomic status, vagotomies, pyloroplasties and heroic surgery for life-threatening haematemesis. What other disorders — cancer, coronary disease — may have an infective element in their aetiology? And, like the global financial crisis of 2008, the Ebola epidemic of 2013 caught us off guard. It also reminded us of how critical the social environment and poverty, in particular, are to the formation of modern infective epidemics.

Complex relationships

In recent years, dramatic developments in our exploration of the universe of infection have led us to the human microbiome — the “organ” that has 10 times as many cells as does the whole of the rest of the human body — that inhabits our gut, skin and other surface tissues, and about which new knowledge is coming to us daily. A 2012 Spanish study described a changing microbiome profile in human breast milk over the months after birth that involved over 700 species of microorganisms.2

I had a glimpse of the importance of the human microbiome in 1968 when working at Baiyer River in the western highlands of Papua New Guinea. We were visited by Eben Hipsley, a nutrition scientist from Canberra, who had an interest in understanding how the local Enga people, naturally muscular and fit, kept their metabolism going without eating much more than sweet potato.3 What about essential amino acids? In private conversation, Eben conjectured that their gut flora generated the molecules missing from this people’s natural diet. Today’s experts in this field presumably have a much better idea of Papua New Guinean nutrition, but Hipsley respected what he knew, even then, of the human microbiome. Contemporary experts now agree that while human microbiota do not fix atmospheric nitrogen, they can upgrade dietary nitrogen-containing compounds into essential amino acids.4

Together, we triumph

In terms of infection control, the global response to HIV has been an astounding exercise that combined technology, preventive science, biological insight, social understanding, philanthropy and dogged global political action. This, together with the GAVI Alliance (made up of such heavyweights as the World Health Organization, UNICEF, the World Bank, the Bill & Melinda Gates Foundation and donor countries), the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the elimination of smallpox, should surely give heart to those who doubt the value of medical research and action. Rather than lamenting what we can’t do, these achievements signal what amazing things we can do together when we try.

Latent infection in HIV-positive refugees and other immigrants in Australia

To the Editor: Refugees and other immigrants may carry latent infections not endemic to Australia. Immunocompromised people, including those living with HIV, are at particular risk of reactivation of such infections.1 Screening for schistosomiasis and strongyloidiasis in patients with HIV is not currently recommended by Australian guidelines2 or the United States guidelines that they reference;3 however, it is recommended by those of the United Kingdom.4

We sought to determine the prevalence of latent tuberculosis (TB), Schistosoma spp. and Strongyloides stercoralis in a cohort of people living with HIV attending a tertiary care hospital in Melbourne. The study received approval from our research ethics committee. Between 1 January 1990 and 6 March 2014, a total of 500 patients were under the care of the HIV clinic. These patients were included in a retrospective analysis of data extracted from existing pathology and administrative databases.

Mean age at presentation was 38 years, median length of time attending the clinic was 24.5 months (range, 1–289 months), and 383 patients (77%) were male. Two hundred and twenty patients (44%) were born outside Australia in over 60 different countries. Fifty-eight patients (12%) originated from low-income countries, 106 (21%) from middle-income countries, and 324 (65%) from high-income countries, including Australia.

All patients were included to assess screening for TB in accordance with existing guidelines, which currently recommend screening at diagnosis.2,3 Only patients from areas endemic for schistosomiasis (> 10% prevalence)5 were included in the data extraction for schistosomiasis screening. Similarly, only patients from areas endemic for strongyloidiasis (> 20% or unknown prevalence)6 were included in the data extraction for strongyloidiasis screening.

We also performed a prospective analysis of previously unscreened patients attending the clinic from 7 March to 29 August 2014.

Serological testing comprised QuantiFERON-TB Gold (Cellestis) (Mantoux testing for some patients before 2004), Schistosoma IgG indirect haemagglutination assay (ELITech), and Strongyloides IgG enzyme immunoassay (DRG Diagnostics).

In the retrospective audit, five of 58 patients who had been screened for schistosomiasis returned positive serology results, indicating past or current infection. In the prospective sample, one of 22 patients was found to have a past or current Schistosoma infection that was previously undiagnosed despite the patient originating from an endemic country.

In our retrospective analysis, seven of 83 patients who had been screened for strongyloidiasis returned positive serology results, indicating past or current infection. In the prospective phase, one of 20 patients was found to have a past or current S. stercoralis infection that was previously undiagnosed despite the patient having come from an endemic country.

In the retrospective audit, 10 patients were diagnosed with active TB and were excluded from further analysis. TB screening was recorded in 257 of 490 patients (52%); of these, 24 (9%) were positive and 11 (4%) had indeterminate results. In the prospective sample, two of 19 patients not previously screened for TB returned positive results. Both of these patients were born in high-risk countries.

Our results suggest that screening for TB, strongyloidiasis and schistosomiasis should be a part of primary care for HIV-infected patients originating from areas endemic for these infections.

Medical cannabis: time for clear thinking

Australia is behind the times on the medical use of cannabis

The debate about the medical use of cannabis in Australia has become confused with the proposal for a formal clinical trial instead of proceeding to legislation in New South Wales, the Australian Capital Territory and Victoria. Debates about prohibition of cannabis have a long history,1 as has the proposal for medical cannabis in Australia.2 Politicians are nervous about being “soft on drugs”, especially before an election. The clinical trial proposed, if successful, presumes that cannabis would then be approved and regulated as a pharmaceutical substance.

We need to be across the facts and options. Cannabis can never be a pharmaceutical agent in the usual sense for medical prescription, as it contains a variety of components of variable potency and actions, depending on its origin, preparation and route of administration. Consequently, cannabis has variable effects in individuals. It will not be possible to determine universally safe dosage of cannabis for individuals based on a clinical trial.

Extreme views in the debate about any form of cannabis decriminalisation are advanced with almost religious fervour. On the one hand, some assert that cannabis is a dangerous, highly addictive drug which causes schizophrenia, and that any move to relax prohibition would be a disaster. This view defies published evidence. On the other hand are those who have used cannabis for years, swearing it causes no trouble. They see prohibition as a totally inappropriate curb on individual freedom.

Facts about cannabis

The assertion that cannabis is highly addictive ignores firm evidence. The most authoritative review comparing addictiveness of drugs rates physical dependence on a scale of 0–3.3 Heroin is ranked 3; tobacco, barbiturates and benzodiazepines, 1.8; alcohol, 1.6; and cannabis, 0.8. Cannabis may, of course, be a pathway to more addictive drugs if obtained from illegal sources that also offer powerful alternatives.

The view that cannabis carries no risk likewise ignores much published evidence.4 Recent Australian and New Zealand longitudinal studies show significant social, behavioural, educational and mental problems with frequent use of cannabis by young people (aged 15–25 years). Psychosis occurred more frequently following long-term heavy use than among non-users, but no schizophrenia was noted in this study.5 A recent review of the evidence implicating cannabis in the development of schizophrenia found only that it can accelerate its expression at an earlier age and may aggravate existing schizophrenia. Of course, non-users also develop schizophrenia.6 Others have identified heavy cannabis use in the young as a possible factor in later psychosis, without specifying schizophrenia.7

Australians, together with citizens in the United States and New Zealand, are the world’s greatest users of cannabis per head of population.8 Prohibition has failed to prevent widespread use and young people report that they can readily access it.9 Young people need to be strongly dissuaded, on health grounds, from frequent or even regular use of cannabis, but this has little relevance to cannabis used for medical purposes or the debate surrounding it. Potential medical users are often, for example, in the later stage of a battle with painful cancer, finding problems with morphine, other analgesics and nausea with chemotherapy. Others seek relief from painful conditions such as muscle spasm in multiple sclerosis. Cannabis is believed to reduce seizures in Dravet syndrome, a rare genetic myoclonic epileptic encephalopathy beginning in infancy.10 Most parents of affected children (84%) report much lessened frequency or abolition of seizures with medical cannabis. They should have continuing access to it until trials using purified cannabidiol (CBD), believed to be the active component for these children, provide a superior agent.

We are behind the times on medical cannabis. Currently, 23 states in the US have legalised use of cannabis for medical conditions, as has Canada since 2001. Other countries approving it include Israel, Holland and the Czech Republic. Portugal, in 2001, removed penalties for personal possession and use of all illicit drugs, but with rigorous administrative processes to handle problem use. Eliminating prohibition is not a disaster if there are sensible processes to control drug-related harms.11

An Australian and US study found that removal of legal action and possible imprisonment for possession and use makes no difference to the patterns of use of cannabis.12 World Health Organization mental health surveys of 17 countries found that “countries with stringent user-level illegal drug policies did not have lower levels of use than countries with liberal ones”.13 There is no rational basis for the view that weakening prohibition to permit use for medical conditions would lead to a surge in general use.

Cannabis has at least two important active elements: δ-9-tetrahydrocannabinol (THC) and CBD. The former is responsible for the high of intense comfort and pleasure when presented to the brain in sufficient quantum. Its presence is greatly enhanced by heating marijuana above 170°C, as in a bong, converting the inactive precursor THC-A to THC. THC infused at high dose can produce a powerful euphoria but also hallucinations and other psychotic effects in some normal individuals, followed by complete recovery.14 CBD, on the other hand, does not give a high but has other effects including suppression of nausea and pain. It counteracts some of the effects of THC.15 The plant Cannabis sativa has more than 100 alkaloids with potential to influence the cannabis receptors CB1 and CB2, which respond to normal cannabinoids.16

Response to cannabis varies from person to person, partly due to genetic variation among users.17 The content of THC and CBA varies among different strains of marijuana. Some users vary the type of plant they use to benefit from these different effects.

What would a clinical trial entail?

Cannabis as such cannot be subjected to a double-blind clinical trial. Participants would have to agree to be treated with it, hoping to gain relief from distressing pain or nausea. Each would become aware whether they are receiving cannabis or a placebo. Dose would have to be adjusted for each individual. Any trial would use cannabis with multiple active constituents, varying with the source of marijuana used and its preparation.

If a person in the late stages of painful cancer seeks the euphoria of THC, why should they not have it? They must have a right to withdraw from a trial if it does not suit them. Participants in the control group may demand to transfer to the active arm on seeing others feeling better. Cannabis should supplement morphine for pain as necessary, not replace it.

Are there barriers in principles of medical practice?

There may be medicolegal issues if a medical practitioner prescribes a preparation of unquantified potency or with an incomplete description of its constituents and without full knowledge of side effects and their extent. But this has not proved to be a problem in those US states where the patient makes the choice to use cannabis following a medical consultation. A recent readership survey conducted by the New England Journal of Medicine sought comment on a published case report of a cancer patient where a senior psychiatrist and a pain management specialist had both recommended against use of cannabis. Seventy-six per cent of respondents from several countries responded that they would recommend use of cannabis in such a case.18 Medical marijuana is now widely used. A recent US study found that the states with medical cannabis use over 10 years had a lower death rate from opioid overdose than those without.19

Why not go ahead with legislative approval?

The real question is whether a person who is suffering pain and distress can access cannabis on their own initiative, following medical consultation as to their symptoms. They can access other herbal remedies from authorised providers such as health food stores or a pharmacist. If legislation permits sale to people suffering from a condition diagnosed by a doctor and scheduled in legislation, there should be no problem with provision of cannabis by this route without waiting for completion of a clinical trial. This is especially the case with Dravet syndrome patients where a formal clinical trial with a proprietary CBD concentrate20 may take several years to complete.

We should ensure that cannabis is provided only to approved users who should be registered. As there is no legal supplier, users should have permission to grow their own plants — up to 10 at any one time — but be forbidden from selling their product. Any proposal for commercial production should be subject to strict control, with analysis of THC, THC-A and CBD content by a government toxicology laboratory for both cannabis oil and the leaf product. Venues for sale, presumably pharmacies or health food shops, should be registered. People aged between 15 and 25 years should be excluded as recipients, except where it is provided specifically for a cause covered by legislation. The legislation should also make cannabis available for medical research.

In summary, use of cannabis should be decided by the patient, following medical advice about the condition from which they seek relief, with patients being registered under state legislation. If there is to be a nationally approved trial, it should be one of documenting clinical experience from cannabis use under state legislation of the kind foreshadowed by recently elected Victorian Premier Daniel Andrews.21

Ethical challenges for doctors working in immigration detention

To the Editor: Sanggaran and colleagues starkly illustrate the ethical dilemmas of doctors contracted to an organisation delivering substandard medical care to asylum seekers.1 They pose the question of whether doctors should boycott the system.

The same ethical dilemma sometimes faces doctors working in the limited-resource environment of public hospitals in Australia. The following example illustrates how boycotting the system can achieve results.

In May 2003, medical administrators at Sir Charles Gairdner Hospital (a tertiary referral public hospital in Perth) were alerted to looming problems with provision of prostate biopsies, including failing equipment and unacceptable waiting times for urology patients. In April 2006, amid ongoing administrative inaction despite repeated meetings and correspondence, a patient was diagnosed with metastatic prostate cancer while still on a waitlist for a prostate biopsy.2 Four of five urologists consequently resigned, arguing that they could no longer be part of a system that presided over this sort of substandard care. Their en-masse resignations were widely reported in the media, prompting the direct intervention of the then Western Australian Minister for Health. Only by boycotting the system were their concerns properly addressed.

The American Medical Association Code of medical ethics advocates use of ethically appropriate criteria when allocating limited medical resources.3 Most importantly, the treating physician must remain an advocate for patients.

When we find ourselves involved in organisations delivering substandard medical care, all of us must take the lead of Sanggaran et al and continue to speak out — and sometimes boycott the system — to effectively advocate for our patients.

Ethical challenges for doctors working in immigration detention

To the Editor: As psychiatrists and physicians working with adults and children in mandatory, often prolonged, immigration detention, we confirm Sanggaran and colleagues’ account.1

Quality evidence from diverse, independent, multinational sources, including legal and medical investigations over two decades, finds that immigration detention:

contravenes multiple international conventions that Australia has signed;2
harms mental health of detained children and adults, and detention employees, in a process likened to torture;3
incurs vastly greater financial and legal costs than alternatives, and makes profits for multinational companies from desperate, traumatised people;4
fails to deter people from seeking asylum and is unnecessary to prevent their absconding (because they rarely abscond);2
compromises ethics, through mandating secrecy, neutralising advocacy and destroying independent oversight;5 and
fosters conditions for systematic institutional child abuse and its lifelong consequences.6

Immigration detention fails every standard of medicine — science, ethics, health economics, pragmatics and human rights (including freedom from abuse and the right to highest attainable health standards). Yet despite accumulated evidence and established opposition from national professional bodies — including medicine, paediatrics, psychiatry, public health, psychology, nursing, social work and medical students — successive governments deny or rationalise inveterate harms, arguably implicate professionals in legitimating abuses the professionals cannot prevent, and deflect needed policy change.7 The case against immigration detention is irrefutable.

As immigration detention’s damages are unmitigated by any (mental) health intervention, and immigration detention renders clinicians ineffectual, a strong clinical and ethical argument exists for withdrawing services. Rather than health care for asylum seekers and detainees remaining with the Department of Immigration and Border Protection or being outsourced, federal or state health departments should provide and manage services and monitor standards independently. This will not resolve the problem of immigration detention, but it may attenuate some of its worst effects.

Global health with justice

ALTHOUGH the title of Gostin’s latest book, Global health law, may suggest a dry legal tome, it is, in fact, a highly readable exploration of the major issues and debates in the field of international health policy and governance. For those new to the field, Gostin offers an insightful overview of the overarching legal and policy regime and key institutional actors. However, the book is not a neutral primer in the basics of health law. Rather, Gostin’s ultimate goal is prescriptive: he sets forth in Chapter 1 his vision for “global health with justice” as requiring a more equitable distribution of health resources than the current status quo. In turn, much of the book is devoted to making the case for the political, legal and institutional reform that would be necessary to achieve this end.

“Global health law” is not a clearly defined set of legal instruments — rather, it includes both “hard” law (treaties that are binding on state parties) and “soft” law (non-binding agreements by states). Given this complex legal landscape, as well as the fact that much of the relevant legal architecture does not specify concrete obligations for state parties, Gostin takes a more expansive approach to the field. He examines not only international legal frameworks and relevant agreements, but also good governance practices for key institutions, such as the World Health Organization, as well as diverse stakeholders in philanthropy, business and civil society.

Gostin covers a great deal of ground — from the lack of political will at the WHO, to human rights, and the impact of the current international trade and intellectual property regimes on health outcomes. He concludes with a series of case studies on a diverse set of health problems. While this approach inherently eschews a certain degree of depth on a number of issues, it is valuable in that it provides readers with a comprehensive understanding of the multiple intersecting factors — social, legal, political and economic — that shape international health policies and processes.

Ultimately, Gostin’s case for an urgent need for global health with justice is compelling. The final chapter highlights the opportunity for advocates and policymakers to capitalise on current international attention on health to push forward two new initiatives: a proposal for a binding international “Framework convention on global health”; and a multilateral treaty to incentivise research and development based on universal need rather than profit. If successful, either would be a major step forward in strengthening the global health legal framework.