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tag:theconversation.com,2011:/au/health/articles Health + Medicine – Articles – The Conversation 2014-11-21T03:26:03Z tag:theconversation.com,2011:article/34296 2014-11-21T03:26:03Z 2014-11-21T03:26:03Z Rise in anti-psychotic scripts for kids is a serious worry

Children exhibit signs of psychotic illness in very rare cases. Philippa Willitts/Flickr, CC BY-NC

News this week that as many as 100,000 prescriptions for anti-psychotics were written for Australian children in 2013 is cause for concern. Though the drugs may be appropriate in a small number of cases, their possibly irreversible side effects make them highly undesirable for use in children.

Anti-psychotic drugs have traditionally been prescribed to adults with severe mental illnesses, such as schizophrenia or bipolar disorder.

While these medicines are often the best option for treating such illnesses, they are also known as "dirty" drugs because their effects on the body and brain are broad. That's because they weren't specifically designed to target the symptoms they are prescribed for.

And they can produce a range of side effects. These include significant weight gain, increased risk for diabetes, movement disorders, heart disease and sexual dysfunction.

Children exhibit signs of psychotic illness in very rare cases. Prescribing anti-psychotic drugs in those instances is appropriate.

But these drugs are clearly not being reserved for rare cases of childhood-onset psychosis. They're being prescribed for a range of other illnesses, including autism, obsessive compulsive, attention deficit and Tourette's disorder. And they're also being given to children with intellectual deficits who exhibit behavioural problems.

Not surprisingly, the same negative side effects found in adults are being reported in the children treated with anti-psychotics.

Increasing use

Anti-psychotics are increasingly being prescribed to children for a number of reasons.

In the last few decades, there's been a shift from thinking of psychiatric illness as a result of environmental influences to understanding the biological basis of these disorders. So medical treatments for psychiatric illnesses are becoming more common.

It is also being recognised that the symptoms of the disorders, though often identified in early adulthood, are already present to a lesser degree in childhood. And there's been a push to treat them earlier in the hope of improving prognosis.

It's generally newer, second-generation anti-psychotics that are prescribed to children. These drugs are said to be atypical because they're thought to be more effective and have fewer side effects. That makes them more palatable to give to young people.

But the reality is that they have side effects similar to those of the older drugs. And while there's evidence of safety and efficacy for their short-term use, long-term outcomes are still unknown because studies don't tend to extend beyond a year.

Anti-psychotics are often prescribed "off label", which means they haven't been approved for use in children. This is not always because the drug is dangerous but may instead reflect that prescription is uncommon for that group. But since a growing number of children are being prescribed anti-psychotics, it's clearly time for research to ascertain whether this is appropriate.

Cause for concern

The most disturbing research in this area suggests long-term anti-psychotic drug use might shrink the brain independently of the effects of psychiatric illness. This finding has been reported in both macaque monkey and human studies.

The idea that, in addition to potentially dangerous side effects already reported, anti-psychotics might have this other effect on the brain is a terrifying thought for anyone taking the drugs. And it's of particular concern for children because their brains are still developing.

Despite concerns about all the possible side effects of the drugs, the fact remains that some children suffer from very serious psychiatric illnesses that respond poorly to talk therapy alone. So people taking them should not suddenly stop.

A wholesale ban on children taking anti-psychotics is not the answer either. Rather, given the potentially severe side effects of these medications, guidelines on their administration should be reviewed.

It may be more appropriate for children to be prescribed anti-psychotics by specialists rather than general practitioners, for instance. Or it might be useful to ensure all other alternatives have been ruled out before anti-psychotics are prescribed. Another important step is to educate the parents and guardians of children who are given the drugs.

The increasing number of anti-psychotic prescriptions for children is worrying because of their significant and possibly irreversible negative side effects. This trend has increased much more rapidly than the supporting evidence for it; it's time to review and evaluate the implications of this practice for children.

Erica Neill does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Erica Neill, Post Doctoral Researcher at Monash University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/34248 2014-11-20T19:27:46Z 2014-11-20T19:27:46Z Serial: murder, mystery and the science of memory

The podcast Serial investigates the murder of 18-year-old American student Hae Min Lee 15 years ago. LukaTDB/Shutterstock

Can you recall what you were doing last Wednesday between 2.15pm and 2.36pm? Where were you? What did you see? Who did you talk to? How well do you remember those 21 minutes?

Now try to recall Wednesday six weeks ago. What about a Wednesday 15 years ago?

How detailed and accurate do you think your memories are of these recent or long-ago events?

An addictive new weekly podcast, Serial, asks questions such as these to "search for the truth" about the murder of 18-year-old American student Hae Min Lee.

On Wednesday, January 13 1999, Hae disappeared in Baltimore County, Maryland. Four weeks later her body was found in a shallow grave in nearby parkland; she had been strangled. Six weeks later Baltimore City detectives arrested Hae's ex-boyfriend, Adnan Syed.

Adnan's trial hinged on where he was for 21 minutes between 2.15pm and 2.36pm on the day Hae disappeared; the time she died.

The state's case against Adnan and his eventual conviction for first-degree murder relied on the testimony — the reported memories — of another teenage boy named Jay. There was little or no physical evidence linking Adnan to the crime. Jay said Adnan murdered Hae. Adnan said he had nothing to do with it and didn't know who did.

 Adnan Syed in 1998. Courtesy of Serial

Serial's host and co-producer, Sarah Koenig, tries to piece together what happened through memories: memory reports from then, as told at the trial; and memory reports from now, 15 years after these events, of Adnan (who is serving a life sentence in jail), Jay, their classmates, friends, families, the police and even Hae (via the diary she left behind).

Koenig's search, successful or not, raises fascinating questions about the nature, meaning and complexities of personal recollections.

How does memory work?

In essence, memory can be thought of as a sequence of information-processing stages with three basic tasks:

get information in (encoding)

save information over time (storage)

get information out (retrieval).

As we go about our daily business, we perceive and experience things that are captured in great detail and go into sensory memory for a brief period of three to four seconds. Most of this information we lose. But information that we pay attention to or that captures our attention is transferred to short-term memory; this is what is in your mind right now (the words of this article, for instance, and their meaning).

Short-term memory can hold a small amount of information (seven items, plus or minus two) for a limited time (about 15 to 20 seconds). If we don't use that information almost immediately (such as dial a phone number we've just been told) or rehearse it, we forget it. But if rehearsed, it becomes encoded and can be stored in long-term memory.

Information that reaches long-term memory can last there for long periods of time and be retrieved – brought to consciousness – as a memory report or behaviour, such as dialling that phone number again.

So for Adnan, Jay and their friends to remember what happened on the day Hae disappeared 15 years ago they need to have encoded, stored and be able to retrieve those memories.

But memory is never guaranteed. An event may not be encoded in the first place, it may be difficult to retrieve, or it may be lost from storage.

 A tribute to Hae in the 1999 Woodlawn Yearbook, posted by a Reddit user. Reddit

Memories decay over time, as Koenig discovered when in episode five she interviewed Will, one of Adnan's friends who might have been able to confirm Adnan's alibi of where he was when Hae died:

Will: It's hard to remember that one interaction.

Koenig: You mean I should have asked you 15 years ago?

Will: Maybe five I would have remembered.

Of course, people forget for other reasons, such as intentionally trying to suppress or not think about certain, perhaps upsetting, events. And people can misremember in myriad ways that have nothing to do with deception. They confuse events from different days, or confuse details and events they experienced themselves with ones they learnt about from someone else.

Or they fill in gaps in memory with their best guess of what they probably did and later confuse this with their original memory.

What should we expect from memory?

In most situations, we don't need to recall everything that happens to us every minute of any particular day. Remembering the gist of what happened is often sufficient. But in the legal setting, a high level of precision is usually expected and needed, even when long periods have elapsed since the event in question.

Surveys suggest that people expect they can accurately reproduce details of long-ago events, especially emotional events, even though research shows we are prone to memory failures and errors.

In episode one of Serial, Koenig describes Adnan's memories of January 13 as "mushy", "unhelpful" and "problematic". This is because he remembers only the gist of the day and not details, although he is adamant he did not kill Hae Min Lee. "Why can't you remember anything?" Koenig challenges Adnan.

 Adnan remembers the gist of the day but not the details. Courtesy of Serial

Koenig seeks (but often does not find) detailed and consistent accounts of events she now knows are significant. Significant or emotional events typically are better remembered, especially when well rehearsed. But even reported memories of significant, well-rehearsed events can vary over time. Such fluctuations may be important or unimportant; it is difficult to tell.

This is an area of great practical significance for the legal system and needs more research.

How can we tell if memories are accurate?

In one episode of Serial, Koenig worries that Adnan is lying to her — "playing her" — because his memory reports of the day Hae disappeared seem so vague. In another episode, Koenig points out major inconsistencies in Jay's seemingly more complete accounts of what happened that day.

In the absence of definitive physical evidence or corroboration, how do we judge memories?

People routinely make judgements about the origin or reality of their own memories: "Did I experience it, imagine it, hear about it on the radio?" Memory researchers call this "personal source monitoring". And we routinely make judgements about other people's memories; researchers call this "interpersonal source monitoring".

Everyone has intuitions about what a true memory looks and sounds like. In fact, we use the presence or absence of certain memory qualities — such as completeness, coherence, confidence, emotion — to judge the source or accuracy of our own and others' memories.

On average, memories based in reality contain more perceptual, conceptual, emotional and contextual details. But lots of different kinds of details do not guarantee that a memory is accurate even if the details are persuasive to yourself and others. An event you imagined, for instance, can have similar qualities to an event you genuinely experienced.

 Memories aren't like photographs. Photographee.eu/Shutterstock

Still, in Serial, in courtrooms and in everyday life, detailed, complete and consistent memory reports often are given more weight than vague, fragmented and/or inconsistent memories, which are treated with suspicion.

Since eyewitness memory remains a central form of evidence in criminal proceedings, we need to be aware – as courts increasingly are – that incompleteness doesn't mean inaccurate and completeness doesn't mean accurate. And honest witnesses can be mistaken about the past.

Shouldn't our memories make sense?

In the latest episodes of Serial, Koenig complains that at times neither Adnan's nor Jay's stories make sense. "It doesn't add up," she says.

We like memories to make sense. We strive for meaning and coherence in stories of our personal and collective pasts. If we can't find meaning, we sometimes impose it.

There is risk in looking for or imposing meaning where there is none or where there is messiness. Psychologists Kevin McConkey and Peter Sheehan, who collaborated with Australian police forces to evaluate the use of hypnosis to help victims and witnesses recall information, described choices and behaviours of some people involved in the forensic cases as perplexing: "apparent simplicity", they wrote, "clouds considerable complexity".

In the search for meaning in Serial, the past cannot simply be remembered as it was experienced 15 years ago but in light of both the present and events across the intervening years. As memory researcher Martin Conway argues:

Memories are psychological representations and not like photographs, videos or other types of recording.

This reconstructive rather than reproductive nature of memory means that our knowledge now invariably influences our reported memories of then. So the present — Adnan convicted of Hae's murder and incarcerated — must infuse those memories of the past that Serial is trying to faithfully reconstruct.

It's unclear whether Koenig will find the truth of Hae Min Lee's murder. Memory research suggests that in the absence of physical evidence, she may get no further than a constructed tapestry of what is now believed in reported memories rather than the genuine reality of what happened to Hae.

In any case, Serial is compelling listening. It has been the most downloaded iTunes podcast in recent weeks and has sparked countless water-cooler conversations about who is telling the truth, how memory works and who is responsible for the murder of Hae Min Lee.

Listen to or download the first nine episodes of Serial here.

Editor's note: Amanda will be answering questions between 4 and 5pm AEDT on November 21. Ask your questions about memory in the comments below.

Amanda Barnier receives funding from the Australian Research Council.
 Amanda Barnier, Professor of Cognitive Science and Australian Research Council Future Fellow at Macquarie University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/33257 2014-11-20T05:09:32Z 2014-11-20T05:09:32Z Fixing broken health systems in the aftermath of conflict

Crowding in refugee and internal displacement camps create conditions ripe for disease transmission.

Conflict continues to afflict the globe at a seemingly undiminished rate. The world's attention is focused on Syria and Iraq in an escalating conflict that has resulted in about three million refugees from Syria and nearly two million internally displaced people within Iraq.

Less attention is focused on the many smaller conflicts. Within the Asia-Pacific region, continuing low-level conflicts – such as those between the Indigenous populations of West Papua and Indonesia, and sectarian violence in Bangladesh and Myanmar – attract little attention but continue to cause disruption and hardship, and often death.

Alongside the host of human tragedies, conflicts challenge efforts to ensure health, security and access to basic health care for the world's poorest and most vulnerable populations. Such populations are disproportionately represented in conflict-affected regions: chronic conflict causes chronic poverty and poverty causes conflict.

Dysfunction and disruption

Health systems are disrupted by conflict and insecurity in multiple ways. Health workers flee conflict zones where they are often prized assets, liable to be captured and put to work by rebel armies. Infrastructure is damaged. Records are lost and destroyed.

Injuries from the violence itself may only be the tip of the iceberg of ill health caused by conflict. Infectious disease thrives amidst population disruption. People come into contact with unfamiliar disease vectors to which they have not developed resistance. Crowding in refugee and internal displacement camps creates conditions ripe for disease transmission. Conditions in such camps are also often associated with domestic, sexual and gender-based violence, drug abuse and alcoholism, and mental health problems.

 Conditions at refugee camps can exacerbate mental health problems. IHH Humanitarian Relief Foundation/Flickr, CC BY-NC-ND

In many cases, conflict arises in areas where health systems have long been dysfunctional or barely functional. Take Sierra Leone, which is struggling to contain Ebola. In 1980, 20% of local government areas had no government facilities. Public health expenditure then declined by 60% between 1980 and 1987. This occurred before, and perhaps contributed to, the outbreak of civil war in 1991.

In Syria and Iraq, in contrast, conflict has devastated previously functional health systems. Syrian health statistics had been improving steadily for decades but the conflict has had a severe effect on resources available in the system. The numbers of health staff and hospital beds available have been reduced by more than half.

The Assad regime has reportedly systematically attacked health facilities in opposition-held areas, resulting in the deaths of health professionals and the destruction of infrastructure. The country's pharmaceutical production system has been badly damaged.

The Iraqi system has continued to function but a once excellent system has been eroded by the first Gulf War, international sanctions, the second Gulf War and now the effects of displaced populations.

Such conditions affect people with all kinds of health conditions and medical needs. The disruption of the drug distribution network sends those dependent on regular medication to the black market. Those with acute conditions may lose all access to services.

Rebuilding health systems after conflict

Once peace is re-established, there is a window of opportunity to construct a health system that is less constrained by entrenched political interests. I'm researching these processes as part of the ReBuild consortium, which is building the evidence base to support health-system development in conflict-affected states. ReBuild works with partners in Cambodia, Sierra Leone, Uganda and Zimbabwe.

A number of countries including Afghanistan and Cambodia have used contracts between their health ministries and non-governmental organisations to deliver primary care. There is some evidence that this has enabled a more accessible and effective primary health system to operate when government capacity was weak.

 International health strategies have to be adapted for local communities. DFID - UK Department for International Development/Flickr, CC BY

In Cambodia, for instance, international non-government organisations have been able to manage staff to focus on outputs such as immunisation rates and protocols of care for children. Governments of states that are unaffected by conflict, by contrast, are often unwilling to give up direct provision and the associated degree of control of resources.

Getting investments right in the potential window of opportunity may set the direction of the system for some time. However, the task is formidable. In the immediate post-conflict period, countries are often swamped by multiple humanitarian agencies, presenting challenges for often weak government actors to manage. The agencies' sheer numbers and diversity require complex co-ordination.

Staff members of these organisations tend to be internationally experienced but locally inexperienced, requiring that their strategies are well-adapted to local realities. The ReBuild consortium is helping to build local capacity to translate internationally sponsored visions for the future health system into feasible and well-adapted reform programs.

The complexities of health system development in the aftermath of conflict can be daunting. Aid to conflict-affected countries has historically been lower than to others like them, presumably because of the conflict. However, the post-2015 development agenda will not tackle the issues affecting the world's poorest and most vulnerable if it neglects conflict-affected states.

Barbara McPake is Research co-Director of the ReBuild Consortium which is funded by the UK Department for International Health and Development.
 Barbara Mcpake, Director, Nossal Institute for Global Health at University of Melbourne Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/33895 2014-11-19T19:26:30Z 2014-11-19T19:26:30Z Brain food: diet's impacts on students are too big to ignore

High intake of take-away foods, red and processed meat, soft drinks, and fried and refined food is a risk factor for poor academic performance.  Jay Peg/Flickr, CC BY-NC

As their children submit themselves to the ordeal of all-important end-of-year exams, parents of high school and university students may be wondering what they can do to help. One thing they ought to consider in particular is diet and its potential impact on academic outcomes.

Unfortunately, there's relatively little research into the effect of nutrition on scholastic performance in young adults. But we do know that what we eat affects brain power.

Research findings

Let's start with a brief overview of what the research says. Regular meals three times a day have been linked to higher academic performance in Korean adolescents, in a study from 2003.

In Norwegian teenagers, regular meals (lunch and dinner) were negatively associated with self-reported learning difficulties in mathematics. While foods reflecting a less healthy diet (including soft drinks, sweets, snacks, pizza, and hot dogs) were linked with learning difficulties in maths.

In the same 2013 Norwegian study, regular breakfast was associated with fewer learning difficulties, not only in maths but also in reading and writing.

In a 2008 Canadian study, higher academic achievement was reported in adolescents who consumed more fruits, vegetables and milk. Increased fish consumption positively influenced academic grades in Swedish teens, according to a paper published in 2010.

Another 2010 paper showed that, in Iceland, adolescents who had poor dietary habits (with higher consumption of chips, hamburgers and hot dogs) had lower academic achievement. In contrast, adolescents with higher fruit and vegetable consumption achieved higher academic scores.

In Australia, data from the long-running Western Australian Raine study have shown teenagers' diet impacts cognitive performance, which is a significant predictor for academic achievement.

Specifically, my colleagues and I found a "Western" dietary pattern (high intake of take-away foods, red and processed meat, soft drinks and fried and refined food) at age 14 is associated negatively with 17-year-olds' thinking abilities, especially reaction time and memory.

 A healthy diet may be key to good cognitive performance. Kayla Seah/Flickr, CC BY

We also evaluated the school performance of teenagers in the Raine study. A higher intake of the kind of unhealthy food described above was linked to worse scholastic performance. The adolescents we looked at had poorer scores in mathematics, reading and writing, even after we had corrected for their body mass index and physical activity levels.

In contrast, we found a diet richer in fruit, yellow and red vegetables and whole grains was associated with better academic performance.

Diet and the brain

How exactly does diet affect mental performance? Adolescence is a sensitive time for the developing brain, particularly for the prefrontal cortex and other important brain structures, such as the hippocampus, which are critically involved in learning and memory. Research shows diet is likely to be a significant influence on brain capacity during this stage of life.

The Western dietary pattern appears to provide particular reason for concern at this critical time. This diet correlates with a high overall intake of total fat, saturated fat, refined sugar and sodium but lower levels of significant micronutrients, including folate and iron.

Folate has been positively linked to academic achievement in adolescents while iron deficiency has been associated with poorer mathematics scores in children and adolescents.

More generally, the Western dietary pattern is associated in young people with biological changes linked to metabolic syndrome, a term used to refer to a range of bodily changes associated with increased risk of cardiovascular disease and diabetes.

And this as well as high levels of fat and carbohydrate consumption are linked with impaired thinking skills through changes to key areas in the brain.

All these research findings are consistent with the idea that diet has impacts on teenagers' thinking skills. In particular, they suggest the Western dietary pattern is a risk factor for poor academic performance.

Getting young people to take any advice from their parents is always challenging. But parents who can ensure their teenagers eat well may be conferring significant benefits on their academic performance.

Jonathan Foster has received funding to undertake research from the Australian Research Council and National Health and Medical Research Council and from similar government and not-for-profit funding agencies in the United Kingdom, Canada and the United States. He has received previous private sector funding from Unilever and Pfizer.
 Jonathan Foster, Curtin Senior Fellow, Professor & Clinical Neuropsychologist at Curtin University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/34201 2014-11-19T03:22:10Z 2014-11-19T03:22:10Z Sterilisation deaths: family planning isn't just economics

The death of 13 women in sterilisation camps in India has caused uproar.  AAP

Public outcry, demonstrations and riots have followed the death of 13 women at a government female sterilisation camp in the Indian state of Chhattisgarh. Investigators have blamed tainted medicines and expect the death toll to rise as 20 women remain in hospital in the state capital, Raipur.

Many people may find the whole idea of sterilisation programs abhorrent given contemporary birth control methods are better than any time in history. But the controversy here is not about the utility of birth control and family planning.

There is, in fact, wide agreement among feminists, development practitioners, health authorities and even in most Indian families that limiting the number of children is desirable. The campaigns in India have been successful in raising awareness of the health benefits of family planning.

The main reason the Indian government is so pro-active about population control is economic; it's about poverty reduction and economic growth rather than the happiness and health of families. And the lesson from this terrible episode is that it must not focus on just the economic benefits of sterilisation programs.

Sterilisation programs

At its best, sterilisation happens when a woman, after talking with her husband, decides two or three children are enough and receives a safe and free tubal ligation that she could not otherwise afford. But it's not always that way.

The Indian government's promotion of sterilisation has a long and chequered history. It became highly controversial when, under the state of emergency declared by Indira Gandhi's government in 1975-1977, sterilisation programs were aggressively, and sometimes coercively, implemented.

Clearly, some problems remain.

The first issue is the focus on female fertility. Programs focus on women, by tying their fallopian tubes (tubal ligation) through keyhole surgery. Male sterilisation is far easier but only 2.5% of sterilisations in India are vasectomies, which seems neither efficient nor fair.

Tubal ligation is simple and has very low rates of serious complication, but the absolute number of complications will be high when so many operations are done (around four million a year).

 Sterilisation programs mainly target women, even though the procedure is much less invasive for men. AAP

The greater problem is the difficulty in guaranteeing quality of care, whether it be the skill of the surgeon, the hygiene of the clinic or the quality and safety of medicines, which seems to have been at fault  in this tragedy.

Another problem is that sterilisations are provider-driven and there is typically no cap on the number of operations the government will subsidise. In a culture where the doctor's advice is not questioned, and particularly not by poor and uneducated women, there's a strong risk women might be pressured into the operation by surgeons, private clinics and drug companies who all stand to financially benefit.

Although sterilisation is supposed to be voluntary, under financial or political pressure to meet targets, undue force has been widely documented over the past 40 years.

Similarly, giving women a financial incentive for sterilisation is problematic as it can be a form of force. The women sterilised in the Chhattisgarh program received 1400 rupees, or A$23, which is the equivalent of a monthly wage for many poor villagers.

Land, fertiliser and household goods have also been given out to achieve target rates. These incentives can result in women being pressured by their families or by their extreme poverty into having tubal ligations and hysterectomies, often at a young age and against their wishes.

A measured response

As India transitions to a middle-income country, and as child mortality and death rates drop, large families are generally no longer as desirable as they once were. And given the scale of the sterilisation program, adverse events will happen. But when they result from a government-sanctioned and non-essential surgery there is rightly an outcry.

Still, it's important to remember that deaths resulting from sterilisation camps are rare events for what is a very common and usually safely performed procedure. So suspending the country's sterilisation program on the basis of 13 deaths might be an overreaction.

But this tragic event does provide a healthy space for reviewing the inherent problems in such schemes so women are better protected from coercion and to ensure that family planning is safe and minimally invasive. While economically important, the policy and program cannot and should not be measured solely by its economic impact.

Nathan Grills does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Nathan Grills, Public health physician and post-doctoral researcher, Nossal Institute of Global Health at University of Melbourne Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/33409 2014-11-18T19:24:47Z 2014-11-18T19:24:47Z Health risks of nicotine cast doubt on 'safer' e-cigarette

E-cigarettes should not be sold in Australia, as a therapy or a consumer product. gdvcom/Shutterstock

British American Tobacco Australia has lobbied Australia's Therapeutic Goods Administration to have electronic cigarettes (e-cigarettes) classified as a harm-reduction pharmaceutical product. If successful, this would allow media advertising for e-cigarettes similar to that seen for nicotine replacement products.

On Friday the ABC revealed the TGA had mistakenly approved an e-cigarette device as a "quit smoking aid". The product remained on the Australian Register of Therapeutic Goods for two months before the TGA realised the error and began a review of the product.

E-cigarettes, of course, are battery-operated devices that vapourise fluids so they can be inhaled deep into the lungs. The nicotine enters the arterial blood and goes straight to the brain, much like the nicotine from regular cigarettes.

There is no evidence e-cigarettes help smokers quit. Nor are they harmless; even without the smoke, nicotine poses a number of health risks.

E-cigarettes should not be sold in Australia, either as a therapy or a consumer product.

Not a tool to help smokers quit

Proponents of e-cigarettes argue the product represents an important advance in harm reduction, so Australia's ban on the sale and promotion of e-cigarettes is "counterproductive". Because the vapour contains lower levels of the chemicals found in cigarette smoke, they argue it poses less of a risk to users and bystanders.

They also argue e-cigarettes may be more effective than unassisted quitting or nicotine-replacement therapies such as patches, gum or inhaler.

Those urging a more cautious approach, as we do, point to the near-complete absence of any rigorous analysis of their safety, usage patterns and effectiveness in helping smokers quit.

 E-cigarette manufacturers produce a variety of sweet-flavoured vapourising 'juices'. librakv/Shutterstock

Opponents are also concerned about the appeal of e-cigarettes to non-smokers, particularly adolescents and children. They may be attracted by the commonly added range of candy, fruit and other flavourings.

These concerns are exacerbated by the tobacco industry's determined entry into the e-cigarette market in recent years. Regulatory uncertainty in the United Kingdom and United States, for instance, has allowed the industry to aggressively promote e-cigarettes that are designed and packaged to look like traditional products in markets where cigarette advertising has been long prohibited.

Promotion and the increasing use of e-cigarettes in public spaces threaten to undo decades of progress in tobacco control. This also represents an important strategic opportunity for the tobacco industry to circumnavigate advertising restrictions at precisely the moment when a number of countries are removing package branding and point-of-sale displays.

Health risks of nicotine

Curiously, the key issue of health risks associated with nicotine has been largely marginalised in the e-cigarette debate. In a letter to World Health Organisation Director-General Margaret Chan earlier this year, proponents of e-cigarette stated: "We have known for years that people 'smoke for the nicotine, but die from the smoke'." But the health risks extend beyond the smoke.

A recent article in Nature Reviews Cancer suggests nicotine is genotoxic (capable of damaging DNA and leading to cancer), promotes tumours and is linked to the onset and growth of head and neck, gastric, pancreatic, gallbladder, liver, colon, breast, cervical, urinary bladder and kidney cancers, as well as small-cell and other lung carcinomas.

There are also potential implications for immune response. Nicotine is an immunomodulator, an agent that can alter the body's ability to produce antibodies. This can impact a range of cells involved in inflammatory processes, including those in the lung and vascular system.

This may have important implications for those infected with tuberculosis and other bacterial diseases. It could also have particular implications for those with compromised immune systems. Patients with HIV/AIDS, for instance, are more vulnerable to tuberculosis infection.

 There's no evidence e-cigarettes help smokers quit. Gianluca Rasile/Shutterstock

Nicotine can impact on fetal brain development and cause acute nicotine toxicity. The number of cases of nicotine poisoning caused by swallowing e-cigarette liquids containing nicotine has risen sharply in the US and UK.

Recent research on second-hand exposure indicates that while vapour from e-cigarettes is less harmful than cigarette smoke, it can expose bystanders to nicotine as well as other potentially toxic elements.

Time to re-frame the debate

Disagreement on the potential health impacts of e-cigarettes has divided the tobacco control community unlike any other recent topic, except perhaps for the "safer" cigarette notions of low-tar and light. Unregulated advertising of these no-less-harmful products allowed them to flourish in a sea of unsubstantiated health claims.

Nicotine is potentially addictive regardless of how it is consumed. This raises questions about the logic and morality of licensing new delivery systems as consumer products. Further, focusing on its addictive properties has arguably contributed to public misconceptions about nicotine's links to carcinogenesis and other health risks.

We need a greater understanding of the health effects of nicotine – and e-cigarettes in general – to inform current regulatory debates at the national and global level. Until then, there is enough evidence to support a precautionary approach to e-cigarettes that puts public health concerns ahead of the commercial freedoms of the tobacco industry and other e-cigarette manufacturers.

Ross MacKenzie has received research funding from the Rockefeller Foundation, the National Institutes of Health, and the Cancer Council NSW.

Benjamin Hawkins receives funding from the NIH.

Thomas Novotny receives funding from The National Institutes of Health, the SeriousFun Foundation, and the University of California Tobacco Related Disease Research Program. He is the CEO of the Cigarettee Butt Pollution Project, a 501c3 Tax-exempt Organization registered in California..
 Ross MacKenzie, Lecturer in Health Studies at Macquarie University Thomas Novotny, Professor of Global Health at San Diego State University Benjamin Hawkins, Lecturer in Global Health Policy at London School of Hygiene & Tropical Medicine Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/23928 2014-11-18T03:32:41Z 2014-11-18T03:32:41Z Resettled refugees adopt Australia's bad food habits

Newly arrived refugees face many obstacles to making healthy food choices. Lucian/Flickr, CC BY-NC

Refugees settling in Australia constantly face new challenges. They have to re-adjust to new income levels, cultural practices and language. They also face a new food environment, where many traditional foods aren't available and Western foods and preparation styles seem strange or unfamiliar.

In Australia, refugees are often resettled in areas with many unhealthy foods outlets and poor access to fresh fruit and vegetables. Newly arrived refugees have little money to spend on food. They also often don't have access to a car or nearby public transport, diminishing their ability to make healthy food choices.

This situation is leading to an unhealthy assimilation. By adopting unhealthy diets, refugees are at risk of excess weight gain. In turn, that can lead to chronic illnesses such as type 2 diabetes, cardiovascular disease, arthritis and osteoporosis.

Existing disadvantage

For refugees, many factors impact on food preferences. These include housing insecurity, employment, financial hardship, changed social status and adapting to a new culture and environment. Parents may prioritise other settlement needs, such as settling children into school and earning an income, ahead of their own health.

Added to these burdens, many newly arrived refugees are contending with significant mental health issues. A large British review that tracked 7,000 refugees in resettlement found 9% of adults and 11% of children had post-traumatic stress disorder (PTSD) and 5% of adults suffered major depression.

Pre-arrival factors that may continue to influence diet and nutrition during settlement include prolonged deprivation, malnutrition, contaminated water, untreated or undiagnosed illnesses such as parasitic infections and chronic diarrhoea, and dental problems that may cause difficulties eating.

Refugees are then faced with unfamiliar Western foods, different food preparation styles, changes to lifestyle and exercise, lack of nutritional education and reduced local access to affordable food. They may not be able to access the traditional foods they're used to and prefer.

The poor financial situation refugees find themselves in, coupled with a lack of family support and multiple psychosocial stressors, greatly diminishes their ability to make healthy food choices.

Case study: Woodridge

We mapped the availability of food outlets and vegetable consumption among a group of resettled African refugees in Woodridge, in Queensland's Logan Central area.

Woodridge has a total population of 20,650. There are 0.9 fast food outlets per 1,000 people and only 0.1 healthy food outlets per 1,000 people.

We asked 28 participants to complete a questionnaire on household vegetable availability and consumption. The participants ranged in age from 19 to 52 and had lived in Australia for an average of 4.5 years.

We then mapped the routes (using the streets network analysis) from each of the 28 participants' households to their nearest food outlet.

Within a radius of two kilometres from their home, the participants had access to three healthy food outlets, with a median distance of 841 metres and walking time of 10.5 minutes. They had access to 19 fast food outlets, with a median distance of 641 metres and walking time of eight minutes.

We found participants who lived near a healthy food outlet such as a supermarket or farmers' market had a higher intake of vegetables than those who lived further away. The critical threshold was around 400 metres.

Those who had significantly better access to takeaways and convenience food shops favoured unhealthy food.

Adapting to the new food environment

This complex problem requires a strategic multilevel response. Public health policymakers need to work with refugee communities to develop and implement health promotion strategies to improve diet and nutrition early in the settlement process.

First, initial health assessments must identify nutritional deficiencies and take into consideration the impacts of malnutrition.

Second, newly arrived communities need more information and education about the nutritional value of Western foods, how to assess their healthiness and how to substitute unhealthy foods with more nutritious options. Dietitians and social workers also need to be trained to address cultural differences and traditional preferences.

A culturally sensitive model to "train the trainers" could help newly arrived refugees adapt to their new food environment. This is when one individual from the community is trained, then teaches the skills to others and so on. The training could increase awareness of available healthy Western food, improve cooking skills and educate community members about the impact of unhealthy diets on health.

Finally, and most importantly, governments need to act on the heavy distribution of unhealthy food outlets and lack of access to healthy foods, particularly in refugee settlement areas.

This article was co-authored by former Griffith University PhD student Catherine Gichunge.

The authors do not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article. They also have no relevant affiliations.
 Ori Gudes, Research fellow at Curtin University Sanjoti Parekh, Research fellow at Griffith University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/32625 2014-11-17T19:17:14Z 2014-11-17T19:17:14Z Justice for all: how should the law deal with false confessions?

The vulnerability of mentally disordered people warrants a range of strong protections to prevent wrongful convictions Emmanuel Huybrechts/Flickr, CC BY-SA

Confessions constitute strong evidence of wrongdoing, but not all of them are reliable. So what can the legal system do to ensure justice is done? A US judge is deciding on exactly this matter in a prominent trial of a man accused of what The New York Times has described as "one of the most infamous crimes" in the city's history.

Pedro Hernandez, a 53-year-old man described as being of limited intellect and with a history of mental illness, is charged with the historical murder of Etan Patz. The six-year-old boy disappeared on his way to school in Manhattan in 1979.

The case remained unsolved for 33 years until police arrested Hernandez on May 23, 2012. He is said to have confessed after a long day of "emotional" questioning.

At issue now is Hernandez's confession; the legal discussion has been about whether it should be admissible as evidence in his trial.

Inbuilt biases

There's a strong body of evidence about confessions. In the past, a number of wrongful convictions have relied on false confessions: the Guildford Four and the Birmingham Six are the most famous British cases.

While being questioned by police, a suspect may make a false confession while exhausted, intoxicated or withdrawing from drugs or alcohol; they may not understand the purpose of the interview or how their confession will be used in court; or their confession may be influenced by mental illness or intellectual disability.

In the case of Hernandez, it's suggested he was not read the standard caution until six hours into the police interview in which he confessed to killing Patz. And that he did not understand his right to remain silent.

Most jurisdictions protect the rights of a suspect and generally ensure police caution them about such rights. They also allow the suspect to seek legal advice prior to interview. But research shows the wording of such cautions may require language skills commensurate with mid-secondary schooling.

Given the prevalence of mental disorders, cognitive impairment and language disorders in the criminal justice system, the caution and language used may be too complex for a significant number of suspects.

An independent observer or an assessment of fitness for interview by a forensic medical officer or psychiatrist are possible safeguards, but both measures still rely on recognition of potential disorders by police.

Researchers who have investigated the basis of false confessions highlight interrogation techniques and tactics that may increase untrue confessions, as well as characteristics of the person being questioned.

In particular, they propose some people are suggestible, will acquiesce, or are unduly compliant. In the context of an emotionally charged interview, they may be prone to confessing to offences they didn't commit. Even when subsequently retracted, the confession evidence may be sufficient to result in conviction.

The law's disinterest

In addition to structural and political biases that may be associated with incorrect findings of guilt, retrospective assessments of miscarriages of justice often note that a confession may prevent proper scrutiny of other – potentially exculpating – facts.

Evidence law provides a statutory framework to determine what material can be presented to a judge or jury. As in the Etan Patz case, there may be dispute about the understanding of a caution, the circumstances of interview and whether cognitive impairment or mental disorder resulted in unreliable admissions.

At issue here is a strong piece of evidence that may bring to justice the murderer in a shocking and emotional case. But the justice system shouldn't be blinded by emotion or overlook troubling elements of a police interview and confession, as well as the characteristics of the accused person.

In Australia, the Uniform Evidence Law has over recent years provided a robust framework to restrict the admission of evidence to what has been properly obtained. What's more, the likelihood that evidence is probative (assists the court) must outweigh its potential unnecessarily to prejudice a judge or jury.

Nevertheless, we could still perhaps do more to ensure that vulnerable people are identified and appropriately supported during police interviews.

For Pedro Hernandez, the discussion about the admissibility of his confession may seem abstract and technical, involving mental health professionals and cognitive and psychiatric assessments. But the vulnerability of mentally disordered people warrants a range of strong protections to prevent erroneous convictions. These may otherwise diminish the reputation of the justice system.

Danny Sullivan does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Danny Sullivan, Adjunct Senior Lecturer in Psychiatry at Monash University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/33669 2014-11-17T03:05:11Z 2014-11-17T03:05:11Z Health Check: is controlled crying the best way to get baby to sleep?

Leaving distressed babies to cry without comforting them may compromise their psychological development. Pedro Klien/Flickr, CC BY-SA

Controlled crying has been hotly debated since it was first recommended in a 1985 book about infant sleep problems. It involves letting a baby cry itself to sleep without any interaction once it has been put to bed, but leaving distressed babies to cry may compromise their psychological development.

Most behavioural approaches applied to infant sleep problems, including controlled crying, derive from a learning theory-based process called extinction. In its pure or unmodified form, this involves removing all rewards, including attention, for a particular behaviour until it's no longer in the child's repertoire.

But controlled crying is at odds with research on infant development that shows the foundations for lifelong psychological health are laid down in infancy when distress is responded to promptly and reliably.

Better ways

There are now several gentler approaches involving modified extinction. These can help resolve both infant sleep problems and maternal depression arising from chronic sleep deprivation.

Modified extinction approaches include the progressive waiting method, which involves putting the baby to bed while awake and then gradually withdrawing attention, comfort and reassurance. Then there's systematic ignoring with minimal checks, which involves patting and vocal soothing, but not picking the baby up or offering the breast while it remains unsettled. Co-sleeping and parental presence also form part of gentle sleep training routines.

"The sensible sleep solution" involves developing age-appropriate pre-sleep and sleep routines. You might breastfeed the infant just before bedtime, for instance, but not breastfeed it to sleep, in order to encourage the development of effective sleep habits.

These modifications have softened the hard edges of the original approach, which often resulted in babies left to cry to the point of extreme hyper-arousal and distress that could result in screaming, vomiting, hyperventilation and breath-holding.

Psychological implications

A baby's cry signals that all is not well - although the opposite is not necessarily true when crying stops. Children whose emotional communications are systematically ignored initially respond with acute distress, followed by a gradual and painful process of realisation that the caregiver is not available. Ultimately, they adapt to neglect by ceasing their attempts to engage their caregiver.

Observational studies from the 1950s of institutionalised infants whose distress cries went unattended showed a typical pattern of protest (intense crying), despair (quiet, passive sitting) and detachment (from relationships).

These observations were subsequently confirmed for children younger than four years old who experienced even brief separations from their mothers.

For some infants and children, every sleep episode may be emotionally challenging because it involves a separation. Before recommending behavioural approaches to infant sleep problems, health professionals need to assess the whole family – particularly the mother's attachment to her infant, overall parenting style and psychological well-being – to ensure the chosen approach is appropriate.

Facts about infant sleep

Sleep disturbance in infants and young children is common; up to 40% of normally developing children experience difficulties in either initiating or maintaining sleep.

This proportion increases to 80% in children with medical conditions, such as developmental deficits or obstructive sleep apnoea; those with psychological conditions, such as anxiety, ADHD, autism spectrum disorders and depression; or behavioural problems that often arise from poor parental management, such as inconsistent limit-setting and disorganised bedtime routines.

Too little sleep and too much crying are injurious both to a child's development and to parental well-being. Some children will simply outgrow their sleep problems, but many won't without a specific intervention.

Parents need to consider a wide range of strategies and apply them appropriately to different forms of sleep disturbance. In a minority of cases where the infant or child has particularly difficult sleep problems, short-term medication may be the answer. Drugs such as clonidine, trazadone and antihistamines may work but their long-term use is ineffective and not recommended.

For those having trouble falling asleep, melatonin, which is an endogenous hormone that controls the sleep-wake cycle could work. Behavioural strategies, such as anxiety-relaxation techniques (co-sleeping with minimal responding, for instance) and the use of the gentler sleep management approaches described above, may reduce disruptions to overnight sleep.

Applying behavioural sleep routines

The age of the child is critical in selecting the best sleep-support method. No unmodified extinction-based behavioural strategies, such as controlled crying, are recommended for infants, especially those younger than three months of age.

For children who can talk, cognitive-behavioural approaches or one of the other modified extinction options discussed above may be effective in managing unsettled sleep habits.

Although there's evidence controlled crying "resolves" infant sleep problems, there's also evidence that the intense level of stress induced by repeated, prolonged, uncontrolled crying may damage the infant's developing brain and impair subsequent emotional regulation.

Several factors contribute to a child's reaction to sleep time, including their level of object and person constancy – that is, their understanding that mother still exists even though she's out of sight. Also influential is their innate temperament (some are just easier to settle than others) and the appropriateness of parental responsiveness to the baby's general needs and communications.

The overall quality of parent-child attachment and parental behaviours at sleep time also affect infant sleep patterns. If baby is unsettled, myriad causes may be responsible. Parents need to check that their baby is not hungry, colicky, too warm or too cold, has a dry nappy, is not ill, feverish, or uncomfortable from teething, and so on.

Parents also need to review their sleep time routines to ensure they are not inadvertently exacerbating their infant's sleep difficulties. If the sleep routine is not conducive to settled sleep and results in sleep disturbance, this needs to be resolved through parental education and counselling.

A settled parent is necessary for a settled and secure infant. After that, baby's sleep routine may benefit further from gentle modified-extinction procedures, especially those involving parental presence.

Editor's note: Dianna will be answering questions between 3:30 and 4:30pm AEDT on November 17. Ask your questions about controlled crying in the comments below.

Dianna Kenny receives funding from the Australia Research Council, the Australia Council for the Arts, and the NSW Department of Juvenile Justice. She is the author of Bringing up Baby: The Psychoanalytic Infant Comes of Age (Karnac, 2013).
 Dianna Kenny, Professor of Psychology and Music at University of Sydney Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/34000 2014-11-16T19:16:46Z 2014-11-16T19:16:46Z Hay fever survival guide: why you have it and how to treat it

Antihistamines are the first-line treatment for those with mild or occasional hay fever. Tina Franklin/Flickr, CC BY

Three million Australian adults – 15% of the population – struggle through spring and summer with watery eyes, running nose, itchy throat and the hallmark hay fever symptom, sneezing.

When people with hay fever are exposed to particular pollens, their body mistakenly thinks this is a threat and triggers an allergic reaction. Inflammatory cells quickly release mediators such as histamine and that's when the symptoms kick in.

In some people with hay fever, pollen allergens can trigger allergic symptoms in the lower airways as well as the nose, making it difficult to breathe. Under certain climatic conditions, such as after thunderstorms, pollen allergy can trigger asthma attacks, even in those without a history of asthma.

Hay fever can have a profound effect on our ability to function normally. The problem seems to be getting worse, or at least consumers are increasingly looking to alleviate their symptoms. In the ten years to 2010, the wholesale turnover of drugs to treat hay fever doubled.

Why you have it

Grass pollens are the major outdoor allergen trigger for hay fever in Australia. The timing and severity of the grass pollen season varies considerably between years and places, according to a recent analysis of 17 sites across Australia and New Zealand.

With a temperate climate, Melbourne usually has a short but intense grass pollen season, peaking late in spring (October to November). In Hobart, the grass pollen season peaks slightly later and the pollen load is low.

In contrast, Brisbane and Darwin have grass pollen seasons extending most of the year, with peaks in summer for Brisbane (January to March) and in the dry season in Darwin (May and June).

Adelaide, Sydney and Canberra have the temperate grass pollen season in spring but also have secondary peaks in summer. These late summer peaks in grass pollen are likely to be due to subtropical species.

 Levels of airborne pollen are influenced by weather and pollen production. Juan Ojeda/Flickr, CC BY-NC-SA

Australia is yet to establish a standardised network to monitor the timing and magnitude of pollen exposure. Levels of airborne pollen are influenced by weather and other factors affecting pollen production. Predictions of airborne pollen in the absence of actual pollen counts are therefore inaccurate and unhelpful.

Beyond biology, location and flowering times, patients with hay fever in Australia also show region-dependent patterns of allergic responses to subtropical and temperate grass pollens. This can affect the diagnosis and treatment of grass pollen allergy in Australia and elsewhere.

How to manage your symptoms

A number of oral medications, nasal sprays and eye drops to treat hay fever are available over the counter at pharmacies. They work in different ways and have different pros and cons.

Antihistamines have been used to manage hay fever for decades and can be the first-line treatment for those with mild or occasional hay fever. When you can predict exposure to an allergen, such as when lawn mowing or going on a picnic in spring, taking an antihistamine before the exposure will provide better protection. They are also safe to use in the long term.

Opt for the newer, non-sedating varieties of antihistamines. The older drugs, which are still available, cause drowsiness and have been shown to contribute to workplace accidents in adults and impaired learning in children.

Antihistamines in general are good for itching, sneezing and watering symptoms, but do not relieve nasal blockage very well. Decongestant tablets and sprays can do this job, but they are limited to relieving symptoms only and do not resolve the underlying inflammation.

 Some people with hay fever have troublesome eye symptoms, usually itching, watering and redness. Andrew Goloida/Flkickr, CC BY

Overuse of decongestant nasal sprays can lead to longer-term problems with nasal blockage, so limit their use to a few days only.

For people with moderate to severe and persistent symptoms of hay fever, the most effective medications are the intranasal steroid sprays. The older ones are now over-the-counter items and others are available by prescription.

These sprays have a "preventative" action and are most effective when use begins before the pollen season. If not, they will start relieving symptoms after a few days. The sprays must be used every day during the season to allow the best chance of success and to minimise side effects in the nose. They have also been shown to reduce allergic eye symptoms.

Some people worry that these are "steroid" sprays, but they differ greatly from traditional oral steroids. The modern topical steroid sprays are barely absorbed into the body and don't have the much-feared muscle-building steroid side effects. A small percentage of people will experience some nasal bleeding, even if using the spray correctly; this is the most common side effect.

A number of people with hay fever will have troublesome eye symptoms, usually itching, watering and redness. If this isn't relieved with topical nasal sprays, topical antihistamine eye drops can be very effective. Rinsing the eyes with an artificial tear solution of saline fluid can also be very soothing.

For people with severe and prolonged symptoms or who can't gain adequate control with available medications, allergen-specific immunotherapy is available. This should be prescribed by an allergy specialist who determines the correct "vaccine" for the therapy. The immunotherapy program may extend over three to four years and is the only therapy that can provide long-lived benefit.

If you suffer from regular hay fever symptoms and medications don't seem to be working, talk to your doctor. They can help guide you to the safest and most effective treatment option.

Janet Davies receives funding from the National Health and Medical Research Council, The University of Queensland and The Princess Alexandra Hospital Foundation. She has consults to Stallergenes Pty Ltd and has received Honorarium from Glaxo Smith Kline and in kind research support from ThermoFisher (Sweden) and Sullivan Nicolaides Pathology (Australia). The Australian Aerobiology Working Group was supported by the Australian Center for Ecological Analysis and Synthesis and co-sponsored by untied funds from Merck Sharp and Dohme.

Connie Katelaris has received honoraria from Meda and also Stallergenes for giving lectures.
 Connie Katelaris, Professor of Immunology and Allergy, UWAS & Head of Unit at South Western Sydney Local Health District Janet Davies, Senior Research Fellow, Lung and Allergy Research Centre at The University of Queensland Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/34233 2014-11-14T04:13:05Z 2014-11-14T04:13:05Z Should people with acute mental suffering be allowed to die?

Too stringent an approach to assisted dying risks locking people with mental illness out of the right to make decisions about the end of their lives. Thomas Hawk/Flickr, CC BY-NC

Euthanasia advocates often assert a distinction between dying with dignity (good) and suicide (bad), drawing on the community's twin commitment to both permitting euthanasia in some circumstances, and preventing suicide. But rather than being distinct, euthanasia and suicide are points on a continuum of death decisions, that overlap uncomfortably where intractable mental suffering is asserted as grounds for assisted dying.

The tension between the two was played out this week in the Northern Territory, where the local Civil and Administrative Tribunal is considering whether to uphold the Medical Board of Australia's suspension of Philip Nitschke's medical licence after a three-day hearing.

The suspension came after Nitschke discussed assisted suicide with 45-year-old Perth man Nigel Brayley even though he knew Brayley did not have a terminal illness. Brayley reportedly told Nitschke in an email that he was "suffering" in the sense that he was deeply unhappy in his life. Nitschke did not refer to him to a psychiatrist or offer any other help.

More complex than it appears

Nitschke's actions have been roundly criticised, particularly by other euthanasia advocates, who seek to distance themselves from existential justifications for assisted suicide. However the idea that euthanasia should not be offered for mental suffering is not universally agreed, and requires some further consideration.

In the Netherlands and Belgium where euthanasia is legal, assisted dying for emotional suffering is permitted. Approval will only be granted where where applicants are of age, mentally competent and their suffering constitutes an "incurable condition" that causes continuous and unbearable anguish.

Of the 1,432 recorded cases of euthanasia in Belgium in 2012, 52 were on psychological grounds. In the Netherlands, the figure was 42 out of a total of 4,829 cases in 2013.

Still, the idea – and practice – remains deeply controversial. Concern often focuses on a lack of confidence in the notion that mental illness or emotional pain should ever be regarded as "incurable". A troubling question then arsies as to whether we might be too carelessly priviliging the right to autonomy, and undermining our responsibility to protect vulnerable people from harm.

 There's concern about the confidence with which we can say that mental illness or emotional pain should be regarded as 'incurable'. Porsche Brosseau/Flickr, CC BY

Others have suggested that if we extend the right to die beyond those who are actually already dying, we risk setting off down a "very dangerous path and one that's extremely slippery". This worry seems to be that we slide into a situation in which marginalised and vulnerable people's right to life will not be sufficiently protected.

A fine line

But too stringent an approach risks locking people with mental illnesses out of the right to make decisions about the end of their lives – and this might be discriminatory.

In a troubling 2012 UK case, for instance, a hospital was ordered to cease a palliative care program consented to by a 32-year-old woman with anorexia nervosa and to forcibly re-feed her despite her deep distress at the prospect. The woman had consistently refused re-feeding over the past several years, experiencing it as a violent assault.

The court decided the fact that she had an eating disorder made her incompetent to make a legally enforceable decision to refuse treatment. The implication of the decision was that, by definition, people with anorexia cannot make an end-of-life decision, no matter how harrowing and intractable their illness becomes.

It was a conclusion that bitterly disappointed the woman's parents, who said:

It seems strange to us that the only people who don't seem to have the right to die when there is no further appropriate treatment available are those with an eating disorder.

Nitschke may well have made errors in his assessment of Brayley. These will be considered by the tribunal. But he had a reasonable point when he said that he had suffered a "political deregistration" because "a government board … doesn't agree with the beliefs of its citizens". Certainly there are a range of defensible views on what is a good life and when assisted dying is acceptable. In any case, the fact remains that assisted dying for mental suffering is a long way from achieving broad acceptance in Australia.

If you have depression or feel very low, please seek support immediately. For support in a crisis, contact Lifeline on 13 11 14. For information about depression and suicide prevention, visit beyondblue, Sane or The Samaritans.

Sascha Callaghan does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Sascha Callaghan, Lecturer in Health Law & Bioethics at University of Sydney Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/33191 2014-11-13T04:44:32Z 2014-11-13T04:44:32Z Ebola's 'other' victims: how the outbreak affects those left behind

Even before the Ebola outbreak, Guinea, Sierra Leone and Libera were among the world's poorest countries. EPA/Ahmed Jallanzo

Media coverage of the growing Ebola epidemic in Guinea, Sierra Leone and Liberia has presented world audiences with apocalyptic predictions of ultimate death tolls and grisly imaginings of its spread to other shores. But we've heard little about the people left behind. What impacts has the epidemic had on their livelihoods?

Consider this story of an okada (motorcycle taxi) driver in the Sierra Leonean city of Makeni. Following the Ebola-related deaths of a number of this man's relatives, the Sierra Leonean government – not unreasonably – placed him under quarantine for 21 days. When he emerged with clear test results he found that the government had banned okadas from operating, in an attempt to contain the spread of infection.

Despite avoiding infection, the driver was unable to make a living. He later doused himself in petrol (gasoline) to end his life. For this young man and many others among the 25 million people of Guinea, Sierra Leone and Liberia, Ebola is not just an epidemiological terror, it is also a socioeconomic disaster.

Before the epidemic, these three countries were already among the world's poorest. They ranked within the bottom 5% of the Human Development Index. Five million of their combined population is considered undernourished.

Though the causes are longstanding and complex, one reason for this poverty is the region is still recovering from another disaster, the Mano River Wars (including the Civil Wars of Sierra Leone from 1991 to 2001 and Liberia from 1989 to 1997 and 1999 to 2003). These wars displaced millions, destroyed infrastructure and ruined countless livelihoods.

An important effect of wartime displacement was the meteoric growth of urban centres such as Freetown. In the post-conflict context, many recovering households have become dependent on incomes from serving the needs of new and expanded urban markets.

 Fuelwood is harvested in rural villages, before being transported and sold in nearby urban centres. Photograph provided by Energy For Opportunity, Author provided

In Sierra Leone, for example, there is a thriving trade in forest products including construction timber, firewood and charcoal.

Harvested in rural villages, these commodities move through complex transport and trading systems for final sale by thousands of urban vendors. This provides incomes for large numbers in every corner of the country.

The functioning of these economic networks and most others in the region, however, depends critically on both mobility and public assembly. Both of these have been severely constrained by necessary Ebola counter-measures such as quarantines (often of entire cities), highway closures and urban lockdowns. Given the widespread poverty in the region, with people living hand to mouth, this is undoubtedly causing severe impacts on already vulnerable households.

Compounding this issue, schools are closed in all three countries, and are likely to remain so well into next year. This is a major concern for a region with low rates of adult literacy: Sierra Leone 43.3%; Liberia 42.9%; and Guinea 25.3%.

The myriad impacts on already weak health sector systems are also serious. Before the outbreak, Sierra Leone was estimated to have around 120 physicians serving its population of 6 million. This equates to around two doctors per 100,000 people. For a comparison, Australia has around 390 physicians per 100,000.

So far five Sierra Leone doctors have already died from Ebola infection (nearly 5% of the physician population in the country), with more currently suffering from Ebola infections. This not only limits the country's capacity to tackle the Ebola crisis, but will also have a debilitating impact on the country's health sector, now and in the future. Many people have already died in the region after avoiding medical care for fear of contracting Ebola.

 The economic networks of Sierra Leone, Liberia and Guinea depend on mobility and public assembly. EPA/Ahmed Jallanzo

Similarly, development programs have been halted or cancelled due to health risks to international staff. Despite recent good progress, all three countries were already struggling to meet their Millennium Development Goals. The Ebola crisis has almost completely ensured they will not be reached.

Ultimately, however, it's clear that dealing with setbacks in achieving regional development priorities is both secondary to, and dependent upon, coping with the immediate effects of near-total economic shutdown.

The Ebola crisis presents a cruel paradox. Efforts desperately needed to contain the infection of thousands are simultaneously causing major, and in some cases severe, economic hardship for a population of millions. The international Ebola response will need to continue well after the crisis has faded from world news reports.

The authors do not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article. They also have no relevant affiliations.
 Paul Munro, Lecturer in Environmental Humanities at UNSW Australia Greg van der Horst, PhD Candidate in Resource Management and Geography at University of Melbourne Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/33882 2014-11-12T19:30:18Z 2014-11-12T19:30:18Z Paramedics administer drugs and deliver babies, they deserve national registration

National registration would set educational and professional standards to better protect patients.  AAP Image/Peter Scarf

Paramedics are one of the few health practitioners who can administer drugs and anaesthetics, deliver babies and perform high-risk interventions, all with relative autonomy.

Yet the paramedic profession is largely unregulated – and what regulation there is is becoming increasingly inconsistent. In fact, paramedics are the only group of mainstream health practitioners not governed by the national regulator, the Australian Health Practitioner Regulation Agency.

National registration is important because it allows the profession to establish national educational standards, professional codes of conduct and practitioner disciplinary measures. These help ensure the delivery of quality care to patients and allow regulators to restrict or suspend the practice of impaired or under-performing practitioners.

National registration also benefits practitioners. It allows for transferable qualifications so people can move from job to job. It offers support and guidance for impaired practitioners. Importantly, it recognises registered practitioners as independent professionals who have obligations to their patients, the profession and their employers.

But the Australian Health Workforce Ministerial Council recently decided to defer the decision about whether to include paramedics as part of the scheme until some time in 2015. This was a mistake. Paramedics should be part of the national registration scheme. And this transition needs to begin now.

What do paramedics do?

In 2012-2013 New South Wales paramedics responded to more than 1.2 million emergencies and other call-outs. The care they provide includes:

inserting needles and tubes into patients' bodies;

administering heavily regulated and dangerous drugs such as morphine and anaesthetic agents;

managing labour and delivering babies.

They commonly require patients to disrobe. These procedures are usually undertaken in the pre-hospital environment which is, unlike a hospital, largely uncontrolled. This increases the risk that these already risky procedures pose to patients.

The nature of the work and the access to scheduled drugs also increases the risk of paramedics developing a drug dependence or mental health condition, which can impair the practitioner and risk harm to the patient.

 Most state ambulance services fall within the responsibility of the Minister of Health. AAP Image/Julian Smith

The Australian Health Ministers' Advisory Council identified criteria that must be considered when deciding whether a currently unregulated health profession should be subject to professional registration. This includes whether the occupation poses "a significant risk of harm to the health and safety of the public" – clearly it does – and whether existing regulation provides adequate protections.

State-based registration

Some organisations, including the peak professional association Paramedics Australasia, argue existing regulation is inadequate to provide protection to the public because there is no national mandatory minimum set of prescribed skills, education or professional standards that applies to paramedics.

Although most government-related ambulance services now require a tertiary university degree as the minimum entry to practice, standards for practice vary across states and sectors.

And unlike the national scheme, there is no publicly available, easily accessible mechanism that allows the public or employers to check whether a paramedic has significant health, conduct or performance issues that may threaten patient safety.

In the absence of national paramedic registration, the states are beginning to move on their own.

Until recently, for example, the "paramedic" title was unprotected at law, meaning anyone could call themselves a paramedic without holding any formal training or certification. South Australia and Tasmania have now introduced laws that will protect the "paramedic" title and established core criteria that are required to be met in order to be eligible to use it.

 State-based schemes make it difficult to move between different jurisdictions. AAP Image/Careflight

Victoria has announced it will also do this as it considers going even further and introducing a state-based registration scheme that is modelled largely on the national scheme.

This go-it-alone approach presents a number of problems. Among them is the unnecessary cost of duplicating a scheme in each state that is already established nationally for 14 other groups of health professionals.

There is also the potential for the development of a divergence in law between the jurisdictions. This could bedevil attempts to develop a cooperative national scheme and perpetuate the application of different standards of care and governance for patients, practitioners, public and private providers alike.

There are at least 122 permanent private organisations that employ paramedics across Australia. Under the Tasmanian legislation for example, private providers will be unable to use the title "paramedic" without approval from the Commissioner regardless of their skill or qualifications.

If more states move to a "registration" system as Victoria plans to, it may mean that the 50% of private providers who work across state boundaries will be required to "register" in multiple states.

Towards national registration

It is currently unclear why the Health Ministers Council decided to defer the decision regarding paramedic registration under the national scheme, but doing so now risks the further fragmentation of paramedic regulation under various state based schemes.

National registration now would avoid that and allow for the consistent application of standards and mechanisms nationally across both the public and private sectors. It would facilitate the development of a more flexible and professional workforce and demonstrate that patient safety and protection is really front and centre of health care policy across all care areas.

Ruth Townsend was previously employed as a paramedic with the Ambulance Service of NSW and is the co-author and co-editor of the text, 'Applied Paramedic Law and Ethics'. Ruth is completing a PhD examining the regulation of paramedics.

Michael Eburn receives funding from the Bushfire CRC and the Bushfire and Natural Hazards CRC. He was previously a member of the Ambulance Service of NSW.
 Ruth Townsend, Lawyer and PhD Candidate at Australian National University Michael Eburn, Associate Professor in Law at Australian National University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/31910 2014-11-12T03:28:40Z 2014-11-12T03:28:40Z What about the mental health of kids with intellectual disability?

The mental health problems of children with intellectual disabilities are largely undiagnosed and untreated. SriHarsha PVSS/Flickr, CC BY-NC-SA

High-quality epidemiological research shows children and adolescents with intellectual disability are four times more likely to have diagnosable mental health problems compared to others their age. This mental health inequality clearly needs attention.

Part of the problem is a process called diagnostic overshadowing: symptoms are incorrectly assumed to be related to the child's disability rather than an underlying mental health issue. This often makes it difficult to identify mental health problems in children with intellectual disability.

After we account for the impact of diagnostic overshadowing through the use of specialised assessment tools, Australian research shows over 40% of children with intellectual disability have mental health problems that may be serious enough to lead to a psychiatric diagnosis.

The importance of early intervention

Birth cohort studies follow the development of groups of children that are representative of the population. Data from such studies in the United Kingdom and Australia show the inequality in mental health between children with intellectual disability and those without emerges early.

By the time children with intellectual disability are three years old, they have more mental health problems than other children. What's more, the mental health problems in these children and adolescents persist over time.

A 2006 Australian study of over 400 children and adolescents with intellectual disability found only a small reduction in mental health problems over its 14-year follow-up. It seems that once mental health problems emerge, children with intellectual disability are likely to suffer from them for a long time.

But despite the high level of mental health problems in this group of children, access to treatment is poor. Recent UK research on over 600 children with intellectual disability who also have autism, for instance, showed less than a quarter of those with mental health problems had any contact with relevant services in the previous six months.

Similar results have been found in Australia. In the Australian study mentioned above, researchers found only 10% of their sample had received specialised mental health treatment from an expert in intellectual disability and mental health.

Clearly, effective early intervention for these children is needed. It could target factors shown to influence their mental health, including improving parent-child relationships, reducing family poverty and other deprivation, and increasing parental mental well-being.

A mainstream issue

A significant proportion (35% to 40%) of children with intellectual disability may have mental health problems. Put another way, 14% of all children with a mental health problem will also have an intellectual disability. This figure represents large numbers of children with significant needs: approximately 85,000 in England and 50,000 in Australia.

So this has to be accepted as a mainstream issue rather than a specialist area. These children represent a high-risk group whose needs have to be addressed by mental health services generally. There are a number of key issues.

Even where there are specialist child intellectual disability mental health services available, such as in many areas of the United Kingdom, practitioners have only a very small evidence base from which to draw.

There are few assessment tools to help clinicians identify mental health problems in these children, especially in those with more severe disability. The evidence base for treatment options is also very small.

Children with intellectual disability are often excluded from mainstream trials of mental health treatments, and specialised research focused only on them has been rare.

We need to invest in developing methods for identifying mental health problems in children with intellectual disability, and to test treatment approaches. And we need a greater understanding of the barriers to accessing mental health services faced by them and their families.

A combination of better evidence and improved access to treatment should help ensure that the mental health problems of children with intellectual disability are recognised and treated.

Richard Hastings receives funding from Cerebra and several government health research funders in the UK. He is affiliated with the charities Mencap, Sibs, Cerebra, and Ambitious about Autism.

Bruce Tonge receives funding from Commonwealth research bodies( NHMRC, ARC) and Philanthropic research foundations eg. Pratt foundation, beyond blue, Dara foundation. He is a member of the Board of AMAZE (Autism Victoria) a not for profit peak body NGO.

Glenn Melvin receives funding from beyondblue, NH&MRC, Disability Donations Trust, & Endeavour Foundation.

Kylie Gray receives funding from federal funding bodies in Australia (NHMRC, ARC). She also receives funding from a range of philanthropic organisations e.g. the Disability Donations Trust, Endeavour Foundation, Mental Health Australia, Financial Markets Foundation, APEX, and SFARI and the NIH in the US.

Vaso Totsika receives funding from UK research councils and voluntary organizations.
 Richard Hastings, Professor of Psychology and Education at University of Warwick Kylie Gray, Associate Professor and Deputy Director of the Centre for Developmental Psychiatry and Psychology at Monash University Vaso Totsika, Senior Research Fellow; Psychology and Education at University of Warwick Glenn Melvin, Senior Lecturer in Developmental Psychology at Monash University Bruce Tonge, Professor Child adolescent and developmental psychiatry at Monash University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/34073 2014-11-11T19:31:24Z 2014-11-11T19:31:24Z Six reasons Australia should pilot 'pill testing' party drugs

Young people want better information about illicit drugs so they can make informed choices.  Jirka Matousek/Flickr, CC BY-SA

The death of 19-year-old Georgina Bartter at a music festival on the weekend from a suspected ecstasy overdose could possibly have been avoided with a simple harm-minimisation intervention. Pill testing, or drug checking as it's known in Europe, provides feedback to users on the content of illegal drugs, allowing them to make informed choices.

Taking illicit drugs, especially ecstasy, is not particularly unusual for someone of Bartter's age. A 2010 survey found more than 11% of 20- to 29-year-olds and 7% of 18- to 19-year-olds had taken the drug in the previous 12 months. According to annual research among 1,000 ecstasy users, 70% of these pills are taken at clubs, festivals and dance parties.

Australia is internationally applauded for our harm-minimisation approach to drugs but we have failed to introduce pill testing, even though it is an intuitively appealing strategy.

Wide support

Pill-testing kits or booths at venues where pills are known to be consumed could inform users about the content of illicit drugs. As we have equipment that can test drugs in real time, people intending to take them could have them checked beforehand.

Research shows young people are highly supportive of pill testing; more than 82% of the 2,300 young Australians aged between 16 and 25 years surveyed for the Australian National Council on Drugs in 2013 supported its introduction. The finding is consistent with young people's overall views about drugs: they want better information in order to make informed choices.

 We have equipment that can test drugs in real time, so people intending to take them could have them checked beforehand. Chris Breikss/Flickr, CC BY

Pill testing is not a radical idea. As a harm-reduction intervention provided by community and local governments, it's available in several European countries including the Netherlands, Switzerland, Austria, Belgium, Germany, Spain and France. But the legal status of the service is unclear and there is no formal government endorsement of the measure.

Nonetheless, its effectiveness is strongly grounded in evidence. There are good reasons why this country should introduce the measure.

Five good reasons

First, pill testing has been shown to change the black market. Products identified as particularly dangerous that subsequently became the subject of warning campaigns were found to leave the market.

Research also shows the ingredients of tested pills started to correspond to the expected components over time. This suggests pill testing might be able to change the black market in positive ways.

Third, pill testing changes behaviour: research from Austria shows 50% of those who had their drugs tested said the results affected their consumption choices. Two-thirds said they wouldn't consume the drug and would warn friends in cases of negative results.

Visits to pill-testing booths create an important opportunity for providing support and information over and above the testing itself. They enable drug services to contact a population that is otherwise difficult to reach because these people are not experiencing acute drug problems. Indeed, the intervention has been used to establish contact and as the basis for follow-up work with members of not-yet-problematic, but nevertheless high-risk, groups of recreational drug users.

 Pill-testing kits or booths at venues where pills are known to be consumed could inform users about the content of illicit drugs. Mark Vegas/Flickr, CC BY-SA

Finally, pill testing means we can capture long-term data about the actual substances present in the drug scene. And it creates the potential for an early warning system beyond immediate users. This is becoming all the more important as new psychoactive substances that may be used as adulterants are appearing more frequently.

Not a panacea

A harm-reduction approach to drugs is always a balance between benefits and risks: the availability of pill testing reduces harm, but it may increase risks for some. Not everyone will use the service and some may ignore the results and risk being subject to potentially harmful drugs.

It may also lend the appearance of safety when, in reality, the pills remain illegal and potentially harmful. What's more, we will need to ensure that pill-testing results are accurate by researching the effectiveness of testing kits.

Of course, critics will argue the measure will "send the wrong message". But the messages we're currently sending are that we don't want informed consumers and we don't want to reduce harm from illicit drug use. They're clearly not quite right either.

Australia should run a trial of pill testing and assess its benefits and harms so we can then make an informed choice about this intervention.

The growth in new psychoactive substances and the ever-evolving chemical composition of drugs, coupled with the need to reduce the harms from pill use, means this is an idea whose time has come. And although the coroner has yet to confirm the exact cause of her death, the final reason for introducing pill testing is that it may help avoid the needless loss of young lives like that of Georgina Bartter.

Alison Ritter receives funding from Australian National Council on Drugs, which funded the youth survey mentioned in this article.
 Alison Ritter, Professor & Specialist in Drug Policy at UNSW Australia Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/34012 2014-11-11T04:21:38Z 2014-11-11T04:21:38Z How to draw the line between 'good' and 'bad' reasons to die

Terminal cancer patient Peter Short gives evidence on voluntary euthanasia to the Senate Committee on Legal and Constitutional Affairs, which tabled its report on Monday. Tracey Nearmy/AAP

A Senate inquiry into legalising voluntary euthanasia for terminally ill people has recommended a conscience vote on the proposed bill after technical matters, such as what constitutes a "terminal illness", are clarified.

While this is an important step forward in grappling with the idea of the "right to die", drawing a line at terminal illness for this purpose will be difficult. What's more, restricting the right to die to people who are terminally ill is very different to what most of us think of as justifiable euthanasia.

Research shows more than 82% of Australians support voluntary euthanasia where "a hopelessly ill patient, experiencing unrelievable suffering, with absolutely no chance of recovering" asks for help to end their life. This description covers terminal illnesses as well as other incurable conditions causing great suffering in which death may not be imminent.

Refusing treatment

As the law stands, mentally competent people can reject medical treatment that will keep them alive. This is the case even when a person is not actually terminally ill. As suicide itself is not unlawful, it remains an option even when the person states their sole motivation for refusing treatment is to end their life.

Courts have confirmed that life-support machines can be turned off, feeding tubes can be removed and hunger strikes in hospital may not be forcibly interfered with by hospital staff. These cases involved people suffering extensive paralysis and chronic debilitating illnesses, all of which caused pain and suffering but were not, strictly speaking, terminal conditions.

Indeed, that was part of the problem the people in these cases faced: in their own estimation, their suffering was great but their lives might go on for a very long time. Still, while all competent patients may refuse medical treatment in order to end their lives, they may not be entitled to active euthanasia under a restricted law.

If it's not exactly terminal illness that Australians have in mind when they think of who might legitimately seek euthanasia, and if we can tolerate and even condone the suicidal wishes of some people, it is perhaps a particular kind of suffering that we wish to restrict euthanasia to.

Perhaps we feel physical suffering is a better reason for ending one's life than, say, suffering caused by grief, or shame, or hopelessness. Or perhaps it is the quality of "incurability" that we demand; we are more willing to accept physical illness may be beyond help, than psychiatric illness or emotional pain.

The problem is that while many of us may hold these views, they aren't empirically true, and opinions differ.

In some jurisdictions where euthanasia is legal, it is also legal to be helped to die because of psychiatric illness when there is "unbearable emotional suffering". While this has been controversial, groping for objective reasons why only some forms of death decision are all right is doomed to fail because the lines we draw between acceptable and unacceptable death decisions are cultural and arbitrary.

But that doesn't make such line-drawing invalid.

The right line

To achieve defensible policy, we need to understand what's really going on when we struggle with legalising assisted suicide. And it is simply this: the decision to die is not an ordinary choice.

Deciding to end one's life has the quality of tragedy – and not only for people who love you, as not everyone has loved ones. Rather, all our deaths are important because, as the English poet and cleric John Donne wrote, we are all "involved in mankind".

Death remains tragic no matter how inevitable it is or what causes it. And in a very deep place, human societies have always considered death itself to be bad, in a moral sense.

Death is punishment; in many cultures, it is what separates us from ancient gods. The inevitability of death is the ultimate source of existential suffering because all of us know we will die, as will everyone we love.

So even if we can bring ourselves to accept that a life can be so full of suffering that death is preferable, we still remain deeply anguished about it.

If society is going to be involved in death decisions by giving legal permission for doctors to bring about death, it is important to specify some conditions. But there will be few bright lines to discern between "good" and "bad" reasons for choosing death.

We do need to decide which deaths we are prepared to countenance. We may each decide quite differently. But all of us must think long and hard about where and why we draw those lines.

Editor's note: Sascha will be on hand to answer questions at 12:30 tomorrow afternoon (November 12). Post any questions about "good" and "bad" reasons to die in the comments below.

Sascha Callaghan received a PhD scholarship from the NHMRC.
 Sascha Callaghan, Lecturer in Health Law & Bioethics at University of Sydney Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/33948 2014-11-10T19:30:47Z 2014-11-10T19:30:47Z Medicare spending on general practice is value for money

If we want to ensure the health system remains sustainable, it makes sense to use its cheapest and most efficient arm: general practice. Iakov Filimonov/Shutterstock

Last year taxpayers spent A$6.3 billion on GP services through Medicare, about 6% of the total government health expenditure. This was a 50% increase (A$2.1 billion) in today's dollars over the past decade and equates to about A$60 more per person in real terms.

Health Minister Peter Dutton says this growth is "unsustainable". He plans to introduce a GP co-payment in hope of reducing the number of times Australians visit a GP and to ensure users foot some of the bill.

But targeting primary care for cost savings could backfire. Research we're releasing today shows that while the number of GP visits has increased, the services are cost-effective. If the same services were performed in other areas of the health system, they would cost considerably more.

Under pressure

Unsustainable or not, Australia's health-care system faces a number of challenges, most notably from the rising prevalence of chronic conditions, such as type 2 diabetes, heart disease and cancer. This is due to three major factors.

Australia has an ageing population as our world-class health system keeps us alive longer.

In response to government encouragement through Medicare initiatives, GPs are diagnosing disease earlier and providing preventive interventions for health risk factors and diseases such as hypertension, high cholesterol and type 2 diabetes.

An increasing proportion of Australians are overweight or obese, putting them at risk for chronic conditions.

Earlier diagnosis means people are living longer with diagnosed disease. The result is exponential growth in required care over their lifetime.

The search for more cost-effective health care for our population should be applauded. But reducing spending on GP services is not the answer.

What do we get?

Our team has been studying general practice activity for over 16 years through the Bettering the Evaluation and Care of Health (BEACH) program. This cross-sectional encounter-based study uses changing random samples of about 1,000 GPs per year, each of whom contribute details of 100 encounters with consenting patients. This provides a representative sample of about 100,000 encounters per year from across the country.

Results from one of the BEACH books, released today, shed some light on what we got for the $2.1 billion of extra Medicare spending on general practice. In 2013-14 there were 35 million more GP services than ten years earlier, a 36% increase. This included 17 million more attendances by patients aged 65 years and over (a 67% increase).

Length of GP consultations recorded through BEACH suggest that the average consultation now takes almost one minute more than a decade ago. The result is that GPs spend an extra ten million clinical hours with their patients, a 43% increase.

The number of problems managed at these consultations has also significantly increased. GPs managed an additional 68 million health problems at these encounters (an increase of 48%), including 24 million more chronic problems.

Management of these problems involved an additional ten million procedures (a 66% increase) and 12 million clinical treatments, such as counselling, advice and education, than a decade ago.

  Prepared by The University of Sydney for the BEACH study.

Clearly, increases in the amount and complexity of GP clinical work are reflected in additional Medicare expenditure. If other medical specialists and/or emergency departments had provided these extra services, they would have cost far more.

The average cost of a GP visit was A$47 from Medicare, plus a A$5 patient contribution. For a private specialist, the average visit costs Medicare A$82 plus a A$38 patient fee.

A visit to the emergency department, which is paid by state and territory governments, costs far more. In Western Australia, for example, an emergency department visit in 2011-12 cost A$599 on average.

More, not less primary care

International research has repeatedly concluded that investment in primary care is the most cost-effective way to provide population health care. As GP services are far cheaper than other types of medical services, discouraging GP visits by introducing a standard co-payment for most patients would increase costs to governments, now and later.

It may seem counter-intuitive, but one effective way to contain the cost of Australia's health care would be to expand the use of GP services.

One issue not acknowledged in the discussion about health costs is the increasing number of patients with multiple chronic conditions. These patients use more resources and are more likely to have fragmented care due to the number of health professionals involved. GPs play the central role in co-ordinating the management of patients with multiple chronic conditions, reducing costly hospitalisations.

As the age of government-supported retirement increases, many Australians will have to work until they are 70. This highlights the importance of promoting good health across the lifespan, through a strong focus on primary and secondary prevention and co-ordinated management of chronic conditions.

In any one year 85% of us visit a GP, but only about 15% of us are admitted to hospital, where a far greater proportion of health funds is spent. GPs supply the bulk of care to the population, so general practice is where our investment should be.

If we want to strengthen our health-care system and ensure its sustainability into the future, it makes sense to encourage people to use its cheapest and most efficient arm: general practice.

Over the past ten years, the Bettering the Evaluation And Care of Health (BEACH) program has been funded through grants from the Australian Government Department of Health. It has also received financial support from the Department of Veterans' Affairs, other government instrumentalities, industry and not-for-profit organisations. Funding is paid directly to the University of Sydney and not to any individual.

Clare Bayram, Graeme Miller, Helena Britt, Joan Henderson, and Julie Gordon do not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article. They also have no relevant affiliations.
 Julie Gordon, Research Fellow, Family Medicine Research Centre, Sydney School of Public Health at University of Sydney Clare Bayram, Research Fellow, Family Medicine Research Centre, Sydney School of Public Health at University of Sydney Christopher Harrison, Senior Research Analyst, Family Medicine Research Centre, Sydney School of Public Health at University of Sydney Helena Britt, Associate professor, Director of the Family Medicine Research Centre, Sydney School of Public Health at University of Sydney Joan Henderson, Senior Research Fellow, BEACH Program. at University of Sydney Graeme Miller, Associate Professor of General Practice at University of Sydney Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/32732 2014-11-10T03:29:50Z 2014-11-10T03:29:50Z Health Check: clash of the orgasms, clitoral vs vaginal

Most women are just happy to have an orgasm, any old way.  Ares Tavolazzi/Flickr, CC BY-NC-SA

Controversy over vaginal versus clitoral orgasm is nothing new; it's a debate that has consumed sexologists and psychoanalysts for the last 100 years. Now, new research has added fresh fuel to the controversy.

Completed by a team of Italian sexologists and published in the journal Clinical Anatomy, the review concludes vaginal orgasms don't exist. Female orgasm is only possible if the clitoris is stimulated during masturbation, cunnilingus, partner masturbation or with a finger during intercourse, the researchers say. Penetration alone is not enough.

This latest swing of the pendulum – from the view that vaginal orgasm is the ideal that women should aspire to and anything else is second rate – is unlikely to actually affect women. Indeed, one of the more interesting threads in this whole debate is the predominance of men's voices. Perhaps what we should be talking about is why male experts dictate the parameters of women's pleasure.

Frigidity and failure

Sigmund Freud was one of the first to investigate the "dark continent" of female sexuality. He declared the clitoral orgasm "infantile and immature". A woman could claim sexual maturity only when she experienced a vaginal orgasm, he said, ignoring her "amputated penis", the clitoris.

Inability to achieve vaginal orgasm meant a woman was "frigid" or "not a real woman", claimed Freud and many of his followers. This failure was attributed to deep-rooted neurotic problems.

 Sigmund Freud declared the clitoral orgasm 'infantile and immature'. Max Halberstadt/Wikimedia Commons

The pressure was on. To be "normal" and "mature", women had to orgasm during sexual intercourse. And successive generations were diagnosed with sexual dysfunction when they failed to achieve this holy grail of sexual response. Many felt like failures; their bodies had let them down.

Unsurprisingly, faking orgasms during intercourse became the norm. No one wants her partner to think she is failing to be a "real woman".

Celebrating the clitoral orgasm

Then US sexologists William Masters and Virginia Johnson came along. Observing couples having sex in the laboratory in the 1960s, they concluded women's orgasms started in the clitoris and then extended to the vagina.

Any pleasure women experienced through penetration was due to the connection between clitoris and vagina. They reported "frigidity" as resulting from poor sexual technique, not women's ambivalence about their social role. And that women were capable of multiple orgasm, while men were not.

Feminists in the 1960s took up this research with glee, declaring the clitoral orgasm the mark of a liberated woman. Some went further, arguing women should eschew penile penetration altogether. Now a symbol of women's oppression, it was unnecessary for sexual pleasure.

The feminist argument went mainstream when Shere Hite appeared on the cover of Time magazine in 1987. She had interviewed 1,844 American women and declared the "true" female orgasm was clitoral. The female sexual revolution seemed to have been won with women speaking for their own sexual pleasure.

Phallocentric backlash

Then came the inevitable backlash. In recent years, there has been a proliferation of sex research attempting to establish the superiority of the vaginal orgasm, and the role of the penis in producing it.

In echoes of Freud, we are told the vaginal orgasm is the only way for women to achieve sexual, life and relationship satisfaction, as well as good psychological health.

 Women enjoy all kinds of sex – and some prefer to have a cup of tea. danor shtruzman/Flickr, CC BY

Women who don't have vaginal orgasms are described as emotionally unstable, with immature defence mechanisms and low emotional intelligence. Apparently, you can even identify a woman who has a history of vaginal orgasm by her walk – it is that central to her very being.

So what causes a vaginal orgasm, according to these researchers? Not stimulation of the clitoris during intercourse. Rather, a long penis, which allegedly gives an evolutionary advantage to well-endowed men. Or long-lasting intercourse, which we are told is much better than "foreplay", with simultaneous orgasm during intercourse being the best of all.

Would it surprise you if I told you this phallocentric research is all conducted by men? Would their interest in the vaginal orgasm possibly have something to do with maintaining the primacy of the penis?

After all, the implications of the clitoral orgasm are grave for heterosexual men. Women can pleasure themselves (or be pleasured by each other) as effectively as they can be pleasured by a man if the penis is superfluous to their ability to orgasm. A man's fingers become more important, or his smell, which some heterosexual women rate more highly than penis size.

A woman's perspective

From a woman's perspective, this whole debate is a little irrelevant.

Some women enjoy vaginal penetration – with penis or fingers – and gain considerable sexual pleasure as a result. Other women prefer to be touched, use a vibrator, or receive oral sex. A lucky few have orgasms in their sleep, in the absence of any physical stimulation. And some prefer to have a cup of tea.

To imply that all women are the same, that we should have any sort of orgasm and are dysfunctional if we don't, is the most damaging part of this controversy.

Regardless of how orgasm is achieved, it is, by definition, an extremely pleasurable experience. And no woman I know would rate one form of orgasm as more "mature" than another. Most would just be happy to have one, any old way.

Jane Ussher receives funding from the Australian Research Council, Cancer Council NSW, Family Planning NSW, Prostate Cancer Foundation of Australia, and the Community Migrant Resource Centre, for research on sexuality.
 Jane Ussher, Professor of Women's Health Psychology, Centre for Health Research at University of Western Sydney Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/32944 2014-11-09T19:29:57Z 2014-11-09T19:29:57Z Fast-spreading killers: how Ebola compares with other diseases

Ebola is less infectious than other diseases but has a high fatality rate. EPA/Ahmed Jallanzo

The West African outbreak of Ebola has claimed more than 4,800 lives and this number is sure to rise. There is understandably a lot of fear about Ebola, but how does it actually compare with other fast-spreading infectious diseases?

Bubonic plague

Plagues have been reported since biblical times, but it is difficult to know how serious these early epidemics were, or even what the infectious agent was.

We now know that plague is a serious disease caused by the bacteria Yersinia pestis. The Black Death is thought to have been bubonic plague, named after the presence of infected lymph nodes; it killed one-third of the population of Europe in the 14th century. Bubonic plague killed one-quarter of the population of London in 1563, and the Great Plague of London killed 100,000 a century later.

Plague is spread by fleas that usually infest rodents. The disease is still found in parts of Asia, Africa and the Americas. Few humans are now infected, although outbreaks occasionally occur. The extensive wildlife reservoir means that it will never go away.

Influenza

The 1914-18 war resulted in between 15 and 18 million deaths, but the 1918 flu pandemic killed more than twice that number.

Influenza spreads rapidly by coughs and sneezes which release small droplets. These droplets may infect others while airborne or by contaminating surfaces.

Symptoms of the flu can start within a day or two of being infected and last for about a week. But virus shedding begins before the symptoms and one-third of cases show no symptoms at all.

The virus also readily mutates, so past infection does not necessarily provide future protection.

The fatality ratio of seasonal influenza is low, usually claiming one in 1,000 lives, so it is often regarded as inconsequential. But a virus shift can cause a pandemic and increased rates of death.

Bird flu

Of greater concern is the avian influenza reservoir in parts of Asia. Transmission of H5N1 and H7N9 influenza A from birds to humans has resulted in a fatality ratio of 50%.

If these viruses were to mutate and become easily transmitted between humans, public health services would be severely challenged by the resulting pandemic.

The basic reproduction number of an infection, usually expressed as R0, is defined as the expected number of cases that would arise from a typical primary case in a susceptible population.

If R0 is bigger than one, then the number of cases will increase until limited by control measures, behaviour change or the exhaustion of the supply of susceptibles. If R0 is less than one, then the incidence of infection will decrease and the outbreak will fizzle.

Influenza typically has values of R0 between one and three, so vaccinating 67% of the population would prevent epidemics.

SARS

Severe acute respiratory syndrome (SARS) is likely to have emerged from a bat reservoir in China, and spread to a number of other countries in 2003. Its infectious agent is a coronavirus, from a family often implicated in the common cold.

Its mode of transmission was similar to that of influenza but its basic reproduction number, at over three, was twice that of the flu.

With no vaccine available and a fatality ratio around 10%, SARS presented a scary prospect: it caused an estimated US$40 billion of economic damage and severely disrupted international travel.

But SARS had an Achilles heel. The long (four to five-day) incubation period made it amenable to contact tracing, enabling the isolation of contacts before they became infectious.

It was largely these non-clinical interventions that succeeded in reducing the contact rate, and therefore the reproduction number, below one. The pandemic was brought to a halt and the infection eliminated, with the loss of 774 lives.

However, another coronavirus is now responsible for 837 cases of Middle East respiratory syndrome (MERS) and 291 deaths.

Ebola

Ebola is not an airborne infection; it is spread by bodily fluids, which means that more intimate contact is required for transmission. The basic reproduction number is usually estimated to be around two, although a recent estimate for hospital settings in Africa puts the value of R0 over four.

Research suggests around 70% of those infected in the latest Ebola outbreak will die of the disease. However, according to the World Health Organization, past fatality ratios have ranged from 25% to 90%.

It seems that transmission only occurs while the patient is symptomatic, so contact rates must be low even though the probability of transmission given contact is high. The eight to ten-day average incubation period also suggests that contact tracing and isolation should be successful in halting the spread of infection.

HIV/AIDS

While not a fast spreader, another infectious disease that originated in Africa and is transmitted by bodily fluids is HIV/AIDS (human immunodeficiency virus infection and acquired immune deficiency syndrome).

HIV was transmitted to humans in the 1920s from a chimpanzee, but remained largely confined to (what is now) the Democratic Republic of Congo until undergoing an epidemiological transition in the 1960s. The resulting global HIV pandemic has infected nearly 75 million people.

While transmission of HIV and Ebola both rely on the transfer of bodily fluids, there are major differences. A HIV patient can be infectious for many years while not exhibiting any symptoms, and may be unaware of their status.

In contrast, for Ebola, the time from being infected to infecting others is measured in days and, although not as infectious as influenza, it is more readily transmitted than HIV.

Emergence of infectious diseases

While bubonic plague is bacterial, all of the other infections mentioned above are viral. Yellow fever was the first human virus to be discovered in 1901. Since then more than 200 have been recognised.

Most "new" infections result in "species jumps", mainly from mammals and birds. The ability of viruses to adapt should make us wary of the avian influenza viruses and their potential for human-to-human transmission.

Ebola has all the epidemiological characteristics of a containable infection, but it is only now spreading to developed countries that have no experience of dealing with it. The desirable strategy, from global health and humanitarian perspectives, is to eliminate the epidemic at its source.

Mick Roberts receives funding from the Marsden Fund and the Health Research Council.
 Mick Roberts, Professor in Mathematical Biology at Massey University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/33141 2014-11-07T03:00:01Z 2014-11-07T03:00:01Z How the bacteria in our gut affect our cravings for food

Gut bacteria can manufacture special proteins that are very similar to hunger-regulating hormones.  Lighthunter/Shutterstock

We've long known that that the gut is responsible for digesting food and expelling the waste. More recently, we realised the gut has many more important functions and acts a type of mini-brain, affecting our mood and appetite. Now, new research suggests it might also play a role in our cravings for certain types of food.

How does the mini-brain work?

The gut mini-brain produces a wide range of hormones and contains many of the same neurotransmitters as the brain. The gut also contains neurons that are located in the walls of the gut in a distributed network known as the enteric nervous system. In fact, there are more of these neurons in the gut than in the entire spinal cord.

The enteric nervous system communicates to the brain via the brain-gut axis and signals flow in both directions. The brain-gut axis is thought to be involved in many regular functions and systems within the healthy body, including the regulation of eating.

Let's consider what happens to the brain-gut axis when we eat a meal. When food arrives in the stomach, certain gut hormones are secreted. These activate signalling pathways from the gut to the brainstem and the hypothalamus to stop food consumption. Such hormones include the appetite-suppressing hormones peptide YY and cholecystokinin.

Gut hormones can bind and activate receptor targets in the brain directly but there is strong evidence that the vagus nerve plays a major role in brain-gut signalling. The vagus nerve acts as a major highway in the brain-gut axis, connecting the over 100 million neurons in the enteric nervous system to the medulla (located at the base of the brain).

Research has shown that vagus nerve blockade can lead to marked weight loss, while vagus nerve stimulation is known to trigger excessive eating in rats.

This brings us to the topic of food cravings. Scientists have largely debunked the myth that food cravings are our bodies' way of letting us know that we need a specific type of nutrient. Instead, an emerging body of research suggests that our food cravings may actually be significantly shaped by the bacteria that we have inside our gut. In order to explore this further we will cover the role of gut microbes.

Gut microbiota

As many as 90% of our cells are bacterial. In fact, bacterial genes outnumber human genes by a factor of 100 to one.

The gut is an immensely complex microbial ecosystem with many different species of bacteria, some of which can live in an oxygen-free environment. An average person has approximately 1.5 kilograms of gut bacteria. The term "gut microbiota" is used to describe the bacterial collective.

 We each have around 1.5kg of bacteria in our guts. Christopher Pooley, CC BY

Gut microbiota send signals to the brain via the brain-gut axis and can have dramatic effects on animal behaviour and health.

In one study, for example, mice that were genetically predisposed to obesity remained lean when they were raised in a sterile environment without gut microbiota. These germ-free mice were, however, transformed into obese mice when fed a faecal pellet that came from an obese mouse raised conventionally.

The role of gut microbiota in food cravings

There is growing evidence to support the role of gut microbiota in influencing why we crave certain foods.

We know that mice that are bred in germ-free environments prefer more sweets and have greater number of sweet taste receptors in their gut compared to normal mice. Research has also found that persons who are "chocolate desiring" have microbial breakdown products in their urine that are different from those of "chocolate indifferent individuals" despite eating identical diets.

Many gut bacteria can manufacture special proteins (called peptides) that are very similar to hormones such as peptide YY and ghrelin that regulate hunger. Humans and other animals have produced antibodies against these peptides. This raises the distinct possibility that microbes might be able to directly influence human eating behaviour through their peptides that mimic hunger-regulating hormones or indirectly through antibodies that can interfere with appetite regulation.

Practical implications

There are substantial challenges to overcome before we can apply this knowledge about gut microbiota in a practical sense.

First, there is the challenge of collecting the gut microbes. Traditionally this is collected from stools but gut microbiota is known to vary between different regions of the gut, such as the small intestine and colon. Obtaining bacterial tissue through endoscopy or another invasive collection technique in addition to stool samples may lead to more accurate representation of the gut microbiome.

Second, the type of sequencing that is currently used for gut microbiota screening is expensive and time-consuming. Advances will need to be made before this technology is in routine use.

Probably the greatest challenge in gut microbiota research is the establishment of a strong correlation between gut microbiota patterns and human disease. The science of gut microbiota is in its infancy and there needs to be much more research mapping out disease relationships.

 Probiotics contain live microorganisms. Quanthem/Shutterstock

But there is reason to be hopeful. There is now strong interest in utilising both prebiotics and probiotics to alter our gut microbiome. Prebiotics are non-digestible carbohydrates that trigger the growth of beneficial gut bacteria, while probiotics are beneficial live microorganisms contained in foods and supplements.

Faecal transplantation is also now an accepted treatment for those patients that have a severe form of gut bacterial infection called Clostridium difficile, which has been unresponsive to antibiotics.

The use of such targeted strategies is likely to become increasingly common as we better understand how gut microbiota influence our bodily functions, including food cravings.

Vincent Ho does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Vincent Ho, Lecturer and clinical academic gastroenterologist at University of Western Sydney Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/31521 2014-11-06T19:26:47Z 2014-11-06T19:26:47Z Why placebos for chemotherapy side effects are hard to swallow

Vomiting, nausea and diarrhoea are common chemotherapy side effects that can be so severe that patients may refuse further treatment. Emergency Brake/Flickr, CC BY-SA

It's unthinkable to give a placebo to someone to treat their cancer, but could we use one to treat chemotherapy's well-known side effects? Unfortunately, we may never be able to answer this question because the biggest obstacle to finding out whether it would work is emotional rather than scientific.

Let's first consider the reason for the proposition. Recent research shows placebos are just as effective as prescribed medicines for treating emergency room patients with nausea. As nausea and vomiting are also common side effects in chemotherapy, there's a clear scientific rationale to using them for cancer patients as well.

And there are medically valid reasons for trials to test whether this could work, especially as a way to reduce the large number of medicines cancer patients usually need. But cancer is much more emotive than other diseases and despite good reasons and intentions, we may never find the idea palatable enough to test whether it works.

The ethics of placebos

A placebo is a medicine that doesn't contain an active drug ingredient but still has a therapeutic effect. Many studies have demonstrated a strong placebo effect. They can work even when people are told they are being given a placebo (although they work better when people are not told). But the ethics of placebo use is rather complicated.

The strange powers of the placebo effect.

Consider the ethics of these two scenarios using placebos - treating a psychosomatic disorder and testing a new drug.

For a placebo to work for a psychosomatic disorder, the patient has to be unaware they're taking an inactive substance. In this situation, the doctor has prioritised their patient's interest in getting better over their right to make an informed decision about whether or not to take a "medicine".

Placebos are also used in clinical trials to help researchers identify whether a new drug works better compared to an inactive alternative. The best clinical trials use a "double-blinded" approach, where the participants know they may be given a placebo but neither they, nor the person giving them the drug, knows if they have.

There are no ethical problems with using placebos in clinical trials, assuming participants have been properly informed and given consent. But it's not as clear-cut for psychosomatic disorders.

Even if someone's condition is pyschosomatic, their symptoms can feel just as real and debilitating as any other ailment. In this scenario, no harm is done when the placebo works. But there could be an ethical problem if the placebo doesn't work as anticipated.

 The seriousness of cancer means it's unethical to give cancer patients placebos because they would very likely die without effective treatment. Phil and Pam Gradwell/Flickr, CC BY

Recall that doctors don't usually tell these patients they were given a placebo because it works better that way. So, when the placebo doesn't alleviate the symptoms it was prescribed for, it becomes a case of missed therapy, which may result in harm or a delay in other appropriate treatment.

Chemotherapy and placebos

Generally, the seriousness of cancer means it's unethical to treat cancer patients with placebos because they would very likely die without effective treatment. But reducing the number of drugs they have to take is desirable because it can be a burden on patients to remember to take the right medications at the right times and missed doses can have serious complications.

Most cancer patients taking chemotherapy drugs will also be given a cocktail of other drugs to treat the side effects of those medicines. These can include drugs to prevent them getting infections, such as antibiotics, chemotherapy adjuvants, drugs to boost blood production and pain killers.

Other common side effects of chemotherapy are vomiting, nausea and diarrhoea. These can be so severe that patients may refuse further chemotherapy. What's more, after the first round of chemotherapy, some patients can experience nausea and vomiting not from the treatment itself but from previously innocuous things, such as the strong antiseptic smell of a hospital or even the sight of the building (a psychosomatic response).

 It's desirable to try to reduce the overall number of medicines a chemotherapy patient needs to take. Derek K. Miller/Flickr, CC BY-NC

Anti-emetic drugs are usually used to treat chemotherapy-induced nausea and vomiting, and patients generally respond well. But why not try to reduce the overall number of medicines a chemotherapy patient needs to take?

If the patient is fully informed and aware they could be given a placebo during treatment, especially if their nausea is psychosomatic, there would be no ethical dilemma. But placebos are most effective when the patient doesn't know they are taking one.

Cancer is a much more emotive disease and chemotherapy is far removed from the rapid decision-making environment of the hospital emergency room, which is where the nausea-placebo study was conducted. In those situations, medical teams make decisions without consulting the patient or their family and may unilaterally decide to use a placebo for nausea.

In contrast, family and friends tend to be much more involved with cancer patients in their treatment decision making. Many may find the idea of their loved one being given a placebo unpalatable.

So what do you think? Should medical staff consider the use of placebos to treat the chemotherapy side effects of cancer patients? Would you be happy if your mother, father, sister or brother was given a placebo while undergoing chemotherapy?

Nial Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible and the Scottish Universities Life Sciences Alliance for research into anticancer drugs.

Betty Chaar has received funding in the past from: NSW Health, Pharmacy Board and the Pharmacy Guild for research conducted on drug and alcohol issues in pharmacy, professional ethics in pharmacy and the role of pharmacy in enhancing health literacy.
 Nial Wheate, Senior Lecturer in Pharmaceutical Chemistry at University of Sydney Betty Chaar, Senior Lecturer at University of Sydney Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/33637 2014-11-06T04:55:23Z 2014-11-06T04:55:23Z Listen up, health officials – here's how to reduce 'Ebolanoia'

Telling people not to panic doesn't achieve its desired effect. EPA/Remko de Waal

An epidemic disease such as Ebola brings suffering to more than those who get ill or die. Social and economic threats can actually outstrip the medical ones. The outbreaks of SARS in 2003, for example, cost the world economy some US$40 billion, partly as a result of highly disputed travel bans.

Epidemic diseases nearly always also lead to stigmatisation and ill treatment of groups associated with the disease. And because there are always people who are especially scared, epidemic diseases can cause social disruption by people who do such things as flee cities, swamp doctors and health services while well, and stockpile food or medicines.

We can't entirely eliminate these costs, but we can minimise "Ebolanoia" by addressing fears and directing people to positive actions. Here are some of the risk communication lessons our health officials and political leaders should be mindful of when they engage with the public about Ebola:

1. Don't panic about panic

Governments and health officials think their job is to stop people panicking. They do this by telling people not to panic and by making emphatic pronouncements that the risk of community transmission is very low or that we are well prepared. But they over-reassure. We say "over-reassure" because this tactic does not eliminate fear and it disastrously erodes trust if it fails to address the complex reality that underlies simple statements, or worse, if it is later proven to be wrong.

Telling people not to panic can ironically strengthen the conceptual link between Ebola and panic – a bit like asking people to think of any colour but red.

Worse, it belittles genuine concerns. Australians who worry about Ebola do so because they see a brutal scenario unfolding in West Africa and they can imagine it happening here. The seemingly relentless physical disintegration that the virus causes in the human body inspires dread. The absence or failure of normal mechanisms of control such as vaccines, treatment drugs and in-patient infection control amplify that fear.

 Possible Ebola vaccinations are still being trialled. EPA/Jean-Christophe Bott

Risk communications experts such as Peter Sandman counsel officials to tolerate this kind of worry and over-reaction as part of the normal range of responses to a significant threat.

Sometimes, communicators may even need to take some responsibility for such reactions. Many infectious disease-control experts, for instance, are keen to see Australia step up its assistance to West Africa and some may emphasise the potential for outbreaks in Australia as a result of unchecked spread there.

It is reasonable for Australians to respond with an increased fear of an outbreak at home. What leaders can do is stay calm and communicate specifically about what is being done and why. It is better to tell people "There is a small chance Ebola could come to Australia, but we have prepared specialist spaces within hospitals to ensure it won't spread beyond one case" than "We are well placed to deal with this threat."

2. Understand risk perception

Extensive studies have revealed how predictably people's perceptions of risk are influenced by certain factors, especially dread and control. "Bleeding from every orifice" or "having your brain turn to mush" create feelings of dread that drive up fear.

The severity of an outcome tends to make people over-emphasise their risk of getting it – this is called availability bias. It happens despite the relatively low infectivity of Ebola compared to diseases such as measles.

Also at stake is our sense of control – a disease with, as yet, no technological saviours (such as vaccines), and that is crossing national borders, strongly threatens this. Health officials need to restore people's sense of control as much as possible, in part through establishing trust in their own competence and integrity and providing actions we can take.

3. Build trust

If we want people to follow directives about behaviour, to self-report illness, or voluntarily observe isolation, then they need to trust that health-care officials are acting in their best interest. Leaders should focus on the qualities that build trust: competence, objectivity, fairness, consistency and empathy. These qualities are communicated through what is said – and not said – but also through actions and timing.

Actions speak louder than words. The recent reported decision of the Australian government to cancel all temporary visas from Guinea, Sierra Leone and Liberia, including humanitarian visas, communicates neither fairness nor competency when it has no basis in evidence. Taking such action signals that Ebola is a real and frightening threat, a signal that will over-ride reassuring words to the contrary.

 Health officials can help people to feel more in control by building trust in their processes. EPA/Olivier Hoslet

Transparency enhances trust. In an epidemic, this usually means communicating early and often. But it also includes being candid about what you don't know and explicit about the rationale for policy decisions.

Officials may find this counter-intuitive and worry about public reaction to debate and uncertainty. But openness expresses trust in the public and if they know what's going on, they also feel more in control.

If our leaders in the Ebola response can sustain public trust, they will have some leeway to make mistakes or shift or reverse earlier policy decisions without losing too much of this trust. Mistakes and changes are likely in an uncertain and developing situation. The best combination for crisis communication is a confident tone and tentative content, so that there's flexibility to change tack.

4. Give people something to do

The fastest way to re-establish a sense of control is to be able to act. The public don't have many actions at their disposal. They may hear stories about high-tech measures such as N95 masks, body suits and vaccines that they can't access. But they can get into the habit of good infection control with hand-washing.

They can also contribute to the Ebola response in West Africa by donating to organisations like Médecins Sans Frontières and the Red Cross.

5. Work with medical reporters

Many people will blame the mass media for generating "Ebolanoia". It's true that a competitive media market drives sensationalist images and headlines. But overall the Australian media has done a reasonable job of sticking to the essential messages of concern for the situation overseas, the conditions under which it most poses a local threat, and the low risks within Australia.

We found in our research many knowledgeable and experienced journalists who act as gatekeepers and tone setters within the media. Scientists and health policymakers who want to ensure that the media contains accurate and complete information need to be constantly and immediately available to these journalists (especially to fact-check stories), sensitive to their deadlines, and able to offer them exclusive or advance access to important stories.

In the end, good risk communication requires the integrity to act according to the best evidence and in the collective interest and the courage to communicate openly about those choices.

This sort of communication can feel risky, leaving leaders vulnerable to making mistakes in public. But it's the only way to earn the sort of trust that achieves compliance with quarantines and civil responses in a serious emergency. And it supports compassionate, reasonable and effective policy-making, which will continue to be of benefit once this particular disease threat has passed.

Julie Leask is an NHMRC Career Development Fellow and has a visiting appointment at the National Centre for Immunisation Research and Surveillance.

Claire Hooker does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Julie Leask, Associate Professor at University of Sydney Claire Hooker, Senior Lecturer and Coordinator, Health and Medical Humanities at University of Sydney Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/33681 2014-11-05T19:24:50Z 2014-11-05T19:24:50Z Zoe's Law could take NSW backwards in women's rights

The consequences of fetal personhood on women's rights in pregnancy and childbirth, and for abortion, are uncertain. SIOBHAN MARREN/AAP

A bill due to be debated in the upper house of the NSW Parliament will bestow legal personhood to fetuses of 20 weeks or more for the purpose of grievous bodily harm offences in the Crimes Act, if passed.

With the potential to erode women's rights to autonomy, informed consent and liberty over pregnancy and childbirth decisions, "Zoe's Law" takes the state into uncharted legal and medical territory.

Christian Democratic Party MP Fred Nile introduced the bill in the wake of the loss of Brodie Donegan's unborn baby, Zoe. She was stillborn at 32 weeks when a drug-affected driver drove off the road and seriously injured her mother on Christmas Day 2009. The driver was charged only in relation to the harm caused to Brodie Donegan – and her loss – and the bill seeks to change that.

It was later revised and re-introduced as the Crimes Amendment (Zoe's Law) Bill 2013 (No. 2) by independent MP Chris Spence, in whose constituency the Donegans live. The bill passed the lower house by a comfortable margin of 63 votes to 26 on November 21, 2013.

There is a risk that Zoe's Law will affect the legality of abortion in New South Wales, one of only two Australian states where there has been no reform of abortion law. Terminating a pregnancy remains a criminal offence in the state under legislation from last century.

Zoe's Law could provide ammunition to make abortion more difficult to obtain, but that is not the most significant matter at stake in this debate.

Why fetal personhood matters

If passed in the upper house, this would be the first time in Australia that a fetus is given separate legal status from its mother even though it remains within her body. The law would create a tension between a woman's rights and those of her fetus.

The potential for conflict here is the basis of opposition to fetal personhood by Australian and American health professionals, including the New South Wales branch of the Australian Medical Association, the Public Health Association of America and the American Congress of Obstetricians and Gynaecologists.

These organisations have expressed concern about what such a law might mean for the autonomy and well-being of pregnant women, especially disadvantaged and vulnerable women.

Proponents of the bill say arguments that fetal personhood could be used to deprive women of their autonomy and liberty are scare tactics because the proposed law includes exceptions for actions done by or with the consent of the mother. But efforts to direct or curtail pregnant women's behaviour in the interests of their fetus are not unknown.

A comprehensive survey of US cases in which pregnant women were deprived of their physical liberty because their behaviour might be considered a threat to the well-being of their fetus, for instance, found 413 cases between 1973 and 2005. The researchers thought they had underestimated the number of cases because it was difficult to identify them.

In 86% of the cases (354), women were charged with criminal offences, the majority (295) of which were punishable by more than one year in prison. As well as being arrested and jailed, they underwent forced medical interventions including caesarean sections, drug and alcohol treatments, and in-hospital detention for drug addiction or mental illness.

The authors note that, in most cases, efforts to deprive the women of their liberty "occurred through use of existing criminal statutes intended for other purposes", and 71% involved disadvantaged, poor women. They conclude:

our findings confirm that if passed, personhood measures would not only provide a basis for recriminalising abortion but would also provide grounds for depriving pregnant women of their liberty.

Unintentional effects

Any law that raises the possibility of criminal liability for maternal choices that may be considered not ideal for the fetus, such as refusing a recommended medical intervention, is detrimental to women. It is also a challenge to public health because it fails to recognise and respect that women have the right to autonomy, bodily integrity and informed consent.

Criminalising and enforcing medical intervention for drug addiction and mental illness deters pregnant women with the conditions from seeking antenatal care, and may lead to worse health outcomes. Even though such approaches disproportionately affect vulnerable and disadvantaged women, proponents often fail to appreciate how they potentially increase health and social inequality.

The consequences of fetal personhood on women's rights in pregnancy and childbirth, and for abortion, are uncertain. Clearly, only significant benefits can justify taking such serious risks.

Yet the New South Wales Bar Association is opposed to Zoe's Law. In a letter to Chris Spence, it says it sees "no compelling need for the proposed change" and that the bill will "significantly change New South Wales law". What's more, it points to "legitimate concern about the broader implications of this Bill" in respect to other criminal laws in the state.

Lawyers, doctors and women's groups all agree Zoe's Law shouldn't be supported. Why then are politicians so determined to reject their advice?

Alexandra Barratt receives funding from NHMRC and ARC.
 Alexandra Barratt, Professor of Public Health at University of Sydney Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/32632 2014-11-05T03:40:31Z 2014-11-05T03:40:31Z Nutrition is key to closing the Aboriginal life expectancy gap

Nutrition is one of the most important determinants of health, but has been neglected in policy. Jason Brackins/Flickr, CC BY-NC-SA

Aboriginal and Torres Strait Islander people have significantly poorer health and lower life expectancy than other Australians. But while reducing these inequalities is a priority for governments, national policy has neglected nutrition, one of the most important determinants of health.

Recent reports estimated a life expectancy gap of 11.5 years for Aboriginal males and 9.7 years for Aboriginal females compared to non-Aboriginal Australians. About 80% of this difference is due preventable chronic conditions, such as type 2 diabetes and cardiovascular disease.

The reasons for the difference are made apparent in the recently released results from the Aboriginal and Torres Strait Islander Health Survey. These suggest one in ten adults in this population group has diabetes, a prevalence three times higher than that of the non-Indigenous population. Aboriginal Australians are also developing diabetes 20 years earlier than other Australians.

The main driver of this increase is obesity. The survey shows that it's more common among Aboriginal and Torres Strait Islander people in every age group, including children. The survey showed 60% of Aboriginal and Torres Strait Islander men and 81% of women had a high waist circumference, putting them at risk of chronic disease.

Nutrition is a major contributor to these conditions.

The fall and rise of nutrition

Programs to improve nutrition for Aboriginal and Torres Strait Islander people were once considered a policy priority. But our research, which examined health strategies and plans aimed at this population published between 2000 and 2012, shows while nutrition was initially a priority, it fell off the radar in the second half of the period under examination.

Diet contributes to maternal health, birth weight, child development and oral health, as well as prevention and management of chronic disease. In fact, the World Health Organisation considers "dietary risks" as the leading cause of illness and death in Australia, surpassing both smoking and obesity.

Unfortunately, the impact of poor nutrition has not been adequately evaluated in the estimates of burden of disease in the Aboriginal and Torres Strait Islander population. This has significant implications for setting priorities in the health policy agenda.

Nonetheless, the previous Labor government's Aboriginal and Torres Strait Islander Health Plan, which was released in July 2013, refocused on improving nutrition. The plan was supposed to replace the previous ten-year policy framework and guide action over the next decade towards achieving the health-related targets for bridging the gaps in health and mortality between the Aboriginal and Torres Strait Islander population and the rest of Australia.

The plan was generally hailed as a step forward as it emphasised the centrality of Aboriginal and Torres Strait Islander culture and resilience to health and well-being. It included a commitment to address the social determinants of health, such as housing, education and employment.

Another strength of the plan is that it was developed in consultation with Aboriginal and Torres Strait Islander people and their peak organisations, which ultimately endorsed it and called for bipartisan support. The plan acknowledged the widespread problem of food insecurity and prioritised nutrition in the early years of life.

The way ahead

The government changed soon after the Health Plan was released. Over a year later, it is yet to be implemented. In fact, the Coalition criticised the plan when it was released.

Assistant Health Minister Fiona Nash announced in May that the government would develop a blueprint for implementing the Health Plan by the end of 2014. With only two months remaining, this implementation plan has still not seen the light of day.

In the meantime, the government has decided to replace 150 Indigenous affairs programs with just five, resulting in $239 million in cuts, and an additional $165 million reduction to the Aboriginal health budget.

Improving Aboriginal and Torres Strait Islander health requires coordination, sustainable funding and a well-trained workforce. Implementing the 2013 Health Plan in the way its creators intended is key to improving nutrition for this population and closing the life expectancy and health gap.

Jennifer Browne works for the Victorian Aboriginal Community Controlled Health Organisation (VACCHO). Her position is funded by the Victorian Department of Health. She is a member of the Public Health Association and the Dietitians Association of Australia. The views expressed in this article are those of the author and do not necessarily represent the views of the affiliated organisations.

Deborah Gleeson receives funding from the Australian Research Council for a research project unrelated to the topic of this article. She is a member of the Public Health Association of Australia and is active in the global People's Health Movement.
 Deborah Gleeson, Lecturer in Public Health at La Trobe University Jennifer Browne, Doctoral candidate at La Trobe University Licenced as Creative Commons – attribution, no derivatives. tag:theconversation.com,2011:article/32379 2014-11-04T19:23:56Z 2014-11-04T19:23:56Z End-of-life care: how terminally ill kids and their parents can plan for a better death

Most children have never had legal capacity and are reliant on parents to make health-care decisions for them. drpnncpptak/Shutterstock

The diagnosis of a palliative illness in a child or adolescent is devastating for all involved: parents, family members and the children themselves, as they grieve for life they had planned and believed they would have. The child, their parents (and sometimes siblings) and clinicians will soon begin the difficult process of talking about death and the options for the child's end-of-life care.

Advance care planning and advance health directives are useful tools to help manage the care of adults with palliative illness. They are designed to capture the future health-care wishes of an adult patient while they still have the legal capacity to make decisions for themselves, and record their choices.

When completed properly, the directives and plans are legally binding and come into effect when the patient no longer has capacity. Often they include choices around whether to pursue invasive life-sustaining measures such as mechanical ventilation, or when to withdraw fluid and nutrition. Recording these choices reassures those involved that death will occur with a personalised balance of ongoing treatment while avoiding futile measures and maintaining dignity.

The scenario is different for children with a palliative illness, as most have never had legal capacity and are reliant on parents (or others) to make health-care decisions for them. But this doesn't mean that children and adolescents shouldn't have a say in their future care, or have their choices acknowledged and recorded.

Children and adolescents can use informal or formal documented advance care plans, as well as other forms such as Paediatric Acute Resuscitation Plans (PARP). Although these forms are often not legally binding, the aim is to encourage early and thorough communication between parents and clinicians. And, where developmentally appropriate, conversations can also include the child.

Unlike advance care planning for adults, there remains little in the literature about their use and benefits for children. But we can make an educated guess.

Advance care planning in the paediatric setting ensures parents have time to consider the various health-care options, obtain relevant information, and prepare for the future decisions they may be asked to make. Parents of children with complex illnesses also say the process helps medical staff understand their child.

Children, like adults, are likely to benefit from being involved in the advance care planning process, and children as young as ten have shown capability in end-of-life planning similar to their adult counterparts. This is particularly so for adolescents, who by virtue of not having achieved an arbitrary legal "age of adulthood" may be otherwise denied from making or contributing to important decisions.

Many of the forms, such as the resuscitation plans, include a space to record information about discussions with the child or young person and any requests. This may take the form of expressing a wish to die at home or wanting to avoid painful procedures, as well as proactively wishing to ensure adequate pain relief will be provided.

Where children are involved in the process, differences between the level and types of interventions the parents want, and what the child is prepared to endure, might also be identified earlier and can then be negotiated and resolved. This aspect is particularly relevant to older children who deserve, ethically, to have a say in their care.

The death of a child is always complex and tragic, and in Western countries, is fortunately rare. However this should not leave us unprepared when a palliative diagnosis has been made. Advance care planning may provide important benefits to parents and children by helping guide the provision of care for a child when death is approaching.

This article was co-authored by Dr Christine Mott, Advanced Trainee in General Paediatrics and Palliative Care, the Royal Australasian College of Physicians.

Nikola Stepanov does not work for, consult to, own shares in or receive funding from any company or organisation that would benefit from this article, and has no relevant affiliations.
 Nikola Stepanov, Children's Ethics & Health Law Academic/Lecturer. Discipline of Medical Ethics, Law & Professional Practice at The University of Queensland Licenced as Creative Commons – attribution, no derivatives.

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