Harnessing harm reduction in Australia: an interview with the Hon. Neal Blewett. Interview by Steve Allsop

The National Campaign Against Drug Abuse (NCADA) was established in April 1985. Aiming to provide a national framework to minimize the harmful consequences of drug use, the original 3-year programme was extended to 1997. A key figure in the NCADA, Dr Neal Blewett, was interviewed to gain his perspective on the development and implementation of the Campaign over its first 10 years.     

A Systemic and Value-Based Approach to Strategic Reform of the Mental Health System

Most writers now recognize that mental health policy and the mental health system are extremely resistant to real changes that reflect genuine biopsychosocial paradigms of mental disorder. Writers bemoaning the intransigence of the mental health system tend to focus on a small analytical level, only to find themselves mired in the rationalities of the existing system. Problems are acknowledged to be system-wide, yet few writers have used a method of analysis appropriate for systemic problems. Drawing upon the General System Theory (GST) analytical perspective, this article advances a systematic approach to understand the mental health system and to facilitate the development of reform strategies that recognize the system's complexity and changing nature. The article first discusses the failure of major reform efforts in the mental health system and the limitations of mainstream analysis of mental health politics and policies with respect to the objectives of analysis and reform. This article describes how systems thinking has thus far influenced the study of the mental health policy and politics system, and argues that a systemic perspective is profitable for reconceiving the mental health system, enabling a fresh basis for the development of reform strategies. The mental health system should be seen as a social system influenced by larger political and economic dimensions, not just as a 'delivery system' scientifically constructed by neutral experts. Furthermore, the policy planning process should be viewed as part and parcel of a mental health system modeled as complex and dynamic. The systemic perspective outlined here should help both to clarify the value-based objectives that we hold for the system and, consequently, to plan for the strategic reforms that have so far eluded us. This revised version was published online in July 2006 with corrections to the Cover Date.     

Challenges of and strategies for changing prescribing practices of health care providers

Problems related to inappropriate prescribing practices of physicians in general are well recognized. Dietary fluoride supplements have been implicated as one of the contributing factors in an increase in dental fluorosis. Inappropriate prescribing practices of providers have been cited as a major factor in this implication. Numerous studies of physicians and dentists have documented a lack of knowledge and inappropriate prescribing practices regarding fluoride supplements. The purpose of this paper is to identify barriers to changing fluoride-prescribing practices of health care providers and to suggest strategies for implementing change. To increase optimal and appropriate use of fluoride supplements, educational interventions are necessary for all user groups--detail men and women, physicians, dentists, pharmacists, nurse practitioners, dental hygienists, and the public. In addition, environmental supports for the educational activities in the form of policy, regulation, standards of care, and guidelines are recommended for consideration.     

Restrictions on tobacco and alcohol use in Australian work-places

In a telephone survey of 455 of the top 600 companies in Australia, around three-quarters reported the existence of restrictions on both smoking and alcohol in the workplace. Forty-six percent of companies had a total ban on smoking at work, 31% had designated limited areas where employees were permitted to smoke, and 23% had no policy on smoking. Seventy-seven percent of companies encouraged a total alcohol-free work environment. The larger the company, the more likely it was to have restrictions on smoking in the work-place, but there was no relationship between the size of the company and alcohol restrictions. Government organizations were more likely to have restrictions on smoking than nongovernment organizations, but this difference was not apparent for alcohol restrictions. The major reasons given for smoking restrictions were related to health and comfort, while those for alcohol were related to work productivity and safety.     

特区经济学的理论前提

实行特殊政策和实施特殊管理体制是世界经济特区共有的基本特征。正是这两个基本特征构成了特区经济学的两个理论前提。对经济特区实行特殊政策和实施特殊管理体制进行理论分析 ,目的在于为构筑特区经济学的理论体系作理论上的准备     

Patient satisfaction with health care providers in South Africa: the influences of race and socioeconomic status.

OBJECTIVE: The first democratic government elected in South Africa in 1994 inherited huge inequalities in health status and health provision across all sections of the population. This study set out to assess, 4 years later, the influence of race and socioeconomic status (SES) on perceived quality of care from health care providers. DESIGN: A 1998 countrywide survey of 3820 households assessed many aspects of health care delivery, including levels of satisfaction with health care providers among different segments of South African society. RESULTS: Fifty-one percent (n = 1953) of the respondents had attended a primary care facility in the year preceding the interview and were retained in the analysis. Both race and SES were significant predictors of levels of satisfaction with the services of the health care provider, after adjusting for gender, age, and type of facility visited. White and high SES respondents were about 1.5 times more likely to report excellent service compared with Black and low SES respondents, respectively. CONCLUSION: In South Africa, race and SES are not synonymous and can no longer be considered reliable proxy indicators of one another. Each has distinct and significant but different degrees of association with client satisfaction. Any assessment of equity-driven health policy in South Africa should consider the impacts of both race and SES on client satisfaction as one of the indicators of success.     

The Effectiveness of Pfizer-BioNTech and Oxford-AstraZeneca Vaccines to Prevent Severe COVID-19 in Costa Rica: Nationwide,Ecological Study of Hospitalization Prevalence

BackgroundThe Costa Rican COVID-19 vaccination program has used Pfizer-BioNTech and Oxford-AstraZeneca vaccines. Real-world estimates of the effectiveness of these vaccines to prevent hospitalizations range from 90%-98% for two doses and from 70%-91% for a single dose. Almost all of these estimates predate the Delta variant.ObjectiveThe aim of this study is to estimate the dose-dependent effectiveness of COVID-19 vaccines to prevent severe illness in real-world conditions in Costa Rica, after the Delta variant became dominant.MethodsThis observational study is a secondary analysis of hospitalization prevalence. The sample is all 3.67 million adult residents living in Costa Rica by mid-2021. The study is based on public aggregated data of 5978 COVID-19–related hospital records from September 14, 2021, to October 20, 2021, and 6.1 million vaccination doses administered to determine hospitalization prevalence by dose-specific vaccination status. The intervention retrospectively evaluated is vaccination with Pfizer-BioNTech (78%) and Oxford-AstraZeneca (22%). The main outcome studied is being hospitalized.ResultsVaccine effectiveness against hospitalization (VEH) was estimated as 93.4% (95% CI 93.0-93.9) for complete vaccination and 76.7% (95% CI 75.0-78.3) for single-dose vaccination among adults of all ages. VEH was lower and more uncertain among older adults aged ≥58 years: 92% (95% CI 91%-93%) for those who had received full vaccination and 64% (95% CI 58%-69%) for those who had received partial vaccination. Single-dose VEH declined over time during the study period, especially in the older age group. Estimates were sensitive to possible errors in the population count used to determine the residual number of unvaccinated people when vaccine coverage is high.ConclusionsThe Costa Rican COVID-19 vaccination program that administered Pfizer-BioNTech and Oxford-AstraZeneca vaccines seems to be highly effective at preventing COVID-19–related hospitalization after the Delta variant became dominant. Even a single dose seems to provide some degree of protection, which is good news for people whose second dose of the Pfizer-BioNTech vaccine was postponed several weeks to more rapidly increase the number of people vaccinated with a first dose. Timely monitoring of vaccine effectiveness is important to detect eventual failures and motivate the public to get vaccinated by providing information regarding the effectiveness of the vaccines.     

Papers Please - Predictive Factors of National and International Attitudes Toward Immunity and Vaccination Passports: Online Representative Surveys

BackgroundIn response to the COVID-19 pandemic, countries are introducing digital passports that allow citizens to return to normal activities if they were previously infected with (immunity passport) or vaccinated against (vaccination passport) SARS-CoV-2. To be effective, policy decision-makers must know whether these passports will be widely accepted by the public and under what conditions. This study focuses attention on immunity passports, as these may prove useful in countries both with and without an existing COVID-19 vaccination program; however, our general findings also extend to vaccination passports.ObjectiveWe aimed to assess attitudes toward the introduction of immunity passports in six countries, and determine what social, personal, and contextual factors predicted their support.MethodsWe collected 13,678 participants through online representative sampling across six countries—Australia, Japan, Taiwan, Germany, Spain, and the United Kingdom—during April to May of the 2020 COVID-19 pandemic, and assessed attitudes and support for the introduction of immunity passports.ResultsImmunity passport support was moderate to low, being the highest in Germany (775/1507 participants, 51.43%) and the United Kingdom (759/1484, 51.15%); followed by Taiwan (2841/5989, 47.44%), Australia (963/2086, 46.16%), and Spain (693/1491, 46.48%); and was the lowest in Japan (241/1081, 22.94%). Bayesian generalized linear mixed effects modeling was used to assess predictive factors for immunity passport support across countries. International results showed neoliberal worldviews (odds ratio [OR] 1.17, 95% CI 1.13-1.22), personal concern (OR 1.07, 95% CI 1.00-1.16), perceived virus severity (OR 1.07, 95% CI 1.01-1.14), the fairness of immunity passports (OR 2.51, 95% CI 2.36-2.66), liking immunity passports (OR 2.77, 95% CI 2.61-2.94), and a willingness to become infected to gain an immunity passport (OR 1.6, 95% CI 1.51-1.68) were all predictive factors of immunity passport support. By contrast, gender (woman; OR 0.9, 95% CI 0.82-0.98), immunity passport concern (OR 0.61, 95% CI 0.57-0.65), and risk of harm to society (OR 0.71, 95% CI 0.67-0.76) predicted a decrease in support for immunity passports. Minor differences in predictive factors were found between countries and results were modeled separately to provide national accounts of these data.ConclusionsOur research suggests that support for immunity passports is predicted by the personal benefits and societal risks they confer. These findings generalized across six countries and may also prove informative for the introduction of vaccination passports, helping policymakers to introduce effective COVID-19 passport policies in these six countries and around the world.     

How the war on drugs impacts social determinants of health beyond the criminal legal system

There is a growing recognition in the fields of public health and medicine that social determinants of health (SDOH) play a key role in driving health inequities and disparities among various groups, such that a focus upon individual-level medical interventions will have limited effects without the consideration of the macro-level factors that dictate how effectively individuals can manage their health. While the health impacts of mass incarceration have been explored, less attention has been paid to how the “war on drugs” in the United States exacerbates many of the factors that negatively impact health and wellbeing, disproportionately impacting low-income communities and people of colour who already experience structural challenges including discrimination, disinvestment, and racism. The U.S. war on drugs has subjected millions to criminalisation, incarceration, and lifelong criminal records, disrupting or altogether eliminating their access to adequate resources and supports to live healthy lives. This paper examines the ways that “drug war logic” has become embedded in key SDOH and systems, such as employment, education, housing, public benefits, family regulation (commonly referred to as the child welfare system), the drug treatment system, and the healthcare system. Rather than supporting the health and wellbeing of individuals, families, and communities, the U.S. drug war has exacerbated harm in these systems through practices such as drug testing, mandatory reporting, zero-tolerance policies, and coerced treatment. We argue that, because the drug war has become embedded in these systems, medical practitioners can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and by becoming engaged in policy reform efforts.

KEY MESSAGES

• A drug war logic that prioritises and justifies drug prohibition, criminalisation, and punishment has fuelled the expansion of drug surveillance and control mechanisms in numerous facets of everyday life in the United States negatively impacting key social determinants of health, including housing, education, income, and employment.
• The U.S. drug war’s frontline enforcers are no longer police alone but now include physicians, nurses, teachers, neighbours, social workers, employers, landlords, and others.
• Physicians and healthcare providers can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and engaging in policy reform.