Injecting nation: achieving control of hepatitis C in Australia

Since Australia banned heroin in 1953 consumption of illicit drugs, deaths, crime and corruption related to drugs have steadily increased. Injecting drug use (IDU) in Australia is now a significant public health problem linked each year to approximately 500 overdose deaths and more than 6000 hepatitis C infections. At least 85% of prevalent and incident hepatitis C cases in Australia are injecting drug users (IDUs) with annual incidence estimated at 15%. Although poorly documented, increasing numbers of patients with end-stage liver disease from hepatitis C now appear to present in Australia. This reflects a heroin-injecting epidemic commencing a quarter of a century ago, the close association between drug injecting and hepatitis C and the long delay between hepatitis C infection and complications. The overall health and economic burden of hepatitis C may soon exceed HIV. Control is far more difficult to achieve for hepatitis C than HIV because of much higher baseline prevalence levels and far greater infectiousness by blood to blood spread. Transmission appears to follow minimal breaches of infection control guidelines. Hepatitis C has not yet become a priority public health issue in Australia. No national prevention strategy has been proposed. Prevention strategies (such as needle exchange or methadone) which controlled HIV among IDUs should be expanded, with the expectation of some useful reduction of spread but without achieving control of hepatitis C. Other options for control must be considered. Eradicating illicit drug use in Australia is unachievable. Virtually eradicating injecting drug use by facilitating a switch to non-injecting routes of administration (NIROA) is achievable (although difficult) and this could control hepatitis C. NIROA will have the probable additional benefit of reducing drug overdose deaths. NIROA has begun recently to replace injecting in several countries without government intervention. Powerful cultural, pharmacological and economic factors strongly reinforce drug injecting. Economic impediments to NIROA could be reduced by drug policy reform. Facilitating a switch to NIROA carries some risk of increased discrimination directed against an already marginalized population. A major obstacle to harm reduction is the common assumption that any relaxation of drug policy invariably leads to increased consumption. Switching the predominant route of administration of illicit drugs from IDU to NIROA should be the major focus of national efforts to control hepatitis C and overdose deaths in Australia.     

Accounting for susceptibility in risk assessment: The need for full disclosure

Many Environmental Laws create the unrealistic expectation that science can be used to determine ‘safety'. The many uncertainties surrounding environmental risks, as well as individual, group and societal differences about what is considered ‘safe', make it inevitable that policy decisions must be made. It is appropriate that such decisions be shaped by politics and social issues, as well as be informed by science and economics, but care should be taken to distinguish between policy and fact. Not much is known about the nature and magnitude of environmental susceptibilities. Credible environmental decisions require that scientists, risk assessors and decision-makers acknowledge this, and that they take care to distinguish policy calls from scientific fact.     

Cannabis laws: an analysis of costs

There is evidence that the use of cannabis is increasing in Australia, with stable black-market prices, despite the 9-year National Campaign Against Drug Abuse, increasing expenditure to enforce the laws against cannabis use, and the seizure of large plantations of cannabis plants. Recent government data are used to estimate the conservative cost of drug-law enforcement against cannabis use as being $329m in 1991-92. Alternatives to the existing regime are examined, including expiation, decriminalization, and legalization.     

The development of guidelines for drug and alcohol dependence treatment: affecting policy and practice

The rationale and methodology behind the Australian Quality Assurance Project is described. The Project aimed to develop guidelines for treatment content based on three sources of information: research findings, current practice and expert opinion. The issue of the gap between research and practice is discussed, as well as the role of dissemination in altering clinician behaviour.     

Harm reduction in the developing world

This paper examines harm reduction from the perspective of poor countries. In considering which elements of the broad approach are suitable for adaptation and adoption by poor countries, there is a need to examine critically the arguments put forth in support of it and which, if any, of these are supported by evidence. There are also significant indirect influences that the approach is likely to have on how drug use is understood and interpreted by wider society. The likely impact of these on areas other than simply services directed to drug users needs to be assessed. There are some features regarding harm caused by alcohol and other drug use that are specific to poor countries. Most important among these is that levels of use which are not deemed to be harmful in rich societies cause grave harm through diverting meagre resources away from survival needs in the poor world. Alcohol, as well as other drugs, tends in deprived settings to cause dependence and other problems much earlier in people's drinking careers and at much lower levels of consumption than in rich countries.     

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.     

论医疗事故赔偿纠纷的法律适用

由于我国医疗事故赔偿纠纷处理的有关法律、行政法规及司法解释之间存在着不统一、不配套的矛盾。因此,在审理医疗事故赔偿纠纷案件中的分歧颇大 这既不利于正确地维护医患双方的合法权益,也不利于医疗纠纷的顺利解决及社会秩序的稳定。因此,正确地认识与解决医疗事故赔偿纠纷法律适用中的矛盾,具有十分重要的意义。     

树立市场经济法律意识繁荣社会主义卫生事业

市场经济是法制经济,社会主义市场经济体制的建立和完善,离不开社会主义市场经济法制体系的建立与完善。在实现两个转变的过程中,加强法制建设,树立和强化法律意识,对推进卫生改革,促进卫生发展具有十分重要的意义。     

Richmond-Kotelchuck健康政策模式图的启示──我国预防医学模式转变中的三个关键问题

Richmond－Kotelchuck的健康政策模式图由科学知识基础、政治意愿和社会行为措施三部分组成。该模式图充分体现了三者对整个健康政策模式图的作用及其相互联系。随着社会的发展,我国当前正面临着转变预防医学模式的任务,借助于该模式图,本文论述了我国预防医学模式转变中值得注意的三个关键问题：科学研究、健康教育和举措设计。     

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.