PopH, PAL, and SFM Flashcards

Question

Define cumulative incidence

Answer 1

Cumulative incidence is the proportion of an initially disease-free population that develops disease during a specified time. The cumulative incidence is calculated as 15/1000 giving 1.5% (or 15 per 1000 women).

Answer 2

A proportion is a comparison of two independent varaibles, whrea numberot is included indenominator. EG prev, incidence, mortality Rate is a special case of proportion, includes a specific time period

Answer 3

The proportion in a defined population who have a specific disease at a certain point or piod of time: no of people with disease ata given time/period divided by no in totatl popoulation at time Can be expressed as percentage or as per 100, 1000

Answer 4

- cumulative: proportion of new cases of disesase in population i in a fgiben period - divdided by pop at risk in psecifc time priod Rperesents risk of developing diseae percent, %/yr, per 1000, per 100k Inc rates: how hast new cases of disease are occuring in pipulation aat risk multiplied by time interval expressed in person-time units: note: 100 new cases of cholera, divided by population at risk of 5000, times 5 years = 0.004 new cases per year OR 4 per 1000 person years | Assumption in calculation= all persons followed for **total** interval

Answer 5

- natural environemnt - built environment

Answer 6

Bio Phys Chem

Answer 7

- dose respinse - exposure - hazard*' - risk characterisation: Risk characterisation examines how well the data support conclusions about the nature and extent of the risk from exposure to environmental stressors.

Answer 8

Risk management involves consideration of reducing the hazard at source, removing exposures at the individual level, and removing exposures at community levels. Idnetify and assesss, develop control measures to reduce it, and monitor effectiveness of control measures ## Footnote Once the hazard has been identified - risk assessment Probability, the likelihood of exposure to the hazard Level of severity of disease or injury that occurs A combination of both Influenced by Hazard nature Dose-response relationship Workplace policy Individual factors

Answer 9

- data collection - data analysi - data interpretation - data dissemination - link to action

Answer 10

Sporadic refers to a disease that occurs infrequently and irregularly. Endemic refers to the constant presence and/or usual prevalence of a disease or infectious agent in a population within a geographic area. In other words, it is the amount of a particular disease that is usually present in a community and is often referred to as the baseline level. For example, malaria is endemic in much of Africa. Hyperendemic refers to persistent, high levels of disease occurrence. Epidemic refers to an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area. Outbreak carries the same definition of epidemic, but is often used for a more limited geographic area. Cluster refers to an aggregation of cases grouped in place and time that are suspected to be greater than the number expected, even though the expected number may not be known. Pandemic refers to an epidemic that has spread over several countries or continents, usually affecting a large number of people. Examples are the influenza pandemics of 1918, 1957 and 1968; HIV and multi-drug resistant tuberculosis

Answer 11

Epidemics can be classified according to their manner of spread through a population. There are two main types: Common-source Point Continuous Intermittent Propagated A common-source outbreak is one in which a group of persons are all exposed to an infectious agent or a toxin from the same source. A propagated outbreak results from transmission from one person to another. The progress of an outbreak is studied using an epidemic curve. This is a plot of the number of cases of disease against time relative to the date of onset. From it's shape we can identify the type of epidemic.

Answer 12

The hierarchy of evidence Meta-analysis of randomised controlled trials Randomised controlled trial Cohort study Case-control study Cross-sectional study Ecological study Case series

Answer 13

Advantages Disadvantages Describes the demographics, presentation or prognosis of people who have a particular disease. Has no comparison group. Can draw attention to an emerging issue and lead to confirmatory studies using higher quality study designs

Answer 14

Ecological level variables may be: aggregrate measures: summaries of observations derived from individuals (e.g. incidence of a disease, proportion of smokers, area level deprivation indices), environmental measures (e.g. air pollution level or hours of sunlight) global measures for which there is no distinct individual level measure (e.g. Gross Domestic Product, population density) Advantages: Useful for comparing health between different populations or over time Useful for highlighting issues that can be investigated in future studies Inexpensive and quick as can use existing sources of data, such as published statistics Useful in environmental epidemiology where we often can not measure exposures at the individual level for large numbers of subjects Useful for the evaluation of the impact of new policies, programmes and legislation on the population Negatives: Has no comparison group. The people who are exposed may not be the same ones who experience the outcome. If the associations detected at group level do not hold on an individual level, the study suffers from a type of bias known as ecological fallacy.

Answer 15

In cross-sectional studies, information is collected from a defined population at a single point in time without any follow-up, providing a "snapshot" of their health. Because they measure health status at a point in time, they are often called prevalence studies. Cross-sectional studies usually involve asking participants a series of questions using a questionnaire. Cross-sectional studies may be: descriptive: they measure one parameter, e.g. the prevalence of type 2 diabetes in adults over the age of 40y (often called prevalence studies.) analytical: the measure exposure associations with outcomes, e.g. the association between obesity and type 2 diabetes in the same population. Advantages: Relatively inexpensive and easy to conduct Can provide information on multiple exposures and outcomes Assess the health needs of a population Useful for studying asymptomatic conditions where patients may not present to doctors, such as high blood pressure. The clinical iceberg is a recognised phenomenon in which medical services are only aware of symptomatic patients, i.e. those above the water line. Diasadvantages: Cannot determine causality: measurements of the outcome and exposure are made at the same time, cross-sectional studies cannot be used to determine whether a particular exposure caused the disease. In addition, the exposure may be secondary to the disease (reverse causality). Selection bias: subjects with an interest in the topic may be more likely to volunteer to participate. Selection using random sampling may still result in bias if the response rate to selection is low. Recall bias: cases of disease may be more aware of suspected exposures than participants without disease Confounding: association with a third variable that provides an alternative explanation for the observed association between the exposure and the outcome. ## Footnote note effect modifier -- disappears with adjustment of effect modifier e.g. age adjusted ratio/multivar analysis

Answer 16

Case-control studies start with cases of a disease and uses a comparison of controls, who are similar to cases but do not have the disease. Both groups are asked about their exposure to previous risk factors. Sometimes exposure information is extracted from records. Case-control studies compare the frequency of exposure to a suspected risk factor in cases with the frequency of exposure to that risk factor in controls. The summary measure expressing the association between the exposure and disease is known as the odds ratio (see below). Advantages: - evaluate many different exposures - useful fro rare diseases becuase they start off with caes - quick and cheap tp perform Disadvantages: - not good for rare exposures: bec may involve small numbers - control selection: can be dif to obtain controls that adequately represent the population that cases come from - info bias: recall bias and observer or interviewr bases (if case and control, info not comparable) - confounding - reverse causality: outcome already occurred, dif to tell if exposure preceded outcome - selection bia: arises if cases and controls are no choen independently of the exposures being studied \ eg smoking and lung cancer

Answer 17

In cohort studies a group of people are followed over time to study what happens to them. Information about exposures are usually measured at the start of the study among people who have not yet developed the disease outcome of interest. They are then followed over time to evaluate the occurrence of the outcome. This is known as a prospective cohort study. Sometimes, a retrospective cohort study is conducted where the disease has already occurred and investigators can collect exposure data from pre-existing records. This design is useful for studying long-term exposure effects as the investigators do not need to wait for the disease to develop in a prospective study. Risk ratio Advantages: - The main advantage of cohort studies is that the time sequence of events can be determined. - exposure information is measured before the onset of disease so the temporal relationship between exposure and outcome is clear - provide a direct measure of incidence (risk) - among observational studies, cohort studies provide best evidence that an exposure-outcome association is causal. - can assess multiple exposures and multiple outcomes allowing sub-analyses to be conducted Disadvantges: - Time consuming and expensive as can involve a large number of people being followed for many years. - not suitable to study rare diseases - loss to follow up bias: type of selection bias -- move, oose contact, grow tired, become too ill - confoudning: the exposed and unexposed groups of participants will differ on factors other than the exposure being investigated.

Answer 18

Randomisation is important because it ensures that the two groups are similar on all aspects (e.g. age, sex, general health, socio-demographic factors) other than the intervention. If one group were in some way less healthy than the other at the start this might make this group look worse even if the intervention had no effect. Ideally, neither the participants nor the investigators should know which intervention group patients belong to (called double blinding) so that neither of them can influence the outcome of the study. Best for intervention studies RR or hazard ratio: comparing incidence rates rather than cumulative incidences Advantages: - good evidence of causality - strongest study design that an intervention led to the outcome. - Randomisation - ensures that both groups have an equal chance of receiving the intervention and that they have similar characteristics. The effect of the intervention can be studies without other factors influencing the outcome (confounding). Disadvantages: - Measurement bias may arise if double blinding can not be ensured. - May need to include a large number of participants. - May not be suitable in situations where not giving an intervention may be inappropriate or unethical. Can allocate people to harmful exposures. - can be expensive - randomisation does not guarantee group equivalence if the numbers of participants are small

Answer 19

Multi-factorial causation comprises several factors, or components, that result in sufficient cause.

Answer 20

A necessary cause will always produce disease regardless of other factors

Answer 21

There are four types of factors involved in the causation of disease: - Predisposing factors: age, sex, genetics, previous illness. Enabling factors: factors that favour the development of disease, such as poor nutrition, low income, inadequate medical care, or assist in the recovery from disease. Social determinants of health are important enabling factors. Precipitating factors: exposure to a specific disease agent. Reinforcing factors: repeated exposure to factors or environmental conditions that may aggravate an established condition. This classification underpins the PRECEDE-PROCEED model that is used extensively in health promotion research to identify factors that predispose, enable and reinforce an individuals engagement with health risk behaviours. For example, knowledge and attitudes about smoking was identified as a predisposing factor in a study of smoking during pregnancy in Aboriginal and Torres Strait Islander women (MJA 2009; 190:557-561)

Answer 22

It is not an absolute requirement that all criteria are met in order for a exposure to be considered causal. However, a temporal association and biological plausibility are ESSENTIAL criteria.' Temporality The exposure precedes the occurrence of disease (essential). Is easier to establish in a prospective cohort study than a case-control study. Also important to understand the length of the interval between exposure and disease. Plausibility The causal explanation makes biological sense (essential) Replication & consistency Similar results from other studies in a variety of different situations and in different populations that are unlikely to share the same bias. Strength What is the strength of association between the exposure and disease? A relative risk (or odds ratio) of 3 or 4 is less likely to be due to bias than one of 2 or less. Dose-response relationship Is increased exposure to the possible cause associated with increased effect? Reversibility (cessation of exposure) Does the removal or reduction of a possible cause lead to a reduction in the disease risk? Specificity Are the findings specific? Is the association specific to one disease? Many diseases have several causes and many exposures cause several diseases (e.g. tobacco). However, may be useful for some exposures, for example where an association may be limited to a particular group with a particular environmental exposure. Support from experimental data Including animal or in vitro studies and intervention studies in humans

Answer 23

- Recall bias - Observer bias - Measurement bias (or information bias) - Selection bias

Answer 24

The term "risk factor" is commonly used to describe factors that are positively associated with the risk of developing a disease, but are not sufficient to cause disease. Some risk factors are associated with several diseases (e.g. tobacco smoking), and some diseases (e.g. coronary heart disease) are associated with several risk factors.

Answer 25

An event, condition, or characteristic [or a combination of these factors] that plays an essential role in producing the occurrence of disease. (Webb & Bain p239) In other words, a cause of a disease increases a person's risk of developing the disease.

Answer 26

A necessary cause - any agent that is required for the development of a given disease (e.g. a specific infectious agent). An outcome cannot develop in its absence. e.g. presence of A necessary cause - any agent that is required for the development of a given disease (e.g. a specific infectious agent). An outcome cannot develop in its absence. e.g. P.carinii and pneumonia (but not all who have P.carinii develop pneumonia...), HIV infection for AIDS A component cause - a factor that contributes towards disease causation but is not sufficient to cause disease on its own e.g. smoking and lung cancer A sufficient cause - a factor (or usually a combination of factors) that will inevitably produce disease. OR A minimum set of conditions and events that are sufficient for the outcome to occur. This is a feature of multi-factorial causation e.g. smoking, and asbestos, for lung cancer. n.b. Some can be both necessary and sufficient e.g. Tay-Sachs mutation Equally, some causes may be neither necessary not sufficient e.g. for complex chronic diseases e.g. cancer

Answer 27

Multi-factorial causation therefore comprises several factors, or components, that result in "sufficient" cause. It is not necessary to identify all of the components of a sufficient cause before prevention can be successful. The removal of one component may interfere with the others and therefore prevent the development of the outcome. Chronic diseases are multi-factorial - there are many components, none of which are strictly necessary or sufficient on their own to cause disease. See the smoking and lung cancer example below.

Answer 28

1. Consider alternative non-causal explanations. Could the observed association be an artefact due to chance, bias or confounding? Is the association due to a chance occurrence? Is it due to a flaw in the methodology (bias)? Is it due to some other factor linked to both the exposure and the outcome (confounding)? 2. A formal evaluation of whether an observed association is causal If we are confident from our critical appraisal of a study that the association is not due to chance, bias or confounding we can consider additional criteria to assess whether the association is causal. ## Footnote Unfortunately, there is no clear answer to how big an effect should be for it to be meaningful. An relative risk of 2.0 is generally considered to be strong and therefore practically significant. A RR of less than 2 should not be immediately dismissed without considering the risk (i.e the incidence) in the unexposed group or the total population under consideration. A small association for a relatively common disease can result in a large number of additional cases; conversely a moderate or strong association for a rare disease may only result in a few additional cases.

Answer 29

For something to be a confounder it must: - be a risk factor for the disease in it's own right, and - be associated with the risk factor of interest - must not be an intermediate factor between the exposure and outcome Note: A confounder may: Account for all or part of an apparent association May cause an overestimate or an underestimate of a true association.

Answer 30

Each sample will include slightly different people - their characteristics will be slightly different from those in other samples - just by chance. This is known as random sampling error. It is one of the three main sources of random error in addition to biological variation and measurement error. a) Little systematic or random error: an experienced shooter using a gun with the sights properly aligned - shots will cluster closely around the bulls-eye. The estimate is precise and accurate. b) Systematic error but little random error: an experienced shooter using a gun with sights not aligned correctly - shots will cluster closely but will not be accurate as consistently falling to the right. The estimate is precise but not accurate. c) Random error but little systematic error: a less experienced shooter using the first gun - will be accurate but the shots would be more spread out. The result will not precise but will be accurate. d) Random and systematic error: the less experienced shooter using the second gun. The result will not be precise nor accurate.

Answer 31

What do the overlapping risk factors for NCD/CRD’s tell us? * Both often share environmental/behavioural risk factors (e.g. tobacco, nutrition, indoor and outdoor air pollution, and sedentary lifestyle) * Tobacco smoking is the best-identified risk factor for many non-communicable diseases, including chronic respiratory disease Comorbidities (See other q) Although the absolute estimates of the prevalence and health burden of chronic respiratory diseases increased between 1990 and 2017, there were decreases in age-standardised estimates of prevalence (−14·3%), mortality (−42·6%), and DALYs (−38·2%) in the same period. * Smoking accounted for the highest proportion of disability attributable to chronic respiratory disease in all regions for men. * However, for women, the leading risk factor for disability varied by region: household air pollution from solid fuel use in south Asia and sub-Saharan Africa, exposure to ambient particulate matter in the southeast Asia, east Asia, and Oceania and the north Africa and Middle East super-regions, and smoking in all other super-regions --- Between 1990 and 2017, the total number of deaths due to chronic respiratory diseases increased by 18.0%, from 3.32 million in 1990 to 3.91 million in 2017. * Regions with a low Socio-demographic index had the highest mortality and DALYs. The global trends of mortality and DALY rates for chronic respiratory diseases varied by age, sex, region, and disease pattern * Smoking remained the major risk factor for mortality due to COPD and asthma. * Pollution from particulate matter was the major contributor to deaths from COPD in regions with a low Socio- demographic index. * Since 2013, a high body mass index has become the principal risk factor for asthma - Key Results: * Both socioeconomic and environmental factors impact CRD mortality rates. * Between 2010 and 2017, approximately 21.4 million people died from chronic respiratory diseases in the countries studied’ * 1% increase in GDP per capita results in a 20% increase in the CRD mortality rate. * Mortality increases with greater exposure to PM2.5 * However, an extra year of schooling reduces the mortality rate by 4.79% (− 0.0479). * Further, rate of urbanization is negatively associated with the CRD death rate (− 0.0252)* * the impact of pollution on the risk of morbidity due to CRD is greater that its impact on mortality, since urban areas are expected to offer better access to health care facilities and technologies

Answer 32

People with chronic respiratory conditions often have other chronic and long-term conditions. These ‘comorbidities’ are defined as the concurrent existence and occurrence of two or more medically diagnosed diseases in the same individual, with the diagnosis of each contributing disease based on established, widely recognized criteria. Comorbidity is not a sequel or complication of one disease but two separate diagnosis may have common underlying risk factors. Among people aged 45 and over with COPD: * 55% had arthritis (compared with 33% for people without COPD) * 43% had asthma (compared with 11% for people without COPD) Among people aged 45 and over with asthma: * 49% had arthritis (compared with 32% among people without asthma) * 17% had COPD (compared with 3.1% among people without asthma) Among people aged 45 and over with asthma: *49% had arthritis (compared with 32% among people without asthma) *37% had back problems (compared with 24% among people without asthma) *34% had mental and behavioural conditions (compared with 20% among people without asthma) ***17% had COPD (compared with 3.1% among people without asthma)**

Answer 33

- smoke and bushfires - Drought has both physiological effects as well as serious mental health effects for communities Flooding and storm damage affects health of affected communities Towns without water can see health effects emerge Health services are compromised by extreme weather events including fires, droughts and floods Changes in patterns of diseases – particularly infections

Answer 34

Heat is the natural event that has the highest mortality in Australia Not well reflected in our health data Very high temperatures are an emerging challenge for human habitation in parts of Australia Regional variation in temperature is central to understanding the likely health and biological impacts of rising temperatures -- side note: not exercising because of heat: Loss of muscle tone and strength Metabolic changes including glucose, insulin Blood pressure and HR Mental health affects Bowel and bladder function Chronic disease management Risk of falling increases Exercise is a powerful ‘anti-aging’ intervention. Not exercising can increase frailty.

Answer 35

- many models (lancet countdown, ecological determinants of health, doughnut for anthropocene) - include climate, weather, biodiversity; impact on air, food, water, where and how we live - biopsychosoccial model + environmenyt

Answer 36

The aim of preventive medicine is the absence of disease, either by: a)preventing the occurrence of a disease; or b)halting disease progression; or c)averting complications after its onset. Preventive medicine can be practised by governmental agencies, primary care physicians and the individual himself. Disease prevention is everyone's business.

Answer 37

- WHO - UN agencies e.g. UNICEF, UNFPA, UNDP... - Word Bank - OECD - Bilateral agencies - International Philanthropy e.g. Red Cross, MSF

Answer 38

- primary - preventing disease before it happens - modifying existing risk factors e.g. bike helmets, tobacco cessation - preventing development of risk factors e.g. boke trails located away from vehicles and policies limiting youth from purchasing tobacco - secondary - identifying disease before problem becomes serious e.g. NBS, mammography, BMI screening, BP measurement, regular check ups for smokers - tertiary - preventing complications of disease e.g. post-stroke rehabilitation, blood sugar-lowering medications for diabetes, physical therapy for back injury Primordial prevention targets social and economic policies affecting health. It is to prevent the emergence of predisposing social and environmental conditions that can lead to causation of disease. It is often beyond the control of clinicians as it requires policy-level interventions. But clinicians can be advocates for change. quaternary prevention - action taken to protect individuals from medical interventions that are likely to cause more harm than good - the goal is to reduce overmedicalisation and iatrogenic harm

Answer 39

The key principles of health improvement include: - a broad and positive concept of health - participant involvement - action, and competencies for action - a settings perspective - equity in health Health promotion is defined as the process of enabling people to increase control over, and to improve their health, through a) Building Healthy Public Policy; b) Creating Supportive Environments; c) Strengthening Community Action; d) Developing Personal Skills; and e) Reorienting Health Services.

Answer 40

Health promotion is defined as the process of enabling people to increase control over, and to improve their health, through a) Building Healthy Public Policy; b) Creating Supportive Environments; c) Strengthening Community Action; d) Developing Personal Skills; and e) Reorienting Health Services. Disease or health prevention is defined as measures not only to prevent the occurrence of disease, such as risk factor reduction, but also to arrest its progress and reduce its consequences once established. Equity means fairness. Equity in health means that people's needs guide the distribution of opportunities for well-being. (This also applies to health services access & availability). Individuals live behave and are influenced by various factors operating at different levels e.g. individual, interpersonal, organisational, community and public policy levels. When considering the "three" levels of prevention do not forget the context, and person, place and time. These levels, above, are also where SDH strategies are targeted e.g. a multi-level approach.

Answer 41

Stages include: - 1: precontemplation and ignoring problems - 2: contemplation, and weighing up the pros and cons of the problem - 3: preparation, and planning behaviour changes - 4: action and performing the behaviour - 5: maintenance, and integration of new behaviours in daily life e.g. IHD, asthma, pre-diabetic (T2D) The missing element from this model is that relapse is not an exception but a normal part of human behaviour. Doctors need to assist individuals to get back on course as part of a health promotion and prevention strategy.

Answer 42

- disempowering patterns of thought, language and practice - represents people in terms of deficiencies and failures - places responsibility for problems with affected individuals or communities, overlooking the larger socio-economic structures in which they are embedded - rejecting deficient discourse does not ignore challenges or downplays it but highlights it, ways to alleviate it - consequence: identity becomes defined in negative terms

Answer 43

Social and not biological differences are the primary cause of uneven burden of CKD Multiple different explanatory pathways have been proposed - primary renal disease explanations: higher incidence and greater severity --- reflect processes that cannot be explained by epigenetic and/or SDH - genetic differences -- evidence varies - early development explanations: attributed to adverse intrauterine environment affecting kidney development and predisposing to ESRD-- supported by evidence - socio-economic disadvantage increases ESRD incidence: supported by evidence CKD and ESRF are the result of an additive process of acute and chronic insults to the kidney *Health and disease follow a social gradient, where lower socioeconomic status is associated worse health outcomes *SDH are critical to the creation and maintenance of health inequities - unfair and avoidable differences in health status *SDH can be more important than individual behavior or health care in influencing health outcomes *SDH are often represented in a way that makes sense to social and public health researchers, but can be hard to apply in a clinical setting Acute and chronic insults can be made more prevalent by issues of human security: food, water, housing, environment and health. These are turn impacted by issues of transport, service availability and quality, continuity of care, accessibility, culturally appropriate and safe care, quality, affordability etc Notably, education and income are important factors influencing the inequitable distribution of CKD in Indigenous Australian populations. Broader issues of education access/quality, social/community context, exonomic stabiity, health access and workforce , neighbourhood and built environemnt - all ultimately influenced by inequality

Answer 44

a product of significant social and environmental security challenges, exacerbated by remote geography. actors affecting water security Water security is one of five determinants of human security, a social determinant of health. - contamination by microbes - calcificaiton of pipes - buying water Factors affecting housing security Another determinant of human security. - energy insecure due to pre-payment - no building permits or qualifications required - required maintenance but no tradies - few facilities e.g. washing machines - overcrowding Food security - prevalence higher in remote Indigenous communities comapred to asustralian population (31%, and likely underestimate) - choosing between food and energy - cost in healthy food 52% higher Note: not just a remote issue - Alice Springs, flooded highway #### Geography - similar size to sizable NSW towns e.g. Bathurst, Queanbeyan - fewer supermarkets - 5-7 hours or longer for nearby, if local is out

Answer 45

Services for CKD and ESRF require a complex network of nurses, doctors, community workers, and physical infrastructure Renal care in Central Australia *The Alice Springs Renal unit is the largest single dialysis complex in the Southern Hemisphere *Over 400 dialysis patients and nearly 1000 patients with CKD (2020) *Covers area of 872,861 Km2 *17 remote communities, 15 language groups *Services by the Alice Springs “Renal Mob: *Inpatient, community and home dialysis hubs *Peritoneal dialysis *Renal transplantation services *Interventional nephrology *Chronic kidney disease clinics *Transportation HD units Four HD units in Alice Springs *Kidney Dialysis Unit at Alice Springs Hospital: Inpatient and acute HD, unstable patients Three community units: Note: Purple House/Western Desert Dialysis: renal patients who find it hard to engage with Western models of care Nurse-led units outside Alice Springs - Tennant Creek: Largest satellite unit outside of Alice Springs - Smaller remote units Note: Many of our patients live remotely prior to starting dialysis, which can make CKD follow up difficult. many patients may not have reliable electricity, food or medication security or working fridges when prescribing outpatient management. HOME DIALYSIS HUBS We have home dialysis hubs where patient can do dialysis in a unit in their own community: - requires the patient to undergo home dialysis training with a buddy PERITONEAL DIALYSIS PD is a major issues: - lack of suitable resources in many remote communities to do dialysis in their own home - high infection rate. RENAL TRANSPLANTATION Renal transplantation also has its complications: - high burden of comorbidities - lack of available living donors - difficulties in complex follow up in the remote communities. It is a unit priority to try to work up and list and suitable patients for a transplant. INTERVENTIONAL NEPHROLOGY Alice Springs Renal Unit is one of the few interventional nephrology units in Australia. For many of our patients English is the second, third or fourth language and ALOs can be very helpful in providing interpretation services here. Providing care in remote settings require flexibility, adaptability and commitment

Answer 46

Strategies for kidney disease prevention and providing adequate care - target levels of prevention Notice the difference between levels of prevention and healthcare Public health can tackle primordial prevention. Orimary healthcare can tackle primary prevention Recommendations Recommendations developed in consultation with First Nations communities across metropolitan, regional and remote areas of Australia. **Includes 15 recommendations under 4 areas: *Cultural safe and responsive kidney health care *Screening and referral of chronic kidney disease *Public awareness, education and self-management *Models of care (CKD, ESRF, transplant) **Under each recommendation, report includes:** *Description/background *Community voice *Clinical evidence (incl. certainty of evidence) *Cultural safety considerations *Cost, capacity, equity, and resource implications

Answer 47

Mortality and morbidity from CKD is associated with increasing age and is unevenly distributed across Australian population - highest burden over 65 - uneven distribution: Indigenous status, remote and very remote areas, social disadvantage - data from Indigenous patients: - fewer dying, but incidence not really changing - treatment approach greater prevention programs

Answer 48

NCDs are chronic diseases that cannot pass from one person to another. They develop slowly over time, and generally progress slowly. Non-communicable diseases (NCDs) are the leading cause of preventable ill health, related disability and premature death in the world today. The major groups of NCDs are: *cardiovascular diseases *non-hereditary cancers *chronic respiratory disease *diabetes *mental health conditions NCDs are associated with a high level of social and economic burden. This includes: *reduced quality of life (often for many years) *reduced productivity - affecting economic and social wellbeing for the individual, their family and community *increased burden of health care for the **individual, the family and society**

Answer 49

Non-communicable diseases (NCDs) kill 41 million people each year, equivalent to 71% of all deaths globally. Premature death *Each year, more than 15 million people die from a NCD between the ages of 30 and 69 years; *85% of these "premature" deaths occur in low- and middle-income countries. In Aus= low Socio-economic situations, regiognal and remote areas These four groups of diseases account for over 80% of all premature NCD deaths. *Cardiovascular diseases (17.9 million people annually), *Cancers (9.3 million), *Respiratory diseases (4.1 million), *Diabetes (1.5 million). Note: mental health not on WHO list. Tobacco use, physical inactivity, harmful use of alcohol, unhealthy diets → increased risk of dying from a NCD. *Tobacco accounts for >7.2 million deaths every year * Excess salt/sodium intake → 4.1 million annual deaths *>50% of the 3.3 million annual deaths attributable to alcohol use are from NCDs, including cancer. *insufficient physical activity → 1.6 million annual deaths *Detection, screening & treatment of NCDs, as well as palliative care, are key components of the response to NCDs. Metabolic risk factors contribute to four key metabolic changes that increase the risk of NCDs: *raised blood pressure; ^[biggest] *overweight/obesity; *hyperglycemia (high blood glucose levels); and *hyperlipidemia (high levels of fat in the blood). The leading metabolic risk factor globally (→ death) is elevated BP, followed by overweight & obesity, and raised blood glucose.

Answer 50

- The five disease groups: cancer, MSK, CVD, mental health and SUDs and neurological conditions (instead of respiratory) - vary in fatality (MSK not too much) - Mostly chronic and long-lasting conditions - Cancer contributes most burden, and is very fatal - NCDs = 90% deaths ^[2011] - Disease burden, or DALYs, is not equally shared: NT, remote and very remote areas, and lowest socioeconomic group

Answer 51

A clear trend of greater burden rates with increasing remoteness for: *coronary heart disease *chronic kidney disease *chronic obstructive pulmonary disease (COPD) *lung cancer *stroke *suicide *self-inflicted injuries *type 2 diabetes. In contrast, anxiety disorders, dementia and depressive disorders showed lower rates of burden in more remote areas (AIHW 2019a). Health inequalities in rural and remote areas may be due to factors, including: *challenges in accessing health care or health professionals, such as specialists, allied health *social determinants such as income, education and employment opportunities *higher rates of risky behaviours such as tobacco smoking and alcohol use *higher rates of occupational and physical risk, for example from farming or mining work and transport-related accidents. Health risk factors are attributes, characteristics or exposures that increase the likelihood of a person developing a disease or health disorder. Modifiable risk factors such as: *tobacco smoking (people outside major cities had higher rates of current daily smoking) *poor eating patterns *risky alcohol consumption *not getting enough exercise. Note: prevalence of health risk factors increases with remoteness. Note 2: median age of death **decreases** with remoteness

Answer 52

**Remoteness and Indigenous people** - in very remote areas, 47% of the population are Indigenous - remote areas = 18% - 1.7% in major cities (however most Indigenous people live in cities, or inner regional areas) **Central Australian statistics** *Life expectancy of Aboriginal people 20 years less than for non-Aboriginal Australians. *considerably worse than other comparable indigenous populations, eg the first nation peoples of USA and Canada, and the Maōri of Aotearoa. *Aboriginal boys born today have 45% chance of living to age 65 (81% for non-Aboriginal boys); Aboriginal girls have 54% chance of living to age 65 (89% for non-Aboriginal girls). *Age standardised death rates for Aboriginal males are 2.8 times those for non-Aboriginal males; Age standardised death rates for Aboriginal females are 3.3 times those for non-Aboriginal females. Note: potentially avoidable deaths - 17% of all deaths in Australia - rate increases with remoteness for both males and females (more in females?)

Answer 53

The way people in rural and remote areas access primary health care often differs to those in metropolitan areas. *facilities are generally smaller, have less infrastructure, less capacity i.e. for testing and provide a broader range of services to a more widely distributed population. *Rural and remote populations also rely more on general practitioners (GPs) to provide health care services, due to less availability of local specialist services (Department of Health 2016). Note: NT nurse dependent “Australians living in Remote and Very remote areas experience health workforce shortages, despite having a greater need for medical services and practitioners with a broader scope of practice” (AMA 2017). *health professionals per 100,000 population generally decreased with remoteness *rate of allied health professionals, dentists and pharmacists was lower in regional areas and lowest in Remote and Very remote areas *rate of specialists substantially declined with increasing remoteness *Full time nurses and midwives were highest out of all health professionals in rural and remote GP supply was also unequally distributed as remoteness increased. Data indicate that the rate of GPs in 2017 increased with extreme remoteness, however, care should be taken in interpreting the data as work arrangements in these areas have the potential to be more complicated (NRHA 2017) e.g. part-time, no after hours. A demonstration of the inverse care law. | when answering questions hink of, mgmt vs prevention, non-drug.med,profs

Answer 54

"all actors, institutions and resources that undertake health care actions - where a health action is one where the primary intention is to improve health".

Answer 55

-Attainment of the highest quality of health for a country given available resources -Responsiveness to the expectations of the population -Fairness of financial contributions-

Answer 56

- work force - service delivery - information - medicines and technologies - financing - governance and leadership

Answer 57

- Beveridge - Bismark - NHI model - Out-of-pocket

Answer 58

Financier: government via health tax Provider: Government (majority) Cost control: strictly enforced by the government Profit: HFP Countries: India, UK, Au, Spain, NZ

Answer 59

Financier: sickness finds (employer and employee) Provider: Government (majority) Cost control: negotiated monopsony Profit: NFP Countries: Germany, France, Belgium, Japan

Answer 60

Financier: Government run insurance into which every citizen pays Provider: Private Cost control: negotiated monopsony Profit: NFP Singapore

Answer 61

Financier: individual Provider: private Cost control: none Profit: NFP Countries: USA, India in practice

Answer 62

- frequently beset by long waiting lists for treatment - thus the provision of a regulated optional private insurance system exists to offset public health system pressures, and to cater to certain income and resident groups - provides greater choice for people as they have access to both public and private systems

Answer 63

- all individuals and communities receive the health services they need - without suffering financial hardship - includes the full spectrum of essential, quality health services: health promotion, prevention, treatment, rehabilitation, palliative care

Answer 64

Federal government: - sets national policies - responsible for medicare - joint funding with states and territories of public hospital services - funds pharmaceuticals via PBS - funds NACCHos - supports access to private - regulates private - major funder of research via NHMRC - regulates medicines, devices and blood

Answer 65

- manage public hospotals - license private hospital - responsible for community based and primary health services (mental health, dental health, alcohol and drug services) - deliver preventive services e.g. immunisation and cancer screening - ambulance services - handling health complaints

Answer 66

- provide environmental health-related services e.g. waste disposal, water fluoridation, water supply, food safety monitoring - deliver some community and home-based health and support services - deliver some public health and health promotion activities

Answer 67

- regulation of health workforce - education and training of professionals - regulation of pharmaceuticals and pharmacies - support improvements in safety and quality of health care - funding of public health programs and services - funding of Aboriginal and Torres Strait Islander health services

Answer 68

All Australian government levels have signed a policy, the National Health Reform Agreement (NHRA), that aims to improve health outcomes for all Australians and ensure the health system is sustainable. bullet The NHRA is an agreement between the Australian Government and all state and territory governments. bullet It commits to improving health outcomes for Australians, by providing better coordinated and joined-up care in the community, and ensuring the future sustainability of Australia’s health system. bullet It is the key mechanism for the transparency, governance and financing of Australia’s public hospital system

Answer 69

- primary - secondary - tertiary

Answer 70

- 2% of taxable income - do not have to payif single and taxable income is equal or less than 23, 365 - income over, rate differs

Answer 71

Medicare, implemented in 1984, is Australia's universal insurance scheme. It guarantees all Australians (and some overseas visitors) access to a wide range of health and hospital services at a low or no cost, including: -medical services by doctors, specialists and other health professionals - hospital treatments -prescription medicines (which is covered by the PBS). Medicare Benefits Schedule (MBS) lists the medical services covered by Medicare and the fee involved for accessing each service. As some people may still have to pay out-of-pocket for health care, every year in January, the Australian Government sets safety limits for gap and out-of-pocket expenditure through the Medicare Safety Net. Current Safety Net Threshold for gap amounts is $495.60 and out-of-pocket expenditure is $2,250. You can learn more about additional thresholds by visiting the Services Australia website.

Answer 72

Under the Pharmaceutical Benefits Scheme (PBS), the Australian Government subsidizes the cost of medicine for most medical conditions. PBS medicine is available to: -all Australians and concession card holders who have a current Medicare card -Visitors from 11 overseas countries with which Australia has a Reciprocal Health Care Agreement. If you visit these countries, your health care is covered! - Veterans, war widows and widowers, and dependents who are eligible under the Repatriation Pharmaceutical Benefits Scheme (RPBS)

Answer 73

Bulk Billing in Australia covers: -visits to GPs and some specialists that bulk bill -basic tests and scans like x-rays and pathology tests -eye tests performed by optometrists However, bulk billing is optional for most health care workers. Moreover, health care workers can choose the consultation or procedure fee for a service. This amount may not equal the amount set in the MBS.

Answer 74

Lack of bulk billing and high gap payments

Answer 75

**Advantages** - The Beveridge Model is underpinned by UHC as a core principle that seeks to improve population health outcomes. - Enhances social justice by promoting solidarity and equity as a societal value. - Universal access to state-funded medical treatment is provided. **Disadvantages** - Population demand for health services can be challenging to manage. - Under-resourced health systems can create long waiting lists/queues. This not only affects patients' health outcomes due to delayed care, but can force vulnerable people to purchase private healthcare in order to receive the care needed. - Financial burden as a result of out-of-pocket or private healthcare costs. - Constant high demand for health services can lead to health system inefficiencies, creating a negative spiral of healthcare worker illness, burnout and absenteeism.

Answer 76

- patient financial risk protection: We learned that every year, financial safety thresholds for consumers are set for Medicare and PBS - these in principle are meant to reduce the impact of healthcare-related out-of-pocket expenditure borne by patients and their families. - gatekeeping in primary care:The AHS also reduces the downstream pressures on hospitals and specialist care through general practitioners (GPs) 'gatekeeping' function at the primary care level. - GPs act as coordinators of ongoing and comprehensive healthcare through assessment and referral for individuals from one primary care service to another and from primary services into secondary and tertiary services (such as specialist, hospital and palliative care services) and back again. - Moreover, we shared that bulk-billing by GPs and other health care workers enhances UHC and reduces out-of-pocket costs. However, recall that bulk-billing is optional for most health care workers and may still require co-payments or gap fees to be paid out-of-pocket by patients. - public and private healthcare co-exist: While the AHS is mainly publicly funded, private health insurance (PHI) and private health care co-exist in the country. PHI is readily available and offers coverage for out-of-pocket fees and private providers, a greater choice of providers (particularly in hospitals), faster access to non-emergency services, and rebates for selected services. Government policies encourage enrolment in PHI through a tax rebate (8.5%-33.9%, depending on age and income) and an income-based penalty payment (1%-1.5%) for not having private insurance. However, there are societal inequalities in who can afford PHI and access the linked benefits.

Answer 77

- continuum of care - patient focus - geographic coverage - information systems - governance

Answer 78

Barriers faced by members from CALD communities in accessing health service: - language and communication challenges - higher risk of diseases

Answer 79

Healthcare is expensive and will become even more so. The question is, who pays (more) for it - the clinicians, patients or the government?The Royal Australian College of General Practitioners (RACGP) and the Australian Medical Association (AMA) are both advocating for GP consultation Medicare rebates to increase to continue bulk billing. The increased rebates support GP practices to be economically viable and offer consultation fees that are bulk billed or with reduced gap fees to patients. However, attempting to increase bulk billing rates may in fact reduce access to health services for populations that are regionally and socially disadvantaged, which creates worse health outcomes – a spiral of its own. **In the absence of bulk billing and optimised Medicare rebates, patients end up covering costs!**

Answer 80

- Compilation of risk factors that predispose individuals to developing type 2 diabetes and cardiovascular disease Diagnosis occurs when any three of the following 5 risk factors are present: - waist circumference: population specific definitions - TGs: >= 1.7 mmol/L - HDL: Men<1 mmol/L, women < 1.3 mmol/L - Blood pressure: >= 130/85 - fasting glucose >= 5.5 mmol/L - Drug treatment for elevated triglycerides, low HDL cholesterol, elevated blood pressure, or elevated glucose are alternate indicators

Answer 81

- Varies depending on criteria used to define the MetS and the age, gender, ethnicity, and environment of the population being studied - The National Health and Nutrition Examination Survey (NHANES) reported the overall prevalence of MetS in adults ≥20 years in the US from 2003-2012 was 33% - 67% Australian adults are overweight or obese (AIHW 2017-18)

Answer 82

Target organ damage occurs through multiple mechanisms in metabolic syndrome. The individual diseases leading to metabolic syndrome produce adverse clinical consequences. For example, hypertension in metabolic syndrome causes left ventricular hypertrophy, progressive peripheral arterial disease, and renal dysfunction. [14] However, the cumulative risk for metabolic syndrome appears to cause microvascular dysfunction, which further amplifies insulin resistance and promotes hypertension. [15] Metabolic syndrome promotes coronary heart disease through several mechanisms. It increases the thrombogenicity of circulating blood, in part by raising plasminogen activator type 1 and adipokine levels, and it causes endothelial dysfunction. [16] Metabolic syndrome may also increase cardiovascular risks by increasing arterial stiffness. [17] Additional mechanisms include oxidative stress, [18] which has been associated with numerous components of metabolic syndrome. Etiology is unclear but includes the following: - Insulin resistance - Pancreatic beta-cell dysfunction - Cellular dysfunction by protein kinases and phoshatases - Suppression of insulin receptor substrate-1 and 2 (IRS1/IRS2) gene expression and function - Obesity and lipid toxicity - Oxidative stress and glucose toxicity - Chronic inflammation - Dysrupted circadian rhythm - Genetics and epigenetics - Gut microbial imbalance - Dietary effects

Answer 83

Several risk factors for cardiovascular disease in patients with MetS and T2DM: - pancreas: hyperinsulinaemia - Genetic predisposition e.g. hyperglycaemia - Hyperglycaemia: glycated protein and advanced glycation end-produts - thrombosis - liver: PAI-1, fibrinogen, CRP, TNF-a - obesity: FFAs, decreased HDL, increased TGs, lipaemia - skeletal muscle: increased ffas, hyperglycaemia - contributing to insulin resistance - hypertension and LDL

Answer 84

- Thresholds based on Caucasian populations - **BMI Classification** - Underweight: BMI (kg/m2) <18.5 - Normal range: ≥18.5 and <24.9 - Overweight: ≥25 and <29.9 - Obese - Obese class I: ≥30 and <34.9 - Obese class II: ≥35 and <39.9 - Obese class III: ≥40 - **Waist Circumference** - Measured midway between the lower rib margin and iliac crest - **Gender** - Males - Increased disease risk: ≥ 94 cm - High disease risk: ≥ 102 cm - Females - Increased disease risk: ≥ 80 cm - High disease risk: ≥ 88 cm | Adjustments are needed for ethnic groups, patient groups (athletes,aged)

Answer 85

- *Evolution?* - Ageing and Energy Expenditure - Activity is declining

Answer 86

- Globally, trending downwards (new, deaths) - Overall prevalence up i.e. more people living with HIV - diagnoses have been trending downwards in AU since mid-80s - Australia is considered a low prevalence country (0.1% estimated) -

Answer 87

- chlamydia, high rates, 2/3s young, female - high and increasing among PLHIV and MSM - gonorrhea 2/3s men, increasing in past decade - high among PLHIV and Indigneous people - syphilis: increasing, 80% male; higher in Indigenous, remote - not changing among MSM -

Answer 88

- HIV is a slow virus - long incubation period - attacks immune system - transfers via bodily fluids: via mucous membranes, PC exposure, non-intact skin - infects CD4+, macrophages, DCs ---- - majority of new cases in MSM, gay, bisexual men - most research and prevention in this population - injecting population>>> - declining diagnoses in MSM, particularly AU born - hetero population stable - likely acquisition here (if MSM) - but: LATE diagnoses up -- hetero most liely

Answer 89

- gender (Chlamydia female, gonorrhea male) - remoteness - indigeneity - PLHIV - gonorrhea and chlamydia

Answer 90

- multiple commonwealth strategies: national HIV strategy, Natioanl STI strategy - goals of HIV strategy 1. virtually eliminate transmission within life of strategy 2. stustain virtual elimination among inject, sex workers, congenital 3. reduce mort and morb 4. eliminate stigma, discrimination, legal and human rights impact on health 5. minimise social and personal imapct Targets include: Increase HIV diagnosis/testing, HIV treatment, viral suppression; reduce HIV incidence in MSM; increase PrEP use; increase quality of life for PLHIV; decrease experiences of stigma reported by PLHIV - working in partenrsip: reason for success: research, clinical, govt, community and NGOS

Answer 91

see abive but also: STIs are increasing in many population groups, but especially in MSM due to increases in biomedically-protected condomless sex. Interest is growing in two forms of antibiotic prophylaxis for STIs: STI-PrEP: Taking low-dose antibiotics daily STI-PEP: Taking one antibiotic pill after an episode of sex Due to concerns about antimicrobial resistance, focus appears to be shifting towards STI-PEP. RCTs have shown reductions in gonorrhoea, chlamydia and syphilis in MSM taking doxycycline STI-PrEP

Answer 92

Via testing - reduce infectiousness via immediate treatment e.g. HIV TasP - prevent expisure: condoms (highly effective at preventing HIV, less so fro STI, MSM greater uptake, but generally not popular), risk reduction, sterile injecting equipment - reduce susceptibility: PrEP (two antiretroviral daily or before/after; adherence = effectiveness; on-deman oral PrEP effective for planned; LA-CAB, others emerging), PEP, STI treament and prophylaxis In order to: reduce stigma AND increase access

Answer 93

Young people: Shlirp @ ACT public colleges (year 11-12) Cccares @ canberra college – pregnant and parenting students Belconnen and woden youth centres Aboriginal and torres strait islander project Headspace GBMSM: STRIP Clinic at Meridian Early evening STI/BBV testing and PrEP Belconnen Youth Centre Bit Bent Sex workers: SWOP Clinic: On The Road is sexual health testing held at brothel premises across Fyshwick and Mitchell with access acquired by SWOP with owners and management. The convenience of workplace screening is on offer to sex workers on the premises. Independent sex workers can access screening at SWOP Clinic @Meridian in Turner. AOD: Residential Rehabilitation Locations Hepatitis ACT, Turner Adult students: CIT International students CIT Apprentices

Answer 94

It is easy to do - with only needing access to: A private room A bathroom or toilet Reasonable light The testing process involves: Blood tests Self-collected swabs or urine Self-collected Cervical Screening Test (CST)

Answer 95

Safe workspace Lighting Cleaning Access to do venepuncture Equipment Gloves and goggles Hand wash Sharps container Head light An esky or mobile fridge for specimens

Answer 96

work health code of practice: The work, health and safety guidelines for the sex industry in the ACT. Safety in workplace - duress alarms Managing violence in the workplace Contact with blood or body fluids Visual sexual health checks for clients Skin check and showering sex work act 1992: Under the current Sex Work Act, sex workers and their clients have mandated condom use during commercial sexual services. Prescribed locations of brothels in Fyshwick and Mitchell. Independent sex workers can work anywhere in Canberra but not with another sex worker. Management of premises. 2018 key amendents to sex work act: Removal of stigmatising terms prostitution and prostitute Brothel owners now legally required to provide PPE to sex workers for free (dental dams, latex gloves, water-based lubricant, sponges, latex and non-latex condoms) People with a STI, BBV or are HIV+ can work as a sex worker or see a sex worker with the proper precautions to prevent transmission, now treated the same as the general community in the public health act Independent sex workers no longer need to register with office of fair trading commissioner

Answer 97

The risk ratio can be calculated in longitudinal studies (cohort studies and clinical trials). The prevalence ratio is analogous to the risk ratio, but is used in cross-sectional studies. The odds ratio can be calculated in clinical trials, cohort, cross-sectional and case-control studies. The risk ratio can ONLY be calculated in clinical trials and cohort studies.

Answer 98

Absolute associations Absolute associations are calculated by subtracting the outcome measure in the unexposed group from the exposed group. Examples difference in the prevalence of smoking between males and females difference in cardiovascular mortality rates in people prescribed statins compared to placebo difference in the incidence of hospital-associated diarrhoea in patients treated with IV antibiotics for pneumonia compared to those not given IV antibiotics. Absolute associations can be used for cross-sectional and follow-up studies (cohort studies or clinical trials). Absolute associations are the arithmetic difference in the frequency of the disease outcome between two exposure groups. Remember, disease frequency is measured by proportions e.g. prevalence, incidence, mortality. Absolute association = outcome in the exposed group - outcome in the unexposed group Absolute associations are expressed using the same unit of measurement as for the outcome. This is because the calculation is a simple subtraction.

Answer 99

It can be shown that: The sample means have an approximately normal distribution. The mean of the sampling distribution would be the same as the population mean. The standard deviation of the sampling distribution is called the standard error of the mean. The standard error is calculated as: "the standard deviation divided by the square root of the sample size"

Answer 100

Risk factors can be categorised as: - Biological: genetics, LBW, age, sex - Behavioural: diet, sedentary lifestyle, low physical activity, breastfeeding - Social: unsafe environments, bullying, stress, mental health, belief systems regarding food, family habits - Environmental: green spaces - Economical: socio-economic status - Structural: packaging, food insecurity, food marketing, and weak policies Levels of prevention follow these risk factors from distal to proximal: - Primordial prevention: targeting structural risk factors e.g. policies, taxes, marketing - Primary prevention: targeting social and environmental risk factors e.g. habits, canteen, sports promotion, health education - Secondary prevention: screening programs - Tertiary prevention: mental health support, diet, exercise programs, allied health - Quaternary prevention: individuals --- weight loss and management, utilisation of services, drugs, surgery etc.

Answer 101

four basic principles: Originally from HIPPOCRATIC OATH, now from GENEVA DECL (it’s the same thing re-written for modern day) Beneficence (do good) Non-maleficence (dont harm) Justice Autonomy

Answer 102

In the 70s, paternalism came under pressure, and patient autonomy emerged as a central part of care - in other words, doctors were required to inform patients on **all aspects of care** Autonomy can be defined as self-rule, or the ability to decide for one's self. Obviously the ability to decide for one self depends on having been informed. Autonomy does not simply mean doing as the patient instructs -- but also includes the provision of information that is necessary in order to promote and facilitate good decision making. Informing is thus a major components of medical practice - the provision of information by the doctor puts patients in a position to understand: - the nature and purpose of clinical exams and tests (in other words why and what the test involves and shows) - diagnosis - prognosis - possible treatments Confidentiality Doctors have a duty of confidentiality because there is a public interest in promoting full and truthful disclosure in the context of a therapeutic relationship. The principle of confidentiality is *autonomy enabling*. Thus, other matters of public interest can override this duty. There are mandated reporting requirements in relation to: - particular diseases - knife or GSWs - suspected child abuse or neglect - domestic violence A court may also disclosure of medical records. Privacy Not all those who might access medical records or information related to healthcare have (the same) duties of confidentiality. Hospital and Medicare administrators for example. Privacy laws protect patient data and define legitimate contexts for access and disclosure. This will become particularly important as we develop centralised electronic records e.g. MHR or ACT's DHR for the purposes of distributed access (and, potentially, big data research). This is an area where we can expect to see significant change and development e.g. vaccination 'passports'. A case: Huntington's ruling on doctors' duty to tell patient's family - establishes precedent for relatives' right to know about serious conditions, particularly genetic diseases.

Answer 103

The five torts to remember – the things a doctor can do wrong Negligence – only negligence if you have…. duty of care breach of duty causally related damage (hard to prove) Confidentiality (difficult to prove damages) – detail below Consent: ‘disclosure to avoid assault and battery’ – detail below Informed Consent: - disclosure of material risk (likelihood and concern - Roger v Whitaker - eyes) - therapeutic privilege exception: withholding where it would harm - necessity exception - if its an emergency - if patient would have gone ahead anyway (Rosenberg v Percival - ears) Professional Misconduct - Health professionals Act ACT 2005 “standard adequate to protect public safety” – detail below

Answer 104

Confidentiality Doctors have a duty of confidentiality because there is a public interest in promoting full and truthful disclosure in the context of a therapeutic relationship. The principle of confidentiality is *autonomy enabling*. Thus, other matters of public interest can override this duty. There are mandated reporting requirements in relation to: - particular diseases - knife or GSWs - suspected child abuse or neglect - domestic violence A court may also disclosure of medical records. -- For it to be a breach, its similar to negligence: have to have a duty of confidence, breach of duty, and causally related damage. Difficult to prove. Sources: Hippocratic, now Geneva, and AMA, UNESCO declaration Exceptionals: occupational health assessment, some jurisdictions include car crashes gun shots and domestic violence: Remember: public protection and safety. confidence in equity: obligation of conscience.

Answer 105

Euthanasia/assisted suicide: The hierarchy: Advanced directive Formally appointed guardian Spouse in continuing relationship Carer with no financial relationship Other family Advanced directives: Treatment of minimal accepted quality of life: what is minimal quality? End of life: futile if ‘no reasonable prospect of return to quality of life’ Supreme court decision – Messiah – if doctors and family disagree R v Maxwell - husband ends wifes life under explicit instruction with late stage breast cancer by gassing, pleaded guilty and 18 months suspended sentence. Kerrie Wooltorton - 26, 9x attempt, drank antifreeze, called hospital and gave written instruction: no treatment for life saving, only comfort. Hospital obliged and died that afternoon. No evidence to rebut lack of competence and self harm is not sufficient evidence of lack of capacity.

Answer 106

Mandatory reporting: to AHPRA regulation agency with reasonable belief of notifiable conduct - alcohol, drugs, sexual misconduct, placing public at harm because of impairment, placing public at risk from below standard practise. Must report on students and colleagues. Discretionary voluntary reporting: if they are not suitable or standards are below what should be expected. Complaints: all jurisdiction shave independent complaints system for non-litigious method of handling, deals with all health services, by Human Rights Commision Act 2005. What you can complain about: refusing services, unreasonable provision of service, denial to records, disco sure of health information, anything that would require disciplinary action, failure to investigate comlaint. Doctors are mandatory reporters, must report sexual abuse and physical injury of minors if it comes about at work - not if caused by another minor or if a guardian will step in, or if it has already been reported.

Answer 107

6. **Intersex** - note: not always identifiable at birth - Differences of Sexual Development (DSD) - Invasive surgical procedures on intersex individuals - Rejecting medical normalization and the need for informed consent - ACT: assessment board -- medics, human rights, ethics, variation and psychosocial support - note: does not cover male circumcision Historically, doctors would perform ‘corrective’ surgery on those born with ambiguous genitalia and commonly did so without (fully) consulting parents. More recently, parental consent has been sought, but parents have unsurprisingly tended to be guided by doctors. Over the past two decades or so, those with intersex conditions have made the case for non-intervention. - Being intersex is not a disease or disorder per se. - While some surgical intervention may be medically justified (e.g., ensuring the ability to urinate), ‘correcting’ the appearance of genitalia is not. Best practice is to allow the child to develop, and for any unnecessary medical interventions to be delayed until they can be involved in the decision-making process to provide or refuse their consent. [Intersex Human Rights Australia](https://ihra.org.au/) AHRC published a major [report in Oct 2021](https://humanrights.gov.au/intersex-report-2021) This year the ACT passed the Variation in Sex Characteristics (Restricted Medical Treatment) Act 2023. It requires doctors (and parents) to seek the approval of a review board for any proposed surgical intervention on the genitalia of a child with a Difference in Sexual Development (DSD), with one exception.

Answer 108

Professional Misconduct: The fiduciary relationship: imposed by equity when the fiduciary acts in best interest of the beneficiary, if the beneficiary is weak. A fiduciary duty arises when: confidentiality of medical information not accepting gifts no sexual relationships disclosing medical errors Can be labeled ‘Misconduct’ in three ways ‘conduct substantially below the expected standard or equivalent level of training’ ‘more than one instance that when considered together is substantially below standard….’ ‘conduct inconsistent with being fit and proper to practice medicine’ (Health Practitioner Regulation National Law) Health professionals act 2004: Section 18 ‘The required standard of practice for a health professional is the exercise of professional judgment, knowledge, skill and conduct at a level that maintains public protection and safety.

Answer 109

Medical ethics sources: Hippocratic Oath (reformulated as Geneva Declaration after WWII by World Medical Association) World Medical Association, International Code of Medical Ethics AMA Code of Medical Ethics, Statement of Good Professional Practice For Research: Nuremberg Declaration, Helsinki Declaration NH&MRC Guidelines (ie: giving info. to patients, ART, research) Rulings of clinical and research ethics committees UNESCO: Universal Declaration on Bioethics and Human Rights

Answer 110

Consent: assault: touching someone capable of giving consent who hasn't doesn't so. implied: conduct suggests consent – e.g. holding out arm for blood pressure Expressed: written or verbal agreement. capacity voluntary informed Re B: refusal of treatment Re C - competence of capacity - schizoprenic Rogers v Whitaker: informed consent Must be about to hear information, process and weigh the options, and relay the decision back. Gillicks Competency: as the au

Answer 111

Mill: only time that power can be exercised over a community, diminishing their individual autonomy, is to prevent harm to others - examples of this in practice include seatbelts, driving tests, medical interventions (e.g. taking away licence when losing sight, potential for doctor to break confidentiality...note that this is **not** the first option) The initial presumption should always be that adults are autonomous (i.e. autonomous until proven otherwise). Autonomy means the freedom to decide for ourselves. This extends to decisions we make in every area of our lives, and includes those that cause harm or risk harm to ourselves. Intervening with this basic freedom requires strong justifications. --- What to do if you disagree with a patient's refusal of treatment? The forgoing (and medical ethics and health law in general) might, once the relevant information has been provided, incline us to leave patients to make their own choices. However, we might instead focus on notions of **relational autonomy** and **shared decision-making**. You must continue to communicate to ensure: - has the patient really understood? - have you really understood the patient? Finally, other professionals, such as social workers, are not *entirely* bound by the principle of autonomy.

Answer 112

Mill: only time that power can be exercised over a community, diminishing their individual autonomy, is to prevent harm to others - examples of this in practice include seatbelts, driving tests, medical interventions (e.g. taking away licence when losing sight, potential for doctor to break confidentiality...note that this is **not** the first option) The initial presumption should always be that adults are autonomous (i.e. autonomous until proven otherwise). Autonomy means the freedom to decide for ourselves. This extends to decisions we make in every area of our lives, and includes those that cause harm or risk harm to ourselves. Intervening with this basic freedom requires strong justifications.

Answer 113

Sources: Always say UDHR and ICCPR (universal declaration of human rights and international convenient on civil and political rights) and ACT human rights act 2004 - everyone has the right to life - no one may be arbitrarily deprived of life intrinsic dignity of all human beings inherent right to life prohibition of cruel or degrading treatment (7) privacy (17) free consent before treatment (7) Other sources: State Human Rights Acts Common Law Precedent The Federal Human Rights Act The Australian Constitution Article 7 of the ICCPR – No one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment. In particular, no one shall be subjected without his free consent to medical or scientific experimentation. Note here: what is a refugee: has a ‘well rounded fear,’ ‘unable or unwilling to avail to protection of that country’ OR as a result of such events, will not return to it. AMA says: those seeking asylum have right to medical care without discrimination and with compassion, respect and dignity.

Answer 114

Foetus, Neonates and Terminating Pregnancy: your responsibility is to the patients needs: professionalism vs professional morality. AMA statement: the ability to regulate and control fertility should be regarded as a principal component of the physical and mental health and social well-being of all women of child-bearing age. A doctor can conscientiously object to reform but must refer - cannot limit access to service. When a doctor refuses to provide or participate in a medically appropriate treatment [and conscientiously object], it affects and potentially disrupts the patients access to care… doctors should be aware of their right to not provide or directly participate in treatments to which they object inform patients and relevant colleagues of that objection not use their objection to impede access to treatments that are legal In the ACT: Legal but must be by a doctor in an approved facility. Not in NSW or WA. Legalised abortion must be in an approved facility by a proper physician and the physician has the right to say no, but must refer Important arguments when writing about it: Human Rights Act 2004: everyone has the right to life - no one may be arbitrarily deprived of life - principle in UDHR and ICCPR). Viability: R v Hutty: legally a person is not in being until they are fully born in living state. A baby is fully and completely born when it is delivered from the body of its mother and has a separate and independent existence in the sense that it does not derive its power of living from its mother (fetal capacity for independent existence outside womb) R v King: attack of pregnant victim - grievous bodily harm not murder - Zoe’s Law in progress. Crimes Act for abortion NSW: unlawful administration with intent to procure a miscarriage is liable for 10 years imprisonment. Exception if necessary for social, economic and health. Unlawfully? If in the doctors opinion, NOT the womans, it is justified - consent or desire doesn't make it lawful.

Answer 115

NHMRC code of ethical research, Nuremberg and Helsinki Declarations

Answer 116

Parents have less of a right and more of a duty to their child. The state is the ultimate parent. Court can hand down decisions that over-ride the parents' wishes in the interest of the child. Further downstream, parliament can enact laws to that effect. It has been suggested that parents have a zone of discretion. Ultimate parents extends to children, severely intellectually impaired. Evaluation of the subjective and objective aspects of assessing a child’s best interests. Considering cultural norms and religious beliefs in medico-legal assessments, emphasizing a holistic judgment approach. Wording of the law is broad.

Answer 117

Mature minor Child is <12 years old, Young person is 12-<18 years old (Children and Young Persons Act) Adult >= 18 years old (ACT legislation) To be a mature minor must: 1) Be classified as young person (12-<18 years old) 2) Must be able to understand and be able to communicate their illness, the nature of the procedure being offered & the consequences of the procedure (Gillicks Case in UK, Marions Case in Australia) ADDITIONAL ETHICS: CROC – right for child views to be given due weight

Answer 118

Death is defined by either the: 1) Irreversible cessation of brain function 2) Irreversible cessation of blood circulation If a person freely gave permission for organ donation and this permission remained until death, you may harvest their organs. HOWEVER, if the family objects the organs will not be harvested.

Answer 119

Doctors have a right NOT to be civilly conscripted (i.e. they don’t have to work for the government and can work in the private practice) (Constitution, section 51, 23a)

Answer 120

Quarantine powers Under the constitution, the Federal government has: 1) emergency health powers, and 2) the right to quarantine individuals AT THE BORDER of the country (Constitution section 51, 9)

Answer 121

Limitations on rights (quarantine) must be ‘strictly necessary’: - Respond to a pressing public or social need (health) - Proportionately pursue a legit. aim (prevent spread of infect. dis.) - Be the least restrictive means required for achieving the purpose - All restrictive actions must be scientifically well-supported - All information must be made available to the public - All actions must be explained to those whose rights are restricted & to the public - All actions must be subject to regular review and reconsideration. - Basic needs such as food, water, medicine & preventive care should be provided. - Communication with loved ones / caretakers will be permitted. - Constraints on freedom will be applied equally. - Patients will be compensated fairly for losses, including salary.

Answer 122

The Universal Declaration of Human Rights Article 1: All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood. Article 18: Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief, and freedom, either alone or in community with others and in public or private, to manifest his religion or belief in teaching, practice, worship and observance. The European Convention on Human Rights: Article 9 – Freedom of thought, conscience & religion 1. Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief and freedom, either alone or in community with others and in public or private, to manifest his religion or belief, in worship, teaching, practice and observance. 2. Freedom to manifest one's religion or beliefs shall be subject only to such limitations as are prescribed by law and are necessary in a democratic society in the interests of public safety, for the protection of public order, health or morals, or for the protection of the rights and freedoms of others. The Human Rights act 2004 (ACT): Section 14 Freedom of thought, conscience, religion and belief. AMA also upholds this. Must refer. In Medicine: - Termination of Pregnancy - Reproductive Medicine: IVF & Contraception - Euthanasia (VAD, MAID) - Electroconvulsive therapy*

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- Focusing on aesthetics and certain surgeries related to health - Justification of cosmetic surgeries based on wellbeing and patient autonomy - cosmetic and reconstructive surgeries can improve quality of life and self-esteem - not a rule that applies to all patients i.e. aesthetic for one, improved mental health, wellbeing and functioning for another - Influence of social and cultural norms on cosmetic surgery decisions - Lookism and its impact on women and men - note that men are becoming increasingly more subject to norms, resulting in increasing uptake among men - however people undergoing cosmetic surgery are predominantly women **Further Issues** - Psychological disorders and addiction in cosmetic surgery cases: temporary happiness, choices linked to perceived (previous understanding, but..) - Expanding range of cosmetic procedures, like Labiaplasty/Vaginal Rejuvenation - Prophylactic Mastectomy and its complexity: a question of individual autonomy and risk assessment - Sterilization as an elective intervention: should be an informed and counselled choice

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**Re Heather [NSW 2003]:** Court approved (consented to) chemotherapy for an 11-year-old whose parents wished to explore alternative therapies. **v B [QLD 2008]:** Court concurred with parents and doctors that Termination of Pregnancy for a 12-year-old was in her best interests. **v Kiszko [WA 2016]:** Following the removal of a brain tumor, parents refused chemo- & radio-therapy. Court ordered chemo- but not radio-. Child’s condition deteriorated. An application was subsequently made for radiotherapy, but the Court found that palliative care was now in the child’s best interests. **QLD v Nolan [2001]:** Separation of conjoined twins. One twin had a 60-80% chance of survival, while the other would die. However, without surgery, both would die. Equal right to life, one would benefit, but the other would suffer no detriment. Basis of **best interest.** --- TWO MORE CASES **Re Inaya [2007]:** Court found that the parents of an infant could consent to the donation of bone marrow to a cousin. The court also found the procedure was in the child's best interests despite the accompanying risks of this nontherapeutic intervention. - what constitutes best interest? - relative closeness **Re Sean and Russell [2010 FamCA]:** Court was asked to consent to gonadectomy in two children (18 months and 3 years), a treatment for Denys-Drash syndrome (meaning both children were likely infertile in any event). In both of these cases, the courts found that the parents had the authority to consent. As such, comparable future cases do not necessarily need judicial review. However, it would be prudent to get contemporaneous legal advice to that effect before proceeding. - with modern board may be different ## Footnote BABY M: A LANDMARK CASE IN AUSTRALIAN BIOETHICS Born in 1989, Baby M (14/7/89–26/7/89) suffered from severe birth defects (spina bifida and hydrocephalus). Doctors and parents (who consulted with two Catholic priests) agreed that ‘conservative treatment’ was appropriate. She would be cared for but, in essence, would be allowed to die. Contacted by a relative, a Right to Life organization demanded access to Baby M’s parents, claiming they wanted to adopt her. They subsequently made a police report alleging that Baby M was being drugged and starved to death in the hospital causing detectives to investigate. Subsequent Coroner’s enquiry chastised Right to Life group and exonerated the parents and doctors involved in caring for Baby M. Note : backdrop of letting children with Down's syndrome die on a basis of best for all involved. --- A FEW RECENT CASES FROM THE UK: 1. ASHYA KING 2009- At the age of 6, Ashya King successfully underwent surgeries to remove a brain tumor (medulloblastoma). Ashya was due to receive radiotherapy, but his parents sought proton therapy (possibly less harmful, positive benefit unclear). Unavailable in the UK, the NHS had previously funded treatment abroad. In this case, doctors did not support sending King abroad. On 28/8/14, 6 days after his last surgery, King’s parents took him on a ferry to France without telling hospital staff. They were arrested in Spain on 30/8/14. On 5/9/14 UK High Court ruled parents could take King from Spain to Prague for proton therapy. IIRC, this kind of treatment is now the standard of care. 2. CHARLIE GARD 4/8/16–28/7/17 Diagnosed with a mitochondrial disorder in late 2016. No established treatment, Gard’s prognosis was terminal. Parents explored the possibility of experimental treatment with a neurologist from NY, which GOSH agreed to deliver in the UK. In Jan. 2017 Gard had a number of seizures, and clinicians formed the view that further treatment was futile. Parents sought to take Gard to NY. Clinicians applied to the court for a best interests ruling, which supported withdrawal of treatment. This was upheld at appeal (x3). Some bioethicists argued Gard should receive treatment, although no one serious thought any benefit would result. Gillon/ Savulescu/ Wilkinson: Given Gard’s clinical condition, no harm could be done to him ∴ parental discretion should apply. - Basis: non-maleficence --- ALFIE EVANS 9/5/16–28/4/18 At the age of 6 months Evans’ functioning was assessed as being at the level of a <2-month-old. In late 2016 Evans showed signs of seizures. In Jan 2017 an EEG revealed little reactive activity except when experiencing a seizure. Assessed as having a neurodegenerative condition. Evans’ parents sought to transfer him to Italy. In Sept. 2017 an assessment indicated transportation would induce further seizures, meaning it could not take place. At the end of 2017, without any improvement in Evans’ condition over the previous year, the hospital applied to the court to withdraw life support as he was in a semi-vegetative state and beyond help. Expert testimony agreed that Evans’ condition was fatal and untreatable but differed over EoL care. The court ruled for withdrawal on the 20/2/18. The decision upheld on appeal 6/3/18. All further appeals considered to be without foundation. Ventilation was withdrawn on 23/4/18, Evans continued to breathe unaided until 28/4/18. --- ALTA FIXSLER (23/12/18-18/10/21) Alta Fixsler suffered severe brain damage at birth and was placed on life support. Her parents are members of the Hasidic branch of the Jewish Faith. In 2021 Manchester University NHS Foundation Trust applied to the UK Courts seeking permission to withdraw life support. Permission was granted, subsequent appeals (including to the ECHR) failed. The Fixsler’s then sought permission to take their daughter to Israel. This was refused. They also sought permission to take her home and have life support removed there. This was also refused . Alta’s life support was withdrawn on the 18/10/21, and she was pronounced dead three hours later. --- TAFIDA RAQEEB In February 2019 Raqeeb, aged 4, suffered a brain bleed and was placed on life support. Following assessments that made it likely permission to withdraw treatment would be sought, Raqeeb’s parents requested that she be transferred to Gaslini Children’s Hospital (Genoa, Italy)* in July 2019. Barts Health NHS Trust refused on the basis that it would be contrary to Raqeeb’s best interests. A judicial review of this decision was sought. The court ruled that traveling to Italy was not contrary to Raqeeb’s best interests and that preventing the transfer would be contrary to her rights as an EU citizen. On the 16th of Oct. 2019 Raqeeb was taken to Italy. In March 2022 the BBC reported that Raqeeb’s parents hoped to return her to the UK, although her current condition is not something I could determine. --- ARCHIE BATTERSBEE 10/3/10-6/8/22 (OR 31/5/22?) On the 7th of April 2022 Hollie Dance returned home to find her 12-year-old son, Archie Battersbee unconscious. She called an ambulance & started CPR. Paramedics continued CPR but assessed Battersbee as being a 3 on the Glasgow Coma Scale. Despite having no pulse on arrival at Southend University Hospital (40 mins after being found) circulation was restored. Battersbee was placed on life support and moved to Royal London Hospital the following day. Battersbee’s parents refused consent for brainstem testing, effectively preventing a declaration of brain death. On the 26th of April Barts NHS Health Trust applied to the High Court for: (1) permission to perform the test; & (2) a declaration that withdrawing ventilation would be in Battersbee’s best interests. Permission was given for both brainstem testing & an MRI. Battersbee was declared brainstem dead on the 31st of May. However legal arguments regarding best interests meant life support was not withdrawn until the 6th of Aug.

Answer 125

Describe and give some examples of nosology: A nosology is a system for classifying diseases. Nosologies typically use a range of ways of thinking about “disease”, and often incorporates illness. Diseases are classified in a variety of different ways: E.g. Symptoms Causes outside the body Disease mechanisms

Answer 126

Biomedicine: A domain of healing practices that draws on the natural sciences: Biology, chemistry and physics The western system of medicine is based on a set of scientific knowledge about function and dysfunction or organs, cells and (increasingly) genes in the body. The purpose of biomedicine is to heal through addressing and repairing dysfunction. Culture: The system of shared beliefs, values, customs, behaviours, and artefacts that the members of society use to cope with their world and with one another, and that are transmitted through learning It can affect how people perceive efficacy of treatment 🡪 i.e. believing getting tablets as a treatment is less effective than a needle It can also affect what conditions are considered real, for e.g. Spasmophilia is considered legitimate in Germany but not in Australia. In Australia, the symptoms of spasmophilia would be considered anxiety. Argue the case that biomedicine can (or can’t) be seen as a cultural system: Can be seen as a cultural system: Even within Western medicine there is great variation in the ways it is practiced in different countries Conditions which fall within a psychological spectrum in certain western medicine cultures may be attributed to micronutrient deficiency or organic failure in others. Preferred treatments vary between countries in ways which often reflect underlying culture Can’t be seen as a cultural system: In the process of enculturation we tend to take for granted the cultural knowledge we are provided We tend not to question assumptions that are ingrained in medicine because of its dominance Biomedicine itself may be not a cultural system but the way we interpret the knowledge can depend on our culture.

Answer 127

Dualism: The mind and body are two irreducibly separate things E.g. They can say as much as you want about the problem in the liver. But that’s not who I really am. Whatever is in my liver isn’t me. E.g. Humans are composed of mind and a body. E.g. When I feel sad, I should pull myself together E.g. Someone who is not able to think has lost some of their selfhood Materialism: The physical matter (the body) is the only real thing, and everything can be explained in terms of this. E.g. You find the thing that isn’t working right in my head. Then you will be able to fix it. E.g. Humans are composed of one thing, the body E.g. When we understand everything about the brain we will understand everything about humans. Cogito ergo sum: I think I am Codified the separation between rationality and feeling Identified selfhood with rational thinking self Informs the body/mind distinction in biomedicine

Answer 128

Paternalist mode: Used most frequently in emergency settings or when patients are critically ill. Here the doctor adopts a medical persona that has many features in common with a responsible guardian. Partnership mode: Used most frequently when the patient’s clinical condition requires the doctor to act as a partner to the patient, providing advice and supporting their own autonomy to manage their illness. Here the doctor adopts a medical persona with similar features to a companion. Risks: If the patient and the doctor are not really in a horizontal power relationship. I.e. have to report to third parties Consumerist mode: Used most frequently in situations when the patient has a choice and needs information from the doctor. Here the doctor’s persona is similar to that of an expert advisor. Risks: Failure of communication, power hierarchies in consultations Interpretivist mode: Used most frequently in settings of psychological or psychosocial complexity, where the personal roots of illness, or barriers to wellness, may not be clear to the patient. Here the doctor’s persona is similar to a counsellor. Risks: Time consuming -- Paternalist mode: For a patient who has acute respiratory distress. The doctor will seek his consent for the procedures but she will quite firm in in her advice. She will tell him he needs to be admitted to the hospital. Partnership mode: A patient with chronic lung disease who is living in the community, there will be a consultation between the patient and doctor discussing their medication, oxygen cylinders, and how to live independently. Consumerist mode: A clinician showing a patient examples of the outcomes for rhinoplasty conducted in the clinic, together with risks and costs for surgery. Interpretivist mode: They involve long term patient doctor relationships.

Answer 129

3 proposed frameworks for understanding outbreaks occurrences and poverty: Malthusian corrective thesis: It’s nature’s way Malthusian argues plagues are a natural way of sorting out overpopulation. Argues only host and environment are the important factors Reverse McKeown’s theory: Nutritional and environmental improvement will stop outbreaks This theory says if the population is healthy and well-nourished rates of disease will drop He argues against vaccination (health technology) Theory still used to critique role of technological medicine BUT these critiques use data inaccurately, ignore the role of health advocates and have an ideologically based use of statistics Road stops on the path to health transition: Things will get better as part of the transition process due to health technology Health transition: A characteristic shift in the disease pattern on a population from acute infectious diseases to chronic, degenerative diseases, causing a gradual shift in the age pattern on mortality from younger to older ages Current arguments about improving health services in poor communities: Biomedical approaches vs environmental approaches (e.g. hepatitis B program vs housing program – should fix both and they are not the same problem) Environmental vs political Low cost health solutions vs best practice health solutions

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Impairments: Are problems in body function or structure such as a significant deviation or loss E.g. Impaired and not disabled: A person with hearing loss but able to perform normal activities (e.g. communication skills) with the support of a hearing aid Disability: Is any restriction or lack (resulting from an impairment) of ability to perform activity in the manner or within the range considered normal for a human being. Disability incorporates the notion of what is normative E.g. Disabled but not impaired: The definition of disability basically say if you are disabled this is due to an impairment. However, you could say that someone with psychosocial issues (unable to function) but does not have a psychiatric condition (impairment) still has a disability.

Answer 131

Medicalisation process: It is when a disease is brought into the medical domain that did not used to be there. For this to occur the disease needs to meet the following conditions 🡪 Biologically plausible Current preoccupation, An authority within medicine (e.g. new disciplinary fields - sleep physicians) Method of diagnosis (sleep studies) An acceptable treatment.

Answer 132

It is the transformation of formerly non-commercial social relationships into commercial relationships, relationship of buying and selling. In Australia, organs are not allowed to be commodified, it is a gift. However in other countries, organs can have a price attached to them and have been commodified.

Answer 133

oor people are more likely to have chronic illness, severely disabled. Why is this the case 🡪 Genetic determinants ? Lifestyle choices ? Lack of health services and poorer health hardware Downward drift (e.g. due to loss of employment – this is a massive problem) Environments conducive to ill-health (further away from health services)

Answer 134

The gendering of illness: Genuine biological differences in disease prevalence’s (obscured by past epidemiological research) Genuine differences in seeking health patterns Social difference results in different illness categories being attributed along gender lines Sex: Male and female biology Intersex: Refers to a range of conditions in which biological sex does not match typical notions of male and female Sexual identity: One’s identity about one’s sexual orientation Gender: Social and cultural constructions of male and female Gender identity: One’s personal experience of one’s own gender Gender role: A set of societal norms about ways of behaving that fit with gender Transgender: Gender identity differs from assigned sex at birth

Answer 135

Disability in the media: Heroic model: Disabled people can transcend their disability. They become objects of admiration and inspiration to others. Potentially obliges disabled people to be “better” than everyone else E.g. Paralympians, motivational speakers Objects of charity: Disabled people require help from the able-bodied. Focus is often on the giver as much as the recipient. Working on the principal of moral obligation. E.g. Fund raising charities (this is happening more as government is providing less) Objects of medical rescue: E.g. mercy ship that provides rescue to people in poor countries. This can shade into the euthanasia debate/choose who you rescue. Impacts of different policy approaches to disability: Medical model of disability: Poses that disability is a medical problem that can be fixed. Based on the principle of rescue and can result in devaluing the lived experience of the disabled. Engages mostly in the physicality of disability and not the social aspect Social model (disability is in the eye of the beholder): Poses that disability is a social phenomenon. Based on principle of equivalence and say that disabled people have the potential to reach the same goals as those able bodied. Its helps destigmatise disability and attempts to improve access and availability of work and education. Engages mostly in the social aspect and not the physicality aspect Biopsychosocial approaches: Recognises that bodies suffer in individual ways. Based on the principle of the respect for difference. It prepares for, recognises and responds to fluctuations in physical and emotional capacity. Recognises that the internal and physical world of the person needs appropriate health care provision. You have a customisable approach based on the needs of the person. Engages with both the social and physical aspect of disa | D

Answer 136

Medicine and sexual pleasure in the 14th century Female sexuality: Viewed simultaneously as libidinous and as a passive empty vessel. A dangerous thing for women and there was no place for pleasure. Risk of death during childbirth. Male sexuality: Sexual pleasure was acknowledged but under religious constraints. Church and state defined proper sexual conduct. Medicine and sexual pleasure in the ninetieth century Female sexuality: Ideal women were considered sexually withdrawn. There was still risk of death in childbirth. New belief that the female sexual organ would atrophy with lack of use. Male sexuality: There was a belief that ejaculation lead to loss of vigour (thought there was fatal consequence of masturbation). Parents were frightened about the consequences of self-abuse (ejaculation). Medicine played a more prominent role now in policing sexual desire – advised the use of devices to prevent “self-abuse” that could be quite barbarous. Classifying sexual deviance (nosology) : “paradoxias” – desire at the wrong time, “anaesthetics” – absence of desire at the right, “hyperaesthetics” – excess desire at any time, “paraesthesias” – desire for the wrong object. Medicine and sexual pleasure in the 40’s Kinsey: First study to point to breadth of sexual experience among American men and women. Critiques of his research – informant bias (over representation of prison), moral concerns about data. Biomedicine involving in sexual pleasure: Critical element in changing the position of medicine from policing sex to starting to support sexual pleasure was the pill (the contraception). Medicine and sexual pleasure in the 70’s: Biomedicine involved in sexual pleasure: Masters and Johnston investigated the process of sexual pleasure. Identified the differences in sexual pleasure between men and women. Medicine had explicit enabling function – reproductive safety. Sexual orthodoxy around experimentation. Diverse modes of sexual being. Incendiary debates within the medical profession about failure to police sexuality – i.e. the catholic church saying to doctors that they shouldn’t be providing the pill as it gives people sexual freedom. Female sexuality: Reproductive freedom, ideology of sexual experimentation, perceived freedom from STDs, “Frigidity” a new problem. Male sexuality: Idealised male was sexually aggressive and young. Male sexuality assumed to be “natural” – defined in relation to problematic female sexuality. Democratisation of sex in the 21st century: Female sexuality: Desire a desired state, reproductive freedom. Male sexuality: Sexual performance preserved across life, Viagra available to keep performance going. Medicine and sexual pleasure in 2018: Drug company led dominance of medicine in determining the forms of sexual pleasure. Normalises genital view of sexuality. Notion of sexual rights. Implicitly sexual performance is modifiable through medicine.

Answer 137

Illness vs Disease: Disease: An anatomical and/or pathological disruption of the body Illness: The lived experience of being unwell Examples: You can have a disease without being unwell. E.g. Someone who is diagnosed with Crohn’s disease has a disease but if there condition is stable and has no flares ups they are not ill. People can have an illness without being diseased. E.g. People say they are having symptoms impacting them but no disease state. Grief is an illness, they have distressing symptoms but do not necessarily have a disease such as depression. Approaching illness: Psychosomatic disorders Psychosomatic medicine: The study of how illness and physical disabilities are caused and/or maintained by psychological dynamics. It includes the psychological and emotional factors in functional/psychogenic conditions (no biological basis) and organic conditions. Curing psychosomatic disease: Reassert rationality, cognitive behavioural therapists change fixed patterns of thought. Problems with the term psychosomatic: Tries to integrate the impact of emotions/feeling/bodily experiences on the mind, but actually discounts the whole illness experience Psychosomatic explanations reproduce the dominance of biomedical explanations and continue to devalue patient experience.

Answer 138

Materialist perspective: For someone with this perspective not being told a biological diagnosis can mean they think someone is not taking them seriously. Can also be a result of social norms which say mental disorders/ psychosomatic disorders are not real and can result in ostracism. Treatment: Working with mechanical metaphors, provide somewhat of a biological explanation, alter factors that can be causing illness Dualist perspective: For someone of this perspective, they may not accept they have the disease because they think it threatens who they are. This can be common for people with HIV diagnoses. Treatment: Understanding how selfhood would be threatened by treatment. Social support.

Answer 139

Yellow fever: A disease of the liver or the bloodstream (like hepatitis) A disease of poor morals (like alcohol abuse) A disease of poor environment (like typhoid and malaria) A disease due to a microbe Psychiatric diseases: DSM I: Freudian categories – disease as “reactions” DSM- II: Disease as “neuroses” DSM- III: Disease as a biological pathway DSM-IV: Biological disease in social world e.g. PTSD DSM-V: Society and disease, classified by disease and desired state Glue ear: ENT anatomical problems Learning disorders Asthma: Psychiatric problems due to poor parenting Respiratory problems Atopic disorders

Answer 140

Disease categories reflect our own views of the ideal self and the cultural practices and states of being we value.

Answer 141

Define embodiment: Lived, subjective experience of the body Encompasses the ways our bodily feelings (pain, suffering, symptoms of disease) express emotional, social, cultural and political states. Describe what is meant by a culture-bound syndrome: Definition: Conditions that arise from our culture or are only found in certain cultures Examples of culture bound syndromes: Susto, Koro, Running amok Detailed example of a culture bound syndrome 🡪 Nervosa: Individual: Unrest in stomach, worried, nausea Social: Unsupportive relatives Body politic: War in Bosnia. Ongoing instability in the world No one suffers nervosa like a Bosnian

Answer 142

Bodily expression of illness draws on cultural repertoires of distress and the way in which our bodies express distress often reflects social and political inequality Emotional empathy: “I feel your pain” Actually mirroring disease Cognitive empathy: “I can imagine what it is like to be you feeling your pain” Imagining what their pain is like. Cognitive exercise

Answer 143

HIV/AIDS was a greater catastrophe in Africa as people through it was too expensive to treat, “Too difficult” to ensure compliance, MDF needed to do drug trials to prove that it was possible to treat people in Africa. “West” vs “Africa” causes of disease Demonization of the other “non-medical causes of AIDs, the poor”

Answer 144

What people thought was causing HIV Host: ? Host issues, ? Sexual practices, ? Animal/human miscegenation Agent: New “undercover” agent, ?was there a unique agent at all Environment: CIA spiking of blood, re-use of needles, witches sending sickness. So many people have it so let’s die together. Use the epidemiological triad in social contexts to make it work: Zika virus in Latin America: Host (behaviours in relation to water/container management), environment (crowding, inadequate sanitation) and agent (increased virulence of bug + ?with dengue) However this doesn’t take into account other factors such as deforestation leading to a shift of population to urban areas, international travel between poor countries, policies regarding early detection + termination. Ebola Triad in West Africa: Host (cultural factors), environment (failure of health services) and agent (highly virulent bug). However this doesn’t take into account other factors such as a civil war in 2/3 of the countries, decades of destruction of health services, bottom 5 in UN development index, population flows across borders. You need to place the epidemiological triad in social context of the location that is facing the problem

Answer 145

Very rapid, multi-pronged and pragmatic approach: Needle exchange program: To prevent spread of disease through needles Prominent figures such as the Dean of Melbourne Uni, infectious disease workers and Ita Buttrose encouraged government to have a condom focused program, united sex workers. Solidarity, stable and middle class leadership, political support, relatively tolerant society

Answer 146

Causes: “Man-made” or “natural” Theories: Malthusian: Mismatch between country’s population and its regional food production capacity Entitlement theory: Failure of the poor to have sufficient resources to acquire food Social distribution of the experience of famine: The experience of famine is different between countries with the same capacity to produce food. Therefore there must be man-made factors resulting in this. The Maharashtra drought 1970-3: Urban/rural divide, acute shortage of food but no famine. Probable reasons: Sustained government input into work creation, importation of food, rallying of the poor Most famines are caused by a lack of money and blockages in transport of food to the location needed.

Answer 147

Placebo: Inert substance or therapy which, when applied to person, results in improvement in illness Placebo effect: Psychobiological phenomenon as a result of the use of placebo along with cues about clinical benefit Natural course of illness: Patient with a self-limited illness takes cod liver oil. He attributes recovery to the cod liver oil but in fact was in the process of recovering anyway. Regression to the mean: Patient with fluctuating illness takes manganese. When her symptoms fluctuate back to the mean level, she attribute this to the medication Undetected active substance in ‘placebo’: There is a potential that the placebo has a biological effect that we aren’t aware of. Expectation/condition: Positive expectation with positive symptoms resulting in the placebo effect. Negative expectation with negative symptoms results in nocebo effect.

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placebo: Analgesia: Placebo analgesia appears to occur through expectation (endogenous opioids) AND through conditioning which activates opioid and non-opioid sub systems AND through social learning. Evidence for Parkinson’s: Transplants of dopaminergic neurons into patients with Parkinson’s surgery – sham surgery is effective. Any placebo will improve motor functions, but expensive treatments work better than cheap placebo Depression: PET studies show similarities in regional metabolic patterns in the brain between those on SSRIs, and those on placebo. Both conditioning and expectancy seem to play a part in improvement nocebo: Nocebo effects appear to work through expectation, which heightens anxiety and through conditioning. Nocebo hyperalgesia work through anxiety + cholecystokinin Examples: “The doctor said that this is really going to hurt” “I went to see the surgeon and all he could tell me was everything that could go wrong” “There’s a problem on your test”

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Australian Law: Death is generally defined as either irreversible cessation of circulation of blood in the body of the person OR irreversible cessation of all function of the brain of the person (NHMRC) Before the 19th century: Undecayed bodies could still retain vestiges of life – this influenced forensic cases and medical properties of cadavers Fear of premature death: That people would be buried alive was a very a common concern, many didn’t want to be buried till putrefaction occurred. Why death has moved from the heart to the brain: Location of selfhood: Hippocratic corpus texts reported that selfhood was found in the left chamber of the heart. Ability of technology to prolong life: Due to advances in technology we can keep people alive even once they are brain dead. Reframing of dead body as useful for life for others: Organs from the body and the heart could be used

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No evidence of brain function over a period of time Loss of function not attributable to something else Brain injury sufficient to account for loss of function No reflex actions (cough, gag, pupil, eye movement) No attempts to breath off respirator (high CO2 level) Repeat after 24 hours

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Transitional poverty: People who are temporarily poor but have resources and are likely to transition out of poverty Elective poverty: People who choose to live in a poor fashion, but still can access supports if they need them Life event poverty: Person spirals down socioeconomic strata Intergenerational poverty: Parents were poor, few advantages growing up, poverty is repeated in the next generation.

Answer 152

Challenges: Insufficient income so they can’t buy medicine or pay for the doctor. Food insecurity Work insecurity Underheated and crowded housing Difficulty accessing care partly due to carer overburden Limited education with can impact work security and health literacy Can’t get to appointment because of lack of transport

Answer 153

MESSST – framework for taking social history targeted at social disadvantage M: Money E: Education S: Shelter S: Someone you have to look after S: Someone who looks after you T: Transport Culturally sensitive health care: Doesn’t have a fixed view of culture as immutable (e.g. Aboriginal people think it’s rude if you look them in the eye is a silly generalisation) Is aware that people are individuals and culturally embedded, and through their life course and illness experience they may move between different ways of expressing and feeling the importance of culture Gender specific care, respect the patient’s modesty

Answer 154

An explanatory model is a framework that helps make sense of the illness symptoms and which is then used to direct thinking about treatment What do you believe is the cause of your problem? What course do you expect this illness to take? How serious is it? What do you think this problem is doing inside your body? What are your expectations of how this problem should be treated?

Answer 155

Structural violence: Structural violence refers to systematic ways in which social structures harm or otherwise disadvantage individuals. Structural violence is subtle, often invisible, and often has no one specific person who can (or will) be held responsible (in contrast to behavioural violence). It is the avoidable impairment of fundamental human needs or life, which lowers the actual degree to which someone is able to meet their needs below that which would otherwise be possible It is often embedded in longstanding “ubiquitous social structures, normalised by stable institutions and regular experience”.

Answer 156

Patronage: As Australians we expect the state to provide shelter, income, health and work (strong state client relationship). However, for many refugees they have come from countries that have a weak state person relationship and they have come to Australia where they do not have access to state support. Refugees offer patronage to the doctor (patron) to be able access shelter, work, income and health. For refugees, survivorship often depends upon patronage. However, doctors cannot not offer these, they just refer. When they do not succeed in providing these services, refugees may feel that the doctor has failed them.

Answer 157

Agency arguments and the limitation of agency: Agency is the capacity of individuals to act independently and to make their own free choices. By contrast. Structure is those factors of influence (such as social class, religion, gender, ethnicity, ability, customs, etc.) that determine or limit an agent and their decisions It is one thing to have a structural analysis, but at the end of the day it is through individual agency that structures can be challenged and reformed. Behaviour is ultimately about agency - first personal and then structural. Apply concepts to Indigenous health: Experience with health care institutions historically has been coercive Non-Indigenous workers can have guilt about the past, a paralysis of inertia and leadership and a deep desire to be forgiven. This can get in the way of providing expertise or help. Shame for Indigenous cultures is different to embarrassment and guilt. It is one of the major reasons for Indigenous people not accessing health services. Structure vs agency in Aboriginal health

Answer 158

Be your own anthropologist: Reflexivity has come to have two distinct meanings, one that refers to the researcher's awareness of an analytic focus on his or her relationship to the field of study, and the other that attends to the ways that cultural practices involve consciousness and commentary on themselves. Self-reflexiveness: Be aware of what we think Defamiliarize: New workplace, technologies, language

Answer 159

Ethical arguments: Recipients often believe or delude themselves that the donor is receiving substantial money for the transplant but in reality the donor is unlikely to be paid highly or may be taken from a prisoner or homeless person. Recipient may also believe they have the “right to good health” Sellers may have the right to enter a commercial transaction BUT there are influences such as extreme inequality that push people to make these decisions. Altruism arguments – that people just want to help and donate their organs but in reality it is often the poor donating due to their circumstances.

Answer 160

Factors involved in commodification: Cartesian cogito (I think therefore I am): The separation of mind and body 🡪 people can donate organs without effecting who you are Economic and social inequality Technological advances: Organ transplant technology Anti-rejection technology Artificial organs: E.g. dialysis, ventilator Growing organs

Answer 161

What can be done about illicit trade: Legislation against commodified organ trade (e.g. UK) or can only occur for citizens in the same country (e.g. Singapore) Pursue artificial organs International watch organisations to track illicit donations UN protocol to prevent, suppress and punish trafficking in persons, especially women and children Legalise: E.g. Iran Two charity organisations oversee procurement Government + purchaser pay the vendor (approx. $4000) – you have to be able to afford it No waiting lists but cadaveric donation continues People still procure and sell organs outside of the official system Enlightened commodification: Future in Australia? That government, through Medicare would fund the purchase of kidneys from Australians. The reason why that’s important is that we satisfy the medical and ethical issues which are not satisfied when patients go to Pakistan or other places. Cost would not be prohibitive for the recipient

Answer 162

The elements of medicalisation of sleep: Sleep disorders can be viewed as a problem of neurology, respiratory, chronobiology and sometimes a problem of anatomy. The question is why it’s considered a significant problem now 🡪 There are increasing rates of sleep apnoea (8.3% in Australia have been diagnosed sleep apnoea) In the past: Sleep was approaches as a restorative or revelatory or malleable state. In different cultures there are different patterns for sleeping i.e monophasic sleep cultures, biphasic sleep cultures and napping cultures. There has been an increase in publications on sleep apnoea in the medical literature – before 1972 it wasn’t even discussed. Medications of wakefulness: Through the example of modafinil In Australia, it is tightly controlled and only can be used for narcolepsy In the US, it is marketed for sleep apnoea, CFS, narcolepsy, shift workers 🡪 some of these uses is medicalising wakefulness. Consequences of promoting wakefulness (as a medical condition): Student market, labour market implications (shift workers, long haul workers), natural experiment (what happens if we abolish REM sleep?) Scope of sleep disorders is expanding: Excessive sleepiness, parasomnias, insomnia, chronobiological problems, sleep architecture problems (making your sleep more efficient )

Answer 163

Two step approach: Ask: What would you like to record as your gender identity? Ask: What legal sex were you assigned at birth (e.g. male or female) Medical Hx: Nature and duration of history of gender identity feeling different to the legal sex assigned at birth Care received to date. Who have they disclosed to and their main support (family or other) Past medical history Prescribe and non-prescribed medications, including complementary therapies and self-medicating with hormones Drug and alcohol history Sexual health history and risks of STI or blood borne virus Mental health conditions e.g. depression, anxiety, PTSD, autism spectrum disorder

Answer 164

Diagnosis of gender dysphoria: For gender dysphoria to be present, a patient must have had at least two DSM-5 criteria for at least six months, and it must cause significant distress to the patient. This generally includes any of the following: A significant differences between their own experience gender and their secondary sexual characteristics Strong desire to be rid of their secondary sexual characteristics or prevent their development Wanting secondary sexual characteristics of the opposite gender Wanting to be treated as the other gender

Answer 165

Goals of treatment: Discuss individual goals and needs. This will be different for each individual and may change over time. Not everyone wants hormonal treatment nor does everyone wants surgery 🡪 Social transition: I.e. changing or experimenting with gender presentation Legal processes: Amending names and birth certificate to reflect the person’s identity. Vocal and communication therapy Hormonal treatments Gamete cryopreservation Genital and non-genital surgery Assessment of transgender patients: Providing information on peer support and advocacy If the patient is self-medicating with hormones, sudden cessation is not recommended. Stopping hormones when they have experienced an improvement in mental health associated with therapy may be harmful. Discuss lifestyle changes to address CVD risk with hormonal treatments e.g. smoking cessation, weight loss, regular exercise and managing drug or alcohol dependence. Mental health assessment

Answer 166

Treatment of transgender patients: Informed consent: Traditionally, all patients have had to obtain an assessment by at least one mental health professional before accessing hormonal treatment and least two mental health professionals before surgery. Surgery: Genital or non-genital surgery Medications: MtF: Oestrogens, androgens antagonists, progesterone’s FtM: Androgens. Fertility: All patient should have a discussion about their desire for fertility preservation. It is desirable for patients to make a decision concerning future fertility before starting treatment. Treatment of transgender children: Stage 1 (hormonal blockers): It is not a special medical procedure which means starting the medication is the parental responsibility. Stage 2 (hormonal replacement): Informed consent should be gained from the adolescent (must be Gillick competent) and ideally, but not necessarily, consent should also be obtained from their parents, carers or guardians.

Answer 167

Value neutral: We often think that technology does not encode any moral values. After all, it is a thing, rather than a proclamation. But this is a dangerously unintellectual way to think. Most technologies do encode or reinforce some moral values. The contraceptive pill, for example, carried with it the moral value that women should have autonomy around their sexual lives. Autonomous: Although new technologies are introduced by someone or teams of someone’s. Most fade into the background. Sources of empowerment: We think this because we are usually told that they increase freedom and control for the individual. Most medical technologies – from antibodies to genomic sequencing to clonal technologies – have been introduced with a utopian promise of a better world.

Answer 168

Its development was technologically driven rather than driven by humanitarian impulses. The counter to this position was that the technological developers of IVF were driven by impulses – they both wanted to help infertile families and they wanted to push the technological limits of their discipline. The technology defines women in terms of their reproductive capacity. The advocates of new technology may have underestimated their impact upon women’s health. OHSS which can be fatal, was not recognised at the time as being potentially life threatening. Assisted reproduction and perfection: Two main ideas around IVF that have taken hold are choice and perfection. IVF has re-invigorated notions of choice in biological parenting. The assisted reproductive technologies allow us to invest in trying to create the kind of baby we might desire. This is a long way from earlier approaches to parenthood, where adoption and fostering of non-biological children were the solution to infertility. Egg donation is in the US is an example of commodification.

Answer 169

Australians have become prolific users of overseas surrogacy programs. Surrogacy raises the issue of different types of parents that can now exist. Social parent: The parent that raises you. Gestational parent: The parent who carried you in the womb. Genetic parent: The parent who gives you their genetic material, such as an egg or sperm donor. Commissioning parent: The parent who asks for and arranges for you to be born, usually through paying someone to undergo surrogacy. Cytoplasmic or mitochondrial parent: The parent who in rare cases provides mitochondria to a mother with diseased mitochondria.

Answer 170

There is a strong argument in favour of sex selection, based on respect for procreative autonomy. The autonomy of the couple to decide how to procreate and what children to have. Making sex selection illegal is more akin to Nazi eugenics than allowing couples to decide themselves what children to have. From a population perspective, such an approach has proven disastrous for many Asian countries. The male: female ratio at birth is 105:100 (males are more fragile than females and more are needed to reach sex parity in adulthood). China’s current male: female ratio at birth is 115:100. The social consequences of this high rate of adult men who will never find a single female partner is unprecedented. There was at one stage an argument that perhaps this would result in an increase in status of women. In practice what we have seen is an entrenchment of patriarchy More violence against women, partly attributable to excess of young unpartnered men Trafficking of brides from neighbouring poor countries Bride napping Wife slavery, with one wife being shared between brothers Emerging accounts of male trafficking to richer Asian countries on the promise of marriage and being enslaved to undertake labouring work.

Answer 171

Science - objective standard to base policies on Providing facts - can take on political consequences and become matters of political significance Problem: diversity within science and variation with scientific advice Politicians of the mind that it may protect from criticism as an objective standard Scientists - seen as legitimate holders of knowledge Science vs. Politics E.g. Professor David Nutt (Chair of Advisory Council of the Misuse of Drugs) Editorial about how there is a greater exposure to a serious adverse event when horse riding (+ smoking, alcohol - more common/legal activity) as compared to ecstasy (illegal drug taking) Fired for being an adviser who gave advice in public that ministers did not want to hear - regardless of argument being scientifically founded Competition between scientific facts and implications for culture/financial Evaluative stance: e.g. pill testing Promotion of a harm reduction strategy - performed as a broader stance on drugs (their danger and policies surrounding it) Independence of doctors to society in conducting work - conducted by those with no (obvious) conflict (neutrality) Can work (research) be an apolitical matter? Can studies/health be completely objective? Distinction - conducting research with an approach of neutrality, rather than being not political?

Answer 172

Politics as moral vehicle in health Legalisation as a strategy to create moral change or impose moral views E.g. abortion and euthanasia - push specific ideological values How should the medical profession involve itself in the debate that precede such legislation and lead to change? Doctors as individual practitioners - practice of these ideas, influence on your care of patients if they disagree? Medical association bodies - position gives credence to views, may give rise to campaigning and politicisation of the medical profession? Medical ethics - directly engage with these ideas Medical profession vs. public Should the medical profession have authority for these matters or should it be a case for the public? Responsibilities of doctors - simply medical doctors or contributing to public debate?

Answer 173

Role of science: to provide objective evidence However, government policies do require scientific basis and therefore, there must be some intersection between science and politics Can individuals be apolitical? Can science be apolitical? Conclusion: commitment to objectivity, neutrality, impartiality My conclusion: commitment to truth

Answer 174

Refugee policy - may affect health of individuals Big Pharma - objective of marketing and business, may be prioritised over health Research imperatives - focus on profitable diseases, rather than problems in developing world

Answer 175

Health system building blocks: - leadership and governance - health care financing - health workforce - medical products and technologies - info and research - service delivery For access, coverage, quality and safety Goals are: - imprived health (level and equality) - responsiveness - financial risk protection - improved efficiency