EDITORIAL

Given the disposition of power and prestige out- lined above, it is hardly surprising that the primary preoccupation of medical education is the produc- tion of medical practitioners to deal with individual patients. Even though undergraduate medical edu- cation takes place under the aegis of the universities, the increasing (and appropriate) demands for rele- vance in education, and for clinical competence at graduation, mean that undergraduate programs are nested increasingly in the current acute health care system, which rewards specialism and the applica- tion of technology. However, increasing specialisa- tion in so-called teaching hospitals (or should they be ‘learning hospitals’?), coupled with financially driven declining lengths of stay, makes these institu- tions progressively less valuable as venues for basic clinical education about the health and illness of most of the population. On the positive side, how- ever, this may force a re-evaluation of the potential of other, nonhospital venues for undergraduate ( pregraduate) medical education.

Postgraduate education in the high-prestige spe- cialties takes place almost exclusively in teaching hospital positions accredited by the Royal Colleges. This environment of apprenticeship and patronage is not conducive to change, and it is therefore hardly surprising that reviews of medical education in the English-speaking world have been offering the same criticisms for the last 50 years.

In his acerbic epigram ‘those who can, do; those who can’t, teach’, George Bernard Shaw articulated the world view of the ‘doers’. Although medical edu- cation is theoretically well placed to drive change, it remains culturally subordinate to practice, and this means that in reality its power to drive change is lim- ited.

Even if medical educators en masse felt so strongly about public health that they demanded a more prominent profile for public health in undergradu- ate and postgraduate programs, it is not clear how much the status quo would change. Population Medicine, a separate strand in the undergraduate program in the new medical school in Newcastle, has survived a number of vicissitudes, but has always remained in relative curricular isolation, precisely because it is based on a different world view, which thinks about populations, and not about individuals, as does the dominant majority of medicine. As one of the foundation cohort of Newcastle students observed: ‘You’re trying to train us as apprentices in a world where there are no master craftsmen’. The new graduate medical programs in Australia, at the Universities of Hinders, Queensland and Sydney, all have population-based longitudinal strands running through their proposed curricula; it will be interest- ing to see whether they are any more successful than their Newcastle predecessor in changing the med- ical culture.

Halfdan Mahler, a former Secretary-General of the World Health Organization, said ‘ ... to give pub lic health a new meaning ... needs political will by governments and by people in all walks of life’. Change is said to proceed through revolution or through evolution. The prerequisites for revolution include a weak existing culture, an unstable system, and leadership that displays determination,

charisma and unity. These prerequisites for revolu- tion are not conspicuously evident in today’s Australian health care system, and evolution seems the more likely path.

To develop, even by evolution, the national plans and policies advocated by the Shapiros will require, within medical education, a powerful auspicing body to drive the planning and implementation processes with a strong public health focus. This will require all medical educators to become more aware of, and responsive to, the global context of the health system within which they are operating, and they must be opportunistic in seizing on and exploit- ing those elements which can advance their cause. For example, educators should take an active part in the current discussions on the current Council of Australian Governments framework for reform of community services and health, not least to ensure that public health receives much more considera- tion in the definitive framework than it currently enjoys. Analysis from a public health perspective, coupled with a degree of correction of the myopia that day-today service delivery may induce, has an important contribution to make to such discussions.

Only by energetic and persistent interaction with the health care system will medical educators max- imise their contribution to making the dream of Health For All a reality.

Rufus Clarke Western Clinical School, UniuersiEy of S y d y

Referencea 1. Shapiro M, Shapiro R Medical education and health for all.

AustJPuMic Health 1995; 19: 525. 2. Shorter Oxford Englash Dictionary, 3rd edn. Oxford: Oxford

University Press, 1973.

See no evil, fix no evil In public health, as in many other areas, things that we cannot see tend to be ignored, until we blunder into them. The visibility of population health phe- nomena depends, to a large extent, on statistical information.

Injury is a case in point. Until a decade ago, few people conceived of injury as something that could-and should-be regarded as a public health issue, amenable to systematic study and control in much the same way as, say, infectious disease. Some clinicians and others saw patterns in the stream of cases that convinced them that the adage ‘preven- tion is better than cure’ had real promise in the area of injury control. These pioneers tried to charac- tense the nature and extent of injury, and to pin- point promising preventive strategies. They quickly ran up against lack of information. The administra- tive by-product data collected on deaths and hospi- tal admissions were very limited in scope, and their value, (particularly in the case of hospital data) was diminished by inaccessibility, slow release, incom- pleteness, incompatibility between states, and uncer- tain reliability. Moreover, it was clear that much of the burden of injury is contributed by the large number of cases that are serious enough to warrant

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EDtTOftIAL

medical care, but do not result in hospital admission or death.

One response to this situation was the National Injury Surveillance and Prevention Project, funded by the (then) Commonwealth Department of Community Services and Health between 1986 and 1989 to develop a new approach to the collection and use of injury information. Hospital emergency departments were the main sources of data.’ This method was a big step forward. Designed specifically to support injury prevention, especially at a regional level, the project provided much better insight than the by-product data sources into how and why par- ticular types of injuries occur, and sometimes helped to guide the choice of prevention methods.

At much the same time, the report of the Better Health Commission became the first in a series of national and state strategic plans for public health to identify injury as a topic in which worthwhile health gains might well be achieved in return for modest investment. The commission pointed to the need to improve the information available if the gains were to be achieved. Subsequent reports endorsed the early achievements of the National Injury Surveillance and Prevention Project, and advocated further development of the necessary infrastruc- ture.=

Since then, much has been done to overcome deficiencies in information. At the national level, the Australian Institute of Health and Welfare has been funded to support the National Injury Surveillance Unit. The unit compiles, analyses and disseminates the available data, and develops data standards and systems.

While the activity at state and territory level varies among jurisdictions, all states are now giving some attention to injury. In many respects, Victoria is at the forefront, largely because of the centre of activ- ity that has developed at the Monash University Accident Research Centre. A paper in this issue by two of its researchers reflects some of the achieve- ments in the public health use of injury information, and also the challenges that still lie before us.

Sherrard and Day describe injury morbidity in Victoria among adults aged 25 to 64 years.g That they now focus on this age group indicates the progres sion of the centre’s work. The young and the old are the age groups on which the burden of injury falls most heavily, and the researchers have reported on these groups in earlier work. The use of data from the Victorian hospital inpatient separations collec- tion, along with data from emergency department collections (heirs to the National Injury Surveillance and Prevention Project), provides a picture of the problem better than that provided by any but a few exceptional data systems anywhere in the world.

It is, however, still a limited and uncertain picture. For example, the age group covered by the paper includes most of the usual period of paid employ- ment, yet the paper has little to say about occupa- tional injury. This is not the fault of the authors. The trouble is that Victorian hospital separations data, in common with equivalent data throughout Australia and routine injury mortality data, do not include information sufficient to identify injuries that are recognised as work-related. Likewise, the data can-

not be used to distinguish injuries related to sport, or other major categories. These are fundamental deficiencies. Many injuries occur in these settings, and responsibilities and opportunities for injury control exist in them. Yet our major sources of injury information are not even able to idenw the num- bers of cases.

More fundamentally, the reliability of the data is uncertain. Initiatives at national and state level aim to improve the comparability and reliability of hos- pital separations data.’ The fields recording diag- noses are of key importance. The quality of the data recorded in them is receiving more attention than it used to, prompted in large part by the move to casemix-based payment methods, which rely on this information. Sherrard and Day, in common with other injury researchers, have relied mainly on other information in the hospital separations data collection, which records the ‘external cause’ of injury. Much less attention has been given to the quality of this information. The potential for errors and inconsistencies to mislead has been shown in studies in other count~ies.~*~ We are not aware of published reports in Australia. The National Injury Surveillance Unit has recently been provided with hospital separation data for injury for almost all jurisdictions. Early results show some large differ- ences in statespecific injury separation rates. One difference, for example, results in separation rates attributed to ‘suicide and self-inflicted injury’ for one state that are about twice those for other juris dictions. A real difference of this size would be important, and might prompt special action. A little further analysis, however, suggests that the differ- ence is an artefact resulting from differences among states in the interpretation of coding guidelines.

Reports like Sherrard and Day’s are lenses that are beginning to bring injury into focus, enabling effec- tive public health responses. The images now avail- able are good enough to guide much of what needs doing. The lenses are, however, far from perfect. They leave us with important blind spots and pro- duce distortions, some of which have been men- tioned above.

Some of these deficiencies may be corrected by better use of the available data. For example, allowance can be made for welldefined differences in the interpretation of coding guidelines. The increased attention being paid to hospital data sys tems generally may improve the reliability of the ‘external causes’ data, so significant for injury sur- veillance and control. However, uncertainties about the quality of the data will greatly limit the reliance that can be placed on them until quality assurance monitoring is in place and the results are available to users of the data. Most blind spots can only be over- come by collecting relevant information. Thus, work-related and sport-related injury cases will be identifiable among future hospital separations if a suitable data item codes this information. The 10th revision of the International ch.wfication of diseases, which will begin to be used to code Australian hos- pital data within a few years, includes a suitable item: ‘activity at the time of injury’. The sooner this item is added to hospital separations data sets, the sooner these debilitating blind spots will be removed.

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EDITORIAL

In addition to these improvements to mass data systems, injury prevention and control require more detailed data on the circumstances and conse- quences of some cases. This richer information is not needed for all cases; in any case the costs of uni- versal collection would be prohibitive. The comput- erised, goodquality information systems now emerging in the health sector offer the prospect of obtaining the necessary information on welldefined samples of cases (inpatients and people treated at emergency departments), and transferring it promptly to centres capable of analysing and dis seminating the information to those who can use it to reduce the burden of injury.

James Harrison Austradian Institute of Health and Weyare

National Injurj SuruGiUance Unit, A&luidc

Refmncw 1.

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Vimpani G, Hanley P. National injury suwalloncc and prcvm bim, pwjd final n$mt Canberra: Australian Government Publishing Senice, 1991. Better Health Commission. M n g Javmd to bet& hcowr 2 vols. Canberra: Australian Government Publishing Service, 1986. Health Targets and Implementation (Health for All) Committee. Health Jm all Austrdans. Canberra: Australian Government Publishing Service, 1988. Nutbeam D. Wise M, Bauman A, Leeder S. Gooh and targcts Jm Austmh‘a’s hmlth in the year 2000 and bqmd Canberra: Australian Government Publishing Service, 1993. Department of Human Services and Health. Bdtcrhedch out mmes for Austmlianr. Canberra: Commonwealth Department of Human Services and Health, 1994. Sherrard J, Day L. Injury morbidity in Victoria among adults 2 m years of age: implications for prevention. AusfJFublic Health 1995; 1 9 4704. Australia’s Health 1994. Fourth biennial report of the Australian Institute of Health and Welfare. Canberra: Australian Government Publishing Service, 1994: chapt 5. Shevchenko IP, LynchJT, Mattie AS, Reed-Fourquet LL, et al. Verification of information in a large medical database using linkages with external databases. Stat Med 1995; 1 4 51 1-30. Sellar C, Goldacre MJ, Hawton K. Reliability of routine hoct pital data on poisoning as measures of deliberate self-poi- soning in adolescents.JEpidnnio1 ConrmuniQ Health 1990; 44: 313-15.

Diabetes in Aborigines and Torres Strait Islanders: effects, causes and strategies When diabetes mellitus is detected by screening, its significance may not be apparent. The syndrome of thirst, increased urine volume and high blood sugar levels is no passive partner of the aging process, because damage to the small blood vessels of the retina and kidney, large blood vessel disease, infec- tion and many other complications may follow. Alternatively, many persons develop complications before the diagnosis of diabetes is tnade. Therefore, to prevent the effects of diabetes is a major chal- lenge to public health agencies working in concert with health care providers.

Many prevalence studies of diabetes in diverse Aboriginal settings have been reported. Phillips et

al. now add valuable documentation of the associ- ated effects on health (pp. 482-6).’ The authors show that diabetes doubled the risk of death in a cohort of Aborigines with diabetes (compared with Aborigines without it) in the Northern Territory. The report describes higher proportions of renal disease and infectious complications and less ischaemic heart disease as the cause of death, com- pared with the pattern of complications in the non- Aboriginal population.

The careful paper by Phillips et al. exemplifies the value of longitudinal study design, with greater insights into effects on public health than allowed by cross-sectional research. These investigators included prevalent cases in the definition of the cohort of diabetic persons for the survival analysis undertaken: after eight years, some 45 per cent of men and 20 per cent of women had died, with sub stantial additional mortality attributable to diabetes. Although a future study might usefully examine sur- vival restricted to incident cases and make compar- isons with other populations, the present report provides a baseline for estimating the benefit of health programs for Aborigines and Torres Strait Islanders with diabetes.

Underestimation of the effects of diabetes has been recognised as a problem of death certification for many years.P Diabetes is so closely related to other disease processes that it may rank as high as the fourth leading cause of death in developed countrie~.~ Just how the effects of diabetes should be attributed remains a subject of debate. International differences in death certification and diagnostic prc+ cedures may preclude valid comparisons of the out- come of public health or health care measures.

Effects Phillips et al. show that diabetes ‘amplifies the effect of the community prevalence of infection and renal disease’ . I Infectious complications, in particular, should no longer feature as highly as shown in the Aboriginal cohort. Acute diabetesrelated deaths, including but not restricted to infection, should be declining among Aborigines as they have in most developed countries.’

Renal disease in Aborigines has been singled out as requiring particular research efforts5 Diabetes and rend disease overlap but excess mortality from kidney failure in Aborigines is not fully explained by differences in the prevalence of diabetes between Aboriginal and other Australian populations. The observation that persons with diabetes often have renal pathology additional to diabetic nephropathy complicates the question further6 Chronic bacterial or parasitic infection, high blood pressure and high insulin levels may all contribute-in various ways- to the epidemic of kidney failure. Noninvasive eval- uation criteria are needed to explain how urinary abnormalities relate to diabetes, renal disease and mortality,’ particularly in view of the high rates of withdrawal from dialysis by Aborigines.B

An excess of deaths from infectious and renal complications leaves a smaller proportion of deaths related to ischaemic heart disease than is found in other groups with diabetes. Vascular disease remains, however, the principal cause of death in the

442 AUSTRALIAN JOURNAL OF WBUC HEALTH 1995 va. 19 No. 5