Transcript: Social dimensions of alcohol (and drug) problems

 AIFS seminar: Social dimensions of alcohol (and drug) problems - Tuesday 25 March 2014

Audio transcript (edited)

The following audio presentation is brought to you by the Australian Institute of Family Studies as part of our monthly seminar series in which we showcase national and international research related to the family. The seminars are designed to promote a forum for discussion and debate. They are open to the public and free of charge.

Seminar facilitated & speaker introduced by Ruth Weston PSM

Professor Ian Webster AO

Well thank you very much for that introduction and the description of all the things I've done, probably is an apology in a way for the rather discursive approach I'm going to take to today's presentation. I'd like to honour the traditional owners of this land and I'd especially like to acknowledge all those people who work to lift the oppression of disease and poverty from the lives of so many people. And in this talk today I'm really going to take the perspective of a physician, so that's being involved with people right up front and thinking about their lives and dealing with their lives and also community medicine. And I'm going to centre on the fact that my view is that our society doesn't like messy problems and is denying to itself the influence that alcohol is having right across the community. And when I say alcohol I'm actually bracketing other drugs with it but I'm mainly focusing on alcohol because it's alcohol which has the most profound social impact. Other drugs tend to affect the individual but alcohol has an immense social impact.

At the same time I also want to make another set of points which is that in the midst of the advocacy about mental health and suicide prevention reform, I was a member of the National Mental Health Commission until the end of last year, what I find remarkable again is that alcohol and drugs, alcohol particularly are neglected and in my view represent a systemic denial within that system of the nature of those problems. Recall the pictures, the paintings of Hogarth, of drunken men and women and neglected children falling about the ale houses of England, this is a picture, a Hogarth picture, Gin Lane, "Drunk for a penny, dead drunk for tuppence, clean straw for nothing". And also at that time opium was being used to quell the hunger pains of infants.

That link between alcohol and poverty drove the moral approach during the 19th and 20th centuries to this problem. General Booth marched with the Salvation Army to save people from alcoholism, which was seen to be linked with poverty. The Methodists and other Protestant groups were involved and so were the Catholics according to Maurice Glasman. And so in those extremes of marginalised people in industrialising societies alcohol and poverty were bedfellows, part and parcel of the lives of marginalised people. And I want us to remember that. I trained in medicine in this city in the 50s and 60s, we were ignorant about alcohol and drugs in those days. Junior doctors did no more than patch up jobs in the emergency department. We rarely ever identified abused children and if women came in with domestic violence we really didn't know what to do and effectively did nothing.

But there was a light on the hill back in those days when in Melbourne the first alcohol clinic was established at St Vincent's Hospital. And in fact alcohol - Melbourne at that time, and it has for many other issues I should say and most of you would appreciate this - was the hub of thinking for Australia about how we should approach problems like alcohol. Some of you won't remember this but it was the time of the Philips Royal Commission into six o'clock closing which led to the liberalisation of access to alcohol which was followed in Melbourne by the Neuenhausen Report which increased the idea that alcohol hours should not be restricted and led to increasing liberalisation. So Melbourne at that time was quite affirmant and I was a university student, I remember Brian Howe and we used to talk a lot about those things in those days. And homelessness was on the agenda at that time too.

Some of you may not know Alan Jordan but Alan Jordan became the CEO of the Hanover Centre and he back then in the early 70s - and I can remember him because he was my tutor in biology - but he suddenly disappeared and years later I found he'd gone off to study the lives of homeless people in Melbourne and he did a remarkable study. As I understand it was one of the first Masters degrees in Social Sciences at La Trobe University. He studied 1100 cases of homeless people in the city He studied the deaths on skid row, he studied the patients at that St Vincent's alcohol clinic, he looked at the Coroners records and very importantly he looked at the histories of 67 men who were brought up in State homes in Victoria. So that was way back in the early 70s. Then in 1984 Alan wrote a review of that thesis and he looked back at how Melbourne over the years had responded to homelessness. And he produced a book published by the Council of the Homeless in this city, and again Brian Howe is mentioned, he wrote the foreword for that book.

And Alan's photographs, which I've taken from that book, this is of the sleeping arrangements and some of you probably can't see it that well but you know, beds all over the place, absolute incredible proximity, chaos, can you imagine what happens in an environment like that. both biologically and physically in the sense of transmission of diseases, but also psychologically and in relationships, the interactions that would take place in that environment. Then there were pictures in the book of men sitting in pews, in church pews in many instances, waiting to be served their meal, having to sing for their supper so to speak. In that picture you can see you know, large numbers of men with desks in front of them waiting for the food to be provided to them.

How obscene those situations were and in some places still are as men and women are harangued by clergy indifferent to their social origins and the causes of their predicaments. I'm sorry, that's right, there's a peculiar screen here, which delivers the pictures in a slightly different way. And this is St Francis' Church, I walked down the street today and took some photographs of it, and you can see a hand reaching out with a pie and a hand reaching up to accept that pie. The point I want to make from this picture is there's no acknowledgement there, no eye contact, incredibly disparaging and demeaning set of circumstances.

But in Alan's book he explained how the spirit of the homeless people was not broken because during the depression the homeless men and women went on strike and they refused to use the soup kitchens of one of the church groups because of the way that church group treated them and spoke to them and dealt with them in that environment. And Alan Jordan said in that book, "Catholics tended to see charitable giving as part of the vocation of a Christian, pleasing to God in itself. Protestants to use relief as a means of saving souls and promoting social conformity".

So over the years - it's been mentioned I work in a clinic for homeless people - and for about 30 years that was at a refuge, Catholic refuge in Sydney and more recently I do it at a centre called Exodus Foundation run by Bill Crews in Ashfield. But over the years I've marvelled at the agencies, which provide asylum to strangers, no ticket, no ID, no Medicare card needed, accepted for what you are. So in a sense that's part of the direction that I'm coming from in speaking to you today but I understand that the Institute now is about to embark on work - or it's already embarked upon work related to gambling and I thought I'd say a few words about addiction from my medical perspective and my experience and try and link that a little with the thinking that may be being entertained around your approach to gambling.

Some of these views I express I find quite hurtful about the way certain people are regarded who have got particular sets of problems. There's a prevailing view that certainly amongst my colleagues and many others, that people who are in chronic pain and use opiate analgesics to relieve their pain, like doing it, they enjoy doing it or they've made a choice to do that. And of course that's not so. They are said to be addicted and sadly those people accept that label of being an addict but they loathe the stigma and all that entails. They are treated very often very badly by the doctors and nurses in hospitals and in other circumstances, in ED and in the hospital wards. So often when I'm down at the individual level seeing patients, this issue comes up, "Doctor I'm addicted". But I feel impelled to explain to them, I say to them, if you had Parkinson's disease or you had bipolar disorder, the medicines you will be prescribed act on your nervous system and the nervous system will adjust to that exposure and the increasing dose, the neurones, the synapses, the neurotransmitters become in technical terms what we call up regulated. Stop the drug and that up regulated system overshoots or overreacts leading to withdrawal symptoms, shaking, belly ache, sweats, feeling desperately uncomfortable, desperately uncomfortable so much so that people desire to get the drug again.

Now these phenomena of being able to tolerate high and increasing doses of a drug and the withdrawal when it stops occur with many drugs, antidepressants, anti Parkinsonian drugs, tranquillisers, anticonvulsants, blood pressure tablets in some cases, drugs to treat movement disorders. But the point is that we don't say to those people, "You are addicted". So this picture of someone being dependent on a medication for relief of an aspect of suffering which I've just described is a very different picture to the picture that we construct about the addict in the street, although they can overlap, something like about 5 per cent in my opinion and according to some research, others will put it higher, of people who will be getting narcotic analgesics to relieve one set of suffering, the pain, will become addicts in the sense that I've been describing when there's these huge behavioural consequences.

Each week in Australia hundreds of patients will get morphine injections in a public hospital or a hospital somewhere and virtually none of them will become addicted. Using the same drug in a different environment in the street carries a high likelihood of addiction. The person in pain wants relief, the vulnerable person wants some sort of happiness, a way out or time out. In fact one way of thinking about drugs is that they take time away. And of course addiction is not a sudden switch, it takes time to develop and evolve and a whole set of circumstances around the person change. And at the same time it can't be turned off like a switch, it takes time to change from being an addicted person to someone who is a normal person or behaving in the way that they had previously.

So addiction is a very complex phenomenon, it's got a compulsive drive for continued and accelerating drug use expressed in high kevels of drug seeking behaviour. Whatever the costs may be to the individual or to those around them, it's as if the systems of reward and pleasure are functioning in overdrive. And so addiction has been described by some as a disease of the reward system. And I must say that these are confusing concepts because in the DSM-IV, which is the criteria that I've put up here for what they call dependence, I've already described aspects of it as addiction or described it as addiction. And you can see in the top part of that some of the definitions, tolerance, withdrawal, excess use over longer periods, they are essentially those sort of biological adaptations, neurobiological adaptations that I was speaking to you about. Whereas the lower part are more about the social behaviours and constructs. And in thinking about the work on gambling I just wonder whether the point at which they diverge is in these ways of characterising the idea of addiction.

So this mixes up both those biological and sociological criteria. The new DSM-V which I was - I don't think I've ever seen yet a final printout of what it's actually saying, I've seen lots of people writing about what it might say, but I'm not sure that it's going to help us distinguish that notion of someone who's dependent in the way I've described versus the person whose behaviour is destructive and harming themselves and creating social harms. Now of course as a physician I've spent a lot of my life dealing with the individuals and the effects that alcohol and other drugs have on individuals, extraordinarily potent effects. Tobacco I describe as an aging agent, alcohol harms every part of the human body in some way. Back in the 19th century the old physicians used to talk about if you knew syphilis you'd know medicine. I sometimes say if you knew alcohol you would know medicine too.

But what I want to do though is shift into the area which is to do with the social harms and harms on communities that alcohol causes. And what's driven this is that when I was the Chairman of the Foundation for Alcohol Research and Education we funded a group at Turning Point but also around Australia to do a study called, "Alcohols harm to others". And they published a report, "The range and magnitude of alcohols harm to others" to address the impact of alcohol on families, children, workplaces, strangers and communities.

So the drinker was in the middle and you can see they were trying to get measures of the effect on strangers, what was happening to close relationships, what was happening in families, what was happening at work. And I think this is the first time this has ever been done anywhere and now other countries are picking up this. WHO has recommended that countries pick up this idea of studying harms to others as an important paradigm for thinking about alcohol, but one might argue about other drugs. In essence the conclusions which I've drawn out of this, and there are many, many conclusions, was firstly clearly we are all in some ways affected by others drinking. More than 75 per cent of adults negatively affected by others drinking in 12-month period. Some it would be trivial but some it would be very significant, like being hit by a motorcar or being punched.

So the idea of alcohol harming others, it can harm strangers, if it's a disease of poverty, a person driving a car can hit a rich person driving in the street, so it respects no boundaries. But the bit I wanted to really highlight in this is that they were able to look at records from - I can't recall which records they looked at but they looked at assault victims, and there were more than 70,000 assault victims in that year related to alcohol, 24,000 victims - more than 24,000 victims of domestic violence, and more than 20,000 children involved in Child Protection alcohol was involved. And that represented about one-third of children in whom records had been kept in the Child Protection systems that they examined, one was the Victorian system, and there were some other States they looked at too.

That's the central point I want to make to you. At the same time we asked the researchers whether they could calculate the economic costs of that, they were a bit reluctant to do it, but in the end they calculated those extra costs which were then added to a study which was done by Professor Collins and Dr Lapsley which had been done every few years in Australia looking at the costs of drugs and alcohol. But their analyses focused primarily on the individual and the costs of looking after the individual to which added the extra cost which turned out to be of the order of 20 million for these other social arms at least I would argue, the estimate is about $36 billion a year.

Now as soon as that got published of course the liquor industry started writing to everybody telling us it was all lies, they hired one of these you know, firms that do analyses to do an another analysis who criticised the analysis. But this analysis incidentally that I've put up here was done by health economists, people who are well experienced in measuring the burden of disease internationally and in Australia. And it's been published; elements have been published in the peer-reviewed literature. To my mind this sort of work is that age-old story I started with, the impact on families and children, workmates and strangers, the sort of thing that Dickens wrote about last century.

Now I want to change direction a bit again and to focus on two communities. I could have picked some other communities like those engaged with the prison service or some of the rural townships but I want to now talk about the impact amongst other things of alcohol on homeless people. Forty years ago drunkenness was par for the course in the cities' night shelters and this is a photograph I took probably about 40 years ago at the Matthew Talbot Hostel in Sydney and the drunk tank, a man lying there intoxicated, he's got an amputated arm. In some ways that's symbolic that many of the people who end up on skid row or in this environment are people who have had impairments. Often very commonly impairments from childhood, intellectual disabilities, problems with hearing, problems with speech as well as the caring and nurturing problems that I know you people are interested in.

But of course alcohol is still there today. Intravenous drug use was just emerging back then in the 70s and certainly in Sydney with the Vietnam War and the starting to - the marijuana became available and people starting to use heroin and injecting drugs, and this poor young man actually looks like a drug addict, labelled as a drug addict, probably is using drugs but in fact he's got schizophrenia as so many have. Jonathan Blain, Anne Deveson's son looked a bitt like that in that environment. And injury and violence were prevalent then, so again at that little clinic in Matthew Talbot where this man came in disorientated, obviously had been taking some form of medication which had altered his mind, he'd been up at the hospital, walked out of the hospital and turned up at this little clinic in a night shelter with these injuries which we had to deal with. And tuberculosis was rife then 35 to 40 years ago and this man has tuberculosis, being lifted out of his bed by a volunteer. Tuberculosis then is now being replaced by Hepatitis B and C and I'm pleased to say certainly in Sydney and I believe in Melbourne that there are now new programs developing to reach out to homeless people to engage them with treatment for Hepatitis B and C.

And of course this man is severely ill from chronic obstructive lung disease but in the environment of the homeless everybody smokes, and so chronic lung disease is par for the course. You can see that he's thin, he's got scars on his skin and the scars are due to the fact that he's been infected with body lice. So way back then in the early 70s we thought we were going to be somewhat of heroes, we had a mobile caravan and we were going to study all the homeless people in Sydney and we parked this down at Woolloomooloo. We studied about 400-odd of them and the point I want to make to you about it is - and it was quite a detailed study, we looked at blood pressure, blood tests, took X-rays because we used mobile screening vans which had been converted from the old TB campaigns of that day. But in the end when you looked, when you look at anybody in some detail in these marginalised groups, none of them are really well. Do breathing tests on people who are homeless you'll find they've got impaired breathing because of the smoking but because of other things?

Then 25 years late in 1998 some other colleagues and remarkable people in Sydney decided again to look at the people in the night shelters in Sydney and they used the criteria, which had been used in the National Mental Health Survey, the same interview schedule, and applied it to the homeless. There you can see that 75 per cent of the homeless in those night shelters in Sydney had a mental disorder, 23 per cent of the males and 46 per cent of the females had schizophrenia. And then you can see the extent of morbidity listed there. One in two females and one in ten males said they had been raped. It's a bit like that story that Alan Jordan was telling about, people coming through the State homes and having that trajectory into homelessness.

But the point I want you to particularly note too is that the rates in the females with mental health problems were massively high compared with those in the males and that's generally true of women in prison, they have absolutely extraordinarily high rates of mental illness compared with the men and also drug and alcohol problems. And physical illness was - every second person in that study had a physical illness and many of them had Hepatitis B and C at that time. And of course we shouldn't have been surprised by those sorts of findings because we're well aware of the sorts of lives they live, the sort of backgrounds that they may have had and to what they are exposed in the environments in which they are to be found.

Alan Jordan many years earlier had described the deaths of men - I think it's predominantly men - Hanover Centre clients, and you can see he had high - the one I was interested in was the suicide rates, OD and gassing. He listed the suicide rates I think separately but high rates of respiratory infection, high rates of heart disease, lots of injuries. In fact one of the things that Alan Jordan wrote about which I often used to talk to medical students about was that when someone had died and the police had found them in Melbourne, you know in a back street or somewhere like that, the officer would write up the report, "An elderly man found dead" in a certain place. But when the Coroner did the study they actually weren't that elderly, just they looked elderly. And so one of the characteristics of people who live these sorts of lives is they look very old, a man of 50 looks about 75, a woman of about 30 looks about 60.

Now the point I want to get across to you is that these are marginalised people, you could repeat these studies almost anywhere in the world. I remember reading about a clinic in New York, a street clinic for homeless people in which the study estimated that on average people had nine medical conditions, not one, not five, but nine. So these are people with multiple problems and compounding needs. And wherever you find groups living at the extremes who are marginalised, you can find the same pattern of diseases.

Another community to speak about is the Aboriginal and Torres Strait Islander communities. This is a report, these are reports of the extent of substance use, and what you can see here is that on the red column are the Aboriginal populations and on the right are the non Aboriginal populations and the rates of use of substances and alcohol is about double that of the non Aboriginal population. Short term risk of alcohol 52 per cent compared with about 35 per cent. Amphetamine use seven compared with about three.

So alcohol and drug use is endemic in the Aboriginal and Torres Strait Islander population and I'm not showing you a slide of this but these are major factors in the deaths of Aboriginal people. Suicides in males highly linked to alcohol, liver disease, assaults, strokes and injury. And that's reflected then in the admissions to hospitals. Drug and alcohol and mental disorders, 4.5 times that of the general population compared with about 3 in females. High rates of transport accidents, self harm, and look at the massively high rates, that red figure there for women admitted with assaults.

So their morbidity is reflected in those high rates of admission to hospital and then there's the under recognised but pervasive foetal alcohol syndrome which has been studied well in Western Australia or as well as it can be done, but probably underestimates it, where compared with the non Aboriginal population foetal alcohol spectrum disorder is about .02 per 1000 live births, in Aboriginal populations in those studies by a number of methods was estimated at 2.76 to 4.7. To me I think we're starting to look at this more closely and people are researching it, in fact we mentioned the Foundation for Alcohol Research and Education and while I was involved in it we started some of the first funding of work into this, I think we set aside about half a million dollars to fund different projects around Australia. So there's a growing research interest in foetal alcohol syndrome disorder and the fact that it's probably a substrate to lots of the marginalisation and disadvantage experienced by Aboriginal young people.

Then there's a remarkable doctor, Ernest Hunter who works in far north Queensland who's reported recently the numbers of Aboriginal people in that part of Australia who've required treatment in treatment services with a psychotic disorder. But again what I want to point out to you is that alcohol had an important and key role in the onset of the psychotic disturbance in 48 per cent, cannabis did too, alcohol had an important continuing contribution to the continuation of the psychotic illness. And the other thing to note about this work that he did that incarceration was common in that group and very high levels of co-morbid intellectual disability.

Now I'm going to change direction again a bit. All Australian governments say that mental health and suicide prevention are priorities for them, and this is reflected in the fact that quite a few of the State Governments and the National Government has established Mental Health Commissions recently. So certainly in the last two years mental health was one of the tops of the public discussion and public agenda. But what I want to do is emphasise the relationship between alcohol and mental illness and propose to you that it is strong and pervasive and more so than is commonly attributed to cannabis and amphetamines. I think it's remarkable that alcohol's relationship with anxiety to depression gets such little mention and yet cannabis and amphetamines capture the headlines.

And suicide is generally regarded in the community as the devastating outcome of a person having a mental illness, predominantly depression. But here are many social and cultural factors, which underpin suicide in a population level. I mean I've been speaking about Aboriginal people, suicide rates in Aboriginal people are not because they're all mentally ill, it's because of their marginalisation and as I'll make a point in a minute, their substance use which contributes to it. Alcohol consumption is one of those substrates or one of those factors in the general population or in the population or in the people at risk that's important in the risk of suicide.

Now I imagine that in this audience every one of you would accept and would appreciate the lifetime risk of suicide in people suffering an effective disorder, depression or in schizophrenia would be high and there it is, 15 per cent and 10 per cent. These were estimates done way back in 1998 I think. But look at alcoholism, 15 per cent, in fact the old psychoanalyst used to describe alcohol as slow suicide, in fact text books used to be written, there's a very famous text book by Karl Menninger, "Man Against Himself", and there's a whole set of chapters called, "Chronic Suicide" and it's about the sort of self destructive characteristics that exist in certain people. But much of it is about alcohol dependence.

And more later analyses again show effective disorder, lifetime risks 6 per cent, schizophrenia, but look again, and yet that's hardly ever mentioned in the public literature or discussion about suicide or mental health. The National Survey of Mental Health and Wellbeing has shown that suicidal ideation and suicide attempts and the lifetime risk of suicide is high in people who are alcohol dependent. Some of the relationships between alcohol and suicide are shown in this slide. Now there are lots of different estimates of the extent to which alcohol is found in the blood of people who have taken heir lives. Some recently as high as 80 per cent, but we generally accept figures of down in the area of 30 to 25 per cent.

Of the people who come to emergency departments with attempted suicide or overdoses, very commonly they've got alcohol in their blood and although the study hasn't been done in Australia, in some European studies I've seen up to 60 per cent of people presenting like that to an emergency department have been drinking heavily in the 12 hours prior to their presentation.

Alcohol intoxication, the risk of suicide is massively increased because intoxication leads to unpredictable behaviour, being more aggressive, not thinking about the ramifications of what's happening to you. And yet intoxicated persons are often set aside, they're not a problem, he's just intoxicated. In fact the converse should apply when people present who are intoxicated and there's this sense of risk or this concern emerges, we should concentrate even more on that group than dismiss them. And certainly that's what happened in Aboriginal populations, very often a drunk Aboriginal person who might have been talking about suicide was set aside, we must not do that, we must respond and recognise it.

Using alcohol, a more lethal means of suicide are more likely to be used and if you look across countries, particularly eastern European countries, rates of suicide and alcohol parallel each other, 11 out of 13 international comparisons have shown that. So the point about that is that for reasons which are complicated and I don't fully understand, we want to not address or recognise that there are problems like alcohol which influence both mental health, suicide risk and many other things, it's as if it's one of those messy issues that nobody really wants to engage with. Mental health legislation excludes those things for the most part and yet these things overlap certainly at an individual level to a very great degree.

And I shouldn't leave it by just saying of course alcohol is the dominant thing but a colleague at the National Drug and Alcohol Research Centre looked at violent deaths reported to the Coroner in New South Wales which were mainly suicides, there were some others there of course, but when he examined them two-thirds had a substance in the blood which means one-third didn't, 40 per cent had alcohol, 25 per cent polysubstances, 20 per cent opiates and 15 per cent had benzodiazepines. This is the sleeper, which is often related to drug overdoses, when people use opiates at the same time as a benzodiazepine. So again in fact this sort of notion that drugs were related to suicide has been a fairly quiet observation but it's now emerging and people are starting to talk about it a bit more and particularly the people at this national Drug and Alcohol Research Centre, they're actually studying it in great detail.

I have chaired the Suicide Prevention Advisory Council, I'm not sure what's going to happen from now on but even our own national suicide strategy hardly mentions it despite the fact that, I'm sort of an advocate in a sense, it doesn't get much of a place in our strategy. And when you look at the United States or England or New Zealand it sort of gets a mention but it's very much an after thought instead of being a major focus in my opinion.

So I think going back to where I started, the finding of alcohols harm to others should change the way we think about alcohol. Far too long we've seen it as a problem of the individual, and the responsibility of the individual. Alcohol harms communities, it impairs relationships, it breaks down taboos and social norms and so I think, I argue we should take a community perspective. And community breakdown of this kind when it's portrayed in the media often relates to Aboriginal communities but there are plenty of other communities in which alcohol has harmed them. Some of the inner city areas, some of the outer urban areas, grog disrupts the community's life and we've seen it recently I presume in Melbourne but certainly in Sydney with alcohol disrupting inner city life. And as a physician visiting a rural area I can almost predict by looking at where the referrals come from what the nature of the problem may well be because some of the villages and hamlets where there's poor transport, low cost housing, people with not much to do, alcohol has become embedded in their communities.

Now I'm going to try and bring this together a bit and suggest that one way of thinking about these issues and I'm suggesting the Institute might have a role in doing this, and I of course have been using alcohol as my window into these issues, but how we can look at the relationship of things such as alcohol and social and community harms and certainly the impact on children and families. Dr Sven Silburn who is now in the Northern Territory, worked in Western Australia and he was very important, he was a psychologist, very important in fostering the West Australian Suicide Prevention Strategy many years ago but again he developed this diagram which lots of people call the messy diagram. What's interesting to me, it actually appeared on the Social Inclusion Board, one of their diagrams about social inclusion.

But essentially it traces you know, what's happening in early life, low socio-economic status, mothers' infections, drug use, exposure to neurotoxins, early neurological development, adverse parenting, availability of harmful drugs, the problems of relationships to peers, negative thinking, acute stress, depression, low self esteem, many, many tortuous pathways ending up in what he was interested in at the time, being suicidal behaviours, the risk of suicide. So he's describing the vulnerabilities at birth through development, peer relationships, various hazards as I've described. And of course these pathways are strewn with hurdles and diversions. But suicide risk is not the only outcome up there is it, it may be poor educational achievement, it may be the mental health problems I'm describing or the alcohol problems or drug use, it may be suicide risk, problems with employment, antisocial behaviour, involvement with criminal justice system.

And there are points on this pathway where lots of our services engage, I've only listed a few here. But you know, involved in education, social engagement, the mental health services, people who support the emotional development of children, early development, people involved with supporting families. So there are points where interventions can take place and where prevention can occur. There are services that exist to promote resilience, to protect young people, and when things go wrong to put things back together again, to provide safe environments, to protect children from physical harm, promote development and education, reduce their exposure to alcohol and drugs and so on.

So there are complex pathways to risk from early childhood and I think it's an interesting way and an important way of thinking about the way we can intervene. Of course it means a lot about what we should do for young people and children and families. I can remember giving a talk a bit like this and John Howard was sitting in the front seat and he was very enthusiastic about suicide prevention but very hard line about drug problems. And I was trying to make the same point in his presence, you know, he had empathy for one but look it could have been easily been the other, the drug problem that developed and so there are overlaps and similarities there.

One of the most hopeful signs I've seen in recent times in Australia and that's because I've been on the Mental Health Commission, we visited various places around Australia, has been the development of local suicide prevention networks. Now I don't think in many ways they will alter suicide rates a great deal in their own community but they have become a galvanising idea, suicide is one of those things which people become impassioned about and very concerned about and those networks which have been established in many communities, it's very strong in New South Wales, in fact the Wesley Mission there made a major commitment to it, I think it's happening in Victoria, it's happening in South Australia. In Western Australia it's a big movement fostered by their Mental Health Commission.

But it enables local communities to start talking together about what will they do when a suicide occurs, who do they contact, how do they get the local media involved, who are the people who can rescue, who can support the family. And more importantly it enables them to think about what's happening in their community about where those negative factors may be operating which increase the risk. So Alan, one of the things I want to suggest at the end of my talk is that - it may be a bit simplistic to you but in many ways the people I work with don't think along that idea of pathways to risk, in fact the medical systems are dominated by the idea you've got to assess risk, you can't do it very well incidentally for all those things. But I think it's possibly a good way and a suggestion from me about the way you might frame some of the work you do in your Institute and beyond. So thank you for listening to me.




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