By Alex Wodak

The Journal of Drug Issues, Summer 1992

Multiple data sources indicate low levels of HIV infection among injecting drug users (IDUs) in Australia despite a high prevalence of behaviours associated with considerable risk of transmission of infection in this population and a high prevalence of HIV infection among homosexual/bisexual males. The containment of HIV infection among IDUs in Australia in the 1980s, a remarkable public health achievemnt by national and international standards, probably represents the most important national accomplishment in the alcohol and drug field durign the past decade. A number of factors can be identified which have probably been responsible for the early adoption and vigorous implementation of multiple complementary prevention strategies. Complacency and supply restriction drug policy are now among the most critical factors limiting further containment efforts. Progress in implementing strategies to reduce HIV transmission among IDUs in prisons proceeds far slower than all other areas associated with control of HI

V infection in this population.

The Arrival of HIV Infection

For many countries, the recognition of AIDS in 1981 came too late. Tens of thousands of male homosexuals, injecting drug users (IDUs) and haemophiliacs were already infected by the Human Immunodeficiency Virus (HIV) and the national blood supply contaminated before the alarm bells began ringing. The goal of national HIV/AIDS policies could, at best, only be to slow down the further spread of HIV infection within and from these groups, and to care for those already infected. After recognising the magnitude of their own national problem, most countries joined the international cargo cult waiting for the arrival of an effective treatment or vaccine. In all bu a few countries, AIDS was not a confern of government.

The first case of AIDS in Australia was recognised in 1982. As in most western countries, HIV infection in Australia first became established among homosexual/bisexual males. Sydney, the capital of New South Wales and the largest Australiana city (with a population of 3.7 million), has a substantial omosexual community and an identifiable gay district in the ineer city. The San Francisco pilgrimage had long been part of the Sydney homosexual tradition and ensured that the gay ghetto in Sydney would become the national epicentre of the HIV epidemic. The gay ghetto is in an area which is also identifiable as the national centre for drug dealing and IDUs. Yet a decade after HIV infection has tragically become established in the Sydney gay scene, the prevalence of HIV infection among IDUs remains well under 5% in most studies, including in Sydney, despite high levels of HIV-risk-taking behaviour (Australian National AIDS and Injecting Drug Users Study 1991).

iN THE MID-1980s Australia ranked fourth or fifth among Organisation of Economic Cooperation and development (OECD) countries in terms of AIDS cases per head of population, but by 1 March 1991 Australia ranked eighth with 2.347 cases (13.9 cases per 100,000) following the United States (161,288; 64.6), Switzerland (1,651;23,3), France (13,145; 23.2), Spain (7,489; 19.1), Canada (4,717; 17.8), Italy (8,227; 14.5) and Denmark (738; 14.2) (World Health Organization 1991). Homosexual/bisexual males constituted 86.5% of 2.347 cases of AIDS reported in Australia by 1 March 1991, with homosexual/bisexual male IDUs comprising an additional 2.6% and heterosexual injecting drug users a further 1.5% (National Centre in HIV Epidemiology and Clinical Research 1991). All western countries with substantial HIV infection, except for Australia and Canada, have a far higher proportion of IDUs among AIDS cases. The proportions of AIDS cases involving IDUs for thirty-two European Countries (30 June 1990) are homosexual/bisexua

l IDUs 2% and heterosezual IDUs 30.8%, while in the United States (September 1990) and canada (1 October 1990) these proportions were 7%, 22% and 3%, 1% , respectively. The proportion of AIDS cases in the United States involving IDUs have almost overtaken cases among homosexual/bisexual males (Wodak and Moss 1990). The epidemic of HIV infection among IDUs in Thailand in 1987-88 and subsequent rapid spread to the general population was the first indication of this problem also threatening a developing country.

By late 1990, twelve published and unpublished studies of HIV infection in IDUs had been completed in Australia (Kaldor in press). The highest prevalence is reported in studies with large proportions of homosezual/bisezual males. In the largest Australian study of this kind reported to date, a sample of 1.245 IDUs were recruited in Sydney in 1989 (Ross in press). Overall HIV seroprevalence of respondents who consented to be tested (including those who reported that on the basis of previous testing they were infected with HIV) was 5.2% with a distinct gradient across sezual orientation (Ross in press). Thus, for the 908 males in the study the prevalence was lowest in the 719 heterosexual males (3.2%), intermediate in the 117 bisexual males (12.1%) and highest in the fifty homosexual males (36%) (Ross in press). This suggest that reported prevalence of HIV in IDUs may be due to sexual transmission, as well as parenteral transmission. Seroprevalence among the 696 respondents who reported that they were not inf

ected or had not been tested was 2.0%.

Australia's Response to the HIV Epidemic

It is important to review Australia's apparently successful response tot he threat of spread of HIV infection among IDUs to identify factors which may have assisted or retarded the development of effective HIV prevention policies for this population. The attraction of this exercise is to extract lessons which could be applied to other countries, while recognising that the response of each country must be considered from the context of unique national perspectives and social conditions.

One possible explanation for the observation that IDUs have not figured prominently in cases of AIDS in Australia thus far is that there are relatively few IDUs exposed to the risk of infection. Although estimating the number of IDUs in a community is beset with well-known problems of definition and methodology (Selwyn 1990), on available data, Australia has a higher prevalence of IDUs than many other western countries including the Netherlands and the United Kingdom although far lower than the United States. The most frequently quoted Australian estimate is of thirty to fifty thousand (0.18-0.29 per 10,000) regular, dependent users with an additional sixty thousand (0.35 per 10,000) occasional users (Department of Community Services and Health 1988). An anonymous questionnaire concerning HIV risk-taking behaviour was completed by 1,566 adult respondents of whom 0.7% reported intravenous drug abuse in the past year and 1.6% reported intravenous drug abuse ever (Ross 1988).

Under-reporting of AIDS cases among australian IDUs is another possible source of error. The original diagnostic criteria for AIDS were based largely on the clinical picture presenting in homosexual/bisexual males. The revision of the diagnostic criteria for AIDS in the United States in 1987 (which came into force in Australia in 1988) was undertaken partly in acknowledgement of the fact that a case definition broader than that for homosexual/bisexual males waw required. Significant under-reporting of AIDS cases has already been documented in at least one Australian state, but there is no evidence at present for any systematic bias in regard to under-reporting of IDU cases. The low prevalence of HIV infection in heterosexual IDUs in the twelve Australian studies is also consistent with the low proportion of IDUs among AIDS cases reported in Australia (National Centre in HIV Epidemiology and Clinical Research 1991).

In the late 1980s the mortality rate among IDUs in New York city was noted to have markedly increased (Stoneburner et al. 1988). Almost half of this increase represented IDUs who had succumbed to complications of HIV infection before developing manifestations satisfying the diagnostic criteria for AIDS. Althhough an increased mortality rate among HIV.infected IDUs has now also been observed in Europe, it is unlikely that this has occurred in Australia without being detected and is responsible for either the low rate of detected HIV infection or reported AIDS cases involving IDUs. All available evidence indicates that HIV seroprevalence (and AIDS cases among Australian IDUs) is very low in comparison with almost all developed countries.

It is tempting to attribute the phenomenon of limited HIV infection in Australian IDUs to capable management with clear-sighted policy formulation and vigorous implementation of prevention measures denying any apossible contribution from good fortune. The speed and pragmatism of Australia's policy response to the HIV epidemic in general, and to the threat of IDUs in particular, is remarkable by international standards and in all probability contributed substantially to the containment of HIV spread in this population.

As HIV infection represents the most serious complication of illicit drug use for both IDUs and the general population, the containment of HIV infection in this population should be the pre-eminent onjective dominating policy, prevention and treatment approaches for drug users. Even a relatively modest reduction in the spread of HIV infection in IDUs is likely to be of greater significance in the reduction of harm resulting from drug use than more substantial advances in the pursuit of alternative alcohol and drug objectives. Considering the magnitude of the potential consequences of an uncontrolled epidemic of HIV among IDUs, national and international approaches to prevention of HIV transmission deserve the most careful scrutiny so that any lessons drawn from nationals uccess or failure can be identified and considered by other countries facing a similar threat.

The Introduction of Needle-and Syringe-Exchange Schemes in Australia

The opening of a pilot needle and syringe scheme in November 1986 by a group of Sydney alcohol and drug workers, frustrated by the slow pace of developments at that time, marked a turning point. Advisory committees had agonised for some time about taking this seemingly momentous first step and how best to monitor and evaluate the effectiveness of such programmes. Although this pilot programma breached recently proclaimed legislation, no police action was taken following decisions taken at a senior level.

In December 1986 the New South Wales Department of Health, having only recently opposed a recommendation to increase the availability of sterile needles and syringes, announced the introduction of a needle-and syringe-distribution scheme through retail pharmacies. Within a few years, all major jurisdictions in Australia had started distribution or exchange of sterile needles and syringes. By late 1990 the state of New South Wales (population 5.5 million) had approved thirty-two primary (i.e., direct exchange or distribution) and ninety secondary (i.e., provision through intermediaries) needle-and syringe-eschange outlets, with five hundred of two thousand retail pharmacies in the state also distributing and exchanging needles and syringes (Intergovernmental Committee on AIDS 1992). About 1.8 million sterile needles and syringes were exchanged or distributed in New South Wales in 1990 for an estimated ten to fourteen thousand IDUs (AIDS Bureau 1992).

The Development of Drug Treatment Services

Expansion and improvement of drug treatment services in Australia received a major impetus in 1986 with the initiation of a National Campaign Against Drug Abuse (NCADA) providing $A100 million funding for demand reduction, supply reduction and treatment initiatives over a three-year period. The principal aim of the NCADA was "to minimise the harmful effects of drugs on Australiana society" (Department of Health 1985). By implication, reduction of drug use was seen as a means to this end but not, significantly, the ultimate objective. The NCADA was a critical factor in Australia's response to HIV infection. Firstly, the pragmatic identification of harm reduction as the principal aim of national drug policies (rather than the unachievable goal of a drug-free society) facilitated the subsequent accommodation of HIV containment policies. Secondly, the expansion and improvement in drug treatment facilities, data collection, training and research, which results form NCADA, prepared a firm base for effective actio

n from which a later change in goals could materialize.

In 1985 admission to methadone maintenance programmes was liberalised in New South Wales to allow for the prompt admission of HIV-infected IDUs on public health grounds alone, even in the absence of criteria required for other patients. Although only a few IDUs were admitted initially on the grounds of HIV infection alone, the change in policy was indicative of a new and pragmatic mood. At the same time, the capacity of drug treatment services, especially methadone, was dramatically increased and the philosophy of drug treatment liberalised considerably. The decision to extend methadone in 1985 was largely motivated by a desire to reduce drug-related crime (although ascribed to HIV prevention in retrospect). By 1990 over eight thousand IDUs were in methadone maintenance treatment programmes in the six most populous of the eight jurisdictions in Australia.

The capacity of methadone programmes throughout the country was expanded more than sixfold in eight years with a commensurate improvement in administration, training of staff and preparation of policies and procedures. The expansion of methadone facilities (including a prison-based programme in two states), highlighted as an objective of NCADA, must be credited with a substantial share of the explanation for the low prevalence of HIV infection in Australian IDUs. It was fortuitous that the decision to increase the availability of methadone treatment pre-dated the firm knowledge that retention in methadone reduced the risk of HIV infection (Ball et al. 1988; Cooper 1989).

Implementing a Broad Range of Prevention Policies

Recognition of the magnitude of potential adverse health, social and economic consequences of an uncontrolled HIV epidemic among IDUs resulted in a burst of activity in Australia from the mid-1980s, including the establishment of national and state committees and speically convened national workshops. Mass media and targeted aducation campaigns were implemented. Efforts were made to change the focus of activities of drug and alcohol workers from and exclusive promotion of abstinence to a broader focus incorporating the prevention of HIV infection. A sustained series of discussions in the mass media convinced the general community of the centrality of IDUs in efforts to control HIV infection over the long term, thus enabling the introduction of hitherto controversial policy options (New South Wales Department of Health 1990). Belach was accepted as the preferred decontamination agent and distributed together with specific educaional campaigns. In view of the importance of also achieving a reduction in high-r

isk sexual behaviour among IDUs, condoms were made freely available at needle and syringe exchanges and safer sex education implemented. In 1988-89 government-funded self-help organisations of IDUs were established in all jurisdictions to provide peer education, facilitate implementation of prevention strategies, and provide advocacy for IDUs support for HIV infected IDUs.

As a high proportion of male and female IDUs engage in prostitution and also spend considerable periods in prison during their drug-taking careers, the potential for substantial HIV transmission among prostitutes and prisoners is of major concern in efforts to control HIV infection in this population. More than 5'% of a cohort of Sydney IDUs who had been previously incarcerated reported sharing injection equipment in prison, with 5% reporting unprotected anal intercourse in correctional facilities (Gaughwin, Douglas and Wodak 1991; Wodak et al. 1991).

The introduction of a range of HIV prevention measures in prostitution services n Australia has been a remarkable achievemnt and is most certainly responsible for the low prevalence of HIV infection among prostitutes (Philpot, Harcourt and Edwards 1990). This contrasts with the patchy implementation of limited HIV prevention measures in Australian prisons (Egger and Heilpern 1991). Although the strategies required to reduce the spread of HIV infection in prisons were identified early in the epidemic and have substantial support among health workers, political considerations and opposition form corrective services staff have obstructed and delayed the implementation of such critical prevention measures as provision of belach or condom distribution. If the HIV epidemic among IDUs in Australia in time follows the now familiar course seen in Europe, Asia and the United States, the partial and delayed implementation in prisons of only some of the effective measures to reduce HIV transmission may well turn out to

have been the critical weakness. It should be emphasised that the modest achievements of HIV prevention in Australian prisons still compare favourably with the bleack situation in many other countries.

Emerging Debate About Drug Control Policy

Calls for drug policy reform have been heard more frequently in Australia following the implementation of needle and syringe exchange. Although drug policy reform is still a minority view, it is gaining increasing support from diverse quarters including senior and distinguished publig support for a review of drug policy. To the question asked of a sample of the public "Would you support or oppose the decriminalisation of small quantities of heroin for personal use in an attempt to reduce infection form the use of dirty needles?", 38% expressed support and 54% opposition (Saulwick 1989). Cautions encouragement of an emerging debate on drug policy has been provided by the Commonwealth. There can be little doubt that the strategies required to most effectively contain HIV infection in IDUs are difficult to reconcile with traditional supply reduction drug policies (Wodak 1990).

Firstly, the establishment of needle and syringe exchange and distribution schemes in Australia (and elsewhere) was delayed by existing drug policy. Attempts to maximise the availability of sterile injection equipment have been frustrated by supply restriction drug policy. Secondly, the success of supply restriction, often judged by the extent to which street drug prices are kept high and purity low, increases the likelihood of drug injection as the preferred mode of administration. High prices and low purity of street drugs are likely to discourage drug users from substituting non-injecting routes of administration, which are not known to be associated with the risk of HIV transmission. Thirdly, supply reduction policies have impeded the expansion of methadone treatment services and increased the cost of their provision. Fourthly, the concentration of IDUs in prison and the extent to which IDUs convicted only of drug-related offences can be diverted from prisons where they are probably at higher risk of HI

V transmission to non-custodial sentences is also largely a matter of drug policy. Although it is still difficult to assess precisely the extent of excess risk of HIV transmission within prison due to the incompleteness of existing data, it is likely that episodes of risk-taking behaviour in prisons such as sharing of injection equipment and unprotected anal intercourse occur less frequently in prisons than outside prisons (Gaughwin 1991; Wodak et al. 1991; Dolan, Donoghal and Stimson 1990). However, on the available evidence, it is likely that such episodes as do occur in prisons are far more hazardous than in the community.

Finally, supply reduction policies are also inextricably associated with the demonisation of IDUs, which hampers efforts to prevent the further spread of HIV infection. The marginality and ostracism of IDUs increases the difficulty of attempts to modify their risk-taking behaviour through mass media, targeted or individual counselling approaches.

Achieving Change

Althoungh a range of pragmatic strategies to contain HIV infection in IDUs has been clearly articulated in Australia, it should not be assumed that these have been adopted without opposition and all implemented with alacrity. Australia's record may compare favourably with many other western countries, but the real criteria against which policies should be measured are the characteristics of HIV and projections of the likely impact of HIV infection on society.

It is tempting to attribute the relative success in acceptance and implementation of pragmatic policies on HIV prevention among IDUs in Australia to a few key individuals. There can be little doubt that Australia was exceedingly fortunate to have Dr. Neal Blewett as minister for health during the critical early years of the AIDS epidemic. His strong record on civil liberties and humanitarian leanings also left its mark on Australia's emphasis on regional and international resposnibilities in responding to the epidemic. Most other candidates for the position of minister for health at the time would have supported a far more conservative response to AIDS. Some of the minister's key advisers at the time had a great personal understanding of the dimensions of AIDS in the early days of the epidemic and undoubtedly inflenced the course of action taken. During the lead up to the 1985 national election campaign, it became public knowledge that the daughter of the prime minister (Mr. R.J.L. Hawke) had serious proble

ms resultin from heroin use. Nonetheless, in 1987 the prime minister's wife clearly and publicly supported effective approaches to HIV prevention in IDUs emphasising the need t minimise the harmful consequences of youthful experimentation. Various politicians from different parties with differing degrees of personal involvement in the HIV epidemic also supported the adoption of a pragmatic approach.

While not denying the importance of key individuals, admirable politicians or their family members or advisers cannot be accepted as the entire explanation for the adoption of pragmatic policies. Ascribing support for pragmatic policies to these key individuals simply begs the question as to how such individuals came to be influential in the first place. The role of a handful of health workers who adopted the implementation of some controversial prevention measures as a cause to be won at all costs has also been largely overlooked. However, it is unlikely that hte range of now well-accepted strategies would ever have been implemented so early or so vigorously without their sustained and relentless pressure.

The Influence of Advisory Bodies

Part of the explanation for Australia's response lies with the structuring of a series of advisory bodies with participants drawn from medifine and the behavioural sciences, the bureaucracy and community groups. Some members of all of these groups could not ingore the extraordinary opportunity for self-promotion and self-aggrandisement entirely when placed in the spotlight of AIDS. Similarly, some of the community groups with recent memories of longstandign discrimination could not resist the temptation to redress former grievances. However, a system of checks and balances evolved not too dissimilar from the political balance between the executive, legislature and judiciary. AIDS was too important to be left to any of these participating groups; experience has shown that each has been less than omniscient. Exclusion of community groups from policy formulation would undoubtedly have reduced the effectiveness of the exercise although their inclusion has not been without cost. Overall, the balancing of interes

t groups has worked well. The establishment of federal and state parliamentary liaison groups has also fostered a bipartisan approach and forestalled the development of a politically-motivated response to HIV prevention. The AIDS policy arena in Australia has been fortunate to attract an extraordinary range of talented and hard-working individuals. Although conflict has inevitably occurred and often been publicly damaging, a harmonious sense of common purpose has been more characteristic. It is somewhat ironic that the defence against the greatest threat to public health in Australia since federation has relied almost without expection on individuals without a previous commitment to public health.

Attitudes to IDUs

In the mid-1980s at the start of the NCADA, the prevailing public image of drug users was of psychopathic demons. Within a few years, more sympathetic portraits were common with increasing attention directed to the complex nature of drug use and the deficiencies of the treatment system. The concept of drug users as archetypal villains became modificed so that IDUs also came to be seen (in part) as victims. Without this change in image, it would not have been possible to generate public support for some of the more controversial measures required to control HIV infection in this risk group. IDUs are still to some extent demonised in Australia, but the AIDS crisis has not only changed the way governments and individuals act, but also how they think.

The federal government structure in Australia has on occasions been of surprising assistance in the facilitation of change. When relatively enlightened states introduced controverisal policies such as needle ans syringe exchange, more conservative states were drawn along, albeit at a slower pace. The number and range of responsible authorities, so often a barrier to progress in Australia, may actually have contributed to the process of change by providing a multitude of opportunities.

From Knowledge to Behaviour

It is often incorrectly assumed that an improvement in knowledge is a necessary or sufficient precondition for attitudinal change, which in turn must occur before any behavioural change takes place. Reality is unfortunately more complex than this simple paradigm. As in most other developed countries, IDUs in Australia became well informed about the AIDS epidemic relatively early. Evidence of behaviour change is not available in Australia as repeated measurement studies have not been published thus far. There is some Australian evidence to support the growing body of international data suggesting that drug users have correctly perceived that their drug-using colleagues are at considerable risk of HIV infection while assessing that their own individual needle-sharing and sexual practices place them (or their partners) at a low level of risk.

Intersectoral Policy Conflict

Efforts to control the HIV epidemic among IDus frequenlty brought health workers into conflict with staff of other government departments. It is understandable athat members of the police force or correction officers may have different goals and aspirations to health staff, and have accordingly been slower to change their perceptions of IDUs from villains to lynch-pins of an ominous and growin public health threat. As government departments operate relatively independently, is has been difficult to even orgnaise inter-departmental structures to facilitate communication. These difficulties have contributed to delays in revision or repeal of legislation which has slowed the implementation adn reduced the effectiveness of needle- and syringe-exchange programs.

The need to review national drug policies to maximally contain HIV infection has also suffered from the fact that illicit drug use and policy relating to it lies outside the direct responsibilities of the health domain and is perceived as part of the bedrock of society. As in most countries, illicit drug use in Australia is still seen predominantly as the responsibility of law enforcement with health and welfare relegated to second place. Consideration of drug policy within the context of HIV prevention has been no easier than other attempts to introduce rationality into the subject. However, just as control of HIV infection in the general population of most western countries is largley detemined by the effectiveness of efforts to contain infection within IDUs, so too does drug policy occupy a central position within efforts to control HIV infection in IDUs.

Summary

In comparison with other western countries, Australia has a relatively high incidence of AIDS per capita. However, HIV infection in IDUs has occurred later and to a far lesser extent than in many other comparable countries despite the fact that the national epicentre for the epidemic in homosexual/bisexual males geographically overlaps an area also associated with extensive drug use and injecting. To a considerable extent, the containment of HIV infection in IDUs can be explained by the early adoption and vigorous implementation of pragmatic prevention policies. However, it is harder to establish why even controversial policies were so strongly supported in Australia. Undoubtedly, a few key individuals deserve enormous credit for this development although this is neither a necessary nor a sufficient explanation.

Australia has developed procedures for, generally, successfully combining policy formulation and implementation advice from biomedical and behavioural scientists, bureaucrats and community groups. The success in maintaining a politically bipartisan approach has undoubtedly also contributed to the broad base of support for potentially divisive policies. Change has required support for controversial policies from the entire community. Skilful exploitation of direct and indirect media coverage has been a consistent feature in being able to capitalise on the fruits of a recent National Campaign Against Drug Abuse by converting some of the gains and strategies to contain HIV infection in IDUs.

Nevertheless, many factors have delayed and obstructed change including entrenched treatment philosphies, irreconcilable differences in priorities and intersectoral policy conflict. Taken overall, the national success in reducing the spread of HIV infection in IDUs to date must be regarded as the greatest and most important achievement of all of the many efforts in the alcohol and drug area in Australia in the 1980s. Although recognised to some extent nationally, there is still little knowledge of this achievement outside Australia. Even within Australia, this achievement receives surprisingly little attention. It is, regrettably, increasingly assumed that the containment of HIV infection in IDUs in Australia is a permanent arrangement.

In the next decade, the major brurden of HIV infection prevention in this population is likely to fall on drug treatment services. The extent to which drug treatment services are able to attract and retain IDUs in treatment will depend largely on changes in policy and incorporation of research findings. The recent increase in amphetamine consumption by ingestion, inhalation and now also increasingly by injection, is a threatening development that will require energetic and flexible responses. The possibility of controlled availability of currently illicit drugs (including amphetamines) will need to be considered and evaluated to determine whether this may reduce the further spread of HIV infection amont IDus by increasing the attractiveness of treatment.

Although it is inviting to speculate which of the HIV prevention strategies has been responsible for the success to date in containing the spread of HIV infection in IDUs, this is an all bu impossible task. A range of strategies was introduced almost simultaneously. Measurement of the intensity of implementation of strategies is fraught with difficulty. Even if data from repeated measurement studies of risk-taking behaviour were available, prrof of causality is all but impossible. In all likelihood the success of Australia's endeavours to reduce the spread fo HIV infection amond IDUs is due to the multiplicity of compkementary strategies, the prominence given to the subject and the emphasis on this objective by leading figures in the community. Standards of prrof are required for public health interventions relating to IDus that are unattainable in practice, inappropriate for the control a rapidly moving epidemic and result from political rather than public health pressures.

The case study of Australia's response to the thrat of HIV infection in IDus stands as an example of both vision and intrasigence, of both success and failure. After difficult beginnings, much has been achieved. However, at the beginning of the 1990s, evidence of the spread of HIV infection in IDUs from an increasing number of developed and developing countries indicated that "the sky was beginning to fall in" (Wodak and Moss 1990). By international standards there can be little doubt that australia's response has been remarkable. Whether it has been enough, time will tell.