ࡱ> g ;bjbjVV lr<r<=9bbbbb " " "8888888$:S=V8 "  " " "8bb8O,O,O, "Vbb8O, "8O,O,v78F8bP,a])8n880908=+=,F8=F8( " "O, " " " " "88O, " " "9 " " " "= " " " " " " " " " : PART V OTHER SERVICES CHAPTER 19 HEALTH NEEDS AND SERVICES 'It doesn't matter because I'm not particularly worthwhile anyway." ...the state of being that is called homelessness is intricately entwined with the aspect of the individual's well-being that is called health. Solutions proposed to remedy one cannot ignore the other.' INTRODUCTION 19.1 Homeless children and young people are likely to suffer from a range of health problems. These may be traceable to their family background and reasons for leaving home. Incest and domestic violence survivors who become homeless may be injured or suffering the physical scars of their ordeal. They probably continue to bear the psychological and emotional injuries and some may have behavioural disorders and even psychiatric illnesses. 19.2 Evidence presented to the Inquiry clearly established that the lifestyle of the homeless involves a plethora of risks to life and health. These include: malnutrition and other diet-related illnesses;3 skin and respiratory infections from exposure and the lack of adequate accommodation; unwanted pregnancies, venereal diseases4 and AIDS from prostitution; drug and alcohol addictions (and the risk of death from overdoses and of AIDS from sharing of needles); behavioural disorders, the causes of which may lie in the isolation, alienation and rejection of the homeless; psychiatric illnesses; depression and attempted suicide. 19.3 Violence is another lifestyle feature which endangers die health and lives of homeless young people: Young homeless people's inability to have any effective input into decisions which affect their conditions of life...leads to high levels of violence in this group violence which can be directed either outward or inwards. It is in the area of self-harm that it is easiest to see this inward direction of violence and anger. This phenomenon of non-suicidal self-harm is rarely seen in adults, but is characteristic of this group of young people.' There is a very close connection between depression, self-harm and violence.' In this chapter we provide more detail about the actual health status of homeless children and young people and consider whether their needs for health services are currently being met. HEALTH STATUS 19.4 Several witnesses noted the severely detrimental effect which the mere fact of homelessness has on the health of most young people.' For example, in Hobart the Inquiry was told: ...physical and mental health and quality of life and their own expectations of themselves in society deteriorate rapidly as they seek a false independence with very few life skills. What they find is instability and insecurity.' A witness from the A.C.T. Health Authority linked many health problems to a lack of self-esteem: They come in, they have got no self-respect, and that leads to poor hygiene for a start, and more serious forms of self-destructive behaviour.' Other witnesses made the point that the lifestyle of many homeless children and young people is one which involves many health risks.' 19.5 The most comprehensive overview of the health status of homeless young people was provided to the Inquiry by doctors and health workers from the Sydney Area Health Service. In the six months between April 1987 when it opened and October when the Inquiry commenced, the inner city Kirketon Road Centre had seen 750 people, 250 of whom had been 'street kids'." Dr Vicky Pearson described the most common ailments suffered by homeless children and young people seeking assistance at the Centre: ...the most common presentations relate to viral illnesses such as colds, flu, gastroenteritis, glandular fever, hepatitis B. Skin complaints are a frequent reason for attendance, maybe acne, eczema, dermatitis or very commonly infections related to poor nutrition or abscess formation after unskilled needle use.' One thing we have seen very commonly is recurrent and debilitating tonsillitis which is not a condition one sees amongst non-homeless youth... Unwanted pregnancy, surprisingly enough, has not been a common problem to date at our Centre but we believe this probably relates to factors such as no ovulation and amenorrhoea as a result of drug abuse or poor nutrition, rather than the success of educational programs on contraception. Syphilis and gonorrhea are not commonly encountered in our experience in street kids but herpes, chlamidia and hepatitis B are very common. Approximately 85% of girls under 18 attending our Centre have had human papaloma virus wart virus identified on routine pap smears and wart virus is now known to have a very strong association with cervical cancer in the longer term." AIDS 19.6 While AIDS is not yet a common problem, Dr Pearson gave evidence that clients at the Centre were at a very high risk of contracting AIDS 'both through their sexual activity and through predisposition to drug abuse '.'4 O'Connor, reporting the results of his survey of 100 homeless children and young people, similarly stated: The level of drug abuse and their involvement in prostitution also suggests that in the future AIDS may be a major health problem for these young people." 19.7 As this Report was going to press the Chairman of the Inquiry confirmed the disturbing results of an August 1988 survey of over 1,000 homeless children in New York. It was found that between one in 14 and one in 15 homeless children are HIV positive. While the problem of AIDS is more severe in that city than it currently is in any Australian city, the fact is that the lifestyles of the homeless children involved in the New York study closely parallel those of homeless children in Australian cities.I6 We ignore the established similarities particularly those regarding prostitution, high risk sexual behaviour and drug abuse at our peril.' More importantly, if we ignore them, we will be mortgaging the lives of many of our children. 19.8 In Brisbane the Inquiry was told that: The potential health problems arising from poor or no accommodation are enormous. A study into the health of unemployed youth in 1984 found that unemployed young women often have greater difficulty than do males in coping with their unemployment status and with maintaining their health. Sexuality, contraception, pregnancy, substance abuse and nutrition are among the particular health issues of importance to young women.' 19.9 In Adelaide the Second Story Adolescent Health Service presented a statistical break-up of the health problems of 595 young homeless clients (397 females and 198 males) over an eight month period in 1987. Together, these clients presented a total of 887 health and related problems. The major problems presented were: Contraception:17019.2%Psychiatric (depression, insomnia, bulimia, anorexia, others):13315.0%Infections (including upper and lower respiratory tract, urinary tract, gastroenteritis, eye and ear infection, hepatitis):9510.7%Sexually Transmitted Diseases and Related:798.9%Skin Problems:677.6%Drug and Alcohol Problems:495.5%Musculoskeletal:434.8% Another 24 patients presented with trauma, 12 had problems with sexual orientation or identity and 11 raised the problems of sexual abuse or assault.' 19.10 A health service attempting to alleviate the ill-health and to promote the health of homeless children and young people faces a major difficulty in that these children lack self-esteem and are often uninterested in their own well-being. There are other hurdles based on the lifestyle of homelessness and transiency. For example, some conditions will only improve if rest accompanies the treatment. Rest and recuperation are impossible for young people in squats or on the streets." Some homeless youth cannot tolerate the hospital environment, discharging themselves before they are well enough.21 As a result, conditions do not heal and infections recur. Healing of even minor conditions is hindered and even prevented when a young person has no access to running water to clean wounds (and so on) and when living conditions are unhygienic. Specialist care is difficult both to obtain and to afford and many young homeless people are too intimidated to keep an appointment with a specialist. They are also unlikely to be able to afford spectacles, non-routine dental work and other necessary items." Drug and alcohol abuse compound all of these problems. In summary, 'the management of [patients is] greatly impeded by the fact that they are homeless'." PARTICULAR ISSUES 19.11 Other witnesses to the Inquiry expressed particular concern about the capacity of existing youth services to respond appropriately to drug and alcohol addicted and behaviourally disturbed children and young people. As detailed in Chapter 15, Youth Supported Accommodation Program, youth refuges were not established with specialist staff who could provide the range of rehabilitation services, including counselling, psychotherapy and the other supports that are required by young people with drug and alcohol problems and severe emotional disturbances. The latter group, which includes those with diagnosable psychiatric illness' expressed through aggressive and bizarre behaviour, is totally beyond the resources of the youth services sector and requires highly skilled and specialised treatment services." A few specialised services have been established and some of these are described later in this chapter. However, evidence to the Inquiry indicates that many more homeless people are affected in these ways than can be catered for in existing specialist services. Drug and Alcohol Abuse 19.12 In Kings Cross the Inquiry was told: The majority of homeless young people in this inner city area are engaging in drug use of some kind. The types of substance used cover the full spectrum of both illicit and licit psychoactive drugs and includes alcohol, cannabis, tobacco, prescription drugs such as the benzodiazapans, over-the-counter medication such as cough mixtures and motion sickness pills and other illicit drugs such as amphetamines.. .and narcotics such as heroin.. .Often combinations of these drugs are used simultaneously..." A streetwork program in Hobart reported that between 55% and 69% of young homeless people contacted experienced drug and alcohol-related problems." A young women's shelter in Launceston stated that many residents were alcoholics.28 19.13 The A.C.T. Council of Social Service also raised drug and alcohol problems as major issues for homeless youth." In Darwin a refuge worker reported residents as young as 11 to 14 years of age with significant drug and alcohol problems." In North Queensland the Inquiry also received evidence that drug and alcohol abuse were major problems for homeless young people,31 and similar evidence was given in Adelaide," on the Gold Coast 33 and in Perth." 19.14 Drug and alcohol rehabilitation services also reported a high proportion of homeless people among their clients. A Brisbane service reported that one-third of those presenting in 1987 had been homeless and that all 12 residents during November 1987 were homeless." A Hobart service for women noted that a high proportion of younger residents 'have no recognised homes'." 19.15 While one witness suggested that the glamorous image of drugs and alcohol is responsible for substance abuse among homeless children and young people," the majority linked substance abuse to low self-esteem and other issues. There are a number of psychological, developmental and social factors that contribute to drug use. It functions in a very specific way...It relieves emotional and psychological distress. Basically it provides emotional anaesthesia. It can operate to maintain the present-centredness that blocks out the past and it helps avoid thinking about the future. Experimental use of a wide variety of substances is common behaviour...but it also provides excitement and is a form of risk-taking. It operates to prop up a low self-esteem in the short-term through the provision of good feelings and then when the potential damaging effects [become apparent, they] are just not viewed as relevant. 'It doesn't matter because I'm not particularly worthwhile anyway'. Drug use facilitates peer cohesion, sociability and bonding and thereby it decreases the social isolation that they experience. It also alleviates boredom and the monotony of an existence where the individual is cut off from the mainstream society through basic lack of financial resources to participate in it. It provides emotional anaesthesia and disinhibiting effects, thereby allowing prostitution and other means of getting an income to be done a lot more easily. So...drug use can be seen as an integral part of the street lifestyle and it is a response to psychological needs and the social context in which they live." 19.16 This analysis was often echoed in the evidence presented, including that given by one young homeless witness who said: I have found also that [due to] the pressures I was under when I was not living in a house, I did resort to alcohol and drugs, just putting myself in a state virtually of unconsciousness, not knowing, because I didn't want to know... I have a very low self-esteem.., so, through these pressures, I quite often resorted to drugs and ended up becoming an addict and an alcoholic all in one..." Intellectual Disability, Mental Illness and Emotional and Behavioural Disturbances 19.17 As noted in Chapter 10, 鱨վ in the Care of the State, the transfer of many young people with intellectual and psychiatric disabilities from institutional to community care, without adequate preparation or support, has led to many becoming dependent on refuges which are ill-equipped to meet their needs. Emotional and behavioural problems are common. Many refuges presented evidence that they are accommodating young people with very serious problems. 19.18 One refuge summarised its situation by stating that it was attempting to accommodate youth: ...who have suffered from psychoses, chronic depression, violent outbursts, participated in self-mutilation and attempted suicide.4 Many refuge workers reported incidents of attempted suicide by residents." Drug rehabilitation services also noted an increase in residents with psychoses in addition to their addiction.' Both the A.C.T. Council of Social Service and the Victorian Youth Accommodation Coalition stressed the fact that psychoses are increasingly widespread among homeless children and young people." 19.19 It is worth pausing here to note the findings of the only recent and comprehensive study of the health needs of the homeless of which we are aware. That study, conducted by the United States Institute of Medicine under the auspices of the National Academy of Sciences, included in its findings the following conclusion concerning homeless adults and children: Homeless people experience a wide range of illnesses and injuries to an extent that is much greater than that experienced by the population as a whole. First of all, health problems themselves, directly or indirectly, may cause or contribute to a person's becoming or remaining homeless. The leading example is major mental illness, especially schizophrenia, in the absence of treatment facilities and supportive housing arrangements.'" In 1988, the Mental Health Foundation of Australia estimated that 240,000 Australians suffer from major mental illnesses and that three million suffer from some form of mental illness that interferes with their daily lives." While the evidence evaluated by the Inquiry is less exhaustive than that accumulated by the US Institute of Medicine," there is no doubt that many hundreds of our homeless children are suffering an extremely difficult additional burden which often overwhelms them. EXISTING SERVICES 19.20 The Inquiry heard a great deal of evidence to the effect that there are too few drug and alcohol rehabilitation centres and residential therapeutic services for young people with psychiatric disabilities, and that many existing services are not geared to cater for adolescents, particularly those who are homeless and present very complex life situations. Those services which are designed for young people are usually operating at capacity and have to reject many referrals. 19.21 In spite of the fact that such programs would be particularly cost-effective in our larger cities, the Inquiry was told that there are few in such locations at present. For example, there is no residential drug and alcohol rehabilitation facility for young people in Adelaide," Hobart," the A.C.T.," or Wollongong in New South Wales." In Sydney, the Inquiry was told, there is only one program which is prepared to accept people as young as 16, a state of affairs which leaves many of those most vulnerable to drug and alcohol abuse, especially those children in the Kings Cross area, without assistance and almost doomed to addiction and its consequences." 19.22 Country areas are even less well-serviced and young addicts must often wait for a local hospital to commence a program" or move to a capital city. Even then, placement in a residential program can involve a lengthy wait which is especially trying, and dangerous, for homeless young people." 19.23 Similarly, there are few youth-targeted residential programs for those with psycho-social problems.54 In Alice Springs, the Inquiry was told, there are long periods when the town has no psychiatrist and there are very few well-trained psychologists in the welfare field. One small non-government home provides some accommodation, but generally the mildly intellectually, psychologically or physically disabled people in the town including homeless youth are provided with very little care." 19.24 Many witnesses expressed concern for homeless children and young people with intellectual and psychiatric disabilities and behavioural problems whom the youth refuges are unwilling to accept and for whom few, if any, specialist services exist. These particularly vulnerable young people are at very great risk of exploitation and death. Barnardo's Australia submitted that: Welfare services often have a 'filtering effect'. That is, the easier clien'ts are assisted whilst the more behaviourally disturbed (who require more skilled intervention and greater resources) are 'defined out' of services or moved on quickly. Thus the welfare system leaves a group of very troubled young people which no agency will accept as a client. Bamardo's believe that it is these most disturbed young people who are the chronically homeless. They have proved to be beyond the resources of refuges or the child welfare system and eventually end up with nowhere else to seek assistance with accommodation." 19.25 Young people generally do not utilise health services to the extent their representation in the community, even as the most healthy sector, would suggest." Homeless young people with their pervasive and extremely serious health problems are, nevertheless, even less likely to utilise health services both because they lack adult 'sponsors' into the health system and independent information about the availability of services, and because of their alienation from society in general. 19.26 Evidence presented to the Inquiry emphasised that health services for homeless children and young people should incorporate certain characteristics. It was submitted that they need to be: specially targeted to youth needs; non-judgmental; and recognise the complex of needs presented either by offering an integrated service (for example, health care, rehabilitation, living skills training, counselling and accommodation) or by accessing a network of compatible services." O'Connor reported that: The one optimistic feature of the discussion of health problems with homeless youth was that, when there was a health service designed to meet their needs, they were prepared to use it." 19.27 A fundamental aspect of any senstively organised health service for young people is the recognition of their right to information about health issues and services that are available. Dr Tim Smyth, Chief Executive Officer of the Sydney Area Health Service, spelt this out clearly when he submitted to the Inquiry that: The health care need priorities of homeless youth appear to be access to health care services that they trust and that they can relate to, health education, sex education, AIDS, sexually transmissible diseases prevention and counselling, drug and alcohol education and counselling, nutrition and dental care. The health needs are inextricably linked to the social and welfare needs of homeless youth, reinforcing the need for that holistic, intersectional approach. There is a need to develop a two-tiered approach to the health needs of homeless youth. The first by integrating health education into the accommodation, living skills and employment training programs by training the youth workers in the health needs of homeless youth. The second tier is the provision of outreach health services and innovative health centres that reach homeless youth...6 19.28 It has been argued that the health system has neglected the health of young people and has missed the opportunity to inform them in a manner which is appropriate and accessible to them. Yet 'the acquisition of relevant information is a prerequisite to self identification by young people of their...needs and rights '.6' ...those forms of information need to be on an outreach basis. There needs to be some mobility of that information. It needs to be better publicised and it needs to be within the territory of young people. I think it is clear from the feedback we have of health agencies that young people do not come to them in droves; that it is fairly off-putting for them to go into, to find where the information is and then to go through that protocol and process to find it." INNOVATIVE MODELS 19.29 The Inquiry was informed of a small number of health services which are now being developed along the lines set out above. In Adelaide, for example, there are `Shopfront' and 'Second Story'. Second Story Adolescent Health Centre is a general practitioner service targeting homeless young people." Shopfront is a health and information service incorporating a family planning clinic, a drug and alcohol counsellor and a counsellor for young people with psychiatric or behavioural problems.' Shopfront's aims are as follows: Provide a contemporary, innovative and experimental response to the health needs of young people. Facilitate the integration of Health Services for Young People and lobby for such services to be 'available for Young People in the Northern area. Influence the relevance, range and provision of health services for Young People. Promote good health and an awareness of healthy lifestyles. Be an information and resource base for Young People, their parents and those professionals who work with/for Young People. Develop an awareness of the health needs of Young People in the community, as well as at the Local, State and Federal Government levels." 19.30 Among other objectives, Shopfront seeks to provide relationships (including family relationships) counselling, to run groups on self-esteem and development, to provide a family planning service and to work with young people with mental health needs. Shopfront promotes the establishment of a drug and alcohol program in its region and wants to extend its service to accommodation referral, placement and support for young people. Local youth workers are to be trained in health and related issues affecting young people." The Inquiry was also told that Shopfront runs a basic living skills course in the local youth refuge. Shopfront is jointly funded by the South Australian Health Commission (two-thirds) and the local government council (one-third). In addition to Shopfront staff, some services are delivered from its premises by sessional staff from other agencies, including the Service to Youth Council, Family Planning Association, Department for Community Welfare and Department of Social Security. In 1986- 87, Shopfront responded to over 4,000 requests for assistance.' 19.31 The `Kirketon Road Centre' in inner city Sydney is specifically designed to attract homeless young people. It: ...offers a general medical and counselling service in an empathetic environment for young prostitutes, street kids and IV drug users in particular:7' Linked to Kirketon Road are other services: The Albion Street Centre operates an Outreach bus targeted towards male prostitutes, transsexuals and street kids. Funding for this service has recently been expanded to enable it to go from two nights a week to seven nights a week. A nurse and a youth counsellor offer health education, counselling, AIDS screening, STD. ..counselling, needle exchange and condoms free of charge. The bus is based in the Green Park area in Darlinghurst and is supported by street working in the Kings Cross-Darlinghurst area from about eleven o'clock at night." SPECIALIST SERVICES 19.32 Residential programs developed to date appear to focus on either drug and alcohol addiction or behavioural problems. In Chapter 15, Youth Supported Accommodation Program, we mention those few services, two in Queensland and South Australia and one each in New South Wales and Victoria, which cater specifically for emotionally disturbed young people. Most YSAP services, however, try to avoid accepting referrals of young people with addictions or behavioural problems. 19.33 Evidence presented to the Inquiry in all States consistently indicated that youth services and non-government treatment facilities are increasingly being expected to provide services for behaviourally disturbed and psychiatrically ill children and young people. Current policies of deinstitutionalisation of psychiatric services were often cited as a major factor in creating this demand. The youth sector cannot reasonably be expected to undertake responsibility for these young people nor can it do so. It is also clear from evidence presented to the Inquiry that effective State services for young people who are psychiatrically ill would remove a major cause of stress in accommodation services for the homeless, enabling those programs to increase their effectiveness. 19.34 The non-government sector is endeavouring to respond to the special needs of behaviourally disturbed adolescents. This is a field requiring intensive resources since it can take many years to achieve a successful result. One program described to the Inquiry is the Knights Hill Community for Social Healing in the Illawarra region of New South Wales which serves young people aged from 13 to 30 (most residents being 14 to 16 years of age). Residents are accommodated in small family-type homes on the 100 acre property, each of which is managed by house parents. Therapy is provided with the aim of returning the young people to the community to live independently or with minimal support. The therapy focuses on self-esteem and living skills." Evidence was given that many young people are referred by the Department of Family and Community Services from institutions unable to cope with their seriously disturbed condition. The people referred are increasingly aged as young as 11 to 13 and, according to evidence presented, exhibit much more violent behaviour than in the past. Knights Hill is willing to care for such children for three years or more in its intensive program and increasingly finds that the children require this length of stay.74 19.35 Such specialist services can complement State services and need to be encouraged so that there is a broad range of options that can be offered for those with emotional and behavioural problems. Moreover, community-based services could fill important gaps particularly in rural and isolated areas where there is a chronic lack of services in this field. While in-patient treatment services are essential for those who are so disturbed that no other program can assist them, the Inquiry believes close attention should be focused on the few innovative programs which have been introduced around the country. 19.36 While most recent models for specialist residential care of children and young people are community-initiatives, the Inquiry was informed of one such program established by a State welfare department. Originally intended as a diversionary program for young offenders, the Intensive Neighbourhood Care (INC) Scheme in South Australia (described in detail in Chapter 18, Accommodation Services) now also caters for 'teenagers exhibiting serious emotional and behavioural problems who will benefit from living with a family'." Placements are for up to 12 months. INC provides an alternative family environment which enables more intensive individual care to young people, allowing them to maintain some 'normality' in their otherwise often disrupted lifestyle." FINDINGS AND RECOMMENDATIONS 19.37 RECOMMENDATION 19.1. The Inquiry recommends that State and Territory health authorities revise their public health education programs directing particular attention to the wide range of health issues affecting homeless young people. Special attention should be given both to the content and the effectiveness of methods used to communicate this information to young people. Appropriate health education programs should be implemented. This is especially urgent with regard to education programs on AIDS targeted at homeless youth who, on the basis of the available evidence, are at substantially greater risk than other children and young people. 19.38 The needs of homeless children and young people are particularly acute. They will be addressed effectively only by carefully integrated health and medical services. At present only a handful of these exist. If we are to afford children 'special protection' and 'protection from abuse and exploitation', the existing deficiencies must be urgently rectified. RECOMMENDATION 19.2. The Inquiry therefore recommends that State and Territory governments establish specialist multi-service health centres in appropriate locations to serve young people, particularly homeless young people, where these have not already been established. Such services are especially important in capital city 'bright light' areas and also in major tourist venues, such as the Gold Coast, where homeless youth congregate. They should incorporate a range of health, counselling, support and referral services." RECOMMENDATION 193 Streetwork/outreach services are basic requirements in meeting the needs of homeless youth and must, therefore, also be established/expanded. Outreach services are particularly important for homeless children and young people suffering from mental illness, alcoholism or drug abuse." RECOMMENDATION 19.4. A community-based health centre model should be developed for major provincial cities and towns." Local government and local community groups must be involved in adapting such a model if the health needs of homeless children in regional centres are to be met. 1939 RECOMMENDATION 19.5 The Inquiry recommends that State and Territory health authorities urgently revise current policies of deinstitutionalisation to ensure that psychiatrically-ill young people are released into the community with appropriate therapeutic and physical support rather than onto the streets. In addition, where necessary, State and Territory health authorities should ensure an adequate supply of residential specialist therapeutic services for those young people in need of such services. However, these services must not place young people in residential psychiatric units basically geared for geriatric and dementia patients. 19.40 RECOMMENDATION 19.6 The Inquiry recommends that State and Territory health authorities fund specialist, professionally run non-government in-patient and out-patient services (in line with established need) for young people with emotional and behavioural disturbances. The aim should be to provide a broad coverage of services with access for residents in rural and isolated areas. Regional services should be adequate to obviate the need for young people to travel to the capital cities to receive treatment. 19.41 Innovation is critical if we are to provide the range of treatment options that the Inquiry has found to be necessary. RECOMMENDATION 19.7 The Inquiry therefore recommends that State and Territory health authorities review the range of treatment programs available for behaviourally disturbed young people, with a view to increasing the range of programs offered and taking account of the innovative programs currently being developed." 19.42 Evidence presented to the Inquiry clearly established the lack of specialist treatment services for drug and alcohol addicted youth. Drug and/or alcohol abuse are pervasive problems for homeless children and young people which compound their already tenuous existence. Such problems can be intractable and effective responses need to be skilled and intensive. RECOMMENDATION 19.8 The Inquiry therefore recommends that State and Territory health authorities urgently establish and adequately fund specific drug-treatment facilities for young people. These should incorporate both de-toxification programs and ongoing treatment and referral services. 19.43 Apart from those with addictions, other groups of homeless children with special needs must also be targeted if we are to honour our commitment to effectively protect our children. Young women, young people with disabilities, Aboriginal youth and young people from non-English speaking backgrounds often have special problems when it comes to accessing the range of health services that they require. We certainly do not intend that such young people be excluded from mainstream health services or the specialist youth services which we have recommended. On the contrary, their participation and access should be facilitated. However, supplementary, specially-framed responses (including additional outreach services) may be required to achieve this access. RECOMMENDATION 19.9 The Inquiry therefore recommends that all health services for young people take account of the special health care requirements of young women, young people with disabilities, Aboriginal youth and youth from non-English speaking backgrounds. 19.44 Evidence presented to the Inquiry, and our own observations, strongly support an approach to the provision of health care to homeless children and young people which recognises that their needs are multi-dimensional. Youth-targeted health services must therefore be an integral part of a network of services catering for homeless youth. In developing such services, authorities need to be particularly aware of the need for integrated services and the development of networks that can effectively address these extremely diverse needs. RECOMMENDATION 19.10 The Inquiry recommends that State and Territory health authorities should particularly concen- trate on the integration of youth health services with other services for homeless young people. 19.45 Additional information and training is necessary for all those, including many medical professionals, who wish to effectively assist our homeless children and young people. We are referring not only to 'medical' training (although the complexity of health problems with which homeless youth often present make specialised conferences or seminars for those involved useful), but also to training which, though less specialised, is essential if doctors and health workers are to have a comprehensive knowledge of services and facilities already existing in our community as well as the ability to respond effectively to the challenges which homeless youth pose. In the words of the United States Institute of Medicine in its recent report on homelessness and health: Many of the adaptive, creative responses that homeless people develop for coping on the streets may work against their being moved into a domiciled situation. Making such changes and adaptations may be overwhelming and frightening for homeless people to contemplate. Finding the innovative approach to engaging such clients and motivating them to try changes is the ultimate challenge of professionals who work with homeless people. The treatment of health problems is complicated by all the psychological problems experienced by homeless individuals and families. Some clients may be distrustful, rejecting or hostile!' RECOMMENDATION 19.11 As a first step, given the current dimensions of the problem: The Inquiry recommends that the Federal, State and Territory Governments jointly convene a national conference in 1989 on the health needs of the homeless, particularly homeless youth. Notes L. Moore, Bourke Street Drug Advisory Service Sydney, Transcript at 164. US Institute of Medicine (National Academy of Sciences), Homelessness, Health, and Human Needs (National Academy Press, 1988) at 36. This evidence is supported by the 1988 Report of the US Institute of Medicine, id, at 66-67: 'Illnesses such as anemia, malnutrition, and refractory asthma were many times more common among homeless children.' The 1988 Report of the US Institute of Medicine also found that all available US studies on homeless children established that sexually transmitted diseases and pregnancy were greater problems among homeless children than in the general juvenile population: id, at 68. I. O'Connor, 'Most of us have got a lot to say and we know what we are talking about' : 鱨վ's and Young People's Experiences of Homelessness (1988) at 210. Id, at 211. This evidence also finds support in the conclusions of the Report of the US Institute of Medicine. Speaking of the homeless population in general, after reviewing available evidence (including that relating to homeless children), the Report concludes: 'Homeless people experience illnesses and injuries to a much greater extent than does the population as a whole.': op cit. at 139. T. Howe, Youthcare, Anglicare (Tas), Transcript at 1488. P. Dugdale, ACT Health Authority, Transcript at 597. See also, D. Wright, Second Story Adolescent Health Centre Adelaide, Transcript at 1327. M.W. Lee, Chelsea-Springvale Youth Housing Project (Vic), Transcript at 1089; T. Campbell, House 64 Port Hedland (WA), Transcript at 777; D. Wright, Second Story Adolescent Health Centre Adelaide, Transcript at 1326; V. Pearson, Sydney Area Health Service, Transcript at 155. IL K. Swanton, Sydney Area Health Service, Transcript at 148. V. Pearson, Sydney Area Health Service, Transcript at 152-153. Id, at 153-154. Id, at 154. O'Connor, op cit, at 202. See generally, Homelessness, Health, and Human Needs, op cit. See generally, Chapter 5, The Experience of Homelessness, and Chapter 7, The Costs of Youth Homelessness. See also, the study by J. Wolk of the Albion St AIDS Centre in Sydney, reported in 'Drug Users Risk Death by Sharing Needles', 3 Jan 1989 The Australian. Wolk reported that more than 80% of intravenous drug users continue to share needles regularly. 9% of 131 intravenous drug users tested were HIV positive. In surveys conducted in Sydney in 1986 among intravenous drug users, only 1% were HIV positive. C. Penn, Youth Advocacy Centre Brisbane, Transcript at 230. S.103, Second Story Adolescent Health Clinic Adelaide, at 1-2. The Kirketon Road Centre in Sydney, for example, has hospitalised a young person to try to ensure she had somewhere to rest: V. Pearson, Sydney Area Health Service, Transcript at 151. Id, at 150. R. Jowle, Karratha Youth Accommodation Centre (WA), Transcript at 789. V. Pearson, Sydney Area Health Service, Transcript at 157. It is relevant and disturbing to note that in the US, which pursued policies of deinstitutionalisation several years before Australia did, the US Institute of Medicine has reported that, 'Approximately one third of all homeless people show symptoms of mental illness': Homelessness, Health, and Human Needs, op cit, at 96. In its 1988 Report, the US Institute of Medicine, referring to three small studies of homeless children and young people in Boston, New York and Toronto, stated: 'The three studies...each reported on shelter populations. Despite the differences among the study populations, the similarities in the fmdings regarding the physical and mental health needs of this population are even more significant. All three studies reported that supportive services, rather than the provision of housing alone, are needed.': id, at 126. See also, id, at 14. L. Moore, Bourke Street Drug Advisory Service Sydney, Transcript at 162. R. Hughes, Stepping Stone Streetwork Hobart, Transcript at 1465. See also, S.27, Youth Affairs Council (Tas), at 6. B. Jolmson, Karinya Young Women's Shelter Launceston (Tas), Transcript at 1580. E. Lamb, Council of Social Service (ACT), Transcript at 569. A. Buxton, Casey House Darwin, Transcript at 1605. T. Smith, Irmisfail Youth Shelter (Qld), Transcript at 475. S.74, YWCA Adelaide, at 2. J. Blakey, Salvation Army Hostel Southport (Qld), Transcript at 397. S.33, Youth Legal Service (WA). H. Polkinghome, Mirikai Drug Rehabilitation Centre (Qld), Transcript at 356. K. Venn, Caroline House Hobart, Transcript at 1511. R. Hughes, Stepping Stone Streetwork Hobart, Transcript at 1466. L. Moore, Bourke Street Drug Advisory Service Sydney, Transcript at 164. Craig, Transcript at 1219. T. Campbell, House 64 Port Hedland (WA), Transcript at 778. See also C. Crowe, ACT Youth Accommodation Group, Transcript at 518; K. Wilkinson, Whyalla Homeless Youth Project (SA), Transcript at 1435; A. Buxton, Casey House Darwin, Transcript at 1605; S. Bayliss, Cairns Anglican Youth Service (Qld), Transcript at 495; S.14, Gold Coast Life Centre (Qld), at 3; S.108, Sunraysia Youth Accommodation Project Mildura (SA); S.69, Wombat Youth Accommodation Service Adelaide; S.74, YWCA Adelaide, at 2; S.57, Capricornia Youth Shelter Rockhampton (Qld). E. Gray, Central Gippsland Youth Refuge (Vic), Transcript at 1100; L. Wheatman, Cessnock Youth Refuge (NSW), Transcript at 1958; S. Bayliss, Cairns Anglican Youth Service (Qld), Transcript at 495; S.27, Youth Affairs Council (Tas). K. Venn, Caroline House Hobart, Transcript at 1511; H. Polkinghome, Mirikai Drug Rehabilitation Centre (Qld), Transcript at 357. E. Lamb, Council of Social Service (ACT), Transcript at 569; D. Otto, Youth Accommodation Coalition (Vic), Transcript at 908. Homelessness, Health, and Human Needs, op cit, at 68. 'A Leader in Mental Health', 7-8 Jan 1989 The Australian. This study was conducted by the Committee on Health Care for Homeless People of the Institute of Medicine assisted by the National Academy of Sciences and the National Research Council. L. Parkinson, Hindley Street Youth Project Adelaide, Transcript at 1279; J. Phillips, Noarlunga Accommodation Services (SA), Transcript at 1363. R. Hughes, Stepping Stone Streetwork Hobart, Transcript at 1469. I. Boyson, Southside Youth Refuge (ACT), Transcript at 582. N. Clay, Wollongong Youth Refuge (NSW), Transcript at 1799; S.58, Wollongong City Council (NSW). J. Brown, Sydney City Mission, Transcript at 137. M. McGregor, SA Department of Community Welfare Port Augusta, Transcript at 1404; H. Polkinghome, Mirikai Drug Rehabilitation Centre (Qld), Transcript at 361. E. Gray, Central Gippsland Youth Refuge (Vic), Transcript at 1098; G. McLimont, Homeless Persons' Council (Vic), Transcript at 957; J. Brown, Sydney City Mission, Transcript at 140. This was the case, the Inquiry was told, in South Australia: C. Hughes, SA Department of Community Welfare, Transcript at 1408; regional areas of Victoria: S.97, Central Highlands Youth Accommodation Coalition (Vic); the ACT: I. Boyson, Southside Youth Refuge (ACT), Transcript at 582; S.45, Galilee Family Placement Scheme (ACT); regional areas of Western Australia: M. Anderson, Hedland Community Youth Service (WA), Transcript at 828; Newcastle and Wollongong in New South Wales: P. Tynan, Centacare Newcastle (NSW), Transcript at 1917; J. Matters, Illawarra Community Housing Trust (NSW), Transcript at 1814; N. Clay, Wollongong Youth Refuge (NSW), Transcript at 1799; S.58, Wollongong City Council (NSW); Alice Springs: G. Costigan, Anglican Parish Alice Springs (NT), Transcript at 1753; and even in Melbourne: S.73, 鱨վ's Clinic, Vic Health Department. G. Costigan, Anglican Parish Alice Springs (NT), Transcript at 1753-1754. S.64, Bamardo's Australia, at 8. See, eg, S. Robertson, 'Health Needs of the Homeless Adolescent' (August 1988) Patient Management 65, at 66-67; I. O'Connor & A. McMillan, 'Youth, The Law and Health: Emerging Issues in Service Delivery' (1987) 17(2) Queensland Law Society Journal 95, at 100-101; M.W. Lee, Springvale-Chelsea Youth Accommodation Project (Vic), Transcript at 1089. See also, O'Connor and McMillan, op cit, at 104. O'Connor, op cit. at 205. T. Smyth, Sydney Area Health Service, Transcript at 24-26. O'Connor and McMillan, op cit, at 104. K. Walker, Streetwork Project (Vic), Transcript at 984-985. D. Wright, Transcript at 1327. K. Grogan, Shopfront Adelaide, Transcript at 1300. S.119, Shopfront Adelaide, at 1. Id, at 2. K. Grogan, Shopfront Adelaide, Transcript at 1304. Id, at 1300. S.119, Shopfront Adelaide, at 3, 26. Id, at 3. T. Smyth, Sydney Area Health Service, Transcript at 23. Ibid. R. Gemmell, Knights Hill Community for Social Healing (NSW), Transcript at 1832-1833. Id, at 1834. S.120C, South Australian Government, at 9. Ibid. It is, in our view, relevant to note that the US Institute of Medicine, under the auspices of the National Academy of Sciences, recently reached a very similar conclusion - citing, in particular, the need for a 'holistic' and 'multidisciplinary' approach if we are to effectively address the needs of the homeless - including homeless youth: Homelessness, Health, and Human Needs, op cit, at 113. Outreach was one of the key principles identified as central to the success of all programs for the homeless by the US Institute of Medicine, id, at 105, 113. The US Institute of Medicine concluded that, in establishing services for the homeless, structure and administration seem to be most effective when they reflect the individual characteristics of a specific city: id, at 116. The need for a wide range of services was strongly supported as one of the key factors in meeting the needs of the homeless by the US Institute of Medicine, id, at 114-116, 129. Id, at 133-134. 235 236 237 238 240 241 242 243 244 245 246 247 #$=>: L ɷ}jWD3j!hI56B*CJOJQJph%hI56@B*CJOJQJph%h:FN56@B*CJOJQJph%hI56@B*CJOJQJph&h:FN5@B*CJ0OJQJRHnph&hI5@B*CJ0OJQJRHnph"h:FN5@B*CJ#OJQJph"hI5@B*CJ#OJQJphjhZhIUh:FN&h:FN5@B*CJ0OJQJRHnph&hI5@B*CJ0OJQJRHnph$>M Z  |  $Hl]Ha$$H]^a$ g H$H]Ha$ S Hdh$@]@^a$^dd dd ^L M Y Z _ %    { | İ~n`L8~(hIB*CJH*OJQJph&h:FN5@B*CJOJQJRHnph&hI5@B*CJOJQJRHnphh:FNB*CJOJQJphhI@B*CJOJQJphhIB*CJOJQJph&h:FN5@B*CJOJQJRHnphhI@B*CJOJQJph&hI5@B*CJOJQJRHnph&h:FN5@B*CJOJQJRHnph&hI5@B*CJOJQJRHnph%h:FN56@B*CJOJQJph M ^ _  V1񳟏{k[K=KhIB*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJph&h:FN5@B*CJOJQJRHnphhI@B*CJOJQJph&hI5@B*CJOJQJRHnphh:FNB*CJOJQJphhI@B*CJOJQJphhIB*CJH*OJQJphhI@B*CJOJQJphhIB*CJOJQJph01LhϿs_O?/?hI@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph&h:FN5@B*CJOJQJRHnphh|@B*CJOJQJph&hI5@B*CJOJQJRHnph&h:FN5@B*CJOJQJRHnph&hI5@B*CJOJQJRHnphh:FN@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph1iZA   l] ^$ H] ^a$pd[$]p^gd|$a$  $Hl]H H]^$$l]^a$ z Hdhi4YZ`@A߿o_Ko7&h:FN5@B*CJOJQJRHnph&hI5@B*CJOJQJRHnphh:FN@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphA  o?PSxtdTdFd6hI@B*CJOJQJphh:FNB*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphhIB*CJOJQJphhIB*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphjhZhIUh:FNh:FN@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphn!9;:;?@AFϿϿq_M9&hI5@B*CJOJQJRHnph"hI5B*CJOJQJRHnph"h:FN5B*CJOJQJRHnph"hI5B*CJOJQJRHnphh:FNB*CJOJQJphhI@B*CJOJQJphhIB*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph;@(B P!/">"} $If^$pH]p^a$ }$H^$ H] ^a$ 5H^  H] ^ $p]p^a$ x$H^ d^$ l] ^a$ F !m'().Z繁{m[G7hI@B*CJOJQJph&hI5@B*CJOJQJRHnph"hI5B*CJOJQJRHnphh:FNB*CJOJQJphhI@B*CJOJQJphhIB*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJph&hI@B*CJH*OJQJRHxphhI@B*CJOJQJph"h:FN5B*CJOJQJRHnphhI@B*CJOJQJph&'+AB m O!P!!˻˃scUE5hI@B*CJOJQJphh:FN@B*CJOJQJphhIB*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJph"h:FN5B*CJOJQJRHnph&hI5@B*CJOJQJRHnph"hI5B*CJOJQJRHnphh:FN@B*CJOJQJphhI@B*CJOJQJph&hI@B*CJH*OJQJRHxphhI@B*CJOJQJph!"."/"=">"A"B"G"H"I"""""""""#######C#D#F#G#K#L#M#[#\#^#_#o\%hZh:FN@B*CJOJQJph%hZhI@B*CJOJQJph%hZh:FN@B*CJOJQJph%hZhI@B*CJOJQJph hZh:FN!hZh:FNB*CJOJQJph!hZhIB*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphhIB*CJOJQJph$>"B"H"I"""" $If^Xkd$$IfF,U     4 a $If $Z$If]Za$""###} $If$Z$If]Za$$If]^Xkdv$$IfF,U     4 a##D#G#L# $If $Z$If]Za$ $If^Xkd$$If=F,U     4 aL#M#\#_#d# $If $Z$If]Za$ $If^Xkdb$$IfF,U     4 a_#c#d#e#################<$=$C$$ %%ð֬o_OAhIB*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJph"hI5@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphjhZhIUh:FN%hZh:FN@B*CJOJQJph%hZhI@B*CJOJQJph hZh:FN!hZh:FNB*CJOJQJph!hZhIB*CJOJQJphd#e#### $If $Z$If]Za$ $If^Xkd$$IfF,U     4 a##### $If $Z$If]Za$ $If^XkdN$$IfF,U     4 a####=$*)<)q---yjbZH^l^$ H] ^a$ d^$ $] ^a$  ] ^d0Xkd$$IfF,U     4 a %&&& 'k'A(( )))*);)<)B) *n**+,m,,8-p-ͽͽweﭽUGͽhIB*CJOJQJphhI@B*CJOJQJph"hI5@B*CJOJQJph"h:FN5@B*CJOJQJph"hI5@B*CJOJQJph"h:FN5@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJph"hI@B*CJH*OJQJphhI@B*CJOJQJphp-q------}..///0r000ʺxjZJ<,hIB*CJH*OJQJphhIB*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhIB*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJph"h:FN5@B*CJOJQJphhI@B*CJOJQJph"hI5@B*CJOJQJph"hI5@B*CJOJQJph"h:FN5@B*CJOJQJph-/0[233467$::)<|<K>>$^$PH]P^a$^ l]^$H l]H ^a$$Od[$]O^a$gd|$ H] ^a$$ l] ^a$$@ H]@ ^a$000^112 2,2I2K2Z2[2a22"33333ͽ{iYII73h:FN"h:FN5@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJph"hI5@B*CJOJQJph"h:FN5@B*CJOJQJph"hI@B*CJH*OJQJphhIB*CJH*OJQJphhIB*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJph"hI5@B*CJOJQJphh:FN@B*CJOJQJph3339444#555556666778889#:$:°~n^N@^@@^hIB*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJph#hI@B*CJOJQJRHiphhI@B*CJOJQJphhI@B*CJOJQJph"h:FN5@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJph"hI5@B*CJOJQJphjhZhIU$:*:::: ;;(<)<{<|<<<= >J>μ~lZH8(hI@B*CJOJQJphhI@B*CJOJQJph"hI5@B*CJOJQJph"h:FN5@B*CJOJQJph"hI5@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphhIB*CJOJQJphhI@B*CJOJQJph"h:FN5@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJph"hI5@B*CJOJQJphJ>K>Q>>>?/?0?1?2?@m@@@@̺vhXH6"hI5@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphhIB*CJOJQJphh:FN@B*CJOJQJph&hI@B*CJH*OJQJRHxphhI@B*CJOJQJphhI@B*CJOJQJph"h:FN5@B*CJOJQJphhI@B*CJOJQJph"hI5@B*CJOJQJph"h:FN5@B*CJOJQJph>2?@BCEEEEGLJwKlM{$ @$] ^@a$ $ @] ^@a$$ @H] ^@a$ @d^@  @] ^@$Ha$$H H]H ^a$$P$]P^a$$Pl]P^a$ H H]H ^ @AAABBBRCCCCjk}~= aˁ́윰t؜`N<"h:FN5B*CJOJQJRHiph"hI5B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiphI:;TUo6@AGİxİtiUA1hI@B*CJOJQJph&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiphjhZhIUh:FN&hI5@B*CJOJQJRHiph"h:FN5B*CJOJQJRHiph"hI5B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiphц҆0fɵyeQ=-hI@B*CJOJQJph&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiphhIB*CJOJQJph ҆j~~|$$l]^a$ & F hl]^` dH^$$]^a$ d$^ $]^a$$ & F  l]^`a$ dH^ fΈ4ij}~މ4S͹kWC3#hI@B*CJOJQJphhI@B*CJOJQJph&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph"hI5B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiphhIB*CJOJQJphhI@B*CJOJQJph SWϻkWC/&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiphhI@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJph &!߿oaM9%&hI5@ B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiphhIB*CJOJQJph&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiph&hI5@B*CJOJQJRHiph&h:FN5@B*CJOJQJRHiphhI@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJph ߑzMuҖ ϿϿp`PB0"hI5@B*CJOJQJphh:FNB*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphhIB*CJOJQJphjhZhIUh:FN&h:FN5@ B*CJOJQJRHiphhIB*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphhI@ B*CJOJQJph I Sؘp$ `H] ^`a$ & F   H] ^` & F  ^`Bdd[$^BgdZ$ & F  0p0$]p^0`a$ & F  X8l^8 8dl^8 $h ]h ^a$ HI @KRSʺܺscQcA3hIB*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJph&h:FN5@B*CJ#OJQJRHiph&hI5@B*CJ#OJQJRHiphjhZhIUh:FNh:FN5B*CJOJQJphhI5B*CJOJQJph"h:FN5@B*CJOJQJph"hI5@B*CJOJQJph"h:FN5@B*CJOJQJphĘטؘ'+P)Ě-IWX\cd`ӜۜҴҢҒp^NhI@B*CJOJQJph"h:FN6@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FNB*CJOJQJphhI@B*CJOJQJphhIB*CJOJQJphhI6B*CJOJQJphXd;ldP & F hH^`@$^@$ & F   H] ^`a$ & F   H] ^`$ & F  H^`a$$ & F   $] ^`a$ & F  l^` & F   $] ^`>I!4oz$/:;?Jͽyyk[kM͙h:FNB*CJOJQJphhI6B*CJOJQJphhIB*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJph"hI6@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJph;KWq)4oѦ & F hH^` & F h $] ^`$ & F hH^`a$$ & F h H] ^`a$ & F hH^JKOVWaipqסxhXH8hI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@ B*CJOJQJph"hI6@ B*CJOJQJphhI@ B*CJOJQJphhI@B*CJOJQJph"hI6@B*CJOJQJph"h:FN6@B*CJOJQJphס()΢٢!,34\jnohξ|l^Nξ<^"hI6@B*CJOJQJphh:FN6B*CJOJQJphhIB*CJOJQJphhI6B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJph"hI6@B*CJOJQJphh|.ƦʦЦѦGRo_M_=9h:FNh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphhIB*CJOJQJphh:FNB*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphP YΩ2W$ & F hH]^`a$ & F h8H^8 & F h8$^8 & F h^`$ & F hH^`a$̧קߧ <GOPy٨²n^N>h:FN@ B*CJOJQJphhI@ B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphjhZhIU FQXYyũͩΩϽϭ{kYkIϽϭ9hI@ B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJph)12[f$^iVWĬϬ ξzjXjF6hI@B*CJOJQJph"hI6@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJph"hI6@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@ B*CJOJQJphhI@ B*CJOJQJph"hI6@ B*CJOJQJph >?_m+69=>mst~l\J"hI6@B*CJOJQJphhI@B*CJOJQJph"h:FN6@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhIB*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJph"hI6@B*CJOJQJphW?>th:vװ ^$ & F hH]^`a$ & F h$]^` & F h$^` & F hH^` & F hH]^`(gh߯&19:cnuvϿϭߛߋ{i{Y{i{YI7"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJph"hI6@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphְװ GRױ$KV]Ͻϭ{m]mK;K;hI@B*CJOJQJph"hI6@B*CJOJQJphhI6B*CJOJQJphhIB*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJph]^ʲղزKitó fqdo}}}m]K]"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphhIB*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FNB*CJOJQJph *ӷ5qø! & F h@H^@ & F h@$^@ & F h^`$ & F hH ^`a$$ & F hH]^`a$$ & F hH^`a$ )*y"r}Ͽ}m}m]M;M"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJph"hI6@B*CJOJQJphhI6B*CJOJQJphhIB*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@ B*CJOJQJphhI@ B*CJOJQJphh:FN@B*CJOJQJph÷˷ҷӷ %-45ZepqtоЮ|lZlJ|8#hI@B*CJOJQJRHiphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN@ B*CJOJQJph"hI6@ B*CJOJQJphhI@ B*CJOJQJphjhZhIUh:FNh:FN@B*CJOJQJpht|¸ø  !%-.RSW\]˻yggWGgh:FN@B*CJOJQJphhI@B*CJOJQJph"h:FN6@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJph#h:FN@B*CJOJQJRHiph"hI6@B*CJOJQJphhI@B*CJOJQJph!.S])/[;~ & F h $] ^` & F h H] ^`$ & F h H] ^`a$ & F h@dH^@ & F h@dl^@ & F h@H^@ ]ع()./ͽ{m]M=mhI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphhIB*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJphh:FN6B*CJOJQJphhI6B*CJOJQJphh:FN@B*CJOJQJph"hI6@B*CJOJQJphhI@B*CJOJQJph=JNZ[ۼ/3:;ؽܽξޮ޾Ό~n\JF\JFhI"h:FN5B*CJOJQJRHnph"hI5B*CJOJQJRHnphh:FN6B*CJOJQJphhIB*CJOJQJphhI6B*CJOJQJph"hI6@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJphh:FN@B*CJOJQJphhI@B*CJOJQJph"hI6@B*CJOJQJph d -& +D̀d-,& +D€^d-<,&+DȀ^p#d-,& +Dǀ^p#d7,&+DȀ^d {0 & +DҀ & F hH^`   #$%()*-ܮ܊x܊xhXHhI5B*CJOJQJphh:FN5B*CJOJQJphhI5B*CJOJQJph"h:FN5B*CJOJQJRHiph"hI5B*CJOJQJRHiph"h:FN5B*CJOJQJRHnph"hI5B*CJOJQJRHnphh:FNB*CJOJQJphhIB*CJOJQJphhIh:FN5B*CJOJQJphhI5B*CJOJQJph $%)*./3489:; & F hH^`"d-<-& +D^"d-<-& +D^"d*6<-&+D^"dE-,& +DĀ^(#d 9(&+D^(#$dL-& +D΀a$-./23478:;h:FN6B*CJOJQJphh:FNB*CJOJQJRHiphhIB*CJOJQJRHiphhIh:FN5B*CJOJQJph (. A!"#$,% + 0. A!Z" #$,% (. A!X"f#$% (. A!"# $ % (. A!"# $% (. A!"#$_% 21+:p|. A!"#$% 21+:pZ. A!"#$% 21+:pZ. A!"#$% (. A!"0# $% (. A!"# $% (. A!P"# $ % (. A!*"#$ % 21+:pZ. A!"#$% (. A!*"#2$ % t$$If!vh#v#vU#v :V ,55U5 / 44 t$$If!vh#v#vU#v :V ,55U5 / 44 t$$If!vh#v#vU#v :V =,55U5 / 44 t$$If!vh#v#vU#v :V ,55U5 / 44 t$$If!vh#v#vU#v :V ,55U5 / 44 t$$If!vh#v#vU#v :V ,55U5 / 44 t$$If!vh#v#vU#v :V ,55U5 / 44 j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  #(-27<;930-# #(-27<?  +=M\Gn}; j *j Wj j j j j 3k gk k k k l Cl wl L hAF!_#%p-03$:J>@E9""#L#d###->lM5WTb}y;W!;aeimnoprstw|L::# @9`(   9 V _x0000_s0"`  3 < 3"`  0 < "`  - < 3"`  # < "`   < "`   < "`   < 3"`   <  "`     <  3"`     <  "`     <  "`   6B   g B S  ? +M\\Gn};9 {0*M1T@370K8J@0-,.T@--</<J@#-,|.T@ -{&.T@'6*tL-.T@ 9,9J@E-<-.T@*6f1`7J@-<-.T@-<-.T@N W  P R EP!*np!!""##J$U$q$|$&&''++----Z.c.0 1c4n455\6f6H>O>EEFF.G6GTGaGKHTHtI{IjJqJdKnK5L>LLLNNN'NNNP!PBPMPhRoRSS`TjT`ViVVVRW\WcWmWWWWWrZ{ZZZU[^[\\\\`]i]^^g^^^0_;___````a"a{aaaanbybccddeeg"gFgSg5h>hk"kllhouop"puu>wIw~wwxxyy3zIz6}A}TaHT :D!&Ɋ&1&dg37-5^j՛ܝ4>Ɵɟܠ֠#Ȣ07ݣڣȣϣ٤Ϥդۤ9<vhkv}=C^ikr©CIDIKT6>­ʭ/1(+ʰӰ5>9<|1 3 A C glPV""J'L'j'l'22II5L>L_QR\\__a"a\upuw xxx}}ʔҔΚؚƟɟ9<˯9<33333333333333333333333333333333333333 ++==MM\\HnHn}}<z L{yaD>/I4> (U9V : Q*X"b-*'h^7@B*CJH*OJQJRHdphsH .* ^57@B*CJH*OJQJRHiphsH  'h^7@B*CJH*OJQJRHdphsH .' ^7@B*CJH*OJQJRHdphsH .;'h^7@ B*CJH*OJQJRHdphsH .' ^7@B*CJH*OJQJRHdphsH .'h^7@B*CJH*OJQJRHdphsH ' ^7@B*CJH*OJQJRHdphsH  : Q"byaI4(U9z I:FNZ|@;X@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7. [ @Verdana5. .[`)Tahoma7.@ CalibriACambria Math"qh)Ԛ\J2]J!*220ܵCHX $P:FN2!xx  David Mason David Mason,        Oh+'0$ px    David Mason Normal.dotm David Mason2Microsoft Office Word@F#@Y]@Y])Ԛ՜.+,0 hp  $鱨վJ\  Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry F a]Data 1Table=WordDocumentlSummaryInformation(DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q