Volume 167 Issue 11

MJA: Guest - Special pleading at Kyoto Special pleading at Kyoto Australia's economic argument on greenhouse gases is a health hazard MJA 1997; 167: 567-568 Global climate change reflects the major social and economic issues of our time. Poverty, population growth, unequal consumption of resources, energy production, the growth of cities and industries, and agricultural and food practices all now affect global ecology, and ecological changes, including the influences of greenhouse gas emissions on climate, will have adverse effects on the health of human beings.1,2 As major advisers on health matters, medical professionals should stay informed about the status of current negotiations in Kyoto about reducing greenhouse gas emissions. Australia was one of the first countries to ratify the Framework Convention on Climate Change in 1992, adopted at the Earth Summit in Rio de Janeiro.3 Only general principles were agreed, leaving specific targets for reduction of greenhouse gas emissions to be negotiated at future meetings of the treaty parties. The Australian Government has threatened to walk away from negotiations to set binding uniform emissions targets in Kyoto this month,4 arguing that Australia's economic interest in protecting our fossil fuel industry requires a policy of "differentiation" or non-uniform targets. While the Australian Government notes "that the balance of evidence suggests a discernible human influence on global climate",5 thus accepting that there is a problem, its solution remains a matter of international disagreement. According to our Ministry for the Environment, "differentiation" is intended to produce a "fair, achievable and therefore environmentally effective outcome. Uniform targets [for limits to greenhouse gas emissions] are flawed because they are unrealistic and impose different economic costs".6 It is possible that a form of "differentiation" could be equitable. Indeed, the 1992 climate change convention itself raises the possibility of different targets for developed and developing countries. The problem with the Australian position is its narrow focus on economic considerations. The Government has sought a balance between the threat of climate change and "the significant economic costs that will affect some countries far more than others". 6 Australia's arguments have alienated the United States, the European Union and Japan. More importantly, this stance downplays the threat to life on this planet. Although much of the pollution that has contributed to global climate change has been produced by developed countries, it is likely that the worst consequences will be felt by Third World nations and by future generations. The lack of resources to stem flooding and to adapt agricultural practices to climate change will increase the human vulnera bility that accompanies the exponential growth of poorly housed populations with inadequate infrastructure for health services. International cooperation will be needed to understand and prevent adverse health effects of global climate change, such as increased morbidity and mortality from a greater frequency of heatwaves and drought, and changes in the distribution, incidence and severity of vectorborne diseases.1,2,7 The role of public health research in this area is to provide forecasts of major consequences to inform pre-emptive policymaking.8 In our region, studies of climate-related arboviral diseases are under way,9 and projections of the numbers of heat-related deaths expected with global warming in Australian coastal cities are available.10 However, a health-based argument cannot and should not rest on local data. It is concern for human health worldwide, with the possibility of problems escalating over coming decades, that justifies setting serious greenhouse gas emission targets in Kyoto. The optimism that followed the Earth Summit in Rio de Janeiro in 1992 has degenerated into a "babble of diplomatic doubletalk".11 The effort of the fossil fuel industry and other lobby groups to delay the setting of mandatory emission targets for developed countries beyond 2000 has been a perverse success. The climate change convention can only become effective at Kyoto if wealthy nations like Australia are active partners to any agreement reached. We need global action. The Canadian Medical Association has called on its federal government to reaffirm a position for achieving reductions in greenhouse gas emissions (Emeritus Professor John Last, University of Ottawa, personal communication). The Australian Medical Association could follow this example, thus adding to its significant role in the debate about global environmental matters in recent years.12,13 The (American) Institute of Medicine identifies three requirements for promoting participation in international health matters by developed nations, namely "protecting our people, enhancing our economy and advancing our international interests".14 However, unless more countries can meet those aims simultaneously, we are all likely to be losers in the climate change stakes.15 In the game of global sustainability, all nations are ultimately on the same side. In considering long-term policies across government sectors that will affect climate and health, we have to face the reality of "our common future", which for some has become merely a clichŽ.16 The Australian Government's position on "differentiation" arises from its wish to pay less for contributing to pollution, and from ignoring the "polluter pays" principle. "Differentiation" on economic grounds, as Australia would have it, may imply that countries with the highest emissions would be required to do the least to reduce them, while countries that have already done most to reduce their emissions could be required to do more.4 Regardless of whether the Australian Government's approach survives at Kyoto in the present state of uncertainty about the effects of climate change, the "precautionary principle" should apply. In the context of environmental conservation, the precautionary principle recognises the existence of uncertainty and ignorance, accepts that uncertainty should not be used as an excuse for doing nothing, and shifts the onus of proof away from opponents to proponents, who must demonstrate that, to a very high degree of probability, a project will not cause significant harm to the environment.17 Anticipatory and preventive actions are also central to this principle. Precautionary measures aimed at reducing greenhouse warming would soon demonstrate benefits for public health. For example, reduced use of private motor vehicles would bring immediate health gains (such as reduced air pollution and increased fitness). In turn, less air pollution would reduce health hazards from inadequate water quality (acid precipitation).1 It is also possible that economic benefits would accompany increased efficiency of energy consumption, an area that needs research and development.18 Concentrating on the economy without ensuring the health of human populations does not make sense. Rather than taking a narrow, short term view of national self-interest, Australia should play a major part in international agreements and action to abate greenhouse gas emissions. Adaptation, or learning to live with climate change in the future, must not be considered an alternative to reducing the causes now. Charles Guest Senior Fellow, National Centre for Epidemiology and Population Health Australian National University, Canberra, ACT McMichael AJ, Haines A, Slooff R, Kovats S, editors. Climate change and human health: An assessment prepared by a Task Group on behalf of the World Health Organization, the World Meteorological Organization and the United Nations Environment Programme. Geneva: World Health Organization, 1996. Jackson EK, Guest CS, Woodward AJ. Climate, health and medicine in a changing world. Med J Aust 1996; 165: 597-598. Taplin R. Greenhouse: an overview of Australian policy and practice. Aust J Environmental Management 1994; 1: 142-155. Hamilton C. Climate change policies in Australia. Canberra: The Australia Institute, 1997: 3. Office of the Minister for the Environment. The global warming challenge: Australia. Canberra, Parliament House, July 1997. Hill, Senator The Hon. R. The greenhouse challenge -- its role in addressing climate change issues. Address to Minerals Council Conference, Adelaide. 13 October 1997. McMichael AJ, Haines A. Global climate change: the potential impacts on human health. BMJ 1997; 315: 805-809. Haines A, McMichael AJ. Climate change and health: implications for research monitoring and policy. BMJ 1997; 870-874. Lindsay M, Mackenzie J. Vector-borne viral diseases and climate change in the Australasian region: major concerns and the public health response. In: Curson P, Guest C, Jackson E, editors. Climate change and human health in the Asia-Pacific region. Canberra: Australian Medical Association. In press. Guest CS. Climate change and human health: global and regional perspectives. In: National Academies' Forum (Farquhar G, chair). Australians and our changing climate. Canberra: Australian Academy of Science, 1997: 48-50. Gelbspan R. The heat is on. The high stakes battle over earth's threatened climate. Reading, Mass.: Addison-Wesley, 1997: 112. Arnold P, editor. Our health -- our environment: a national stocktake. Canberra: Australian Medical Association, 1995. Weedon D, on behalf of the Australian Medical Association. Climate change: a perspective from the medical community. Submission to the 1996 Major Review of the Greenhouse Response Strategy. Canberra: Australian Medical Association, 1996. Institute of Medicine. America's vital interest in global health. Washington: National Academy Press, 1997. Woodward A. Climate change and human health: the vulnerability of the Asia-Pacific. In: Curson P, Guest C, Jackson E, editors. Climate change and human health in the Asia-Pacific region. Canberra: Australian Medical Association. In press. McMichael AJ, Hales S. Global health promotion: looking back to the future. Aust N Z J Public Health 1997; 21: 425-428. Diesendorf M. Principles of ecological sustainability. In: Diesendorf M, Hamilton C, editors. Human ecology, human economy. St Leonards: Allen & Unwin, 1997: 64-97. Wilkenfeld G. Greenhouse gas emissions from the Australian energy system: the impact of energy efficiency and substitution. Canberra: Report to the Energy Research and Development Corporation, 1991. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Charles Guest

Cloning: potential benefits for human medicine Of babies, lambs, medicine and milk MJA 1997; 167: 568-569 Recent developments in cloning of animal cells (such as the creation of the lamb "Dolly")1,2 and the consequent ban by President Clinton on cloning humans in the United States3 have stimulated much discussion of the merits and ethics of cloning. Indeed, a number of countries (e.g., Germany and Denmark) and Australian States (e.g., Victoria) ban all forms of cloning in human reproductive medicine by legislation or regulation. The most publicised advance in cloning attended the birth of Dolly, a lamb created from a ewe's mammary cell.2 This achievement showed that completely differentiated cells (both fetal and adult) may be reprogrammed to return to multipotential embryonic cells. This is done by inducing a quiescent state (G 0 phase of the cell cycle) in the somatic cell and then fusing it with the enucleated cytoplasm of a mature egg (Figure 1). The fused product then acts as an embryo and develops according to a preset maternal program rather than as the original somatic cell. At present, the procedure is relatively inefficient and confined to ruminant species (sheep and cattle).1,2,4,5 It is unsuccessful in rodents,6,7 which have been the model for understanding mammalian cell differentiation and tissue formation. It is not known if humans fit the ruminant or rodent model, although the recent births of rhesus monkeys derived from embryonic cells (Dr D Wolf, Senior Research Scientist, Oregon Regional Primate Research Center, Beaverton, Oregon, US, personal communication) suggest the former. This finding has major implications for medicine and agriculture, as it opens the way to use differentiated somatic cells as vectors for genetic engineering to produce transgenic animals and for gene therapy. Considerable research on developing such vectors has focused on embryonic stem (ES) cells. Rodent ES cells have been widely used for determining gene function, as they can be manipulated to "knock out" or upregulate genes or to introduce foreign genes.8 ES cells combined with early embryos contribute to all body tissues during development, including gonadal germ cells. When bred, the resulting animals transmit the ES cell genotype, allowing the effects of the gene manipulations to be analysed. It would be even more efficient to genetically manipulate somatic cells of sheep or cattle in culture and to use these cells for cloning 2 (Figure 2). Offspring would probably always have the desired transgene. This could code for a human protein used to treat or prevent disease (such as factor VIII and interferon), and large quantities of the protein could be produced in the animal's milk under the control of specific promoters. As proteins can be isolated from milk relatively simply, this might be an extremely cheap and efficient way to produce large quantities of human or animal pharmaceuticals. It might also be very competitive with present methods of producing recombinant proteins (e.g., from bacterial, yeast and mammalian cell lines). When one considers the cost and problems of producing antiviral drugs as well as proteins for immunisation and therapy (e.g., for haemophilia, HIV infection and multiple sclerosis), the potential for pharmaceutical production in cattle becomes economically attractive. Australia has a unique position for developing this biotechnology as our sheep and cattle are relatively disease-free. What might be other benefits of the recent advances? The search for human multipotential cells as vectors for gene therapy and as universal transplantation cells for correcting abnormal tissue function or tissue damage in humans has also focused on ES cells. 9 These have been derived from the embryonic inner cell mass,10 undifferentiated gonadal cells (GS cells),11 and stem cells which form specific tissues.12 Progress on producing these cells has been limited, although a rhesus monkey ES cell line was recently produced.13 However, ES cells may still be recognised as foreign and be rejected by the recipient. Cloning a patient's somatic cells could be a way of producing multipotential cells that are genetically identical to those of the patient and therefore not subject to rejection (Figure 3). These cells might be ideal vectors for gene therapy, but would also need to be clonally stable and to produce the cell type needed for transplantation, which requires considerable further research. These potential benefits of cloning are often ignored in the debate about its use for human reproduction. Yet, cloning could not reproduce an individual with the same attitudes, beliefs and behaviour as the original person because of the predominant influence of non-genetic factors in human development.14 While no real objection is raised to identical twins produced by natural conception, or even as a result of in-vitro fertilisation, cloning of individuals from somatic cells has no biological or social merit and in this context is unethical. However, we should not lose the substantial benefits of other applications of cloning technology in the regulatory and legislative processes, and moratoriums should not impede progress to achieve these benefits. Alan O Trounson Professor, Institute of Reproduction and Development, Monash University Monash Medical Centre, Melbourne, Victoria Campbell NHS, McWhir J, Richie WA, et al. Sheep cloned by nuclear transfer from a cultured cell line. Nature 1996; 380: 64-66. Wilmut I, Schnieke AE, McWhir J, et al. Viable offspring derived from fetal and adult mammalian cells. Nature 1997; 385: 810-813. Gorman C. To ban or not to ban? Time 1997; June 16: 66. Willadsen SM. Nuclear transplantation in sheep embryos. Nature 1986; 320: 63-65. Tatham BG, Dowsing AT, Trounson AO. Enucleation by centrifugation of in vitro matured bovine oocytes for use in nuclear transfer. Biol Reprod 1995; 53: 1088-1094. Surani MAH, Barton SC, Norris ML. Experimental reconstruction of mouse eggs and embryos: an analysis of mammalian development. Biol Reprod 1987; 36: 1-16. McGrath J, Solter D. Nuclear transplantation in the mouse by microsurgery and cell fusion. Science 1983; 220: 1300-1302. Joyner A. Gene targeting and gene trap screens using embryonic stem cells: new approaches to mammalian development. Bioessays 1991; 13: 649-656. Trounson A. Research on the development of human embryonic stem cells. Sing J Obstet Gynaecol 1994; 25: 245. Pedersen RA. Studies on in vitro differentiation with embryonic stem cells. Reprod Fertil Develop 1994; 6: 543-552. Travis J. Human embryonic stem cells found? Science News 1997; 152: 36. PrŸmmer O, Fliedner TM. The fetal liver as an alternative stem cell source for hemolymphopoietic reconstitution. Int J Cell Cloning 1986; 4: 237-249. Thompson JA, Kalishman J, Golos TG, et al. Isolation of a primate embryonic stem cell line. Proc Natl Acad Sci USA 1995; 92: 7844-7848. Machin GA. Some causes of genotypic and phenotypic discordance in monozygotic twin pairs. Am J Med Genet 1996; 61: 216-228. Reprints: Professor A O Trounson, Institute of Reproduction and Development, Level 5, 246 Clayton Road, Clayton, VIC 3168. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Alan O Trounson

Medicine, modernism and after: a new role model for the doctor? "Everyone has something to contribute to the truth . . ." Aristotle 1 MJA 1997; 167: 570-571 Mainstream philosophy, which is characterised by the philosophical ideas of the Enlightenment, has been strongly criticised in the past 30 years or so for being too "rational" and too "empirical". Its critics have insisted that the basis for knowledge is much less secure than these schools of philosophy, which include logical positivism and scientific realism, would have us believe.2 Side by side with this critique, there has developed a critique of the North-West European (specifically, Scandinavian) Welfare State, which has been called a modernist attempt to achieve the "good life" or a "good society" by rational, empirical means, such as equal distribution of goods meeting "basic human needs". The Welfare State has been characterised as the welfare expression of one kind of economic rationalism. The most radical of "postmodern" critics, however, claim that the rationalist project has failed. We cannot even define things like "truth", let alone legislate to achieve "the good", says this line of argument: everything has to be determined by discourse among local communities; it is up to the individual citizen to decide how to live his or her life; one claim is as good as another -- relativism rules. This negative critique has been directed at the State in general, under the ideological motto "Less State, more community". Combatants in politics and political philosophy should learn, however, from combatants in branches of philosophy, particularly the philosophy of science. They have had to learn the dangers of throwing out the baby with the bath water. Thus, it has not been possible to jettison concepts of truth and rationality, but it has been necessary to repolish them and repair the damage done by the critiques.3 It is true that the institutions of the Welfare State have become paternalistic, have suppressed the autonomy of citizens and neglected the diversity of perspectives and values within pluralistic societies. There is no doubt that all this should be opposed. But there is little reason to think that nations will benefit from dismantling State institutions, and replacing them with entrepreneurial services operating within the marketplace. What is needed instead is a radical understanding and disclosure of the mechanisms which have sometimes made the State a controller rather than a system promoting human well-being.4-6 Instead, critics have claimed that a dangerous symbiosis has developed between paternalistic welfare systems and irresponsible citizens, who perceive opportunities to accumulate wealth by exploiting the system. There is, however, absolutely no reason to believe that a politics which defends the rights of citizens and which provides necessary services should in any way undermine human autonomy. Equally, there is no reason to believe that people living in local communities without State interference would be any more responsible than citizens in a State devoted to providing security and opportunities. The "Less State, more community" catchcry assumes that the Welfare State has systematically corrupted its citizens. There is little evidence to support this claim. The German philosopher Hegel argued that there were strong reasons to believe that the activities of the State were perfectly compatible with the development of autonomy, 7 and there is no reason to doubt that he was right. Hegel claimed that the modern idea of the self-conscious individual, with ideas of freedom and autonomy, is based on the presupposition of a social structure, with institutions that included social and public services. To put this in a European context: what makes a Danish citizen a Dane is his or her being part of a society where institutions of social justice have been created, in which it would not in principle be accepted that any individual in that society should fall by the wayside, and that everything possible should be done to allow individuals and groups to flourish. It is not the citizenry that is in decline. The decline is in politics and politicians. It is the gradual destruction of the political institutions built over the past century or so that undermines individual autonomy and social cohesion, and diminishes the notion of social justice. Has medicine a part to play in reconstructing the performance of the body politic and a respect for politicians? To begin, it might need to broaden its view of its knowledge base, taking a more generous view of the truths that come to it from outside its very reductionist science. Its concern with human welfare would then start to look rather like the avowed concerns of the Welfare State. However, there may be a more direct role for medicine. From at least the time of Aristotle, Western medicine has inherited the idea of an analogy between medicine and politics. Both have practical goals: medicine, the health of the patient; politics, the conditions for human security and well- being. They are both (or should be) responsive to the individual. In medicine, there is a perceived inequality of power between the doctor as expert and the patient as supplicant. The person of practical wisdom (the ideal politician), on the other hand, "engages you actively in the 'treatment', taking your view of things as seriously as his own; he leads you on through the interchange of calm and clarifying argument to what he hopes will be an articulated picture of the good".8 In an age when politicians and planners often do not live up to this model, medicine might try to realise an even closer analogy between the doctor and the person of practical wisdom than Aristotle thought possible. Medicine might play a role in redeveloping the Welfare State as a system realising the Aristotelian ideal that "everyone has something to contribute to the truth . . .".1 We are left with two final questions, which are also challenges. Do doctors in general have the capabilities needed to act according to this ideal of practical wisdom? And, if not, how should medical education be changed to legitimate and encourage these capabilities? Uffe Juul Jensen Professor, Department of Philosophy University of Århus, Århus, Denmark Aristotle. The ethics of Aristotle: the Nichomachean ethics. London: Penguin, 1976. Rorty R. Philosophy and the mirror of nature. Princeton, NJ: Princeton University Press, 1979. Putnam H. Reason, truth and history. Cambridge: Cambridge University Press, 1980. Jensen UJ. Practice and progress -- a theory for the modern healthcare system. London: Blackwell Scientific Publications, 1987. Jensen UJ, Mooney G. Changing values: autonomy and paternalism in medicine and health care. In: Jensen UJ, Mooney G, editors. Changing values in medical and health care decision making. New York: John Wiley and Sons, 1991: 1-15. Jensen UJ. The year 2017: a revolution for democracy? The future of general practice in Europe. Copenhagen: European Union of General Practitioners, 1992: 18-24. Hegel G. The philosophy of right. Oxford: Oxford University Press, 1952. Nussbaum MC. The therapy of desire -- theory and practice in the Hellenistic era. Princeton, NJ: Princeton University Press, 1996. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Medical information and the World Wide Web Separating the signal from the noise MJA 1997; 167: 571-572 Ideally, the practice of medicine in Australia should combine the best of scientific medicine and the traditions of Sir William Osler, the pre-eminent physician of the turn of the century. The art of Osler's medical practice was to foster a personal relationship based on trust and confidence and make this relationship intrinsic to the therapeutic process.1Before the explosion of biomedical knowledge and technology, the communication of clinical information was not central to this patient-doctor relationship. The generation whose expectations were shaped by the Depression and World War II tended to respect the medical system and to follow doctors' orders without actively pursuing or questioning health matters.2 In stark contrast is the unquenchable thirst of the "baby boomers" for medical information. Their assertive consumerism and aggressive pursuit of information and choice2 has been accompanied by an explosion of mass media medical information. With this societal paradigm shift, the provision of clinical information is now integral to building trust and confidence in the patient-doctor relationship; in fact, the Consumer Health Forum of Australia recently reported that "consumers want communication by medical and hospital staff to enable patients, patients' families and carers to be better informed", and that "up to date information is essential to ensure that informed decision making processes are in place".3 Thus, the provision of reliable and relevant information has become a primary component of quality health care.4 There is no doubt that the Internet, particularly the World Wide Web (WWW), represents one of the most powerful vehicles yet created for disseminating such information.5 The opportunities for rapid communication and education are clear, and access to health care information on the Web should be of major benefit to both consumers and providers of health care. In June of this year, the United States National Library of Medicine, part of the National Institutes of Health (Bethesda, Maryland), inaugurated a program of free access for all Americans to MEDLINE -- the world's most extensive collection of published medical information -- on the Web.6 Announcing the service, the United States Secretary for Health and Human Services, Donna Shalala, said: "American citizens now have at their fingertips both the scientific information gathered by the National Library of Medicine as represented by MEDLINE and the extensive consumer information on Healthfinder.7 We are committed to using the new technology including the WWW and the Internet to provide health information to the public."8 However, the Web, despite its promise to deliver medical information and the presence of high quality medical resources (including medical journals such as The Medical Journal of Australia 9 ), is ruled by anarchy and information bedlam prevails. Anybody with a computer and Internet connection can be an author, editor and publisher rolled into one, and can do so anonymously. There is no accountability for the quality and safety of information. Impicciatore et al. recently surveyed the accuracy of medical advice management of fever in children on the Web.10 The keywords "fever management", "child" and "parent information" retrieved 41 Web pages, 32 produced by commercial ventures and nine by individual practitioners, clinics, academic institutions or other educational organisations. Only four of these pages adhered closely to the main recommendations of conventionally published guidelines. The authors of the report suggested there was an urgent need to check public-oriented health care information on the Internet for accuracy, completeness and consistency.10 This should not be terribly surprising. After all, those with medicopolitical or commercial agendas have the same access to the Web as those seeking to publish science. The activities of the former are illustrated by the unreferenced claims and rhetoric of pressure groups11 as well as the growing number of dubious or even preposterous health claims on the Web (e.g., shark cartilage has been "shown to be effective in inhibiting tumour growth and cancer; helpful in the treatment of arthritic conditions, macular degeneration, psoriasis and cartilage support"; and melatonin "strengthens the immune system, and reduces free radicals in the body"12 ). The simple search words "alternative medicine" open a virtual bazaar in the US, offering a wide variety of substances to treat any ailment.12 Despite the glitter and buzz of the technology, publishing medical information on the Web still relies on content; Silberg and colleagues argued recently that the quality criteria applied to medical information in print should be applied equally in the electronic world.13 The International Committee of Medical Journal Editors has agreed on a minimum set of benchmarks for medical information posted on the Internet (Box). Others have outlined criteria useful for evaluating Web pages and ways of measuring their impact.13,15 Criteria include: Credibility and conflict of interest (owner or sponsor of site; author credentials); and Structure and content of site (reference to sources; scope, accuracy and currency of content; readability; quality of links to other sites; media used to communicate material; function and impact of site). There is no reason that medical information on the Web should not receive the same scrutiny for its impact on clinical outcome and cost effectiveness as other methods of delivering the same information. Efforts to assess the quality of medical information are under way. For example, the Geneva-based Health on the Net Foundation has established a six-point code of conduct for sites providing medical information.16 In the United Kingdom, the Organising Medical Network Information initiative is attempting to provide a gateway to high quality biomedical information for the higher education and research communities.17 These initiatives to ensure quality of medical information on the Web are not attempts to stifle or censor information. Patients and medical practitioners are faced with an enormous quantity of information of variable quality, and the calls for rigorous adherence to quality are attempts to separate the wheat from the chaff, the useful from the harmful.11 The time has come for active regulation or accreditation of health care Web sites. After all, the health of the people of our global village is at stake. Martin B Van Der Weyden Editor, The Medical Journal of Australia Wheeler HB. Shotkick Lecture: healing and heroism. N Engl J Med 1990; 322: 1540-1548. Moloney TW, Paul B. Rebuilding public trust and confidence. In: Gertius M, Edgman-Levitan S, Daley J, Delbanco TL, editors. Through the patient's eyes. San Francisco: Jossey-Bass Publishers, 1993: 280-298. Consumer Health Forum of Australia Inc. Consultations on a health service standard report. A report to the Department of Health and Family Services on consumer community consultations. Lyons, ACT. Consumer Health Forum of Australia Inc, 1996. Daley J. Understanding and promoting patient centre care. In: Gertius M, Edgman-Levitan S, Daley J, Delbanco TL, editors. Through the patient's eyes. San Francisco: Jossey-Bass Publishers, 1993: 72-95. Coiera E. Guide to medical informatics, the Internet and telemedicine. London: Chapman and Hall, 1997: 275-292. PubMed: URL: http://www.ncbi.nlm.nih.gov/PubMed URL: http://www.healthfinder.gov National Institutes of Health. National Library of Medicine press release. 26 June 1997. URL: http://www.mja.com.au Impicciatore P, Pandolfini C, Casella N, Bonati M. Reliability of health information on the world wide web: systematic survey of advice on managing fever in children at home. BMJ 1997; 314: 1875-1879. Australian Vaccination Network: http://www.ozemail.com.au/~shotinfo/ Bower H. Internet sees growth of unverified health claims. BMJ 1996; 313: 381. Silberg WM, Lundberg GD, Musacchio RA. Assessing controlling and asuring quality of medical information on the Internet. JAMA 1997; 277: 1244-1245. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. JAMA 1997; 277: 927-934. Wyatt JC. Commentary: measuring quality and impact on the world wide web. BMJ 1997; 314: 1879-1881. Health on the Net Foundation. http://www.hon.ch Coiera E. The Internet's challenge to health care provision. BMJ 1996; 312: 3-4. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Information technology in medicine Changing the way we practise MJA 1997; 167: 574 In its enthusiastic embrace of information and communications technology in the health care sector, Australia is part of an accelerating universal phenomenon. While telemedicine today embraces very expensive robotic surgery and virtual reality, its current basis is the provision of simple, cost-effective methods of communicating and disseminating information for better medical practice. In this issue of the Journal, we find three articles dealing with means of sharing medical information. The simplest illustration is found in the article by Ian Charlton, in which printed material, videos and tapes in a practice library are made available to patients wanting more information about their disease management or about lifestyle issues.1 Next, Taylor and colleagues evaluate the use of well established technology -- the fax machine -- in informing family practitioners that patients from their practice have been admitted to hospital.2 Finally, Blackwell et al. report the use of "state of the art" diagnostic telemedicine, with real-time transmission of ophthalmological slit-lamp images from Mt Isa to specialists in Townsville.3 All three projects report significant success, and the last raises the possibility that telemedicine could result in cost savings for the community. The two major components necessary for successful telemedicine are the idea and the technology. Undoubtedly, ideas abound, as the number of technologies available for application in the health care sector is increasing rapidly. Meanwhile, current technologies are becoming cheaper and thus more widely applicable.4 Nevertheless, they are still costly and this, together with many unresolved issues such as State versus national licensure and charging structures for teleconsultation, currently limits the application of telemedicine largely to the public sector.5 Indeed, the Department of Defense in the United States remains a prime mover and funder of telemedicine in that country.6 Confined largely to the public sector, most telemedicine applications to date have been applied in giving rural communities better access to health care. The Mt Isa ophthalmology project reported in this issue of the Journal ( page 583 ) is a good example of this. Another is the South Australian Telepsychiatry Rural Service, which is the most established telemedicine service in this country,7 and an excellent example of the application of videoconferencing to provide real-time interaction between patients and doctors. Current activity in telemedicine applications in Australia -- at present predominantly rural -- leads to the conclusion by Yellowlees and Kennedy4 that telemedicine is here to stay. What of the future? Today's technologies will be further developed and refined, they will become cheaper, and new applications will be developed. Already we are witnessing the application of the personal computer and the Internet and other broadband mechanisms in "medical informatics" to transmit patient data in community-based care. Importantly, telemedicine will probably move from being used mostly in its current rural settings into more widespread use. By early in the next century, health care delivery will emphasise the importance of bringing care to patients rather than bringing patients to the health care system and tertiary hospitals, regardless of where patients live. "Multimedia e-mail" are current buzzwords in telemedicine. They refer to the development of store-and-forward electronic mail, allowing transmission of not just text, but also audio, still images and video. In the future we will have more sophisticated and affordable real-time videoconsultation, and the luxury of multimedia consultation, to be accessed when convenient. Concomitantly, if the vision of such projects as the APEC (Asia-Pacific Economic Cooperation Forum)-endorsed "Interactive Medical Curriculum" project of Health OnLine in South Australia becomes a reality (see the website at http://www.hol.com.au), the ongoing education of practitioners in the community (and of their patients) will be vastly different and delivered "online" to their homes. The implications of such changes inspired by information and communications technology are difficult to appreciate, but health care delivery in the 21st century will certainly apply such technology more effectively and, hopefully, less expensively. We will witness a significant change in the role of the tertiary teaching hospital, and increasingly empowered family practitioners with their better-informed patients will enforce a new role on the specialist practitioners. For better or for worse, communication in medicine will be different. Malcolm Mackinnon Professor of Telemedicine, Flinders University of South Australia and Director, Health OnLine Charlton I. Usefulness of a patient library in a suburban general practice. Med J Aust 1997; 167: 579-581. Taylor DMcD, Chappell-Lawrence J, Graham IS. Facsimile communication between emergency departments and GPs, and patient data confidentiality. Med J Aust 1997; 167: 575-578. Blackwell NAM, Kelly GJ, Lenton LM. Telemedicine ophthalmology consultation in remote Queensland. Med J Aust 1997; 167: 583-586. Yellowlees P, Kennedy C. Telemedicine: here to stay. Med J Aust 1997; 166: 262-265. House of Representatives Standing Committee on Family and Community Affairs, official Hansard Report, Health Information Management and Telemedicine. Canberra: The Parliament of the Commonwealth of Australia, 1997. In press. Edwards J, Motta C. Telemedicine and the military. In: Bashshur R, Sanders J, Shannon G, editors. Telemedicine, theory and practice. Springfield, Ill.: CC Thomas, 1997. Kavanagh S, Yellowlees P. Telemedicine -- clinical applications in mental health. Aust Fam Physician 1995; 24: 122-125. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Malcom MacKinnon

Facsimile communication between emergency departments and GPs, and patient data confidentiality David McD Taylor, John Chappell-Lawrence and Ian S Graham MJA 1997; 167: 575-578 Abstract - Introduction - Methods - Statistical analysis - Results - Discussion - References - Authors' details - - ©MJA1997 Abstract Objective: To assess general practitioners' perceptions of the effectiveness of facsimile notification of their patients being admitted from the emergency department (ED), and its adequacy in terms of patient confidentiality. Design: Questionnaire survey, before and after the initiation of facsimile notification. Setting: A provincial community of approximately 120 000 residents in Victoria. Main outcome measures: Changes in GPs' ratings of communication with the ED; acceptability of facsimile notification; and concerns about patient confidentiality. Results: 77 of 85 GPs participated; only 44 (57.1%) returned both questionnaires. ED-GP communication ratings of "adequate" or better increased from 48% to 100% ( P < 0.05). The proportion of GPs who were notified of all admissions increased from 0 to 41% ( P < 0.05). The proportion of GPs who preferred facsimile for notification increased from 39% to 68% ( P < 0.05). Most GPs found the initiative acceptable and reservations about confidentiality decreased from 36% to 16% ( P < 0.05). 38 of the 887 patients admitted from the ED (4.3%) refused facsimile notification. Conclusions: Facsimile improves ED-GP communications and may, in turn, improve the quality and continuity of patient care. Informed consent should be obtained from all patients. MJA 1997; 167: 575-578 Introduction With shorter hospital stays and a greater emphasis on same-day surgery and domiciliary or "hospital in the home" services, the involvement of general practitioners in coordinated patient management is increasingly important.1,2 Unfortunately, many GPs report progressive alienation from their community hospitals.1,2 Poor communication between public hospitals and GPs is a major cause of negative effects for both doctors and patients,1,3,4 and has been linked with discontinuity of treatment and patient dissatisfaction with the transition of care between hospitals and primary practice.1,3Anecdotal evidence suggested that there was room for improvement in communications between our hospital (Ballarat Base Hospital) emergency department and local GPs. In particular, a 1995 survey showed that 84.4% of the Ballarat GPs who responded wished to be notified of their patients' admissions (Dr Mark Fitzgerald, Emergency Department Director, St John of God Hospital, personal communication). Ballarat Base Hospital medical officers were required to notify GPs of patient admissions by telephone. However, as 62% of patients are admitted from the emergency department (ED) between 1800 and 0800 (unpublished data) and GPs can be difficult to contact after hours, GPs were often not notified. To rectify this problem, and to improve the relationship between the hospital and GPs, Ballarat Base Hospital and the Ballarat and District Division of General Practice aimed to establish a system of facsimile notification of GPs of patient admissions. Advantages of facsimile transmission of patient information include speed and accuracy of transfer, accessibility, low cost, and the possibility of direct transfer from the computer screen.5-9 However, there are potential problems of misdirection of transmissions and of document security at the transmission destination.10-14 In this study, we aimed, firstly, to examine the perceived success of this initiative in improving communications between the emergency department and GPs, and, secondly, to address potential problems and establish appropriate confidentiality protocols and controls governing the use of facsimile for this purpose. Methods The Ballarat Base Hospital is a community teaching hospital in provincial Victoria serving approximately 120 000 residents in both urban and rural areas. The Ballarat and District Division of General Practice includes all of the 85 GPs who serve this population. All of these GPs regularly refer to the hospital and often contribute to their patients' inpatient and postacute care. Details of our facsimile study were mailed to all these GPs, and they were advised that their participation would involve receiving facsimile admission notification and providing relevant patient information if required. The ED purchased a dedicated facsimile machine with a preprogrammable number dialling facility to ensure that, if an incorrect number were pressed, the facsimile would be sent only to another participating GP. The machine was positioned in a secure area of the ED clerical office where incoming and outgoing facsimiles could not be accessed by unauthorised people. To test the system, a test facsimile was sent to all preprogrammed numbers of participating practices, which were asked to verify the security of their machines and their commitment to the confidentiality of the study by endorsing the test facsimile with the practice stamp and refaxing it to the ED. Specially designed facsimile notification sheets recorded: The GP's name; Patient identification (name, age, date of birth, unit record number, address) and admission details (date, time, diagnosis, ward and inpatient unit); The patient's signature (indicating consent for their GPs to be notified and to provide any relevant medical information by facsimile); and A request from the ED for the GP to provide specific and any other relevant medical information in a space provided (the same facsimile could then be returned). Before each admission, an ED clerk completed the notification sheet, which was checked and signed by the patient. Only the patient, or a parent in the case of a minor, could consent to transmission. Family members were not permitted to sign on behalf of patients. For patients either physically or mentally incapable of consenting, facsimiles were not sent. The completed sheet was then checked and signed by the ED medical officer. If a notification sheet was not sent, the reason was noted in the space provided for the patient's signature. Facsimile notification of patient admission began on 6 June 1996; the study period ended on 31 July 1996. Perceptions of communication between the ED and GPs before and after the establishment of facsimile notification were assessed by two questionnaires, posted to participating GPs in the week before and immediately after the study period. The questionnaires were identical, except for an additional question in the one sent at the end of the study period. For each question, respondents were asked to select the most appropriate response, and were invited to elaborate descriptively. GPs who did not respond were reminded by mail, fax or telephone. Statistical analysis For Questions 1-5, the change in response as a result of the initiation of facsimile notification was used as the variable of interest. The sign test was used to test the null hypothesis ( if the intervention had no effect, the number of positive and negative differences should be similar ). Questions 6-8 required a "yes" or "no" response and the results were analysed using McNemar's test (α = 0.05; df, 1). SPSS 15 was used for all analyses. In all cases, the change from before to after the intervention was considered. Results Seventy-seven GPs (90.6%) agreed to participate in the study. A further seven had no facsimile machine in their surgeries, and one GP elected not to participate. During the study period, 887 patients were admitted from the ED. Facsimile notifications were sent to the GPs of 548 patients (61.8%). A further 74 patients (8.3%) were visitors or transferred from outside the area, 73 (8.2%) were unable to provide informed consent, 47 (5.3%) had GPs with no facsimile machine, 38 (4.3%) refused permission to send notification, 32 (3.6%) had no GP, and 14 (1.6%) had been admitted to the ward before authorising the notification. For the remaining 61 patients (6.9%), no explanation could be found for failure of notification. Usually, no attempt was made to notify GPs if a facsimile was not sent. Of the 77 participating GPs, 44 (51.7%) completed the first, 55 (71.4%) completed the second, and 44 (57.1%) completed both the questionnaires. The demographic characteristics of the 77 GPs, comparing the 44 who completed the study with the 33 who did not, are shown in Box 1. Responses to the questionnaires, before and after the intervention, by the 44 GPs who completed the study are compared in Box 2. After the intervention, there was a significant improvement in GPs' perception of overall communications from the ED (Question 1; P < 0.001). Similarly, GPs reported a significant improvement in the frequency of notification (Question 2; P < 0.001), and in communications (Question 3; P < 0.001) from the ED after one of their patients was admitted. Responses to Question 4 showed a significant change in GPs' preferred mode of communication after the intervention ( P < 0.01). Before the intervention, most preferred a direct telephone call from the admitting officer, while after the intervention most preferred a facsimile. When asked how notification of their patients' admissions from the ED would affect [had affected] their management of those patients (Question 5), most GPs stated, both before and after the intervention, that notification would encourage them to visit their patients in hospital and assist in planning postacute care. After recoding to adjust for the effect of multiple answers (more than one response was allowed), no statistically significant change was found as a result of the intervention. The number of GPs responding that they had recently been aggrieved or inconvenienced as a result of the ED not notifying them of the admission of one of their patients (Question 6) fell significantly after the intervention ( P < 0.001). After the intervention, only two additional GPs responded that prompt notification of a patient's admission was of significant importance to the ongoing management of that patient (Question 7); this was not statistically significant. The number of GPs who had reservations about confidentiality associated with patients' medical records being transmitted by facsimile with their consent (Question 8) fell after the intervention ( P < 0.05). Finally, the question included only in the second questionnaire showed that 43 GPs (97.7%) were prepared to support the continuation of the ED facsimile notification initiative. It also showed that 39 (88.6%) and 40 (90.9%) GPs, respectively, were prepared to support its use in all admissions and discharges at Ballarat Base Hospital. Discussion Our findings clearly show that GPs perceived an improvement in their communications with the ED after the advent of facsimile notification. At the end of the study period, there was a significant increase in the number of GPs who preferred to be notified by facsimile, and a significant reduction in the number of GPs who had reservations about patient confidentiality. Most GPs responded that notification allowed them to visit their patients in hospital, to contribute to inpatient care, to plan their patients' postacute care (e.g., home-help, meals-on-wheels, district nursing and family counselling), and to avoid interruption of the GP-patient relationship. Such continuity of care may affect readmission rates. Objective measurement of whether facsimile notification actually affects GP behaviour and patient outcomes may be worthy of further study. A drawback of our study was its low response rate. Despite encouragement, a considerable number of GPs did not complete both questionnaires. While there were no obvious differences between those who did and did not complete the study, the low response rate may have introduced bias into the results by selecting for more motivated GPs, or those with a special interest in the study. The fact that more GPs responded to the second questionnaire may have indicated some enthusiasm for the project. Lack of confidentiality has been identified as one of the most serious drawbacks of using facsimile machines in clinical practice. The sender loses control once a fax is transmitted, and information can be misdirected as a result of dialling wrong numbers.10,11,13,16,17 None the less, we considered facsimile notification a more appropriate initial step than other accepted methods, such as encrypted electronic data transfer. The infrastructure was easy and relatively cheap to establish. It was also easy for the ED staff to use, with completion and transmission of each notification sheet taking approximately five minutes. Finally, the method allowed the patients to view the notification document before its transmission. The safeguards we used in the facsimile transmission of patient med- ical information (Box 3) have been recommended by other investigators.6,11,12,14,16,17 We contend that, if these safeguards are established, the standard of care for the protection of patient information transmitted by facsimile should be at least as high as that provided by conventional mail. A message reaching a secure facsimile machine is no more susceptible to loss, misdirection or unauthorised access than an opened letter in a doctor's "in-tray". It has been suggested that an authorisation procedure should be in place to facilitate obtaining informed consent for any facsimile transmission of personal information.6,12,14,16,17 We felt that if patients were shown the information that was to be transmitted, its destination and the format in which it was to be sent they could make an informed decision about whether or not GP notification was appropriate. The number of patients who refused consent for facsimile notification (38, or 4.3%) was surprising; our study had not been designed to record the reasons for these refusals and this matter deserves further study. Regardless of the reasons for refusal, patients could suffer distress if medical information was transmitted without consent, and legal action could result from misdirection of unauthorised, non-urgent medical information. Our protocol represented a change in Ballarat Base Hospital's facsimile policy as consent had previously been assumed. In most hospitals, providing the name of the GP at registration or admission is considered implied consent for the hospital to communicate directly with the GP. Letters, discharge summaries and death notifications may be sent by facsimile, electronic transfer or mail. With increasing use of telecommunications and information technology, we contend that it may be appropriate to question some of the practices that are currently undertaken routinely with only the implied consent of patients. Other Australian emergency departments are developing facsimile and electronic data systems for the transfer of patient information. Facsimile remains a "paper-based" technology and is likely to become superseded by electronic data transfer systems. Indeed, the American College of Emergency Physicians believes that, along with facsimile, electronic data facilities should be available to all emergency departments.6 Various electronic data transfer systems have been developed to coordinate the shared care of patients,18 to establish electronic medical records,19 to facilitate communication between hospitals and GPs,20 and to streamline patient referrals.21 While these "paperless" systems may be superior to facsimile, they also raise confidentiality issues. These are being addressed with the use of cryptography,22 digital signatures,20 "need to know" staff clearances,20 and legislation.20,23 Meanwhile, facsimile is accessible and relatively inexpensive, and is likely to remain useful, at least in the near future, until electronic systems become more prevalent. We recommend the use of facsimile transmission for notification of patient admission, provided that adequate safeguards are in place, and that informed consent is obtained before transmitting medical information. Following the success of facsimile notification of admissions from the ED, Ballarat Base Hospital has continued its use and is considering extending it to all hospital admissions and discharges, ED discharge letters and, possibly, to service providers other than GPs. Presently, the hospital is investigating software which will allow computer-generated facsimile transmission and is looking ahead to electronic data transfer. References Bella JI, Jamieson WE. Improving the continuity of care between general practitioners and public hospitals. Med J Aust 1994; 161: 656-659. Freeman G. Continuity of care in general practice: a review and critique. Fam Practitioner 1984; 1: 245-252. Interaction with Fremantle Hospital: final report. Fremantle: Fremantle Regional Division of General Practice, 1994: 1-40. Morrison WG, Pennycook AG, Makower RM, Swann IJ. The general practitioner's use and expectations of an accident and emergency department. J R Soc Med 1990; 83: 237-240. Magennis AW. Fax units in general practice. Aust Fam Physician 1989; 18: 1259-1264. American College of Emergency Physicians. The use of facsimile machines and electronic data transfer in the emergency department [policy statement]. Ann Emerg Med 1993; 22: 266. Spigelman A. Faxed electronic summaries are valued by general practitioners [letter]. BMJ 1995; 311: 746-747. Cole DR, Johnson MS, Heaton CJ, Petti M. Fax/modem board communications decrease preceptor communication costs. Fam Med 1994; 26: 418-420. Yamamoto LG, Wiebe RA. Improving medical communication with facsimile (fax) transmission. Am J Emerg Med 1989; 7: 203-208. Marr P. Maintaining patient confidentiality in an electronic world. Int J Biomed Comput 1994; 35 Suppl: 213-217. Brent N. Facsimile systems revised: focus on confidentiality and privacy. Home Healthcare Nurse 1991; 9: 6-8. Larkin GL, Moskop J, Sanders A, Derse A. The emergency physician and patient confidentiality: a review. Ann Emerg Med 1994; 24: 1161-1167. Carman D, Britten N. Confidentiality of medical records: the patient's perspective. Br J Gen Pract 1995; 45: 485-488. Capen K. Facts about the fax: MDs advised to be cautious. Can Med Assoc J 1995; 153: 1152-1153. SPSS/PC+ statistics [computer program]. Version 4.0. Chicago: SPSS Inc., 1990. Genesen LB, Sharp HM, Genesen MC. Faxing medical records: another threat to confidentiality in medicine [letter]. JAMA 1994; 271: 1401-1402. Grant AE. Legal matters -- facsimile transmissions. Canadian Nurse 1996; 92: 47. Branger P, van't Hooft A, van der Wouden HC. Coordinating shared care using electronic data interchange. Medinfo 1995; 8: 1669-1674. Walker D. Transferring electronic medical records. Aust Family Physician 1997; 26: 48-55. Fisher F, Badge B. Data security and patient confidentiality: the manager's role. Int J Bio-Med Comp 1996; 43: 115-119. Gaudet LA. Electronic referrals and data sharing: can it work for health care and social service providers? J Case Management 1996; 5: 72-77. Biskup J, Bleumer G. Cryptographic protection of health information: cost and benefit. Int J Bio-Med Comp 1996; 43: 61-67. Cassidy SO, Sepulveda MJ. Health information privacy reform. J Occup Environ Med 1995; 37: 605-614. (Received 20 Feb, accepted 23 Jul, 1997) Authors' details Ballarat Base Hospital, Ballarat, VIC. David McD Taylor, MD, FACEM, Former Acting Director of Emergency Medicine (currently, Instructor in Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA); Ian S Graham, MB BS, FRACMA, Executive Director, Clinical Services. Ballarat and District Division of General Practice, Ballarat, VIC. John Chappell-Lawrence, BBSc(Hons), DipEd, Project Consultant. No reprints will be available. Correspondence: Dr D McD Taylor, A2, 5237 Fifth Avenue, Pittsburgh, PA, 15232, USA. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

John Chappell-Lawrence · Ian S Graham

Usefulness of a patient library in a suburban general practice Ian Charlton MJA 1997; 167: 579-581 Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1997 Abstract Objectives: To provide health information by means of a patient library in an Australian general practice, and to examine the effects of such information on patient knowledge, anxiety and behaviour. Design: Questionnaire survey of patients who borrowed library items and of doctors within the practice. Setting: A five-doctor suburban practice serving approximately 7000 patients. Results: 210 items were purchased and made available for loan over the two years of the study; 164 questionnaires were obtained after 229 borrowings in the first 15 months. Patients who borrowed items were mostly women (88%) and a high proportion of borrowers (47%) felt that the doctors' surgery was their main source of health information. 98% felt that borrowing an item had been "useful" or "very useful", 88% felt that it had increased their knowledge, 48% felt it had decreased their anxiety, and 79% felt it had changed their behaviour. The doctors were generally positive about the library. Conclusions: The practice library was a very useful addition to the surgery services and provided a valuable clinical tool for the doctors. MJA 1997; 167: 579-581 Introduction A s medical treatments become more complex, it has become more difficult for patients to absorb the information they need to make their therapies successful.1,2 Patient information booklets and sheets have been used to help overcome this problem,3-5 but a more organised approach may be for medical practices to have patient libraries.6 Libraries can contain books, audio and video cassettes and journal articles, enabling doctors to select relevant information in a format that patients can absorb. Patients can also be encouraged to select items for themselves. A United Kingdom study has evaluated the impact of establishing a patient library.7 A 200-book library covering 107 topics was established by a general practitioner and librarian at a cost of $1600. Each book contained a questionnaire, to be completed when the book was returned. Over 15 months, 243 books were borrowed; 163 questionnaires (67%) were returned. Sixty-five per cent of respondents in this UK study would not have sought the information elsewhere, and 98% found the books useful or very useful. Forty-four per cent felt their anxiety levels had reduced as a consequence of reading the book.7 My purpose was to replicate this work in an Australian setting, aiming to determine the value of providing health information by means of a patients' library in an Australian general practice, and to examine the effects of such information on patient knowledge, anxiety and behaviour. Methods A patient library was established in a five-doctor suburban partnership serving approximately 7000 patients on the Central Coast of New South Wales. Items for loan, including books, pamphlets, cassettes and videos, were chosen with the help of the consumer health information service (Health Link) at Westmead Hospital. Items were selected to suit patients' needs rather than those of doctors. The library was available to all patients based on both the recommendation of items by their doctors and on personal selection from a catalogue in the waiting room. The loan period was two weeks and a $2 lending fee was used to cover loss and damage. The study period was 24 months, during which time the number of items borrowed was recorded. Library items were classified into 22 subject categories and the number of items borrowed from each category was also recorded. Items were available for loan from 1 May 1994. During the first 15 months (i.e., until 31 July 1995) patient questionnaires were provided with each item when issued. To assess patients' usual reading habits (and modelled on the UK study) the questionnaire asked about their use of the public library service and whether or not they read books or articles on health matters. Patients were also asked how useful they had found the item from the library and whether they or their doctor had selected it. They were asked about their perceptions of their anxiety, knowledge and behaviour after borrowing an item from the library, and whether they would have sought health information elsewhere if it had not been so readily available in the practice library. Finally, they were asked to record the title, and to comment on the item they borrowed. At the end of the 24 months, the doctors in the practice were asked to complete a short questionnaire which sought information about their impressions of the library, how they used it, the problems they encountered, and the ways in which it could be improved. Results A total of $2400 was spent in acquiring 210 books, pamphlets, booklets, videos and cassettes. The price ranged from $3 to $38; the mean item cost was $12.70. At the end of 15 months, 229 items had been lent and 164 questionnaires returned (response rate, 72%). The findings, in comparison with the UK study, are summarised in Box 1. During the 24 months of the study, 322 items were borrowed, while the practice generated 52 076 consultations, giving a borrowing rate of one item for every 174 consultations. Box 2 illustrates the frequency of borrowings from the 22 categories of items available, and Box 3 lists the 10 most popular books. Patient questionnaire Thirteen per cent of patients (21/157) reported usually obtaining health information from the library, 29% (46/158) from newspapers, 47% (74/158) from the doctor's surgery, 46% (73/157) from magazines and journals, and 11% (18/159) felt the question was "not applicable" (patients could respond to more than one question). Thirty-nine per cent of patients (61/156) felt their knowledge had increased "a lot", while 49% (76/156) felt it had increased "a little". No patients reported feeling more confused as a result of borrowing a library item. Twenty-six per cent of patients (38/145) reported their behaviour had changed "a lot", while 53% (77/145) reported their behaviour had changed "a little", as a result of borrowing a library item. There was no difference in this regard between patients who had been recommended the item by their doctor and those who had selected it themselves. Doctors' questionnaire The doctors in the practice felt the library had been beneficial because it "enabled more detailed information to be provided", "saved time in explaining complex conditions" and "enabled the patient to set a more realistic agenda". All the doctors commented that they felt the library had given the patient a greater sense of control. The doctors' use of the library varied. One doctor liked to use the books to reinforce a message, another to use the books to increase the patient's understanding of their condition and so improve compliance, and another used the books for areas he personally found difficult to deal with. At times, books were used as a way of providing a second opinion. In so doing it was felt that the book reduced the need for a referral, investigation or prescription. The biggest frustration reported by the doctors was finding books out on loan or missing when they were required. With over 200 books in the library, it was not possible to be familiar with all the items in the library and their philosophies. One doctor commented that it was awkward when patients came back knowing more than the doctor. On one occasion, having become aware of the significance of her scaly scalp condition through reading a book on arthritis, a patient was able to raise the possibility of psoriasis. This was a symptom that had been overlooked by both doctor and patient in previous consultations. Discussion The value of the practice library was apparent from the high proportion of patients who reported that borrowing an item had been "useful" or "very useful", had increased their knowledge, changed their behaviour and reduced their anxiety. Although this study was based on patient self-report and cannot verify these reported changes, findings of other studies suggest that they may have occurred. Roland and Dixon found that an educational booklet on back pain significantly improved knowledge and patient behaviour up to a year after it had been issued.8 Similarly, Sorby et al. demonstrated that an anxiety management booklet significantly reduced anxiety.9 However, the value of using health information as a way of changing patient behaviour has been challenged. In a comprehensive review of health education material, Gatherer et al. commented that "written instructions appear to be inferior to most other sorts of instructions".10 Further, changes in behaviour as a result of the distribution of books may not always be desirable. A randomised controlled study evaluating a booklet for parents on childhood illnesses found that the number of day-time consultations in the intervention group fell by 28% but home visits rose by 173%!11 A possible source of bias in this study is that patients were able to borrow more than one item, and therefore might have completed more than one questionnaire. My intention was to evaluate specific items of health information and their effects on individuals rather than to evaluate individual patients. Only one book was deemed inappropriate and removed from the library. My findings were very similar to those of the Stevenage study,7 indicating that a patient library is an equally acceptable concept to Australian patients. A major difference between the studies was in the use of public libraries, with comparatively few Kincumber patients (13% v. 77% in Stevenage) reporting using the public library as a place to seek health information. This may reflect a different attitude towards public libraries in Australia, but may also be the result of the inaccessibility of public libraries in Kincumber, with the nearest public library about a 20-minute car journey away. As 47% of Kincumber patients saw their GPs as their main source of health information, a practice library seems an ideal way to help fulfil this need as well as to improve the profile of the practice within the community. As in the Stevenage study, the main users of our library were women (88%). This is no surprise as women attend surgeries more often than men. It does, however, raise the concern that men may be missing out on health information and that other strategies may need to be employed in communities to provide men with health information. Both doctors and staff found the exercise of running the patient library very satisfying, even though one staff member needed to spend time chasing up overdue books. Ten items were lost during the two years of the study, mostly because patients failed to register them with the reception staff after having had the item selected by their doctor. The $2 loan charge more than covered these losses and has enabled us to update and expand the library. A card index system, as used by most public libraries, proved an effective system for monitoring borrowing and was more acceptable to staff than a computerised database. The qualitative impression generated by the responses to the doctor questionnaire was that the library offered the doctors another option in their clinical management of patients. Although research has shown that simply increasing doctor (and patient) knowledge does little to improve patient care,12-14 a process that empowers patients to take control of their illness and reinforces a message presented by their GPs may be effective. A more sophisticated study would be required to determine if a practice library actually influenced management, compliance and outcomes. Practices wishing to establish a library may find our list of "top 10 books" helpful. Such was the demand for these books that three copies of each title were required. Other titles, such as Cleft lip and palate, were used only once in the two years of the study, but made a tremendous difference to a mother whose baby had been born with a cleft lip. As might be expected, the Stevenage practice had a different top 10 (menopause, cystitis, stress, Alzheimer's, bereavement/death and dying, child care, phobias, women's health, candidiasis, and diabetes), although a number of the topics were popular in both study groups. Our practice would recommend the patient library and we now wonder how we managed without it. We were fortunate to be able to purchase library items as part of a research project, although it would be possible to build up a collection without straining the practice finances by applying a borrowing fee. The outlay of $2000, with a $644 return over two years, together with the time it took one of our staff to administer the borrowing list, could not be seen as profitable. Nevertheless, the status the library gave to the practice and the help the library gave to both doctors and patients was worthwhile. Notably, we received only one complaint about the borrowing fee during the two years. Acknowledgements I thank the Royal Australian College of General Practitioners for the grant of financial support, Dr Allens for help with developing the computer program, Margaret Borg for her tireless work in administering the library, and Moira Bryant, of Health Link, Westmead Hospital, for her help in selecting library items. References Ackroyd E. The patient's complaint. Br J Hosp Med 1986; 36: 454. Hilton S, Sibbald B, Anderson HR, Freeling P. Controlled evaluation of the effects of patient education on asthma morbidity in general practice. Lancet 1986; i: 26-29. Ellis DA, Hopkin JM, Leitch AG, et al. "Doctors' orders": controlled trial of supplementary, written information for patients. BMJ 1979; 1: 456. Laher M, O'Malley K, O'Brien E, et al. Educational value of printed information for patients with hypertension. BMJ 1981; 282: 1360-1361. George CF, Waters WE, Nicholas JA. Prescription information leaflets: a pilot study in general practice. BMJ 1983: 287: 1193-1196. Varnaavides CK, Zermansky AG, Page C. Health library for patients in general practice. BMJ 1984; 288: 535-537. Collings LH, Pike LC, Binder AI, et al. Value of health information in the general practice setting. Br J Gen Pract 1991; 41: 466-467. Roland M, Dixon M. Randomised controlled trial of an educational booklet for the patients presenting with back pain in general practice. Br J Gen Pract 1989; 39: 244-246. Sorby NGD, Reavley W, Huber JW. Self help programme for anxiety in general practice: controlled trial of an anxiety management booklet. Br J Gen Pract 1991; 41: 417-420. Gatherer A, Parfit J, Porter E, Vessey M. Is health education effective? London: Health Education Council, 1979. (Monograph No. 2.) Usherwood TP. Development and randomised controlled trial of a booklet of advice for parents. Br J Gen Pract 1991; 41: 58-62. White PT, Pharoah CA, Anderson HR, Freeling P. Randomised controlled trial of small group education on the outcome of chronic asthma in general practice. J R Coll Gen Pract 1989; 39: 182-186. White P, Atherton A, Hewett G, Howells K. Using information from asthma patients: a trial of information feedback in primary care. BMJ 1995; 311: 1065-1069. Freemantle N, Harver EL, Grimshaw JM. Printed educational materials do not change physician behaviours or patient outcomes. Evidence Based Med 1977; 2: 395. (Received 8 Apr, accepted 11 Sep, 1997) Health Link Consumer Health Information Service Health Link was established at Westmead Hospital in 1984 as a drop-in centre supplying patients, carers and staff with health information from a medically reviewed collection of resources. In late 1995, Health Link relinquished this role, turning instead to providing PC-based electronic directories for practising GPs of accurate information about health-related services throughout Australia as well as details of a range of publications on health topics written for consumers. For more information, telephone: 02 9845 7307 Authors' details The Surgery, Kincumber, NSW. Ian Charlton, MB BS, MRCGP, General Practitioner. Reprints: Dr I Charlton, The Surgery, 7 Tilba Street, Kincumber, NSW 2251. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Ian Charlton

Telemedicine ophthalmology consultation in remote Queensland Nikki A M Blackwell, Graeme J Kelly and Lee M Lenton MJA 1997; 167: 583-586 Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - ©MJA1997 Abstract Objective: To assess the use of remote telemedicine ophthalmology in patients presenting to an emergency department with acute eye problems. Design: A prospective review from 1 December 1996 to 28 February 1997 of referral patterns and telemedicine consultations, comparing referral patterns with the same period one year before. Participants and setting: 24 patients presenting to the emergency department of a remote base hospital in Queensland with an acute ophthalmological problem requiring a specialist opinion. Main outcome measures: Clinical outcomes; use of the Patient Transit Scheme for isolated patients; acceptability to patients and doctors; and ophthalmologists' opinions of the system. Results: No adverse outcomes were identified. Patients transferred for urgent assessment fell from 17 for the corresponding period in the previous year to four during the study period, while respective numbers of patients requiring non-urgent transfers (for surgery or postoperative review) during the same periods were 41 and 30. Both patients and staff (including the ophthalmologists) found the telemedicine facility very acceptable. Conclusion: Ophthalmology is well suited to telemedicine for the diagnosis and management of acute conditions and postoperative assessment of patients in remote areas. It offers considerable potential benefits to patients, and enhances the skills of local practitioners. Introduction Telemedicine is "the use of transmitted images, voice and other data to permit consultation, education and integration in medicine over a distance".1 This technology is increasingly viewed as a means of improving specialist services to rural and remote parts of Australia,2 but there are few published studies about the clinical outcomes of telemedicine services.3,4 Critics often cite inability to examine the patient as a reason why telemedicine does not substitute for face-to-face specialist consultation.5 However, in medical specialties that depend heavily on visual observation, such as dermatology or radiology,3,4,6 telemedicine has been shown to be an effective means of providing accurate specialist opinion. Ophthalmology is another specialty which lends itself well to televised con sultation, and acute problems in ophthal mology are an area where telemedicine may augment existing specialist services. Many ocular conditions present acutely and require immediate specialist referral. While the remote town of Mt Isa, in central Queensland, has a visiting specialist ophthalmology service, the clinics are too infrequent to be useful for acute problems. Consequently, patients with acute ocular disease often require transfer to Townsville, 900 km away, for specialist consultation. In 1996, Mt Isa Base Hospital transferred 196 ophthalmology patients, representing almost 25% of the total patients transported under the Patient Transit Scheme in that year. Based on the cost of a return flight to Townsville of $500, and not allowing for the costs of patient escorts or accommodation, the cost to the hospital was approximately $100 000. Following the generous donation to Mt Isa Base Hospital of a slit lamp with a camera facility by OPSM (Optical Prescription Spectacle Makers Industries Limited) in October 1996, we conducted a three-month evaluation of remote consultation for ocular conditions. Our aim was to examine clinical outcome, the effect on Patient Transit Scheme use and expenditure, acceptability to both patients and doctors, the ophthalmologist's evaluation of the transmitted slit-lamp images, and any problems encountered with the system. Methods All patients presenting to Mt Isa Base Hospital (i.e., a non-metropolitan hospital serving a number of smaller health care facilities) with acute eye conditions from 1 December 1996 to 28 February 1997 were assessed by the Emergency Department Director. Patients with a clear indication for immediate referral (e.g., penetrating eye injury) were transferred to Townsville as usual. For those requiring specialist ophthalmological opinion, a telemedicine consultation was arranged during normal working hours within 24 hours of presentation. Each patient was examined by slit lamp at Mt Isa Base Hospital, while a high resolution televised image was assessed simultaneously by the specialist in Townsville, in voice and visual contact with the patient and local practitioner (see Figure). After the consultation, the recommended treatment was initiated and local follow-up was arranged as necessary. Patients could be discharged, referred to the visiting ophthalmology clinic, or transferred to Townsville if necessary. In addition, the ophthalmologists arranged for patients who required routine postoperative review during the study period to be assessed on the telemedicine link rather than having to travel to Townsville for an outpatient consultation. To gauge the impact of the telemedicine system on use of the Patient Transit Scheme by ophthalmology patients presenting to the emergency department, the study period was compared with the corresponding three-month period in the previous year. Acceptability of the telemedicine system to patients and doctors was assessed informally by staff in discussion with patients. Results During the three months of the study, 264 patients presented to the emergency department with an acute eye condition, of whom 24 (or 9%) were considered to require specialist ophthalmology referral, which was then carried out by telemedicine. By comparison, 315 patients had presented in the corresponding period in the previous year, with 17 (or 5.4%) having been transferred urgently to Townsville, and a further 5%-10% being managed after a telephone consultation with an ophthalmologist, without the use of telemedicine. Patient outcomes Our experience with the 24 patients who had telemedicine consultations (31 consultations in all) is shown in Box 1. No patient had an adverse clinical outcome as a result of being assessed by telemedicine rather than face-to-face in Townsville. For the first six patients in Box 1, management was altered as a result of the consultation, and transfer was avoided. For the next 12, management was continued locally as planned and transfer was avoided. For the next four patients, treatment was altered and urgent transfer arranged. For the remaining two patients, treatment was unchanged after telemedicine consultation. Patient transfer Box 2 shows number of ophthalmology patients transferred urgently and non-urgently (for surgery or postoperative review) during the study period and the corresponding period in the previous year. Overall, four patients were transferred for urgent assessment during the study period, compared with 17 for the corresponding period in the previous year. Another four patients were referred to the next local visiting ophthalmology clinic as their problems were not urgent. Comparing the numbers of patients requiring urgent transfer for the two periods (4 v. 17), and based on the costings described above, the hospital saved $6,500 over the three months of the study. In addition, five patients were reviewed locally after surgery (the two children with strabismus correction were seen twice) instead of returning to Townsville, representing a total saving to the Patient Transit Scheme budget of approximately $10 000 over the three months. Acceptability Frail elderly patients who had undergone cataract extractions were happy to avoid a further trip out of Mt Isa. Similarly, the patients who had strabismus correction were all young children with siblings, and it was very convenient for them to be seen locally. Indeed, as previously documented,7-9 all patients seemed to respond well to the new technology, with no patient refusing a teleconsultation, and all saying that in the future they would prefer such a consultation over travelling to Townsville for review. Medical and nursing staff in Mt Isa were enthusiastic about the new facility, often arranging their work so that they could be present at a teleconsultation. The ophthalmologists in Townsville found that the quality of the transmitted slit-lamp image was of sufficiently high quality to allow definite diagnosis in all cases. Discussion Our pilot study indicates that ophthalmology by telemedicine can provide a clinically effective and resource- efficient means of augmenting a specialist service in a rural area. There were no adverse outcomes related to the use of the technology. Indeed, the service for patients seemed to improve, with specialist consultation being provided within 24 hours, allowing appropriate management to be promptly initiated. The ophthalmology telemedicine system, which could be applied across rural Australia, needs local practitioners willing to acquire basic expertise in eye examination, and use of the slit lamp and tonometer. Successful use of the technology requires skilled practitioners at both ends of the transmission10 generating and interpreting slit-lamp images. Yellowlees and Kennedy have identified several key ingredients for successful telemedicine systems.2 Many of these already existed in Mt Isa: an ISDN (Integrated Services Digital Network) videoconferencing system had been in place for two years; many medical and nursing staff had received training in the use of the system; telemedicine remains an initiative strongly supported by the hospital executive; there was enthusiasm for the project in both Mt Isa and Townsville; and Mt Isa Base Hospital employs an Information Technology Coordinator. The success of this new service relied heavily on the enthusiasm and commitment of all involved to ensure that the time of specialists (who donated their services) was not wasted, and that busy practitioners could rely on agreed appointments reflecting accurately the timing and duration of consultations. We found proper notekeeping to be of major importance. Unlike Kavanagh and Yellowlees, who provided case management referral letters after televised psychiatry interviews,11 we have not yet been able to organise specialist letters after ophthalmology teleconsultation because of time, cost and reimbursement issues. Hence, it was the responsibility of the local practitioner who attended the consultation with the patient to document the diagnosis and management plan. The fact that telemedicine is not covered by Medicare is likely to act as a barrier to its widespread development. This has been shown to be the case with several telemedicine applications in the United States.2,11-13 While the ophthalmologists involved in this study donated their time, the question of remuneration must ultimately be addressed. The great sense of camaraderie generated by the improved contact between health professionals was an unexpected benefit of the telemedicine system. As has been suggested,2 the use of telemedicine may decrease the professional isolation of rural doctors by providing an interactive medium for medical education focused on immediate clinical management. The telemedicine facility at Mt Isa Base Hospital will continue to be used for informal ophthalmology teaching, with medical and nursing staff encouraged to attend consultations. In addition, a telemedicine link to a day surgery unit in Townsville is currently being used to train theatre staff for the planned introduction of cataract surgery to Mt Isa. Finally, all users of telemedicine should be encouraged to evaluate their services to ensure that they are meeting a clinical need and not just being driven by the technology. Users should be mindful of the lessons from the extraordinary growth of laparoscopic surgery,14 where practitioners have only recently begun to address clinical outcomes after laparoscopy in appropriately designed studies. Rather than being seduced by the promise of the new, technology must be harnessed to help improve patient care. Acknowledgements We thank Shaun Anderson and OPSM for donating the equipment. Disclaimer of conflict of interest: The authors declare no conflict of interest. OPSM donated the equipment, but had no part in planning the study, analysing the results or preparing the manuscript. References Merrell RC. Telemedicine in the 90's: Beyond the Future. J Med Sys 1995; 19: 15-18. Yellowlees PM, Kennedy C. Telemedicine: here to stay. Med J Aust 1997; 166: 262-265. Warren FM, Lesher JL, Hall JH, et al. Telemedicine. J Family Practice 1995; 41: 17-20. Ferrer-Roca O, Diaz-Cardama A, Pitti S, et al. Tele- medicine in the Canary Islands. Lancet 1995; 345: 1177-1178. Appleby C. Telemedicine -- a prison plugs in. Hosp Health Netw 1995; 69: 56. Binkhuysen FH, Ottes FP, Valk J, et al. Remote expert consultation for MRI procedures by means of teleradiology. Eur J Radiol 1995; 19: 147-150. Bergman R. Letting Telemedicine do the walking. Hosp Health Netw 1993; 67: 46-48. Harrison R, Clayton W, Wallace P. Can telemedicine be used to improve communication between primary and secondary care? BMJ 1996; 313: 1377-1380. Telemedicine: fad or future? [editorial]. Lancet 1995; 345: 73-74. Wootton R. Telemedicine: a cautious welcome. BMJ 1996; 313: 1375-1377. Kavanagh SJ, Yellowlees PM. Telemedicine -- clinical applications in mental health. Aust Family Physician 1995; 24: 1242-1247. Grigsby J. Current status of domestic telemedicine. J Med Systems 1995; 19: 19-27. Puskin DS. Opportunities and challenges to telemedicine in rural America. J Med Systems 1995; 19: 59-67. Johnson A. Laparoscopic surgery. Lancet 1997; 349: 631-635. (Received 17 Apr, accepted 29 Jul 1997) Authors' details Mt Isa Base Hospital, Mt Isa, QLD. Nikki A M Blackwell, MRCP(UK), Director of Emergency Department. Hyde Park Centre, Woolcock Street, Hyde Park, Townsville, QLD. Graeme J Kelly, FRACO, FRACS, Ophthalmologist; Lee M Lenton, FRACO, FRACS, Ophthalmologist. No reprints will be available. Correspondence: Dr N A M Blackwell, Director of Emergency Department, Mt Isa Base Hospital, Mt Isa, QLD 4825. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Graeme J Kelly · Lee M Lenton

Forty years of plotting for public health The fight to have research results applied to people has as much to do with politics as with science MJA 1997; 167: 587-589 Introduction - Public health and the Anti-Cancer Council of Victoria - The cancer outcomes - Cancer research - Bringing about change -- how it all happened - Conclusion - Author's details - - - ©MJA1997 Introduction Graduating in 1953 introduced me to the fascinating world of 1950s medicine. I spent most of that decade, after very basic training, in the practice of infectious disease, much of the time at Fairfield Hospital -- now defunct. Infectious disease was frightening, if rewarding. Every one of the 150 tracheotomies in which I participated scared me. Infant whooping cough, poliomyelitis, diphtheria, tetanus and meningococcal septicaemia needed urgent management and immaculate nursing. Drama was part of daily life. My research training period in Cleveland (USA) in 1958 and 1959 fortuitously put me in the position of administering the first doses of Ender's measles vaccine given to humans and also of Sabin's type 1 polio vaccine to newborns. I recall follow-up jugular punctures on roughly a thousand black children given Sabin vaccine orally at birth. Visiting these children in their homes in Cleveland required the company of a uniformed nurse, for the safety of my white skin. I greatly enjoyed the experience, the people and my first acquaintance with gospel music on the breakfast program. This period turned out to be one of dramatic progress in the field. By the 1960s we knew we had seen the effective end of polio, diphtheria, scarlet fever, whooping cough, measles, tetanus, and of rubella-affected babies. Pneumococcal pneumonia virtually disappeared; staphylococcal pneumonia and osteomyelitis, which sometimes followed it, became controllable; rheumatic fever and acute nephritis became increasingly rare. Vaccination, antibiotics and sanitation worked quickly, eradicating mortality, morbidity and sometimes the disease itself. I left Fairfield in 1964 for a pleasurable four-year stint at the Royal Children's Hospital and, in 1968, was invited by Bill Keogh to apply for his job as Director of the Anti-Cancer Council of Victoria, as he was finally retiring. He said I would enjoy it and I accepted his manipulation, happy in the conviction that he would never give me bad advice. I was by then well informed about epidemiology and preventive medicine as well as about the treatment of infection. Progress had been rapid but was that not what progress was about? Certainly, I was unprepared for the slow rate of change in the battle against cancer. Public health and the Anti-Cancer Council of Victoria Progress in Victoria and Australia has been both surprising and substantial during my 27-year tenure at the Anti-Cancer Council. My current experience, both as Consultant to the European Institute of Oncology and as President of the International Cancer Union (the global volunteer-based non-government cancer body), tells me that such progress is not uniform, even among rich and developed countries. However, Victoria, like most of Australia, is readily organisable. It has an accessible population of three to four million, prosperous and generous, educated and with good social and physical infrastructure (Melbourne has 150 golf courses -- Milan, where I currently live, has five). It is possible to know or find an approach to almost anyone, and sometimes to see, or meet, the Premier in the main street. The Anti-Cancer Council of Victoria, as a well known charity with over 140 000 donors and a high profile in the press, was particularly well equipped to operate in this favourable environment. The Council played a leading role in the initiation and development of virtually all the Victorian cancer control programs, from the establishment of the cancer registry, the first public education programs, cancer research, the cervical and breast cancer screening programs, sun and skin protection, and -- most difficult of all -- the anti-smoking battle. The Anti-Cancer Council was set up by Act of the Victorian Parliament in the early 1930s as a volunteer-based, non-profit cancer charity. I responded to the Executive Committee, which had most of the powers, and the Finance Committee, both of which were advised by a group of issue-specific volunteer committees staffed by clinicians, research workers, business people, ethnic groups, and many others. I was advised by, and advised, distinguished Chairs of the Executive Committee -- Weary (Sir Edward) Dunlop, Tom Hurley, Max Whiteside and Brian Fleming. David Hume, as Chair of the Finance Committee, tolerated but controlled my preference for programs over financial reserves, and Allan Dick, as President, taught me much about management. Between them these individuals converted my creative opportunism into a series of strategies and, at least sometimes, a proper plan. As the frontispiece, I always had rock solid support and good advice. The cancer outcomes Lung cancer mortality in Australian men has declined by about 15% since the mid 1980s. (Yes, I am still surprised by this one.) This is prevention in its most classical form, working faster than expected on lung cancer but even more strongly on heart disease, for which the cigarette is only one of a galaxy of risk factors. This downturn occurred over three decades after we knew with confidence that most, in fact nearly all, lung cancer was caused by cigarettes. By contrast, the rate in Hungary is double that of Australia, and climbing consistently.1 Cervical cancer mortality is half what it was in the 1960s. The reduction is due to progressively more effective application of the Papanicolaou smear. It took a long time (too long) for the Pap smear to achieve its potential. The quality of the laboratory service was always there, but the mortality reduction owes as much to progressive social organisation over time, aided, in Victoria, by a helpful Parliament. Melanoma in both men and women is relatively curable, but shows a doubling of mortality each decade in most white-skinned populations. Australian mortality has reached a plateau in men and shows a slight downturn in women -- a world first. This is the result of early detection, the achievement of which was apparent in the mid 1980s, when over half the melanomas in the Victorian Cancer Registry were less than 0.75 mm thick. Melanoma mortality will continue to decline in Australia. So, in due course, will the incidence of both this disease and non-melanotic skin cancer as the "Sunsmart" program continues to bite. Although the management of breast cancer has become more patient-friendly, treatment has yet to deliver striking change, although modest improvement is apparent. Mammographic screening offers expectation of a mortality decline (if community practice can be brought to match clinical trials) of 30% or better as the technology improves. Its success is dependent on the participation rate and Victoria already promises to deliver a high one. The social organisation developed for the cervical cancer program, and applied in a very similar way to mammographic screening, is theoretically simple but took years to devise and then to evolve. It is now accepted that a Victorian woman of relevant age will receive through the mail, at appropriate intervals, personalised invitations to visit her doctor and enter a screening program based on the Pap smear and, separately, to visit one of the 40-years-plus mammographic screening centres and enter a breast screening program of similar design, again at appropriate intervals based on her age. I personally regard access to these programs in an affluent society as a human right, much the same as the right to be immunised at birth. Similar rights exist in the United Kingdom and Sweden, but not in Italy, France or Spain, or in the United States. These Victorian programs are of excellent quality. The laboratories and mammographic facilities participate in quality control programs, and the results of cervical and breast screening tests are registered and linked with the Victorian Cancer Registry. Thus, mistakes become apparent, are investigated and further improvements made. Organising such systems is theoretically easy, and can be achieved in Victoria, but nothing is ever as easy as it should be. The ability of the Victorian Electoral Commissioner, at one stage, to withhold the Electoral Register -- which is the only public listing on which invitations can be based -- was an illustrative example of what single-minded obduracy can do. Senior political intervention was necessary, and was available, to circumvent this. Cancer research The Council always spent about half its income on research. It fostered the research establishment and trained many good people, but could not have done so if there had not been good people available to support. Fortunately, since his appointment by Bill Keogh in 1953, we also had Don Metcalf as the jewel in our crown. Appointed as Carden Research Fellow in 1953, our investment in his basic research work on haemopoietic growth factors led to a General Motors Prize, and others, and was never questioned. Had it been, I would have expected a thunderbolt from above fired by my now-deceased predecessor. Clinical research was harder to develop. Stimulated by Max Whiteside, we established the Victorian Co-operative Oncology Group (VCOG) in the late 1970s, and over time it became a force for the conducting of clinical trials, surveys of management and other analyses. Both the Anti-Cancer Council Scientific Committee and the VCOG play important roles in Victorian cancer policy. Bringing about change -- how it all happened I was mildly surprised when David Hill, friend, colleague and Associate Director of the Anti-Cancer Council, accused me at my farewell morning tea of being creative, stylish and farsighted. Farsighted? I saw myself as an opportunistic person but I doubt if my executive committee ever saw me as a long term planner. However it was, and is, important for the Director of Victoria's major non-government cancer body to pick the issues and to know, or to find out, what to do. We never saw it as our job to do everything, but it was our job to bring about change when a public health opportunity in the field of cancer control beckoned. Ignoring a new piece of knowledge was inexcusable. Our broad base of community and scientific support came because people saw us as a way they could contribute to change, and not merely as a source of research funds. The role of opportunism is clearly exemplified by my visit to David White, Minister for Health, in February 1987. The agenda was to tell him the background and basis of mammographic screening, to persuade him that its time had come, and that it should be an organised program, based on a proper pilot project, and that it should not be left happenstance to the private sector alone. He listened and accepted this advice, and said, as we finished, something to the effect that this was a non-election year and it might be possible to do something about tobacco. The easily drafted comprehensive submission branded into my brain over 20 years was soon on his desk, and was read. Thus, opportunistically, began the coalition which was to drive the Victorian Tobacco Act through Parliament on November 17 that year -- one of the most serious political defeats suffered by the tobacco industry. The Victorian tobacco story is long and can only be summarised. Health Warnings, given in 1970 by (Sir) Rupert Hamer over the grumpy opposition of Sir Henry Bolte, converted the Government from being pro-smoking (yes!) to anti-smoking, at least in theory, and saw our views gain their first political respectability. Television commercials voluntarily made by Warren Mitchell (as Alf Garnet), Miriam Karlin and local actor Fred Parslowe were dramatic and effective, particularly when Fred Parslowe's send-up of the Marlboro Country ("Cancer Country") advertisement was censored, as we had planned. We had not planned to have our "respectability" commercial, made by Nobel Prize winner Sir Macfarlane Burnet, censored also, but when it was he was delighted and the headlines were huge. Action then moved to Canberra, where in 1975 Malcolm Fraser gave us a radio and television advertising ban, subverted in the closing minutes of debate by the Country Party with an amendment which was to legitimise sporting advertising and the take-over of sport by the tobacco industry for another 17 years. That simple slick manoeuvre taught us a good lesson. The Victorian Tobacco Act of 1987 banned those forms of advertising susceptible to State control, such as billboards, competitions, giveaways, and applied a hypothecated (earmarked) tobacco tax to Victorian cigarettes. This tax was pioneering legislation, which was quickly copied by South Australia, Western Australia, California, Massachusetts and others. The idea of earmarking tobacco tax for buying back sport had surfaced in my correspondence as early as 1981. This very public non-party-political battle was the single most difficult and testing event of my career, and brought into play all the goodwill, supportive networks and moral courage of the Council's officers, committees and staff. This Victorian campaign started in February 1987 with a detailed plan which involved me meeting weekly or fortnightly with David White. Mark Birrell, a long-time supporter and Liberal Leader of the Upper House (as well as Shadow Minister for Health) was apprised early and planned much of the second half of the campaign. It was understood at the beginning that the hardest hurdle was likely to be the Liberal Shadow Cabinet, in which 11 out of 20 votes were needed in order to carry the party room. The plan required us to persuade Cabinet and the Labor Party by August of the need for a Bill, and for the Bill to be drafted within the Health Department by then. It would then be announced and followed by a 6-10-week public debate, during which time we had to persuade the Liberal Shadow Cabinet and back bench, then generate a vocal lobby as Parliament debated the Bill. The plan was military in style, with set times, targets and marshalled resources. We conducted an opinion poll which showed clearly that tobacco tax increases were popular, that tobacco advertising was not, and that tobacco sponsorship of sport, while less unpopular, could be replaced by a tobacco-tax-funded body (which eventually was the Victorian Health Promotion Fund) without upsetting the voters. This impressed Cabinet and Parliament. The Age , after a visit to the editor (Creighton Burns), published a five-day intensive coverage of tobacco on the requested date (to coincide with a key Cabinet meeting). This gave both sides much publicity and allowed our public health case to be seriously contrasted with the rather ugly and certainly specious case of the tobacco industry. Sir Gus Nossal was hunted down in Japan and agreed, with typical generosity, to accept the Chair of the Victorian Health Promotion Foundation at a critical time. A dramatic television advertisement (entitled "Coroner", and depicting a cigarette packet as cause of death) focused attention and infuriated the tobacco industry, which responded with an advertisement we labelled "Commissar" which painted us, implausibly, as Big Government fascists. Other industry blunders helped. One tobacco company reacted to the announcement of the Bill by asking their large staff to telephone, write or visit their parliamentarians. They blocked the parliamentary switchboard, often leaving the company switchboard as the call-back number, thereby enraging many politicians. Our 140 000 donors were requested to do the same and a large but unknown number did so, somewhat more temperately it seemed, but clearly representing grassroots opinion. We solicited support from innumerable community organisations and were rarely refused. The then Opposition Leader, Jeff Kennett, may or may not have been surprised to receive about 20 calls from senior Liberals, including his Treasurer. They were organised by one phone call to a well connected businessman. Two calls to the Anglican and Catholic Archbishops (men I had never met) triggered contacts from them to five important members of the Shadow Cabinet just before the crucial vote. So the Bill came to Shadow Cabinet, was passed, passed the Liberal Party room, and went to Parliament, where it was the object of a filibuster attempt by the National Party. Mark Birrell merely told them Parliament would sit until the Tobacco Bill had been dealt with. I watched the tobacco industry people leave Parliament about 5:30 pm, visibly angry, and stayed to see the Bill passed by a unanimous Parliament late on the night of November 17, 1987. Afterwards, the tobacco industry took their money away, at least temporarily, from the Liberal Party, and I was mortified to discover it was the equivalent of only about 10 per cent of our research budget. Should we have been spending our money on political party contributions instead of research? In 1990, led by the Democrats, Federal Parliament abolished print advertising after a short but well-designed campaign. In 1992, Federal Parliament provided Australia with exemplary tobacco legislation, although the exemptions for Grand Prix advertising will probably remain until the United States and Europe act on this issue. Conclusion Not all of this was science, but it was public health, and it shows what science has to do if the results of research are to be applied to humanity. While tobacco control is political warfare, mammographic and cervical screening also needed explanation and lobbying, albeit to a sympathetic Parliament. So there will always be a role for an activist mouthpiece for public health which is trusted, supported and advised by the diverse members of the cancer establishment. Why DO research if the results are not used when known? Nigel J Gray European Institute of Oncology, Milan, Italy Peto R, Lopez AD, Boreham J, et al. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 1992; 39: 1268-1278. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Nigel J Gray

MaLAM, a medical lobby for appropriate marketing of pharmaceuticals Peter R Mansfield We can protect scientific medicine from misleading promotion MJA 1997; 167: 590-592 Introduction - How MaLAM began - How MaLAM works - MaLAM and the Third World - MaLAM in Australia - MaLAM in the future? - Acknowledgements - References - Authors' details See also Misleading promotion - - - ©MJA1997 Introduction The Lancet has published 11 pieces about the work of the Medical Lobby for Appropriate Marketing (MaLAM), including three in 1996.1-3 At the international level, MaLAM has become a prominent forum for feedback from health professionals to the pharmaceutical industry regarding the scientific justification of promotional claims.4 More recently, MaLAM has expanded this role in the Australian setting. However, many Australian health professionals know little of this international organisation, based in Adelaide, South Australia.5 Here is the story of how one medical student's idea became an international institution. How MaLAM began In late 1981, I went to Bangladesh to do a medical student elective. There, I saw that, in the context of severe poverty, scientific medicine can achieve great good at little cost (e.g., antibiotics for pneumonia). Consequently, in villages where everyone knows young children who have died, parents will make great sacrifices to buy medicines. I was horrified when I saw that inappropriate pharmaceutical marketing was exploiting these parents' concerns and, at the same time, perverting the objectives of scientific medicine. Examples include the promotion of anabolic steroids and glucose solutions for children with slow growth, tetracycline syrups for children, and breastmilk substitutes. Misleading promotion is an emotional issue. However, it deserves the same calm, rational examination as any other medical issue. David Morley's Paediatric priorities in the developing world suggested that a problem deserves priority if it is common, severe, a cause of community concern and amenable to therapy.6 My personal experience in Bangladesh led me to believe that misleading promotion met the first three criteria. More recently, much good evidence has become available which is relevant to these three criteria (see Box). Interestingly, this evidence comes from the developed world, where the impact of misleading promotion on health is probably less severe than it is in the Third World. However, at the time, the challenge for me was to conceive and then implement a "therapeutic" arm to deal with what had become a personal priority -- the problem of misleading pharmaceutical promotion in the Third World. How MaLAM works During the 1970s and 1980s issues related to pharmaceutical use earned the attention of increasingly sophisticated and effective "consumer critics". However, I perceived a "gap in the market" for an organisation for and of health professionals, representing our interest in protecting quality scientific medical care from misleading promotion. All organisations need feedback to enable them to improve their performance, so pharmaceutical companies need honest feedback from health professionals, as well as from health consumers. Consequently, I designed MaLAM to provide an open participatory forum for dialogue between health professionals and pharmaceutical companies. Having been a member of Amnesty International, I was familiar with that organisation's strategy of coordinated letters: members would be asked to send letters on particular issues to relevant individuals or bodies. I decided to adopt a similar strategy and anticipated that subscribers, via their subscriptions, would cover postage costs. I would provide the "labour" for free, hopefully with volunteer assistance. Before commencing, MaLAM was registered under the South Australian Associations Incorporation Act, which provides a legal basis for good governance and financial accountability for organisations with small or large budgets. MaLAM and the Third World I began publishing our "international" editions in November 1983, with much help from my family and many friends. Most of MaLAM's 53 foundation subscribers were recruited personally or with the assistance of Community Aid Abroad. Health Action International assisted MaLAM to contact health professionals overseas. Some of those contacts later became regional distributors of MaLAM editions to other subscribers in their country or region, thus keeping postage costs at a manageable level. MaLAM editions, produced monthly, usually comprise a newsletter and a letter to a pharmaceutical company about one or more of its promotional claims. Each letter includes a summary of the relevant scientific literature and invites the company to justify or amend its claims. Subscribers also receive a support letter, which they can sign and post to the company so as to request a copy of its reply. Topics are selected from the up to 200 advertisements we receive per month from concerned health professionals. Many MaLAM editions have focused on misleading promotion of drugs, which have an important place when used appropriately but could be dangerous or ineffective if misused. We have also chosen to write to companies when advertising is most seriously at variance with the scientific literature. While it is often difficult to assess how large a role MaLAM played in "causing" improvements, the temporal relationships are usually clear. Our first major success was a letter in 1986 requesting evidence to support the promotion of a mixture of arsenic, strychnine, vitamins and alcohol for stress in Pakistan. The manufacturer announced a withdrawal immediately. In the same year, our editions also became available in French. By 1991, pharmaceutical companies had promised to withdraw 11 drugs after receiving MaLAM letters. The most important of these was a chloramphenicol/streptomycin combination, which had been the top-selling over-the-counter product for diarrhoea in the Philippines. We also published a classification of the quality of "evidence" used by pharmaceutical companies to justify efficacy claims when their advertising was questioned. Some companies provided no justification. Others used the following types of arguments: "endorsement by their own staff", "other companies do the same", "government approval" (without any other evidence), "longstanding use", "endorsement by experts", "animal or in-vitro studies", or "clinical trials" which in fact had major methodological flaws. 18 We believe that pharmaceutical companies are more concerned about their image in "major" markets (i.e., in developed countries) than their relatively small profits from poor countries. Further, because pharmaceutical company executives seem to think in political more often than in scientific terms, it was important for them to know that MaLAM reflects the concerns of large numbers of health professionals rather than a government or fringe agenda. MaLAM's design addresses this by involving large numbers of subscribers in the dialogue as the final quality control step. Subscribers, mostly doctors or pharmacists, now number over 6000, spanning over 30 countries. Accordingly, our impact has increased. MaLAM in Australia In 1992, MaLAM received funding, since increased, but then not renewed, from the federal Department of Health and Human Resources' Pharmaceutical Education Program to enable publication of Australian editions focusing on promotion occurring in this country. This enabled the Secretariat to employ up to one full-time and four part-time staff, although volunteer workers have always been essential. Between June 1993 and August 1996, MaLAM initiated dialogue about the promotion of 17 drugs in Australia. All companies but one have replied. Advertisements for seven drugs that we provided feedback about are no longer used. While the Australian edition appears popular with local subscribers, it is not as effective as the International edition in leading to improvements in marketing pharmaceuticals. The scientific issues are more subtle and the profits involved are greater; companies seem less willing to make improvements. We believe companies have sometimes reacted by interpreting our words in a severe and extreme way, allowing them to criticise easily rather than to respond to our real concerns. Fortunately, some companies seem to understand that listening to "customers" may help them to make more money in the long term. There is an encouraging trend towards a more sophisticated market which will reward quality by favouring drugs that come with reliable information so as to produce the best health outcomes. MaLAM in the future? The quality-use-of-medicine activities,19 the evidence-based medicine movement,20 improving medical education, and the ancient but ever-relevant ideal of doing the best for the patient are all forces supporting better prescribing. MaLAM gains strength from these forces and also tries to assist them. In the future, MaLAM may be able to offer more to health professionals. We would like to increase our contribution to medical education because many subscribers have reported that they find MaLAM a fascinating way to improve their critical-appraisal skills. It is also an interesting way to be up to date on the other side of the story about specific drugs, often at a time of important controversies. For example, our international contacts enable us to draw attention to adverse effects which were well documented in languages other than English before they were listed in the Australian product information. There is also a need for ongoing measurement of the impact of promotion on prescribing, especially the effect of pharmaceutical sales representative visits. If the impact can be measured, then the efficacy of interventions to reduce the harmful consequences of promotion could be tested. While it has been suggested that doctors can learn "to sort the wheat from the chaff",21,22 critical-appraisal skills will not protect against the more subtle methods of influence. Therefore, the best that we can do about pharmaceutical promotion is to try to avoid it or improve it. Personally, I am not in favour of the adversarial approach, and believe that pharmaceutical companies will make improvements if they receive a strong signal from the market. If we work together, then we will be able to protect scientific medicine from Misleading promotion. Acknowledgements I thank Robyn Clothier, Joel Lexchin, and Agnès Vitry for their comments. References Frankel DH. Servier criticised on perindopril campaign. Lancet 1996; 347: 183. Alliot LS. Criticism of Servier re perindopril. Lancet 1996; 347: 837. Vitry A, Mansfield P. Promotion of Coversyl by Servier. Lancet 1996; 347: 1411. Anonymous. MaLAM targets IFPMA. Scrip 1996; 2155: 17. Mansfield P. MaLAM: encouraging trustworthy drug promotion. Essential Drugs Monitor 1994; 17: 6-7. Morley D. Paediatric priorities in the developing world. London: Butterworths, 1973. Wilkes MS, Doblin BH, Shapiro MF. Pharmaceutical advertisements in leading medical journals: Experts' assessments. Ann Intern Med 1992; 116: 912-919. Caradang ED, Moulds RWF. Pharmaceutical advertisements in Australian medical publications: have they improved? Med J Aust 1994; 161: 671-672. Roughead EE. The pharmaceutical representative and medical practitioner encounter: implications for quality use of medicines [master's thesis]. Melbourne: School of Health Systems Sciences, La Trobe University, Aug 1995. Lexchin J, Holbrook A. Methodologic quality and relevance of references in pharmaceutical advertisements in a Canadian medical journal. Can Med Assoc J 1994; 151: 47-54. Shaughnessy AF, Slawson DC, Bennet JH. Separating the wheat from the chaff: identifying fallacies in pharmaceutical promotion. J Gen Intern Med 1994; 9: 563-568. Orlowski JP, Wateska L. The effects of pharmaceutical firm enticements on physician prescribing patterns: there's no such thing as a free lunch. Chest 1992: 102: 270-273. Waud DR. Pharmaceutical promotions. N Engl J Med 1992; 327: 1688. Scott DK, Ferner RE. "The strategy of desire" and rational prescribing. Br J Clin Pharmacol 1994; 37: 217-219. Sutherland M. Advertising and the mind of the consumer: what works, what doesn't and why. Sydney: Allen & Unwin, 1993. Consumers Health Forum Pharmaceuticals Project Final Report. Canberra: Consumers Health Forum, 1995. Denig P, Haaijer-Ruskamp FM. Do physicians take cost into account when making prescribing decisions? Pharmacoeconomics 1995; 8: 282-290. Mansfield PR. Classifying improvements to drug marketing and justifications for claims of efficacy. Int J Risk Safety Med 1991; 2: 171-184. Smith AJ. The quality (of) use of medicines. Med J Aust 1996; 165: 8-9. Ahmed T, Silagy C. The move towards evidence-based medicine. Med J Aust 1995; 163: 60-61. Shaughnessy AF, Slawson DC. Pharmaceutical representatives: effective if used with caution. BMJ 1996; 312: 1494. Black F. Teaching rational prescribing. Aust Fam Physician 1996; 25: 1097-1099. Authors' details Medical Lobby for Appropriate Marketing Inc, Bedford Park, SA. Peter R Mansfield, BM BS, General Practitioner; and Director, Medical Lobby for Appropriate Marketing. Reprints: Dr P R Mansfield, MaLAM, PO Box 172, Daw Park, SA 5041. E-mail: peter.mansfield AT flinders.edu.au - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Peter R Mansfield

Medical planning for the Sydney 2000 Olympic and Paralympic Games Your country will need you MJA 1997; 167: 593-594 - - - ©MJA1997 Introduction Planning for an Olympic Games is in one sense unique. It involves deploying resources (human, logistic and material) on a scale almost unprecedented in peacetime. This is for a transient spectacle that rarely returns to the same country, an event equivalent to holding 28 World Championships simultaneously in one city. It is incumbent on planners for the Sydney 2000 Olympic Games to draw on the wealth of experience already available, both in Australia and other countries. This includes at least 18 scientific manuscripts published (or in press) on activities of the Medical Program at the 1996 Atlanta Olympics;1-19 three of these articles1-3 appear in this issue of the Journal (see Brennan et al., Eaton et al., and Keim and Williams). The International Olympic Committee (IOC) has entrusted the task of staging the Sydney 2000 Olympic Games to the Sydney Organising Committee for the Olympic Games (SOCOG), together with the New South Wales (NSW) Government and the City of Sydney. SOCOG's Medical Program is responsible for facilitating the health and wellbeing not only of the members of the Olympic Family (athletes, officials, administrators, staff and volunteers), but also of hundreds of thousands of spectators at the 35 competition venues. The NSW Department of Health, in collaboration with SOCOG, will administer services relating to public health, medical disaster planning, hospitals and health care interpreters. The Ambulance Service of NSW and St John Ambulance are also key participants. Under the aegis of the IOC Medical Commission, SOCOG, through the Chief Medical Officer, is also responsible for administering both the IOC's doping control program, as well as the gender verification program for women competitors. The Olympic Games are centre-stage for scrutinising the abuse of illegal performance-enhancing drugs, and Australia has a proud record to maintain in the fight against doping. The Australian Sports Drug Agency (ASDA) conducts over 3000 tests annually, either in competition or unannounced. ASDA will provide some training services for the extra personnel needed for the Games. Sydney is also fortunate in already having the Australian Sports Drug Testing Laboratory (ASDTL), the first such facility in the southern hemisphere with IOC accreditation. In conjunction with Sports Medicine Australia, SOCOG will help to organise the 5th IOC Congress on Sport Sciences, to be held in Sydney in November 1999. The Olympic Games provide the opportunity for elite sports medicine research. SOCOG will facilitate a series of biomechanics research projects to be carried out at the Games under the auspices of the IOC Medical Commission. Such projects serve to illustrate that performance can be enhanced by means other than doping. What personnel and resources are needed? We anticipate that planning and implementing the Sydney 2000 Olympic Games Medical Program will require about 4500 volunteers from a variety of health care backgrounds to supplement the handful of salaried SOCOG staff. We also envisage that much of the equipment and consumables will be made available through donation or sponsorship. Volunteers will need not only to have first-rate professional skills, but to be able to work in newly assembled teams in an exciting, if at times stressful and unfamiliar, environment. We hope that many who volunteer for the Olympic Games will also assist at the less "glamorous" Paralympic Games. This large and extraordinary event will involve over 4000 athletes with disabilities participating over 10 days of elite competition. Those who give their time to work with the Paralympic Games will be rewarded with a unique and inspirational experience. From 1998 to 2000, a series of "test events" will be held to evaluate venues and logistics, albeit on a small scale. We plan to begin the call for Medical Program volunteers in mid 1998, with the support of the relevant professional colleges, societies, associations and health authorities. What lessons can we learn from previous Olympic Games? Although many aspects of Olympic medical programs remain constant, operational and logistic factors may vary substantially. For example, compared with Atlanta, Sydney enjoys much closer collaboration between the organising committee and government and also between the Olympic and Paralympic organising committees. Hospital and ambulance services in Atlanta were provided via a series of private hospitals, one of which (Crawford Long Hospital) was chosen for athlete care (as described by Keim and Williams,3). In Sydney, a single State-run ambulance service and designated public hospitals will be involved. Surprisingly for such a large event, in Atlanta there were only 306 ambulance transfers and fewer than 70 hospital admissions from Olympic venues (and similar numbers in Barcelona in 1992). However, the potential impact of the Games on the provision of normal hospital and ambulance services needs to be, and is being, considered during planning. Another major difference between Atlanta and Sydney is the Olympic Village Polyclinic. This will provide general and sports medical care for up to a month for the 15 300 Village residents (athletes and team officials) plus several thousand SOCOG support staff (equivalent to the population of a medium-sized country town). In Atlanta, the Polyclinic was housed in the Student Health Center of the Georgia Institute of Technology together with an adjacent Sports Performance Centre, as the Village used campus dormitories for accommodation (see Eaton et al.,2). In contrast, in Sydney all Polyclinic services will be in one building. We will not have the luxury of a dedicated health care facility, as the Polyclinic is destined to become a primary school for the new Sydney suburb of Newington. This poses interesting challenges in design and fit-out which need to be addressed in detail now. The operational aspects of public health programs, emergency medical care and disaster preparedness in Atlanta are well summarised by Brennan et al.1). We face similar organisational challenges in Sydney, except for the lower likelihood of heat-related illnesses, as our Games will be held in spring. We must prepare for the possibility of a disaster (natural or man-made) either within a venue or outside (as happened in Atlanta, with the Centennial Park bombing, and more recently in Israel, at the Maccabiah Games, where a bridge used by competitors collapsed). The Medical Program in Atlanta was well run, thanks to careful planning, good management and the selfless involvement of thousands of volunteers. Sydney has considerable expertise in medical management of mass gatherings (e.g., the annual City-to-Surf run and the 1988 Bicentennial celebrations). Preparations for the Sydney 2000 Olympic Games began even before the successful bid was announced in 1993, and detailed operational planning is now well under way. In cooperation with government, in consultation with a variety of agencies and individuals, and hopefully with the enthusiastic support of health care professionals from Sydney and throughout Australia, we will achieve the same success at both the Olympic and Paralympic Games in 2000. Daniel Stiel Chief Medical Officer Patsy Trethowan Manager Medical Program Nicki Vance Manager Doping Control Program Sydney Organising Committee for the Olympic Games Brennan RJ, Keim ME, Sharp TW, et al. Medical and public health services at the 1996 Atlanta Olympic Games: an overview. Med J Aust 1997; 167: 595-598. Eaton SB, Woodfin BA, Askew JL, et al. The Polyclinic at the 1996 Atlanta Olympic Village. Med J Aust 1997; 167: 599-602. Keim ME, Williams D. Hospital use by Olympic athletes during the 1996 Atlanta Olympic Games. Med J Aust 1997; 167: 602-605. Anderson GV Jr, Feliciano DV. The Centennial Olympic Park bombing: Grady's response. J Med Assoc Ga 1997; 86: 42-46. Cantwell JD. Role of the cardiologist in the 1996 Olympic Games. Am J Cardiol 1995; 75: 1081-1082. Cantwell JD, James B. Connolly; First modern Olympic champion. J Med Assoc Ga 1995; 84: 41-45. Cantwell JD. An explosion in Centennial Olympic Park! Atlanta Med 1996; 70: 41-43. Cantwell JD. The five Olympic passions in sports and medicine. Atlanta Med 1996; 70: 43-44. Cantwell JD. The Olympic medical experience: an overview. J Med Assoc Ga 1997; 86: 13-14. Cantwell JD. Cardiovascular events in the 1996 Olympic Games. Am J Cardiol. In press. Cohen RW. Doping control in the '96 Olympics. J Med Assoc Ga 1997; 86: 33-36. Elsas LJ, Hayes RP, Muralidharan K. Gender verification at the centennial Olympic games. J Med Assoc Ga 1997; 86: 50-54. Henderson JM. The Olympics in Columbus: a first and a legacy. J Med Assoc Ga 1997; 86: 37-40. Mulherin WB. Soccer at Sanford. J Med Assoc Ga 1997; 86: 25-27. Nettles JL. Reflections on the Olympics: the memories linger. J Med Assoc Ga 1997; 86: 18-19. Sparling PB. Environmental conditions during the 1996 Olympic Games: a brief follow-up report. Clin J Sport Med. 1997; 7: 159-161. Wilkes JS, et al. The Olympic medical experience: venue and command center perspective. J Med Assoc Ga 1997; 86: 47-49. Woodfin BA, Eaton SB, Askew JL. Medical care at the 1996 Olympic Village. J Med Assoc Ga 1997; 86: 15-17. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Daniel Stiel · Patsy Trethowan · Nicki Vance

Medical and public health services at the 1996 Atlanta Olympic Games: an overview Richard J Brennan, Mark E Keim, Trueman W Sharp, Scott F Wetterhall, R Joel Williams, Edward L Baker, John D Cantwell and Scott R Lillibridge Planning for the 2000 Sydney Olympic Games may benefit from the experience of the 1996 Atlanta Olympics. Excellent health promotion and prevention activities before and during the Games resulted in fewer medical and public health problems than anticipated. Despite this, there was room for improvement in the level of communication and cooperation between the many service providers to ensure the most appropriate and efficient responses. MJA 1997; 167: 595-598 Introduction - Medical care at the Olympic venues - Prehospital care - Hospital emergency departments - Public health - Disaster preparedness - Conclusion - References - Authors' details - - - ©MJA1997 Introduction The 1996 summer Olympic Games in Atlanta was the largest event in sporting history. With the influx of over 10 000 athletes from 197 countries and an estimated 2.2 million visitors, there were concerns that the city's health services and infrastructure would be strained excessively. Experience at previous Olympics and other mass gatherings had shown that issues of medical care for athletes and visitors, emergency services, public health and disaster preparedness would need to be addressed.1-6 Major anticipated medical problems included heat-related illness, foodborne and waterborne illness, and sexually transmitted disease. With 35 heads of state expected to attend, as well as many other world political and business leaders, disaster preparedness planning had to include the consequences of a terrorist attack with conventional, chemical, biological or nuclear weapons. We review the medical and public health preparation and services provided for the Atlanta Olympics, with emphasis on aspects relevant to the forthcoming Sydney Olympics. Medical care at the Olympic venues Responsibility for providing medical and first aid services for spectators and athletes was assumed by the Atlanta Committee for the Olympic Games (ACOG). Services were provided at all 35 Olympic sporting venues, at the Olympic Village (athletes' residences) and at Centennial Olympic Park (a community park open to the public). Services were staffed with the help of 4000 medical volunteers, including Red Cross personnel, emergency medical technicians, paramedics, nurses and almost 700 physicians from across the United States (US). A venue medical officer coordinated services at each site. Separate medical services and clinics were provided for athletes and spectators. For athletes, in addition to the Polyclinic at the Olympic Village, there was a medical clinic at each sports venue, coordinated by the athlete medical director. Medical care for spectators was provided by: First responders -- Red Cross volunteers, trained in first aid and basic life support, and stationed in the crowd. Advanced life support teams -- teams of two volunteers, at least one of whom was a paramedic, who could be alerted by first responders. They were able to provide advanced medical care on scene, including defibrillation and endotracheal intubation. First aid stations and clinics -- at each venue, staffed by physicians, nurses, paramedics and emergency medical technicians. Medical care included minor suturing, short-term intravenous therapy and basic analgesia. Clinics were equipped with cardiac monitors and defibrillators with pacing capabilities to facilitate management of cardiac and other medical emergencies before hospital transfer. Not all presenting patients required physician assessment, but all those who were reviewed by a physician had a medical encounter form completed to assist with public health surveillance. During the Olympics, more than 30 000 people sought medical assistance at first aid stations and clinics, and 10 723 were examined by physicians. The most common indication for physician examination was injury (34%); heat-related illness was diagnosed in 10%. The busiest medical facility was the Polyclinic at the Olympic Village, where 2474 Olympic staff and athletes were assessed, with many of those from other countries having routine dental and eye examinations (see Eaton et al., page 599 ). Prehospital care Ambulance services for patients who could not be managed at the Olympic venues were provided under agreements with ACOG by the 37 licensed emergency medical services (EMS) -- private ambulance companies -- that service the Atlanta metropolitan area. In addition, some emergency medical technicians used bicycles and motorised golf carts for rapid movement around heavily congested venues and pedestrian areas. A medical helicopter service was on stand-by. Each of the 37 EMS providers in Atlanta services a different metropolitan region. To facilitate the sometimes poor communication and coordination between these providers and regions, the State Emergency Medical Services Advisory Council issued them with uniform recommendations. These included uniform operational plans and procedures developed for the Olympics, agreements on enhanced lines of communication, protocols for management of heat-related illness, and guidelines for response to a mass casualty incident. A major issue for the emergency medical services was to provide quality care to athletes, spectators and visitors without depleting services to the general population. Most EMS providers cancelled employee leave. ACOG and the Atlanta Police Department developed a traffic plan that outlined expedient ambulance routes, and real-time traffic information was provided to the services. During the Games, emergency medical technicians from Atlanta Fire Services (the main first responders within the City of Atlanta) responded to 2163 emergency calls, an increase of 16.2% over usual. Interestingly, average response times did not increase. Use of medical golf carts in the "Olympic Ring", where most Olympic venues were located, was very successful in overcoming the problems of traffic congestion; average response time was an impressive 2.1 minutes for the 414 calls received (Don Hiett, Atlanta Fire Department, personal communication). One patient was successfully resuscitated after a cardiac arrest. Hospital emergency departments Most Atlanta hospitals began serious preparation many months before the Olympics. Staff were educated on heat-related illness, mass casualty incidents, patient overflow plans, traffic projections, and busy event days. Most medical facilities reviewed their disaster response plans and scheduled extra staff to work during the Olympic period. To optimise coordination of emergency and hospital services in case of a disaster, a baseline survey of Atlanta hospital resources was conducted a week before the Games. This determined staffed in-patient beds, emergency department capacities and specialty services. During the Olympic period, hospitals were asked to telephone or fax information on beds and other resources to the central coordinating centre, which generated an Olympic Bed Report twice daily. Most hospitals cooperated, with 68%-92% responding on each occasion (Ruth De Loor, RN, Area Emergency Manager, National Disaster Medical System Coordinator, Atlanta Veterans Administration Medical Center, personal communication). However, the efficiency and accuracy of this system could have been improved by computerised, real-time monitoring of bed status. Ensuring reliable communications among EMS providers, hospitals and coordinating centres was a major consideration. Extra radios were provided to EMS workers by state and federal sources. A communications protocol was distributed to hospital emergency departments in the week before the opening ceremonies. The major means of communication between hospitals and Emergency Operations Centers were routine telephone and fax lines, but about two-thirds of hospitals also had VHF radios as a back-up. Neither the four metropolitan nor the four non-metropolitan sentinel hospitals had a significant increase in emergency department presentations during the Olympics. The number of patients presenting with unintentional injuries and vomiting without diarrhoea increased slightly. The number seen for heat-related illness in metropolitan hospitals peaked at 18 on the second day of Olympic competition, 20 July. There were no increases in numbers of patients presenting with infectious diseases or with sexually transmitted diseases (STDs). Olympic athletes were referred to a single hospital near the Olympic Village, Crawford Long Hospital of Emory University. During the Games, 43 sought hospital care and 22 of these required inpatient admission (see Keim and Williams). Public health Public health services during the Olympic Games were coordinated by the Division of Public Health within the Georgia State Department of Human Resources. Services addressed the major public health concerns of heat-related illness, infectious diseases, food and beverage safety, and environmental health. Surveillance systems were set up to detect emerging outbreaks of infectious disease and unusual disease and injury patterns, and to measure health service use during the Games. Surveillance: Two complementary public health surveillance systems were established specifically for the Games. Surveillance inside Olympic venues was coordinated by ACOG with the assistance of the Centers for Disease Control and Prevention (CDC). Every physician encounter at Olympic venue clinics and first aid stations was documented, and records were faxed to the Olympic Medical Data Center for compilation and analysis. Daily and cumulative summaries were submitted to the ACOG medical coordinator and to state and federal health officials. Rates of illness could be determined for each venue, as attendance figures provided denominators, allowing health and medical interventions to be targeted. For example, the highest rates of heat-related illness were documented at the beach volleyball venue (24 cases/100 000 attendees) and the Horse Park (19.7 cases/100 000 attendees). This information allowed ACOG and public health officials to increase public awareness announcements at these venues, encouraging spectators to drink more fluids, to seek shade and to recognise the symptoms of heat-related illness.7 No unusual disease outbreaks or illness patterns were detected at Olympic venues. Surveillance outside the Olympic venues was coordinated by the State Division of Public Health. The pre-existing passive system for notification of infectious diseases and other significant conditions was augmented by: Active surveillance of medical presentations at eight sentinel hospitals (four in metropolitan Atlanta and four in other cities hosting Olympic events), with daily data transmitted electronically to the Division of Public Health. Daily reports from the Georgia public health laboratory and the state's busiest private laboratory. Encouragement to physicians and other health care providers to report unusual medical presentations directly to the state Division of Public Health. These data were compiled, summarised and reported daily to ACOG and to state and federal health officials. Heat-related illness: Atlanta's hot, humid summer weather, combined with overcrowding on the streets, on public transport and at Olympic venues, made prevention of heat-related illness a major challenge of the Olympics.7,8 An extensive media public awareness campaign was supplemented by pamphlets sent to ticket purchasers informing them of preventive measures. The Georgia State Division of Public Health, the Red Cross and the Salvation Army combined to provide shelter, water, wide-brimmed hats, fans, sunscreen and prevention information to pedestrians along corridors to Olympic venues. In addition, water misters attached to high velocity evaporative fans were placed at 25 of the most crowded sites to help cool spectators and pedestrians. State health officials distributed guidelines on recognition and management of heat-related illness to EMS providers and hospitals. Heat-related illness was less common than anticipated, diagnosed in only 10% of patients examined by physicians at Olympic venue clinics and first aid stations. This may have reflected the cooler than expected weather: average air temperatures and relative humidities during the 17 days of Olympic competition were 23.4¡C and 83% (0700), 29.4¡C and 63% (1300) and 27.7¡C and 67% (1900),9 and the temperature range was 20¡C to 37¡C (Southeast Regional Climate Center, personal communication). In addition, the impressive promotion and preventive activities probably contributed to the control of heat-related illness. Food safety and environmental health: The enormous influx of visitors made food safety and prevention of foodborne illness critically important. About 150 food and drug inspectors from throughout Georgia and other areas of the US were employed to inspect and monitor food vendors, who were required to comply with strict state health and safety regulations and to have an official licence. General environmental health services, such as water testing, sanitation services and solid waste disposal, were augmented by local and state public health officials. On the first day of Olympic competition, two unlicensed food vendors were detected in the Olympic Village, and were implicated in the development of diarrhoeal disease by two residents. However, food safety precautions were in general highly successful. According to the Department of Human Resources, the Atlanta Olympic Games were the first in the modern era to have no major outbreak of foodborne disease. A mosquito infestation at the Olympic Village was investigated by state environmental health officers and control measures recommended to ACOG. Infectious diseases: A large international gathering such as the Olympic Games may allow intercontinental transmission of microorganisms, which may be drug-resistant. 4 During a previous international sporting event in the US, a measles outbreak was traced to a visiting athlete.5 At the Atlanta Olympics, the active surveillance for unusual presentations and infectious disease outbreaks was designed to allow same-day medical and public health interventions. In addition, physicians and public health workers initiated a safe-sex campaign to limit the spread of STDs. Posters, pamphlets and buttons in 17 languages were used to communicate a "safe sex" message, and 50 000 condoms in Olympic colours were distributed at the Polyclinic. The surveillance system detected no outbreaks of any of the 40 diseases notifiable in the US, nor any increase in STD incidence in the Atlanta metropolitan area. Disaster preparedness Disaster planning was a key component of Oympic preparations. The City of Atlanta and the State of Georgia are prone to natural disasters, such as hurricanes and tornadoes; Hurricane Bertha had threatened the Georgia coast in the week before the Games, and state Disaster Medical Assistance Teams had been placed on alert. However, of greater concern was the potential for a major terrorist attack. The recent bombings in Oklahoma City and at the World Trade Center had shown that the US was prone to major terrorist incidents, while the 1995 sarin gas attack in Tokyo showed that terrorists had access to new weapons. Local agencies and institutions within Atlanta worked extensively on disaster planning. As well as revising disaster plans, many medical institutions developed educational programs to address mass casualty incidents. Over 1700 emergency room staff and prehospital personnel were trained in management of patients exposed to chemical, biological or nuclear agents, and disaster drills were conducted. However, the City of Atlanta and each of the seven counties within metropolitan Atlanta had separate disaster plans, and no centralised coordinating body was established to optimise use of the limited resources. State disaster preparedness was coordinated by the Georgia Emergency Management Agency and the Department of Human Resources. State officials, recognising they lacked the resources to deal with a major terrorist event, especially involving a chemical, biological or nuclear agent, officially requested assistance from federal agencies, including the US National Disaster Medical System. Urban Search and Rescue teams were brought to Atlanta from around the US to assist with extrication and care of victims of, for example, a building collapse. Five-member Disaster Medical Assistance Teams were stationed at key points around the city to facilitate a rapid medical response. The Marines deployed a highly skilled 300-member Chemical-Biological Incident Response Force. Forensic and laboratory services were provided by units from the Federal Bureau of Investigation, the US Army and the US Navy, Environmental Protection Agency, and CDC. In addition, members of these units were stationed at a specially convened Science and Technology Center at CDC to provide expert public health and emergency medical, toxicological and scientific consultation. The responsibilities of US federal government agencies in domestic disaster response are outlined in the Federal Response Plan. 10 For the Olympic Games, a supplementary document, the Federal Consequence Management Response Plan ,11 was developed. ACOG also developed a separate medical disaster plan to address incidents within Olympic venues and the Olympic Village. If a disaster within the Olympic "fence" exceeded the capabilities of ACOG, local, state and federal resources were to be mobilised. The bombing at Centennial Olympic Park on 27 July resulted in two deaths and 111 victims presenting to city hospitals. Most injuries were relatively minor, with only 24 victims requiring inpatient admission. The incident was handled with local resources, and the FBI was the only federal agency to respond. Although the medical care provided to the victims of the bombing was excellent, the incident demonstrated the difficulties of effecting a rapid disaster response despite extensive preparations. Coordination of EMS activities was suboptimal, as excessive numbers of ambulances were dispatched before adequate assessment of the scene, potentially depleting EMS services to other areas of the city and contributing to vehicular congestion around the scene. Fortunately, this lack of coordination had negligible effects on patient care and outcomes (Denis Lockeridge, District III EMS Co-ordinator, personal communication). Conclusion During the Olympics, the sheer volume of people visiting the host city poses significant challenges to medical and public health communities. Meeting these challenges requires the contributions of multiple agencies and service providers. Although there were several significant problems of communication and cooperation between providers at the Atlanta Olympics, the overall provision of medical and public health services was of the highest order. Excellent health promotion and prevention activities before and during the Games resulted in fewer medical and public health problems than had been anticipated. As Sydney prepares for the year 2000 Olympics, Australian health officials could do well to learn from the Atlanta experience. References Baker WM, Simone BM, Niemann JT, Daly A. Special event medical care: The 1984 Los Angeles summer Olympics experience. Ann Emerg Med 1986; 15: 185-190. Weiss BP, Mascola L, Fannin SL. Public health and the 1984 summer Olympics: The Los Angeles County experience. Am J Public Health 1988; 78: 686-688. Thompson JM, Savoia G, Powell G, et al. Level of medical care required for mass gatherings: the XV winter Olympic Games in Calgary, Canada. Ann Emerg Med 1991; 20: 385-390. Stienbecker RS, Steinberg JP, Schwartz B, et al. Evaluation of travelers returning from the 1992 Olympics in Barcelona, Spain: did they acquire resistant pneumococci and meningococci? Clin Infect Dis 1995; 220: 731-732. Ehresmann KR, Hedberg CW, Grimm MB, et al. An outbreak of measles at an international sporting event with airborne transmission in a domed stadium. J Inf Dis 1995; 171: 679-683. Leonard RB. Medical support for mass gatherings. Emerg Med Clin North Am 1996; 14: 383-397. Centers for Disease Control and Prevention. Prevention and management of heat-related illness among spectators and staff during the Olympic Games -- Atlanta, July 6-23, 1996. Morb Mortal Wkly Rep 1996; 45: 631-633. Sparling PB. Expected environmental conditions for the 1996 summer Olympic Games in Atlanta. Clin J Sport Med 1995; 5: 220-222. Sparling PB. Environmental conditions during the 1996 Olympic Games. Clin J Sport Med . In press. Federal Emergency Management Agency. Federal Response Plan. Washington, DC: Federal Emergency Management Agency, 1992. Federal Emergency Management Agency. Federal Consequence Management Response Plan -- 1996 Summer Olympic Games. Washington, DC: Federal Emergency Management Agency, 1996. (Received 8 Jul, accepted 28 Jul, 1997) Authors' details Centers for Disease Control and Prevention, Atlanta, Georgia, USA. Richard J Brennan, MPH, FACEM, Visiting Scientist, Emergency, Refugee and International Health, National Center for Environmental Health; Scott F Wetterhall, MD, Medical Epidemiologist, Office of Program Planning and Evaluation; R Joel Williams, DVM, MS, Epidemiology Intelligence Service Officer, National Center for Infectious Diseases; Edward L Baker, MD, Director, Public Health Practice Program Office; Scott R Lillibridge, MD, Associate Director, Emergency, Refugee and International Health, National Center for Environmental Health. Division of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA. Mark E Keim, MD, Fellow in Disaster Medicine. Headquarters, United States Marine Corps, Washington, DC, USA. Trueman W Sharp, MD, MPH, Preventive Medicine Officer. 1996 Centennial Olympic Games, Atlanta, Georgia, USA. John D Cantwell, MD, Chief Medical Officer. Reprints: Dr R J Brennan, Center of Excellence in Disaster Management and Humanitarian Assistance, 1 Jarrett White Road (MCPA-DM), Honolulu, HI 96814, USA. E-mail: brennanrATwebsite.tamc.amedd.army.mil - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Richard J Brennan · Mark E Keim · Trueman W Sharp · Scott F Wetterhall · Edward L Baker · John D Cantwell · Scott R Lillibridge

The Polyclinic at the 1996 Atlanta Olympic Village S Boyd Eaton, Blane A Woodfin, James L Askew, Blaise M Morrisey, Louis J Elsas, Jay L Shoop, Elizabeth A Martin and John D Cantwell The Polyclinic, staffed mainly by volunteers, successfully provided primary health care during 16 519 patient encounters, 64% involving athletes. However, the profile of patient needs held some surprises. MJA 1997; 167: 599-602 Introduction - Planning, physical facilities and staff - Administration - Special services - Clinical services - Ancillary services - Further considerations - Use profile - Conclusions - Authors' details - - - ©MJA1997 The best way to pay tribute to an illustrious past obviously lies in learning lessons from it to prepare for the future. Baron Pierre de Coubertin (instigator of the modern Olympic Games and first President of the International Olympic Committee) Introduction This report describes the challenges and experiences of operating the Olympic Village Polyclinic, the health centre for athletes and staff during 33 days of preparation for and competition in the 1996 Olympic Games. In Coubertin's spirit, we hope the analysis will be useful to medical care planners for future events, including the Sydney Olympic Games in 2000. Planning, physical facilities and staff The Polyclinic's mission was to care for athletes (3100 women and 7750 men) and Olympic "family" (4500 administrators, coaches, officials, physicians and trainers) living in the Olympic Village. Other personnel (4000 volunteers, 3600 contracted service employees and 1800 security forces) were also given emergency and, when expedient, routine services. The planning committee had 25 members, comprising administrators, trainers, dentists, nurses, optometrists, podiatrists and physicians, and began work in 1992. Several members had been observers at the Barcelona Olympic Games (1992) and the Lillehammer Winter Games (1994) and operated a small polyclinic during the 1994 Goodwill Games in St Petersburg. The Polyclinic was established in the Student Health Center of the Georgia Institute of Technology, under a contract between the Atlanta Committee for the Olympic Games (ACOG) and the Institute. The Health Center is a two-storey building with a floorspace of about 2300m2 renovated in 1994-1996. Personnel from the Health Center formed the nucleus of the clerical and administrative staff, while shifts of volunteers helped meet the demands of 24-hour operation. Overall, 18% of staff were employed (39% of clerical and administrative staff) and 82% were volunteers. The physical facilities and staff of the Polyclinic are shown along with patient numbers in Box 1. Administration Patient reception and medical record storage were adjacent, and cross-trained staff could work in either area. Incoming telephone and facsimile lines were also housed there, but use greatly exceeded expectations and hampered other operations. The admitting area was often congested by non-patients. Patient registration and other paperwork were handled manually, as computerised filing was unavailable. The process would have been improved by optical scanning of bar-coded accreditation, automated generation of encounter forms and computerised generation of epidemiological data. Special services Sports medicine: Physical and massage therapy and athletic training were housed in a separate facility about 750 m from the Polyclinic and handled by athletic trainers and physical therapists supervised by the Village Medical Director. Patients could be referred by team or Polyclinic physicians or could self-refer. In the latter case, they were assessed by an athletic trainer or physical therapist, and any whose condition was in doubt were sent to the Polyclinic for evaluation. There were about 2000 visits for massage therapy and 3000 for physical therapy with, to our knowledge, no inappropriate treatment. Doping control: Two rooms were maintained so athletes unable to void after evening competition could be observed in a central location; these were used nearly every day. Gender verification: This program, mandated by the International Olympic Committee (IOC), was segregated from the rest of the Polyclinic, with a separate entrance so that large numbers of athletes could be processed without congesting clinical areas. All women athletes participated, except those competing in equestrian events (which are mixed-sex) and those who had been gender-certified at previous Olympic competitions. Height and weight were recorded, a photo-identification card was made, and a series of buccal smears were obtained for DNA extraction; the process required about 10 minutes. About two-thirds of gender testing was done over the six days around Opening Ceremonies, when the unit operated from 0800 to 2200. It processed 837 athletes on the peak day. Specimens, identified by number, were sent by bonded courier to the Emory University Genetics Laboratory, in Atlanta, for analysis. A few participants were found to have SRY DNA (generally about one woman in 500 has a Y chromosome) and were further evaluated by a medical geneticist and a female gynaecologist, with prompt, confidential examinations to avoid stigmatisation. No men masquerading as women were encountered, and all participants were cleared for competition. However, in future Games, it may be more efficient for gender verification to be housed at the Accreditation Center rather than at a medical facility. Clinical services Dentistry: A team of volunteer dentists (including an oral surgeon), dental assistants and hygienists served about 910 patients, taking over 500 dental radiographs and performing about 400 fillings (290 amalgam, 110 composite), 84 extractions, 62 endodontal procedures and 14 oral surgical operations. Eye services: Each shift included two optometrists, an ophthalmologist and an optician. The 790 patients were provided with 620 pairs of spectacles and 50 sets of contact lenses. Beyond vision correction, clinical problems included corneal abrasions, conjunctivitis, pterygium, pingueculitis, glaucoma and blepharitis. Three chalazion excisions and one repair of a post-traumatic cicatricial ectropion were performed. Primary care: Patients with general medical complaints were treated by internists (primary care physicians) and family practitioners, assisted by registered nurses. Sprains and strains were the most common conditions (Box 2); those involving athletes were referred to orthopaedic surgeons. Exotic infectious disease was less common than anticipated, with eight cases of malaria (seven had been previously diagnosed), three of hepatitis and one of filariasis. Nine patients requested HIV tests, yielding no positive results. An unexpected amount of time was required for telephone consultation with National Olympic Committee team physicians, most of whom requested notification before their country's participants were evaluated or treated. Establishing these contacts was often difficult. Another time-consuming activity involved patients initially sent to primary care but ultimately referred to specialty care. A triage physician stationed in the admitting area would have improved patient flow. Orthopaedics: 222 patients (70% of them athletes) were treated. Knee injuries were especially common (about 70), equalling in frequency the next three most numerous injuries (hand/wrist, ankle, and shoulder). Orthopaedic supports, especially knee braces, were in short supply; a larger stock (starting each day with 6-8 in each size) would have been desirable. Twelve arthroscopic procedures, chiefly meniscectomies and cruciate ligament reconstructions, were performed off site by Polyclinic orthopaedic surgeons during the Games. Other specialty care: Unexpectedly few gynaecology patients (25) were treated, despite a record number of women athletes and staff. A contributing factor may have been the presence of some male gynaecologists; several patients refused services on learning the physician on duty was a man. One athlete was unexpectedly found to be pregnant. Similarly, surprisingly few patients availed themselves of the psychiatry/sports psychology service, and no visits were related to the Centennial Park bomb explosion. However, the encounters that occurred emphasised the service's importance. One athlete became overwhelmed by the prospect of Olympic competition, deciding to return home prematurely, but after psychological intervention successfully advanced to the quarter-finals. In another case, emergency treatment was needed for an acute psychotic breakdown. Podiatrists saw over 200 patients and dispensed modified orthotic devices for 65. Dermatologists treated 112 patients, while nearly 240 additional patients with skin disorders were treated by primary care physicians. Otolaryngologists saw 110 patients; two rooms were originally designated for otolaryngology, but one was sufficient, and the other was used for eye services. Emergency medicine: 24-hour emergency care was provided. Each shift comprised one emergency physician and two ambulance-based paramedics, with two registered nurses during the day, but only one at night. A night-time clerical support person would have been very helpful. Patient numbers ranged from 4 to 22 (night) to 3 to 9 (day). Chest pain, lacerations, abdominal pain, multisystem trauma, head injuries, and seizures were common presenting complaints. Heat-related conditions, often problems at outdoor events, were uncommon (29 cases). Communication with National Olympic Committee team physicians, competition venues, referral hospitals, the medical command centre, and especially with ambulance crews, was a vital emergency physician function. About 125 patients were transported from the Village to one of two nearby Olympic-affiliated hospitals. Of these, about a third were dispatched directly from the pick-up point, while the rest were first evaluated at the Polyclinic. About 70% of patients sent to area hospitals were discharged after evaluation. Ancillary services Pharmacy: Pharmacists were present 18 hours per day; emergency call-back was available but unnecessary, as drugs in the emergency room were adequate for night-time needs. All drugs in the IOC-approved drug formulary were stocked, while restricted and prohibited drugs were stored separately and flagged in the pharmacy computer to prevent inappropriate dispensing. Just over 3600 prescriptions were filled, with a one-day high of 219. Ibuprofen, amoxycillin, naproxen, acetaminophen, cimetidine, clotrimazole, diazepam, terfenadine, guaiphenesin/dextromethorphan and phenol/menthol lozenges were most commonly dispensed, but 282 different preparations were ordered at least once. Clinical laboratory services: Laboratory services were available from 0700 to 2300 during the first 10 days and around the clock thereafter, requiring 10 technicians to work overlapping shifts. About 500 patients were referred for 937 tests, including complete blood counts (213), biochemical profiles (129), urinalyses (114), group A streptococcal screens (42), and erythrocyte sedimentation rates (33). A fifth of all ordered tests were performed at a nearby laboratory (e.g., stool sample culture/sensitivity or "ova/parasites", thyroid profiles and microscopy of malaria smears). Imaging services: In preparation for the Games, the Health Center's radiography room was updated to allow digital acquisition and processing of radiographs. Sponsoring manufacturers provided ultrasound equipment and a mobile magnetic resonance imaging (MRI) unit (placed in a nearby car park). Teleradiography links were established with two Atlanta hospitals. Imaging included 744 radiography examinations on 634 patients (about 60% athletes), with 50 examinations on the peak day; 204 MRI studies (mostly musculoskeletal); and 112 ultrasound studies (about half musculoskeletal). Further considerations Language services were provided by translators, generally via "speaker" telephones; 31 languages were available and service was always provided within 45 seconds. Although translators were not specially trained in medical terminology, it was always possible to obtain adequate histories and other necessary clinical data. As the security cordon around the Village complicated resupply, an individual was assigned logistical responsibility. He became familiar with the elaborate (and frequently changing) protocols for moving supplies and equipment into the Village after "lock-down", and developed a good relationship with logistics and security officials. Thus incorporated into the system, the Polyclinic was able to procure necessary matŽriel despite the burdensome bureaucracy, even when unanticipated needs arose. The possibility of terrorism was considered during planning. Polyclinic personnel received instruction on bomb blast injuries and care of chemical/biological warfare victims. The pharmacy stocked pralidoxime chloride and atropine for treating nerve gas poisoning. A facility was prepared for hosing down individuals contaminated with gas or radio activity. Atlanta's chiropractic community offered to provide services in the Village. This proposal was referred to the IOC Medical Commission, which, in keeping with previous Olympic practice, ruled against accepting the offer. Use profile Use of the Polyclinic followed the Seoul/Barcelona pattern: operations began 13 days before Opening Ceremonies and extended for three days after Closing Ceremonies. The slow first week was invaluable; equipment was tested, personnel became familiar with the system, supply deficiencies were corrected and unexpected problems were addressed. Thereafter, volume increased to a plateau extending from before Opening Ceremonies to the end of the first week's competition. Use gradually declined until Closing Ceremonies, and then fell rapidly. Demand for MRI and ultrasound imaging increased steadily. Conclusions Most Polyclinic staff were volunteers, who provided commitment and enthusiasm, as well as expertise. However, most were unable to serve throughout the Games, which meant personnel varied from day to day, introducing confusion and inefficiency during the early stages and hindering effective communication. However, although using fully contracted staff may have avoided these problems, we believe the esprit de corps provided by volunteers far outweighed the inconveniences. Interaction with public health officers was more important than originally anticipated, requiring near-daily communication between Polyclinic physicians and the public health team, chiefly about potentially communicable diseases. Athletes, and especially Olympic "family", could be regarded as taking advantage of the opportunity to obtain free eyeglasses and dental fillings. Perhaps providing these has become an unstated obligation of the host city; clarification with the IOC Medical Commission is probably in order. No amount of preparation can anticipate all contingencies, so a flexible outlook is essential. While the 1996 Polyclinic usually adjusted appropriately, triage was a failure. The need for a physician to direct patient flow became apparent immediately, but schedules could not be revised to allow this. In contrast, the eyecare team was able to successfully reorganise procedures for spectacle delivery when it became apparent that the original plan was inadequate. While aspects of its organisation and function could have been improved, the Polyclinic achieved its most important objective - providing medical services during 16 519 overall encounters, 10 641 (64%) of which involved athletes. With respect for the sentiments of Baron de Coubertin, and in the Olympic spirit, we hope this report will help health care personnel charged with like responsibilities in the future to approach the optimum more closely. (Received 25 Mar, accepted 26 Sep, 1997) Authors' details Olympic Village, Atlanta, Georgia, USA. S Boyd Eaton, MD, Polyclinic Medical Director; Blane A Woodfin, MD, Village Medical Director; James L Askew, MD, Village Medical Coordinator; Blaise M Morrisey, MHA, Polyclinic Administrator; Louis J Elsas, MD, Gender Verification Director; Jay L Shoop, ATC, Sports Medicine Director; Elizabeth A Martin, PT, Medical Services Program Director; John D Cantwell, MD, Chief Medical Officer, Atlanta Committee for the Olympic Games, Atlanta, Georgia, USA. Reprints: Dr S B Eaton, Suite 110, 3193 Howell Mill Road NW, Atlanta, Georgia, 30327 USA. E-mail: sboydeatonATaol.com - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Blane A Woodfin · James L Askew · Blaise M Morrisey · Louis J Elsas · Jay L Shoop · Elizabeth A Martin · John D Cantwell

Hospital use by Olympic athletes during the 1996 Atlanta Olympic Games Mark E Keim and Dianne Williams Only 43 athletes presented to the hospital at the Atlanta Olympics; their conditions fell within the range routinely seen in modern hospitals. MJA 1997; 167: 603-605 Introduction - Hospital preparation - Presentations - Investigations - Course in the Emergency Department - Course during hospitalisation - Planning for future Games - References - Authors' details - - - ©MJA1997 Introduction The Centennial Anniversary Olympic Games in Atlanta, Georgia, in the summer of 1996 was the largest gathering of athletes for any event in history. Over 10 000 athletes from 197 countries converged on Atlanta. Support services, including medical care, were provided by the Atlanta Committee for the Olympic Games (ACOG). Primary medical and dental care was provided by the Polyclinic in the Olympic Village (a closed compound on the campus of the Georgia Institute of Technology) (see Eaton et al.). Medical evaluation or treatment beyond the scope of non-emergency outpatient care was referred to a nearby hospital, Crawford Long Hospital of Emory University. This 600-bed hospital is located within five blocks of the Olympic Village and within three kilometres of the Olympic Stadium. It was selected by ACOG as exclusive provider of outpatient emergency medical services and hospitalisation for athletes. ACOG also made agreements with local ambulance providers for emergency medical services and transport of athletes to the hospital. Crawford Long Hospital sought advance information on athletes' medical needs at the Olympics, but little has been published on this topic. Only recently have articles on public health and spectator medical care at the Los Angeles, Calgary and Barcelona Games been published.1-4 To our knowledge, no reports have focused on the specific medical needs of athletes at the Olympics. Therefore, we conducted a retrospective review of the hospital records of all Olympic athletes presenting to hospital in the period around the 1996 Atlanta Olympics (July 14 to August 7, 1996). Hospital preparation Armed security was provided for athletes by the hospital security force, which comprises fully deputised public law enforcement officers with full jurisdiction to arrest and detain suspected law violators. The watch around the hospital perimeter and on all hospital property was increased. In the Emergency Department, athletes were evaluated in private rooms with an armed sentry outside the door at all times. During hospitalisation, athletes were housed on a single floor with access restricted by armed security. The placement of sentries in the outpatient diagnostic centre during athlete outpatient visits was not documented. The hospital organised interpreting services with a language translation telephone service provided by IBM, as well as with local multilingual volunteers. Presentations Forty-three Olympic athletes presented to the hospital between 14 July and 7 August 1996; 31 of these presented to the Emergency Department (about 0.31% of all Olympic athletes), with 14 subsequently admitted to hospital. Another eight were admitted after direct referral by team or Polyclinic doctors, and four were referred for outpatient diagnostic services -- bone radioscintigraphy, computed tomography, and magnetic resonance imaging. Numbers of presentations per day ranged from zero to six, peaking on 24 July. No athletes presented after the bombing of the Centennial Olympic Park on 27 July, which killed two people and injured 111. Further, Crawford Long Hospital received few victims despite its proximity to the Park, due in part to a community triage system designed to keep facilities in reserve in case of a secondary attack on athletes. The presenting athletes comprised 16 women (37%) and 27 men (63%), with age range 16-36 years (mean, 24.7 years). Hospital presentations according to competitive event are shown in Box 1; the highest numbers were for participants in boxing, wrestling and track events (five each). The most frequent countries of origin were Australia (four) and Russia, South Africa and South Korea (three each). Fifteen patients (35%) required interpreters. Twenty-two athletes arrived by ambulance. Venues most often needing ambulance transport were boxing (four athletes), track-and-field and cycling (three each), and judo (two). Twenty-two athletes underwent some degree of formal medical evaluation before arriving at Crawford Long Hospital; three of these were evaluated in hospital emergency departments closer to the venue where the injuries occurred, but were then transferred by ambulance to Crawford Long Hospital. No extra security was arranged for this transfer. Most complaints (30; 70%) were described as caused by a sport-associated injury. For 20, the injury occurred during competition and, for seven, during training (time of others was unknown). Ten cases were associated with exacerbation of pre-existing illness or injury, most commonly degenerative disc disease (four), followed by patellar tendinitis and jaw fracture (two each). However, 24 athletes denied any significant past medical history. Investigations Most diagnostic work-ups in the Emergency Department and in hospital were routine. Laboratory studies included 22 complete blood counts, 17 urinalyses, 27 biochemical profiles, microscopy of one malaria smear, and serological tests for dengue fever virus and ehrlichiae. Other investigations included 29 radiographs, six computed tomography (CT) scans of the head, one magnetic resonance imaging (MRI) study of the knee, one bone radioscintigraphy (BRS) study of the leg, three electrocardiograms, one echocardiogram, one pelvic ultrasound examination, and one radionuclide heart scan. In addition, outpatient radiological studies were provided for four athletes: CT scan of the spine for one athlete with back pain (showing no abnormalities), MRI of the ankle for another (showing a tarso navicular fracture), and BRS of the leg for two (showing stress fractures of the femur and tibia, respectively). Course in the Emergency Department Primary diagnoses of the 31 athletes who presented to the Emergency Department are shown in Box 2. Most conditions were trauma-related (23; 74%); none were considered life-threatening. The most common primary diagnosis was concussion (four). Sixteen (52%) were discharged home, while one left without being evaluated after having been referred for an orthopaedic brace. (The athlete did not require medical evaluation but requested only the brace. Hospital policy required evaluation by a physician before goods or medications could be dispensed.) Course during hospitalisation Diagnoses on discharge for the 22 athletes admitted to hospital are shown in Box 3. These athletes spent a total of 37 days at Crawford Long Hospital. Two had same-day surgery (knee arthroscopies) without an overnight stay, and 14 had one-day stays. The longest stay was five days (one patient with malaria with thrombocytopenia, and another with a radius fracture requiring open reduction and internal fixation). There were no complications during hospitalisation. Apart from one appendicectomy, all surgical procedures were orthopaedic (including knee arthroscopy, open reduction and internal fixation of radius, subtotal meniscectomy, three tendon repairs [two patellar and one Achilles], and a closed-reduction of the mandible with wiring). Only one athlete required overnight cardiac monitoring, and none required critical-care facilities. All but one of the hospitalised athletes were discharged home. The exception, who was admitted with fever and a thigh abscess, checked out of the hospital against medical advice after a one-day stay. Planning for future Games The medical and surgical needs of athletes at the Atlanta Olympics fell within the range encountered routinely in modern hospitals. The secondary care of athlete patients required no extraordinary equipment or facilities. However, the situation generated some special needs which warrant consideration by future planners of medical care for Olympic athletes. These include the need for:* A comprehensive memorandum of agreement with ambulance services to allow for a catchment area that includes all athlete activities, including leisure activities, throughout their stay; * A continuous chain of security that includes prehospital transport, outpatient studies, emergency department and inpatient hospitalisations; * An easily accessible language translation service; * Ready availability of hospital-based clinicians, including emergency medicine specialists, orthopaedic surgeons, internists (general physicians), radiologists, neurosurgeons, oral surgeons, cardiologists, general surgeons, and anesthetists; * A small outpatient dispensary as a back-up to provide athletes with medical equipment and supplies not readily available at primary medical facilities; and * A hospital emergency contingency plan that includes response to an attack against athletes and is coordinated with the community response. References Baker WM, Simone BM, Niemann JT, Daly A. Special event medical care: the 1984 Los Angeles summer Olympics experience. Ann Emerg Med 1986; 15: 185-190. Steinbecker RS, Steinberg JP, Schwartz B, et al. Evaluation of travelers returning from the 1992 Olympics in Barcelona, Spain: did they acquire resistant pneumococci and meningococci? Clin Inf Dis 1995; 220: 731-732. Thompson JM, Savoia G, Powell G, et al. Level of medical care required for mass gatherings: the XV winter Olympic Games in Calgary, Canada. Ann Emerg Med 1991; 20: 385-390. Weiss BP, Mascola L, Farnin SL. Public health and the 1984 summer Olympics: The Los Angeles County experience. Amer J Pub Hlth 1988: 78; 686-688. (Received 8 Jul, accepted 26 Sep, 1997) Authors' details Division of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA. Mark E Keim, MD, Disaster Medicine Fellow. Crawford Long Hospital of Emory University, Atlanta, Georgia, USA. Dianne Williams, RN, MSN, Emergency Department Director of Nursing. Reprints: Mark E Keim, MD, Division of Emergency Medicine, 69 Butler Street, SE, Atlanta, GA 30303, USA. E-mail: mkeimATemory.edu - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Mark E Keim · Dianne Williams

Funding Australia's health and medical research A commitment to improving health through high quality research MJA 1997; 167: 608-609 In 1996, the National Health and Medical Research Council's research expenditure was approximately $142 million.1 According to official estimates, this is about a quarter of Australia's total outlay on health research.2 With this level of expenditure, it is reasonable to ask what we gain from this investment. In this issue of the Journal, Bourke and Butler show that in 1995 Australian research provided about 2.5% of new knowledge in medicine and the health sciences (Australian research produced 18390 publications, which were cited over 88000 times), a contribution that has strengthened in recent years.3 This is tangible evidence of our commitment to improving the health of people not only in Australia but in other countries. In one sense, this health research commitment is similar to our other international commitments, such as preserving world heritage areas or reducing emissions of gases causing ozone depletion. Apart from this international contribution to knowledge and new discoveries to improve health, research also benefits Australia itself. For example, health care practitioners with research training are of key importance in ensuring that Australian clinical practice is effective and of high quality because they can access, sift and digest new research findings here and elsewhere. Researchers active in public health are needed to provide informed advice on the benefits and costs of proposed public health measures; for example, the detection and prevention of cancer and cardiovascular disease. The strong base of Australian medical research is also helping to build our biotechnology industry. Finally, and less tangibly, Australians derive satisfaction and pride through the achievements of their health researchers, just as they are proud of high achievers in sport and the arts. The NHMRC now provides research funds across the spectrum of health and medical science via a single Research Committee formed in 1997 by a merger of the Medical Research Committee and the Public Health Research and Development Committee. As the largest single provider of peer-reviewed health research funds for the public good, the NHMRC has the responsibility of ensuring that Australia's health research effort is of high quality: the Research Committee provides funds on the basis of excellence (as judged by peer review), strives for fair, open and competitive processes, considers funding applications in all areas relevant to health, and attempts to ensure that research findings are translated into better health and health care delivery. Health research is conducted mainly in universities, hospitals and medical research institutes (Box 1, above). About 30% of total NHMRC research support is provided to medical research institutes, about half of which is via block funding to five institutes. Box 2 shows the support won by institutes receiving over $1 million, those which are block funded, and the proportion of institute funding going to each State (for institutes receiving over $100 000). NHMRC funding to the major universities is shown in Box 3. The Government provides additional support for hospital and university research via salaries for researchers doing academic or clinical research as part of their teaching and clinical duties, but this does not occur for all research institutes. The institutes also play a valuable role in gaining additional support for health research from private corporations and individuals. The report by Bourke and Butler3 shows that the medical research institutes produce some of our most highly regarded research. Ten of the 12 most cited Australian biomedical research articles are associated with institutes, and the overall citation rate for publications from institutes is impressively high: medical research institutes publish about 13% of all Australian health research articles, and these account for about 21% of the total citations of Australian health research. Underfunding the institutes would jeopardise this high quality output. Bourke and Butler comment that their results raise issues of the efficacy of block funding,3 but stress that conclusions about funding methods require further bibliometric studies. The NHMRC's Research Committee is actively reviewing all aspects of research support, including issues in block funding, such as how best to review institutes and how to increase competition between institutes. Some will argue that the data of Bourke and Butler show that substantial, longer term research support (e.g., block funding) is required in order to achieve the highest impact research. Others will point to examples such as St Vincent's Institute for Medical Research in Melbourne to argue that institutes can achieve outstanding publication results without block funding. The NHMRC supports a pluralistic system because the aims of health research extend well beyond quality research publication. It currently supports three-year project grants (about 48% of the current total NHMRC funding), and five-year program grants (9% of total NHMRC funding) and block grants (13% of total NHMRC funding) to provide for longer term research commitments. New researchers are supported via scholarships and postdoctoral awards (about 9% of funding), and outstanding individuals are supported by Fellowships (11% of funding, exclusive of Fellows on Programs and at block-funded institutes). Nothing in science or medicine is immune to change. The NHMRC's research support system must accord with the ways in which research is currently conducted and be relevant to contemporary health needs. One exciting plan for the triennium 1997-1999 is the introduction of multidisciplinary Health Research Networks in important health areas. This scheme will involve researchers at different locations working collaboratively on research in areas of major health importance. Part of the aim is to capitalise on the merger of the Medical Research Committee and the Public Health Research and Development Committee by creating teams of biomedical, clinical and public health researchers. The Networks will focus on effective delivery of health care or prevention. They will thus be integrated research teams (as in the NHMRC Program Grants Scheme), but multisite and multidisciplinary. Interestingly, Bourke and Butler's article3 shows that research collaborations, both local and international, are growing strongly. The NHMRC-sponsored Networks scheme acknowledges this trend and will help to build new collaborations. Bibliometric data are important for monitoring Australian research. We also need better indicators of the other outcomes of research (such as discoveries which benefit health or reduce health costs, better-informed medical and public health decision making, a vibrant biotechnology industry, and new generations of trained researchers in all areas) so that we can assure the Australian community that its financial investment in health and medical research is well placed. Warwick P Anderson Professor and Chairman, Research Committee (Public Health and Medical) National Health and Medical Research Council, Canberra, ACT National Health and Medical Research Council. 1996 Annual Report. Canberra: AGPS, 1997. Australian Institute of Health and Welfare. Health Expenditure Bulletin No 13, July 1997. Bourke PF, Butler L. Mapping Australia's basic research in the medical and health sciences. Med J Aust 1997; 167: 610-613. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Warwick P Anderson

Mapping Australia's basic research in the medical and health sciences Paul F Bourke and Linda Butler The Institute for Scientific Information indexes most of the major international basic research journals in science in the Science Citation Index (SCI). Australia's presence in the medical and health sciences journals in the SCI and the citations its published research receives in these journals show that Australia's basic medical research has high international "visibility". Mapping the source of the most highly "visible" Australian medical research articles shows high impact research coming from several different sectors (research institutes, universities, hospitals, etc.), but with a concentration in the member institutions of the Australian Association of Medical Research Institutes (AAMRI). Published research from the AAMRI is cited at a rate two-thirds higher than the Australian average for medical and health sciences. (MJA 1997; 167: 610-613) Introduction - Data source - To what extent is Australian basic research in the medical and health sciences covered by the REPP database? - Where is the research being conducted? - Are patterns of medical authorship changing? - How "visible" is Australian medical research? - Where is Australia's most "visible" medical research being conducted? - Where are Australia's most highly cited medical articles produced? - Discussion - References - Authors' details - - - ©MJA1997 Introduction A very high proportion of the articles reporting the results of basic research in the medical and health sciences are in the journals indexed by the Institute for Scientific Information (ISI) in the Science Citation Index (SCI). The SCI is therefore an excellent tool for identifying the sources of Australian published research in this field, while the citations received by (or references to) these articles can also be used to identify the source of the most-cited research. We have focused on Australia's basic research output, not its applied research. Data source The Research Evaluation and Policy Project (REPP) at the Australian National University (ANU) has constructed a database of all Australian research published in ISI-indexed journals for the period 1981-1995. This database has been well documented in several of our published studies, and a description is available on the Internet.1,2 Our analysis of this database is based on the addresses shown on the publications, which we have "cleaned" down to the level of university department. This has been done by ensuring all variants of a departmental, faculty or institutional address (sometimes running into hundreds) are grouped together and given the same "standard" address. The database also contains details of the citations in ISI journals received by these Australian research articles; that is, the number of times Australian articles are in the reference list of other ISI journal articles. We also code the sector -- universities, hospitals, medical research institutes, government institutions, and "other" -- of each address. The medical research institutes sector comprises the 25 members of the Australian Association of Medical Research Institutes (AAMRI). Medical research in the Government sector comes primarily from the Commonwealth Scientific and Industrial Research Organisation (CSIRO) and the State and Federal departments of health. The "other" sector includes industry and non-profit organisations. We acknowledge "grey areas" at the margins of these assignments to sectors. For example, where a research group based in a hospital with a university connection lists the university in the address, we consistently assign the publication to the university. Another example is the John Curtin School of Medical Research (JCSMR), a full-time medical research institute (though not a member of AAMRI), which is also a research school of the ANU funded from that university's operating grant. Its publications are assigned to the ANU and hence fall within the universities sector. Most publications can be unambiguously assigned, but some addresses are not precise guides to the source where the research was conducted. This arises particularly for researchers who hold conjoint or adjunct appointments in two institutions. If such an author nominates a single institution, we accept that this is the location of the research leading to that publication. If an author specifies two separate addresses, two records are created for that publication showing the two institutions (double-counting created by this procedure is removed for sectoral and national analysis, but remains when the individual institution is the focus of the analysis). If the address itself has multiple components, the publication can not be split into multiple records and has to be assigned to the apparent primary institution. Very few publications fall into this latter category, and their existence has little effect on the map of national, sectoral or institutional sites of research. We have used the standard bibliometric practice of ascribing an article to a particular field of research on the basis of the classification of the journal in which it appears. This procedure is not without problems, particularly in the case of analysis at the subfield level, but experience from our other studies has shown that the results are accurate if the data are being used to map research in a large field.3 To what extent is Australian basic research in the medical and health sciences covered by the REPP database? In this field, at least 70% of published research output from universities and medical research institutes is in the form of journal articles, and, of these, at least 70% appear in SCI journals.4,5 We therefore estimate that, as a minimum, the REPP database covers 50% of the published output in these two sectors. SCI coverage of research from the sectors hospitals and government institutions may be less complete in terms of their total research output, but their contributions to basic research will be well represented. In this article, we are using the REPP database to answer questions about the map of medical research in Australia, concentrating primarily on publications from 1990 onwards, but also introducing some time-series analysis. Where is the research being conducted? The sectoral distribution (Figure 1) shows that the bulk of Australia's basic medical research is located in universities and hospitals. Most of the research articles from the universities sector (75%) come from the 10 teaching medical schools and the JCSMR at the ANU. Our data also show that little has changed in the sectoral location of research over the past 15 years: the share of publications from the hospitals sector has remained constant, there has been a small drop in the universities share, and there has been a corresponding increase in the share from the medical research institutes. Are patterns of medical authorship changing? The REPP database enables us to distinguish publications by type of authorship, viz: Single author -- one author only (i.e., no collaboration); Group -- more than one author but sharing the same departmental address; Institutional -- more than one author from different departments/faculties; National -- more than one author from different institutions in Australia; and International -- more than one country listed in the author addresses. Figure 2 shows how the type of authorship of medical research articles has changed in the past 15 years. The two authorship types showing marked decline are "single author" articles, and "group" articles. Medical and health sciences in Australia appeared slow to exhibit the "internationalisation" of research apparent in other fields since the early 1980s, but the period since 1987 has seen a dramatic change. The proportion of publications involving international collaboration nearly doubled between 1987 and 1995. Collaboration with other Australian institutions has also become more common, increasing from 19% to 26% over the 15-year period. (A detailed analysis of Australia's international collaboration in basic research may be found in a monograph we prepared for the Australian Research Council.6 ) How "visible" is Australian medical research? We assess "visibility" by the number of research articles published and the citations those articles receive. Figure 3 plots Australia's share of "world" publications (i.e., of the total in the SCI) in the medical and health sciences and its share of all citations in SCI journals. The chart also plots Australia's Relative Citation Impact (RCI), which is calculated by dividing its share of "world" citations by its share of "world" publications. The most notable feature of this Figure is that Australia's share of publications in SCI medical journals increased by 25% between 1986 and 1995. The average RCI for the whole period was 1, indicating that Australian publications are attracting appropriate notice. Australia's RCI has not changed significantly over time, but remained at or marginally above 1. This is a strong performance as citation rates are influenced principally by publications from the major research centres of America and Europe. Where is Australia's most "visible" medical research being conducted? A standard measure used to compare the visibility of research in different sectors is the average number of citations received per publication (cpp). In Box 1 (below) we relate the number of publications produced by each sector in the period 1991-1995 to the number of citations those publications attracted in the same period. The leading position of the institutes making up the AAMRI is consistent with Richard Smith's impression of Australia's research institutes.7 Some of the differences in cpp rates can be attributed to the varied research profiles of different institutions. Data supplied by ISI enable us to quantify this, as we can calculate cpp rates for sets of journals. For example, articles in immunology journals for the same period attracted citations at the average rate of 6.21, while those in clinical sciences journals averaged 3.81. We would therefore expect hospitals, with their strong clinical focus, to have a lower cpp rate than those AAMRI establishments with a strong presence in immunology. However, the difference in cpp rates apparent in Box 1 (above) cannot be explained fully by differences in field concentrations; we calculate that differing citation rates across fields account for only a third of the gap in cpp rates between the AAMRI institutions and other sectors. The remainder is a measure of the differing visibility and impact of the research. Not all institutions within a given sector have similar visibility. In Box 2 we list the top five institutions (in terms of cpp rates) in each of the four sectors active in medical research. In the universities sector, we looked specifically at the teaching medical schools and for this reason have excluded JCSMR. The institutions in Box 2 are those with more than 100 SCI publications in the period. In this instance, we count publications in multidisciplinary journals such as Nature, Science and Proceedings of the National Academy of Sciences together with publications in medical and health sciences journals, on the assumption that for the listed institutions and faculties these articles would almost certainly relate to medical research. Sorting the institutions in Box 2 by cpp rates within sectors has the effect of allowing volume of publications to be moderated by impact. The consequences of the choice of the measure on which to rank institutions can be seen by a closer examination of the medical research institutes. While the Walter and Eliza Hall Institute of Medical Research has the largest number of publications and citations, and would be ranked first if these were the measures used, the Ludwig Institute for Cancer Research is top-ranked on the basis of average cpp rates. All three are measures of impact and visibility, but cpp rates take institutional size into account. We looked at the research focus of institutions to determine if the higher cpp rates of some institutions resulted from differing fields of concentration. Again, we found that while an institution's cpp rate was affected by the relative impact of the fields in which it was active, this accounted at most for only 30% of the variation in cpp rates between institutions in any given sector. Where are Australia's most highly cited medical articles produced? We identified a very small group of 12 articles, published since 1990, which have attracted more than 200 citations (Box 3). This Box does much to explain the ranking of the AAMRI institutes in Box 2. The Ludwig Institute for Cancer Research had only 135 publications satisfying our criteria of publication date and journal, yet three of these have attracted more than 200 citations. St Vincent's Institute of Medical Research had even fewer publications (130), but claimed authorship of the most highly cited publication for the period, with 551 citations, and another article with 256 citations. Seven of the listed articles, including the most highly cited publication, were "wholly" Australian; the other five articles involved international collaboration. Discussion Studying ISI journals in isolation does not permit conclusions to be drawn about quality. However, an analysis of citations can provide a guide to the source of Australia's most visible research, and there is a well established positive association8 between high visibility in ISI-indexed journals and research judged on other grounds, such as via peer evaluation and esteem measures, to be of high quality. The limitations of bibliometric analysis are well documented.9 Publications can attract large numbers of citations because they contain error, or because they report a new technique with wide application. Citation data are also highly skewed. Many publications attract no citations at all, and most of those that do receive only one or two. These and other problems are of little consequence when the focus is at the national or sectoral level, involving large numbers of publications.10 Our data provide only one approach to constructing a profile of Australian medical research. However, bibliometric or literature-based analysis cannot stand in isolation from historical and other kinds of evaluative judgements, and should not be used in a policy setting apart from those perspectives. That said, we believe that the information reviewed here does allow some interesting points to be made. The most encouraging inference we draw from our study is that, using the measure of Relative Citation Impact, Australian medical research stands relatively high in terms of international visibility. As Box 3 makes clear, Australian-based researchers publish in international journals and have well established links to collaborative projects in the major centres of work in the field.6 The bulk of Australia's basic research in the medical and health sciences comes from the universities and hospitals, but Australia's medical research institutes, the members of AAMRI, have the highest international profiles. Research from these institutions has had a major impact on the international community. However, high visibility is not confined to the AAMRI institutions, and, as we have shown, research achieving very high impact also comes from hospitals and universities. One of the most interesting policy issues which these data raise is the efficacy of block funding by comparison with direct project funding of research. Medical research in Australia is undertaken in a pluralist system, with major contributions from hospitals, universities, AAMRI and government institutions. While at first glance our data may appear to argue for block funding through the prominence of several AAMRI institutions funded in this way, the situation is more complex. Many of the AAMRI institutions are block-funded, but in some instances this accounts for as little as 35% of their total income. Any conclusions about funding await the completion of detailed bibliometric studies of the relative performance of medical research, in which we will attempt to identify the output of research supported by the varying modes of research funding. References Bourke P, Butler L. A Crisis for Australian science? Canberra: Performance Indicators Project, Australian National University, 1993. (Monograph Series No. 1.) < http://coombs.anu.edu.au/Depts/RSSS/REPP/repp.htm > Butler L, Bourke P, Biglia B. CSIRO: profile of basic research. Canberra: Research Evaluation and Policy Project, Australian National University, 1997. (Monograph Series No. 4.) National Board of Employment Education and Training (NBEET). Quantitative indicators of Australian academic research. Canberra: AGPS, 1994. (Commissioned Report No. 27.) Bourke P, Butler L. Monitoring research in the periphery. Canberra: Research Evaluation and Policy Project, Australian National University, 1996. (Monograph Series No. 3.) National Board of Employment Education and Training. International links in higher education research. Canberra: AGPS, 1995. (Commissioned Report No. 37.) Smith R. Top of the pile: the institutes. BMJ 1991; 302: 1006-1010. Narin F. Evaluative bibliometrics. Cherry Hill, NJ: Computer Horizons Inc, 1976. Van Raan AFJ, editor. Handbook of quantitative studies of science and technology. Amsterdam: Elsevier Science Publishers, 1988. Garfield E. In: Evered D, Harnett S, editors. Ciba Foundation Conference: the evaluation of scientific research. Chichester (UK): John Wiley & Sons, 1989. (Received 6 Jun, accepted 29 Sep, 1997) Authors' details Research Evaluation and Policy Project, Research School of Social Sciences, Australian National University, Canberra, ACT. Paul F Bourke, PhD, FASSA, Head of Research Evaluation and Policy Project; and Professor of History. Linda Butler, BEcon, Research Officer. Reprints: Professor P F Bourke, Research Evaluation and Policy Project, Research School of Social Sciences, Australian National University, ACT 0200. E-mail: paulb AT coombs.anu.edu.au - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Paul F Bourke · Linda Butler

The Institute of Medical and Veterinary Science Brendon J Kearney Situated in the grounds of South Australia's principal teaching hospital, the IMVS provides a unique blend of statewide pathology services with comprehensive basic and clinical research programs. MJA 1997; 167: 614-617 Introduction - Growth of the IMVS - Core pathology services - Research at IMVS - The Hanson Centre for Cancer Research - The future of IMVS - References - Authors' details - - - ©MJA1997 Introduction The Institute of Medical and Veterinary Science (IMVS), in Adelaide, South Australia, began in 1938 as a development from the Royal Adelaide Hospital (RAH) laboratories largely because Sir Trent Champion de Crespigny, an eminent physician, Medical Superintendent of the RAH and Dean of Medicine from 1929 to 1947, had a vision for an institute which combined laboratory services, teaching and research.1,2 In this respect, the IMVS differs from pure research institutes and has continued to emphasise an integration of service, teaching and research in clinical medicine. Growth of the IMVS The steady development of the IMVS was interrupted in the late 1970s by a series of enquiries into management efficiency, services provided and internal policies, as well as a critical review of the care and control of animals used in scientific experiments. The result was a major redefinition of core services: the Division of Forensic Pathology and the Division of Biology became the Forensic Science Centre (and relocated elsewhere in Adelaide) and the Division of Veterinary Pathology was transferred to the South Australian Department of Agriculture. In July 1982, a new Act (with a new Council) defined and strengthened the relationships of the IMVS with the RAH and the University of Adelaide, allowing it to concentrate on the mainstream areas of medical pathology and their application to research, teaching and service. In 1986, an internal report (Review of Research) on the IMVS/RAH campus by Professors David Penington and Gustav Fraenkel outlined a framework for the development of research. The integration of service, teaching and research with the outcome of high quality care provided by clinicians actively engaged in research was endorsed in the report, but they also suggested the creation of separate basic science laboratories to support research and avoid disparate but duplicated facilities on the campus. They recommended that this development should be part of the IMVS/RAH campus because the benefits of a separate research centre would be diminished by the separation of research activities from service functions. The IMVS and RAH accepted the challenge, and by 1990 funds had been raised and the Hanson Centre (now the Hanson Centre for Cancer Research) had been established. Over the past decade, the IMVS has organised itself along business lines and become reliant on its ability to provide high quality patient services, attract grants and contract for service and research. About 80% of its $55 million expenditure annually is derived from contracts or grants (for public and private pathology services on a fee-for-service basis); the remaining 20% is derived from direct grants from the South Australian Government for statewide or specific pathology services. Therefore, the IMVS differs from pure research institutes that rely on government grants, research grants and donations. While this adds a complexity to its management, it is also a strength, ensuring that the IMVS remains competitive, efficient and relevant to the services for which it contracts. The strength of the IMVS is its collocation on the RAH and University of Adelaide medical school campus. This allows easy collaboration, integration and coordination with both the hospital and University, which has a symbiotic effect on achievement. This integration between hospital, university, service and research is exemplified by the organisational structure of the IMVS. Core pathology services The provision of a high quality general medical pathology service to the RAH remains the core service of the IMVS, and The Queen Elizabeth Hospital laboratories recently joined the IMVS. The IMVS also provides pathology services to metropolitan and rural areas in South Australia through a network of 12 country and regional laboratories. These comprehensive, regionally based laboratory facilities have ensured that a high quality pathology service is available to most communities in South Australia. In addition, services are provided to the Northern Territory and some areas in Victoria. The integration of the IMVS with a teaching hospital and university medical school has allowed the IMVS to develop a comprehensive teaching and training program in pathology and to become involved in education and training in collaboration with clinical disciplines. Research at IMVS Examples of the symbiotic relationship between pathology services, clinical services and research are illustrated by the research endeavours occurring within the Divisions of the IMVS. Division of Tissue Pathology The Division of Tissue Pathology, developed by Professor Barrie Vernon-Roberts, is one of the largest in Australia, with specialists in tissue pathology subspecialising and with the Division integrated into the University of Adelaide and RAH. The Adelaide Head Injury Group incorporates neuropathology from the IMVS, neurosurgery from the RAH and bio mechanical engineering from the University of Adelaide's Road Accident Research Unit. Together, they form a unique combination collaborating in basic laboratory and clinical research into the effects of head injury caused by road trauma. The research objective of the Adelaide Head Injury Group is to reduce the severity of brain injury from accidents by prevention and early intervention. Until recently, brain injury was believed to be instantaneous and irreversible. Work undertaken by the group suggests that axonal damage evolves over hours and may be modified by early interventions. They have developed techniques to identify the pathological changes occurring within an hour of a head injury. The increased production of an amyloid precursor protein is a sensitive indicator of brain injury and can be used to measure the effectiveness of treatments aimed at reducing axonal damage. The Spinal Research Group has won several national and international awards, including the prestigious Volvo Prize (twice), the International Society for Biomechanics Prize, the Amrad Award, and the Smith and Nephew Spine Research Award (twice). It is supported by the specialised bone and histoquantification laboratories of Dr Robert Moore and Dr Nicola Fazzalari. The group collaborates closely with the RAH Spinal Services and RAH Department of Orthopaedics and Trauma. They used a sheep model to reproduce the pathology of human disc lesions and showed how investigational studies of discs can inadvertently introduce bacteria, causing damage to the disc and adjacent bone,3 and the beneficial effect of prophylactic antibiotics to prevent this common complication.4 Other studies have analysed the damage to the disc resulting from cumulative wear and tear to the spine, and have defined the biomechanical and biochemical characteristics of this degeneration. The researchers are currently examining the vascularisation of the disc during ageing, the potential for allograft disc replacement, and the use of cultured osteogenic precursor cells in surgical fusion of the spine. The Bone and Joint Group, in collaboration with the RAH Department of Orthopaedics and Trauma, studies bone structure and remodelling, with an emphasis on osteoarthritis and osteoporosis, using computerised analysis and modelling.5 The findings are relevant to development of preventive treatment for osteoporotic fractures and osteoarthritis.6 The group has also shown that loosening of artificial joints is caused by particles of metal or plastic released from the articulating surfaces.7 Division of Medical Microbiology and Virology The Division of Medical Microbiology and Virology has a long and distinguished reputation. Dr J E McCartney, Medical Bacteriologist at the IMVS in the early 1950s, was a close colleague of Alexander Fleming (the discoverer of penicillin), who gave him some of the original Penicillium mould. Professor Barrie Marmion, Professor of Virology at the IMVS during the 1980s, worked on developing an effective Q fever vaccine and on hepatitis B. Professor Christopher Burrell, the current Head, is acclaimed for his cloning of the hepatitis B genome.8 This Division is the core of the South Australian Infectious Diseases Service. It provides statewide services in food and environmental testing, monitoring of viral diseases and food- borne microbial diseases as well as the State HIV/AIDS Reference Laboratory and national Salmonella Reference Laboratory. A first for the microbiology laboratories was recognition of the association between commercial potting soils and Legionella longbeachae infections.9 They have played a leading role in developing diagnostic procedures for Legionella spp., as well as researching virulence mechanisms and their source and role in infections in the community. The expertise of the Division in applying research into service was shown during the 1995 outbreak of haemolytic- uraemic syndrome in South Australia.10 Three days after receipt of the first specimen, the laboratories had implemented a gene amplification test to detect toxin in food and clinical specimens, identified the toxigenic Escherichia coli strain and traced its source. The tracing of the source of E. coli within days contrasts to the weeks and months needed in outbreaks in Japan and the United States and was significant in rapidly controlling its spread. Infectious diseases research programs. The Division also maintains programs of basic research related to infectious diseases, largely funded by the National Health and Medical Research Council. AIDS Research Laboratory is one of the component units of the National Centre for HIV Virology. Its goal is to define the early molecular events in the replication of HIV in the infected cell.11 This has led to clarification of the events in cell-to-cell transmission of the virus. A related area of research is the use of antisense molecules as a form of gene therapy to inhibit HIV replication. Hepatitis Research Laboratory is studying the mechanism of infection with hepatitis B and related viruses, including patterns of spread within the body, regulation of the carrier state and ways to interrupt it, and the mechanism of protection by vaccines and ways to improve it.12 Herpes simplex research on the pathogenesis of herpes simplex, with emphasis on latent infections within the nervous system and how the host response reacts to infection, is being directed by Dr Tony Simmons. Papillomavirus research into the replication of papillomavirus, the patterns the virus expresses during infection of epithelial surfaces and the factors controlling the different outcomes of the infection (e.g., warts, cancer) is being directed by Dr Geoff Higgins. Adelaide Infectious Diseases Centre. The Division of Medical Microbiology and Virology provides a continuum from patient diagnostic testing, reference test development and public health to basic research. To maximise synergy between these activities, the Adelaide Infectious Diseases Centre has been established, combining the IMVS Division of Medical Microbiology and Virology, the University of Adelaide Department of Microbiology and the infectious diseases services of the RAH and The Queen Elizabeth Hospital. This group is pre-eminent in South Australia in infectious disease surveillance, reference testing, epidemiological studies and disease outbreak investigation. Division of Clinical Biochemistry Bone research group. Professor Christopher Nordin, Associate Professor Allan Need and Associate Professor Howard Morris are addressing bone loss at the menopause, which, together with age-related bone loss, eventually leads to osteoporosis. Studies have established that increased urinary calcium excretion at menopause contributes significantly to bone loss.13 Increased dietary protein and salt exacerbate the urinary calcium "leak" and its effect on bone loss, while dietary restriction of these helps stabilise bone loss. Studies are being undertaken into the changes in the intestinal absorption of dietary calcium at menopause.14 Studies on new therapies for osteoporosis and on the most effective way of monitoring treatment are continuing. A longitudinal study of osteoporosis in men has found that bone loss commences at age 50 and that the pattern and causes of bone loss are different from those found in women.15 The effects of diet, physical activity, hormone and growth factor levels are being evaluated for their effect on the rate of bone loss. A sophisticated rat model of postmenopausal osteoporosis has allowed investigation of the influences on bone at the molecular level. Local factors have been identified which protect bone from the increased cellular activity induced by oestrogen deficiency.16 The Detectacol bowel screening program was one of the earliest Australian voluntary bowel screening programs using an immunologically based test to detect faecal occult blood.17 It has been running for 15 years and has been endorsed through randomised controlled trials showing a reduction in mortality from colorectal cancer as a result of such screening techniques.18 Bone metastasis research. In collaboration with the Department of Surgery of the University of Adelaide, the Division is using a rat tumour model to study how metastatic tumours develop at incision sites after laparoscopic surgery. They will investigate changes in the immune state of the peritoneum and the effect of the different gases used to expand the peritoneum during laparoscopy. Division of Haematology Bone marrow transplantation. Haemopoiesis research began in the early 1980s, led by Dr Chris Juttner and Dr Bik To. They pioneered blood stem cell mobilisation and transplantation, which has now almost replaced autologous bone marrow transplantation.19 The group is currently seeking to define the role of integrin and bone resorption in mobilisation. Work continues on using haemopoietic stem cells purified using immunomagnetic techniques to refine the application in allogeneic and autologous transplantation in leukaemia, lymphoma and myeloma. Ex-vivo expansion is another project for which the Division has a pioneering role as a way of improving the safety of transplantation.20 Dr Tim Hughes is leading a study of chronic myeloid leukaemia and has established a SCID-NOD model for characterising leukaemic stem cells.21 The group is currently involved in 12 clinical trials in transplantation for leukaemia and lymphoma. Research continues into mesenchymal stem cell and cellular therapies, cell death differentiation and oncogenesis and cellular interactions. The stromal group, led by Dr Paul Simmons, has made a major contribution on STRO-1-positive marrow stromal cell percursor and its role in bone formation, haemopoietic regulation and cellular therapies using marrow stromal tissue. Dr Sharad Kumar's group is studying apo ptosis, including the role, activation and regulation of caspases, the function of homologue(s) of C elegans CED-4 and the identification of CED-4M. The group is studying how integrins may modulate cytokine response and function of tetraspan and GPI-linked molecules. The Hanson Centre for Cancer Research The RAH Board and the IMVS Council have strongly supported the development of the Hanson Centre. Through fundraising, the RAH has provided $7.5 million over the past decade for the construction of buildings and provision of equipment for the Centre. The IMVS provides infrastructure funds from its operations and through its commercial company, Medvet Science Pty Ltd, created by the IMVS Council to commercialise the intellectual property and other biomedical activities of the IMVS/RAH campus, and has contributed in excess of $2 million in research grants and infrastructure funding to the Centre. When the Centre began, in 1991, the core research groups were the RAH Division of Human Immunology and the Division of Haematology, but other groups have since joined, including the University of Adelaide Department of Cardiology and the RAH Departments of Gastroenterology, Rheumatology and Thoracic Medicine. These groups have their research support within the Hanson Centre, but are integrated into the service and teaching activities of the IMVS, RAH and the University of Adelaide. Professor Mathew Vadas, appointed 10 years ago to head the Division of Human Immunology, has developed strong basic research groups of excellence which have become known as the Hanson Centre for Cancer Research. This Centre is now the jewel in the research crown of the IMVS. Professor Vadas's research is focused on vascular biology.22,23 Other groups, led by Dr Shannon and Dr Cockerill, have had success in gene regulation,24 and Dr Gonda's laboratory is working on oncogene research.25 The Lipid Research Laboratory has succeeded in understanding the structural principles that govern the assembly of high density lipoprotein.26,27 It was known from epidemiological studies that the human blood high density lipoprotein fraction was protective against atherosclerosis, but the structural and functional basis for this protection was largely unknown. In collaboration with the Vascular Biology Laboratory, they discovered a novel and likely vital function for this particle that directly regulates the function of the vessel wall, and hence the propensity for atherosclerosis.23 Significant progress has been made in understanding cell death. The orderly and timely death of cells is essential in giving shape to the body and renewing its worn parts. A disorder in this process leads to abnormal growth that is a component of cancer. Work in the Molecular Regulation Laboratory, headed by Dr Sharad Kumar, and the Cytokine Laboratory of Dr Angel Lopez has provided novel insights into this process.28 The signals that are involved in "sentencing" and "execution" leading to cell death have been elaborated, and a new therapeutic agent based on an actual growth factor has been discovered that induces this process in blood cells. It is likely that the clinical implications of these discoveries will be considerable. The future of IMVS The IMVS will maintain a business-like approach to the management of operations and to the continued development of Medvet Science. A recent external review of research on the IMVS/RAH/University of Adelaide campus, led by Professor Lawrie Powell, has commented on the excellent productivity of research on the campus. The IMVS intends to further enhance research through expansion of laboratories for basic research while maintaining the strong integration of teaching, patient services and clinical research. New areas of research are being developed in the neurosciences and in molecular pathology, with an emphasis on cancer genetics. References The Institute of Medical and Veterinary Science. Annual Report 1952. Adelaide, IMVS: 1952: 5. The Institute of Medical and Veterinary Science. 50th Anniversary Review 1938-88. Nicholson B, editor. Adelaide, IMVS: 1988: 33-34. Fraser RD, Osti OL, Vernon-Roberts B. Discitis following chemonucleolysis -- an experimental study. Spine 1986; 11: 679-687. Fraser RD, Osti OL, Vernon-Roberts B. Iatrogenic discitis -- the role of intravenous antibiotics in prevention and treatment. An experimental study. Spine 1989; 14: 1025-1032. Fazzalari NL, Crisp DJ, Vernon-Roberts B. Mathematical modelling of trabecular bone structure; the evaluation of analytical and quantified surface to volume relationships in the femur and iliac crest. J Biomech 1989; 22: 901-910. Moore RJ, Durbridge TC, McNeil PJ, et al. Trabecular spacing in postmenopausal Australian women with and without vertebral fractures. Aust N Z J Med 1992; 22: 269-273. Howie DW, Cornish BL, Vernon-Roberts B. Resurfacing hip arthroplasty classification of loosening and the role of prosthesis wear particles. Clin Orthop 1990; 255: 144-159. Burrell CJ, Mackay P, Greenaway PJ, Hofschneider MK. Expression in Escherichia coli of hepatitis B virus DNA sequences cloned in plasmid pBR322. Nature 1979; 279: 43-47. Steele P W, Lanser JA, Sangster N. Isolation of Legionella longbeachae serogroup I from potting mixes. Appl Environ Microbiol 1990; 56: 49-53. Paton AW, Ratcliff RM, Doyle RM, et al. Molecular microbiological investigation of an outbreak of hemolytic-uremic syndrome caused by dry fermented sausage contained within Shiga-like toxin-producing Escherichia coli . J Clin Microbiol 1996; 34: 1622-1627. Li P, Stephenson AJ, Kuiper LJ, Burrell CJ. Double-stranded strong-stop DNA and the second template switch in human immunodeficiency virus (HIV) DNA synthesis. Virology 1993; 194: 82-88. Triyatni M, Jilbert AR, Qiao M, et al. Protective efficacy of DNA vaccines against duck hepatitis B virus infection. J Virol. In press. Morris HA, Cleghorn DB, Need AG, et al. The 5-year reproducibility of calcium-related biochemical variables in postmenopausal women. Scand J Clin Lab Invest 1995; 55: 383-389. Nordin BEC, Morris HA, Need AG, et al. Dietary calcium and osteoporosis. In: Pietinen P, Nishida C, Khaltaev N, editors. Proceedings of the 2nd World Health Organization Symposium on Health Issues for the 21st Century: nutrition and quality of life. Kobe, Japan, 1993. Geneva: WHO, 1996: 181-198. Need AG, Horowitz M, Stiliano A, et al. Vitamin D receptor genotypes are related to bone size and bone density in men. Eur J Clin Invest 1996; 26: 793-796. Morris HA, Porter SJ, Durbridge TC, et al. Effects of oophorectomy on biochemical and bone variables in the rat. Bone Mineral 1992; 18: 133-142. Bone HA, Roder D, McCaul K, Milliken L. Epidemiology of cancer in South Australia. Adelaide: South Australian Cancer Registry, 1993: 57-63. Weller D, Thomas D, Hiller J, et al. Screening for colorectal cancer using an immunochemical test for faecal occult blood: results of the first 2 years of a South Australian programme. Aust N Z J Surg 1994; 64: 464-469. To LB, Haylock DN, Simmons PJ, Juttner CA. The biology and clinical uses of blood stem cells. Blood 1997; 89: 2233-2259. Haylock DN, To LB, Dowse TL, et al. Ex vivo expansion and maturation of peripheral blood CD34 + cells into the myeloid lineage. Blood 1992; 80: 1405-1412. Hughes T, Iverson PO, Lewis ID, et al. A second generation GM-CSF analogue that prevents dissemination and induces remission of human juvenile myelomonocytic leukaemia in engrafted immunodeficient mice. Blood. In press. Korpelainen EI, Gamble JR, Vadas MA, Lopez AF. IL-3 receptor expression, regulation and function in cells of the vasculature. Immunol Cell Biol 1996; 74: 1-7. Cockerill GW, Rye KA, Gamble JR, et al. High density lipoproteins inhibit cytokine-induced expression of endothelial cell adhesion molecules. Arterioscler Thromb Vasc Biol 1995; 15: 1987-1994. Cockerill PN, Osborne CS, Bert AG, Grotto JRM. Regulation of GM-CSF gene transcription by core-binding factor. Cell Growth Differ 1996; 7: 917-922. Gonda TJ, Favier D, Ferrao D, et al. The c-Myb negative regulatory domain. In: Wolff L, Perkins AS, editors. Molecular aspects of myeloid stem cell development. Curr Top Microbiol Immunol 1996; 211: 99-107. Rye KA, Hime N, Barter PJ. The influence of sphingomyelin on the structure and function of reconstituted high density lipoproteins. J Biol Chem 1996; 271: 4243-4250. Rye KA, Hime N, Barter PJ. Evidence that cholesteryl ester transfer protein-mediated reductions in reconstituted high density lipoprotein size involve particle fusion. J Biol Chem 1997; 272: 3953-3960. Kumar S, Kinoshita M, Noda M. Characterization of a mammalian cell death gene Nedd2. Leukemia 1997; 11 Supp 3: S385-S386. Authors' details The Institute of Medical and Veterinary Science, Adelaide, SA. Brendan J Kearney, FRACP, FRACMA, Director. Reprints: Professor B J Kearney, Director, Institute of Medical and Veterinary Science, PO Box 14, Rundle Mall, SA 5000. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Brendon J Kearney

Doctoring beyond frontiers Peter A Hakewill Working on the front line in humanitarian crises can be challenging and satisfying but, at times, fraught with ethical dilemmas MJA 1997; 167: 618-621 Introduction - Crisis assessment - Medical interventions - Why interventions may not work - Ethical dilemmas - Doctoring at its best - References - Authors' details - - - ©MJA1997 Introduction The modern era of humanitarian medicine began almost three decades ago with massive calamities on opposite sides of the globe: the Bengal crisis, which saw some 10 million refugees flee to India;1 and civil war in the Nigerian State of Biafra, which led to a catastrophic famine. A group of doctors working on the front line in Biafra witnessed the diversion of food aid and the abuse of human rights, perpetuated by both sides in the conflict. Finding themselves unable to influence these events on their own, they later founded a new aid organisation with two objectives: To bring effective and timely relief to the victims of civil wars, famine and natural disasters; and To speak out, when necessary, on behalf of populations in danger. They wanted the values and ethics of impartial medical care to become universally respected, so they called themselves "Medecins Sans Frontieres" -- doctors without borders.2 They barely had time to write their charter before the next crisis came along. Medicins Sans Frontieres (MSF) has since become an international movement, with field volunteers from some 45 nationalities working on emergency and development projects in about 70 countries. The nature of humanitarian crises has become more complex but also better understood.3 Aid carries with it so many ambiguities and paradoxes that MSF now finds it necessary to publish almost annual analyses of the situations its volunteers are dealing with.4-7 Skills and techniques for the medical and logistical side of relief programs have also been refined to the point where humanitarian medicine can be considered to be a subspecialty of international public health.8 However, as in clinical medicine, if the condition of a patient is sufficiently desperate, better knowledge of cause and pathological process does not necessarily influence the outcome: for example, mortality rates among refugees in Goma, Zaire, during the Rwanda crisis in 1994 were among the highest ever documented.9 Crisis assessment Protocols now exist for rapidly assessing the needs and resources of a population in crisis.10 The groups most at risk of dying are children, the elderly, the malnourished, unaccompanied children, and households with no father. Aid workers must act rapidly, for most deaths occur during the first days and weeks of an emergency situation.11 Counting deaths is an important tool, not only for evaluating the baseline condition of the population and how well a relief action is progressing, but also for advocacy purposes. A graph showing death rates is often an essential tool for convincing aid bureaucrats that action is urgently needed. Mortality is measured in terms of deaths per 10 000 population per day, and empirical benchmarks have been developed.12 For example, the average daily crude mortality rate in Australia is of the order of 0.25/10 000 per day; in a non-emergency setting in an average developing country it may be 0.6/10 000 per day. In a well-managed refugee emergency, it may reach 1.5/10 000 per day before falling to a baseline of around 1.0/10 000 per day or less. However, in the Katale camp near Goma at the height of the epidemics of cholera and dysentery in 1994, the average daily mortality was 41.3/10 000 per day,9 and age-specific mortality rates among unaccompanied infants in some care centres reached as high as 817/10 000 per day.13 In non-emergency situations an infant mortality rate of 10/10 000 per day would be considered very high. Medical interventions The medical interventions needed to save the lives of refugees or displaced persons are few and relatively simple. The major causes of death are usually diarrhoeal disease, acute respiratory infections, malnutrition, malaria, and measles.11 Each of these can in some measure be prevented by attention to the basic vital needs of a population, and treated by simple means when they do occur. The vital needs include adequate food rations (average, 2100 kcal per person per day), clean -- or at least chlorinated -- water (20 litres per person per day), sanitation (at least one latrine for 20 persons), and shelter (at least 3.5 square metres per person).14,15 Mass immunisation against measles, prophylaxis with vitamin A, intensive therapy for severely malnourished children, and basic curative care are the medical interventions that must likewise be set up during the first days of a refugee influx. A large portion of potentially fatal cases can be managed by minimally trained health workers wielding oral rehydration salts, an antimalarial, and a simple oral antibiotic. This is fortunate, since the sheer volume of the caseload in an outpatients clinic in a large refugee camp would otherwise overwhelm the capacity of the doctors and nurses available to do the work. Indeed, medical staff need to reorient their thinking from a purely clinical approach to a constant preoccupation with public health interventions. Probably the most important contributions to knowledge in this field have been made by an Australian medical epidemiologist, Dr Michael Toole. Why interventions may not work If these simple and effective techniques of emergency intervention work, the crisis may never hit the world news, and the situation may be handled without major loss of life by relief agencies working in concert with the local ministry of health, usually under the coordination of a lead agency such as the United Nations High Commissioner for Refugees. If, on the other hand, the interventions do not work, it is usually for one of three reasons. Firstly, as in Goma,24 personnel with some relief agencies may be inadequately trained or have insufficient experience; secondly, as happened also in Goma, the conditions in which the refugees find themselves may be so appalling that a catastrophe cannot be prevented (800 000 persons arriving in the space of a few days on a wasteland of volcanic rock); or thirdly, and most commonly, there are political obstacles to effective aid delivery. These political obstacles, which always stem from needs of the State taking precedence over the rights of human beings to survival and health, can only be understood in the context of recent changes in international and national politics. Warfare has changed since the time of our grandfathers when battles pitted soldiers of one nation against those of another. Most wars in the 1990s are internal national rather than international affairs, and most of the casualties occur among non-combatants. Thus, the plight of civilians in war-torn countries has tended to worsen rather than improve. Furthermore, with the fall of the Berlin Wall, guerrilla movements have lost the ideological and material support of one or other of the superpowers and, instead of laying down their weapons, have sought new ways of financing their wars: notably, predation upon civilian populations, and accessorily upon relief aid; and criminal exploitation of local resources such as opium, gold, gems, and valuable timbers.2 Ethical dilemmas Humanitarian aid cannot escape the ambiguities inherent in such situations.25,26 Doctors working in emergencies cannot afford to concentrate only upon their patients, nor even only upon broader public health concerns. They must be aware of both the background of the crisis and the factors that prevent its resolution.7 It should be the responsibility of each aid agency to encourage reflection, debate and vigilance among its field volunteers. Without this vigilance, they risk being drawn into ethical dilemmas of three major types.2 The first ethical dilemma is the humanitarian alibi. Aid can be a fig leaf for States lacking the political will to address the root causes of an emergency. Relief is highly visible, low risk, and, compared with military intervention, cheap. Aid workers may be used as tokens in games they only vaguely apprehend, and it takes courage to resist such manipulation. The dilemma lies in deciding whether to risk perpetuating an untenable situation, or to refuse to collaborate and risk losing access to a population in dire need. A recent example of this alibi phenomenon occurred in Bosnia. For the first two years of the conflict the Blue Helmets of the United Nations were mandated to protect aid convoys but not the civilian populations of threatened enclaves. A second example was the Rwandan crisis of 1994. The international community sat back and watched for 12 terrible weeks while genocide took place, and then rushed its crack troops to Goma, in Zaire, to assist aid agencies in their struggle to save the refugees. It was almost as if this belated enthusiasm could efface the guilt of having done nothing to stop the massacres. Ironically, these refugees were not fleeing the genocide, but, rather, fleeing punishment for having perpetrated it. The second dilemma is that humanitarian aid may confer power and legitimacy upon persons who then use it to the detriment of the population. Many people may remember the Ethiopian famine of 1985: massive aid arrived, and the regime of Colonel Mengistu lost the status of international pariah. Mengistu used the logistics of the aid effort and the weapon of withheld food to force whole swathes of the famine-weakened but rebellious population to relocate. Tens of thousands of unnecessary deaths ensued. Alone of all the aid agencies, MSF denounced this "ethnic cleansing" and was ejected from the country. Ten years later, MSF took a similar ethical stand in the Rwandan camps, and withdrew rather than continue to deal with the Hutu extremists who held the population in their sway.6 Primum non nocere: in both cases, the field volunteers decided that their presence by the side of the civilian population was, on balance, cau sing more harm than good. The third dilemma is that humanitarian aid may prolong a conflict. For example, in Liberia during five years of civil war from 1990,7 humanitarian relief was the nation's major industry. The warring factions extorted relief food from the civilian population. Some factions starved their own population in order to attract aid to their stronghold. Vehicles, fuel and radios were also stolen. These unwilling contributions of aid helped the various factions to prosecute their wars. The answers that MSF teams have found to this kind of dilemma have included negotiating endlessly with warring parties for the right to bring medical aid impartially to all civilians, and feeding people in mass kitchens rather than giving them food to take away, on the principle that what was already in their bellies could not be stolen. Doctoring at its best In the face of such difficulties, why would anyone wish to go doctoring beyond frontiers? The answer seems usually to run along the lines of "because it is simply one of the most passionately interesting ways to practise medicine". There are few naturally occurring situations that give the same adrenaline rush as battling night and day against the ravages of an epidemic of cholera; or toiling with the infinite patience and persistence that is called for in a feeding centre in order to bring hundreds of malnourished children back from the brink of death. This is the kind of medicine many of us dreamed of on the benches of our lecture theatres. And one old surgeon once said to me, "This is doctoring at its best". Since opening its Australian branch in 1994, MSF has received overwhelming support from the profession, with hundreds of doctors manifesting their interest in working overseas and thousands of others supporting the work with donations. None of these colleagues seeks public recognition, but their commitment is emblematic of how the profession as a whole tends to work: quietly, methodically, and with an unassuming dedication to the higher good of those we serve. The Australians who go beyond frontiers to use their skills in solidarity with populations in danger do credit to us all. References Seaman JA. Relief work in a refugee camp for Bangladesh refugees in India. Lancet 1972; 2: 866-870. Rufin J-C. Le piege -- quand l'aide humanitaire remplace la guerre. (The trap -- when humanitarian aid replaces war). Paris: Lattes, 1986. Burkholder BT, Toole MJ. Evolution of complex disasters. Lancet 1995; 346: 1012-1015 Medicins Sans Frontieres. Populations in danger. Jean F, editor. London: Lohn Libbey, 1995. Medicins Sans Frontieres. Life, death and aid. London: Routledge, 1993. Medicins Sans Frontieres. Populations in danger 1995. Jean F, editor. Sydney: Halstead Press, 1995. Medicins Sans Frontieres. World in crisis -- the politics of survival at the end of the twentieth century. London: Routledge, 1997. Toole MJ, Waldman RJ. The public health aspects of complex emergencies and refugee situations. Annu Rev Public Health 1997; 18: 283-312. Goma Epidemiology Group. Public health impact of Rwandan refugee crisis: what happened in Goma, Zaire, in July 1994? Lancet 1995; 345: 339-344. Toole MJ. The rapid assessment of health problems in refugee and displaced populations. Med Global Survival 1994; 1: 200-207. Toole MJ, Waldman RJ. An analysis of mortality trends among refugee populations in Somalia, Sudan and Thailand. Bull World Health Organ 1988; 66: 237-247. Hakewill PA, Moren A. Monitoring and evaluation of relief programmes. Tropical Doctor 1991: 21 Suppl 1: 24-28. Dowell SF, Toko A, Sita C, et al. Health and nutrition in centers for unaccompanied refugee children. JAMA 1995; 273: 1802-1866. Medicins Sans Frontieres. Nutrition guidelines. Paris: MSF, 1995. Medicins Sans Frontieres. Public health engineering in emergency situations. Paris: MSF, 1994. Toole MJ, Waldman RJ. Prevention of excess mortality in refugee and displaced populations in developing countries. JAMA 1990; 263: 3296-3302. Centers for Disease Control and Prevention. Famine -- affected, refugee, and displaced populations: recommendations for public health issues. MMWR Morb Mortal Wkly Rep 1992; 41 (No. RR-13). Moore PS, Toole MJ, Nieburg P, et al. Surveillance and control of meningococcal meningitis epidemics in refugee populations. Bull World Health Organ 1990; 68: 587-596. Toole MJ, Steketee RJ, Waldman RJ, Neiburg P. Measles prevention and control in emergency settings. Bull World Health Organ 1990; 67: 381-388. Magan AM, Warsame M, Ali-Salad AK, Toole MJ. An outbreak of scurvy in Somali refugee camps. Disasters 1983; 7: 94-97. Toole MJ, Neiburg P, Waldman RJ. The association between inadequate rations, undernutrition prevalence, and mortality in refugee camps. J Trop Pediatr 1988; 34: 218-224. Berry-Koch A, Moench R, Hakewill P, Dualeh M. Alleviation of nutritional deficiency diseases in refugees. Food Nutrit Bull 1990; 12(2): 106-110. Toole MJ, Galson S, Brady W. Are war and public health compatible? Lancet 1993; 341: 1193-1196. Siddique AK, Salam A, Islam MS, et al. Why treatment centres failed to prevent cholera deaths among Rwandan refugees in Goma, Zaire. Lancet 1995; 345: 359-361. Rieff D. The humanitarian trap. World Policy J Winter 1995-96; 1-11. Bok S. Complex humanitarian emergencies: moral quandaries. Med Global Survival 1994; 1: 220-228. Doctors recruited by MSF need to have current clinical experience of a broad type -- general practice, hospital residency or general surgery. They need to be able to work well in an international team and in a cross-cultural setting. They should be prepared to come back having learned new things about humanity, about doctoring, and about themselves. Authors' details Medicins Sans Frontieres Australia, Sydney, NSW. Peter A Hakewill, MB BS, MPH, Executive Director. Reprints will not be available from the author. Correspondence: Dr P A Hakewill, Medicins Sans Frontieres Australia, GPO Box 5141, Sydney, NSW 2001. E-mail: 100243.3671 AT compuserve.com - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Peter A Hakewill

Safe motherhood: impossible dream or achievable reality? John O'Loughlin Empowerment of women is the only way to ensure safer motherhood MJA 1997; 167: 622-625 Introduction - Maternal mortality in Australia - Maternal mortality in developing countries - Maternal injury - Consequences of maternal death - Causes of unsafe motherhood - The solution - References - Authors' details - Pictures - - - ©MJA1997 Introduction In Australia and other developed countries, women embark on pregnancy with little or no fear for their own safety. Along with the other great strides that medical science has taken in this century, there have been huge reductions in maternal and perinatal mortality rates. In developed countries, maternal mortality rates are no longer used as measures of the quality of obstetric services. The emphasis has long since shifted to perinatal mortality and morbidity. But how safe is motherhood today in the developing countries of the world or among disadvantaged minority groups? Maternal mortality in Australia The World Health Organization (WHO) defines maternal death as "the death of a woman while pregnant, or within 42 days of the completion of the pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management".1 In Australia each year there are about 260 000 confinements,2 and in 1990 there were 25 maternal deaths3 (i.e., nine per 100 000 live births). This is comparable with the lowest rates reported globally. However, these figures hide an unpalatable fact. Births to women of Australian Aboriginal or Torres Strait Islander descent represent about 3% of the total number of births per year, but account for about 30% of the overall maternal mortality.4 Accordingly, in 1990, the maternal mortality rate among Aboriginals and Torres Strait Islanders was about 40 per 100 000 live births, as opposed to 2-3 per 100 000 live births in non-Aboriginal women. Governments continue to spend very large amounts of money in an attempt to remove this discrepancy, but clearly have not been successful. Money alone cannot improve the socioeconomic status of this disadvantaged group. Maternal mortality in developing countries The difficulties experienced by Aboriginal women in Australia are reflected to a far greater degree among the peoples of the developing world. UNICEF and WHO estimates, based on a new approach to data collection, show that in 1990, 585 000 women died from causes related to pregnancy and childbirth.3 This is in excess of one death per minute. Over 140 000 died from haemorrhage; about 75 000 died from attempting to abort themselves; another 75 000 died from the brain and kidney damage of eclampsia; 100 000 died of sepsis; and about 40 000 died from obstructed labour.5 Eighty-seven per cent of births occur in developing nations, and these births account for 99% of maternal deaths (Box 1). Maternal injury For every woman who dies from a pregnancy-related condition, about 30 more (i.e., over 15 million women per year) sustain a severe and permanent injury, such as chronic pelvic inflammatory disease, vaginal, rectal and perineal tearing leading to urinary and faecal incontinence, or Sheehan's syndrome (excessive blood loss causing pituitary gland necrosis and thus ovarian, adrenal and thyroid insufficiency).5 "Obstetric fistula" is a vesicovaginal fistula resulting from pressure necrosis from the fetal head on vagina and bladder tissues during prolonged and obstructed labour. As a consequence, there is a constant and uncontrollable flow of urine from the vagina. The woman and her clothing smell, her vulva becomes excoriated and painful, and she is often banished from her home to live with the domestic animals. She must walk everywhere as she cannot use any form of transport; she loses her family, her friends and often in despair surrenders her own life. Approximately 80 000 women develop obstetric fistula each year.5 Female genital mutilation -- the cutting away of the external genitalia, often including the clitoris -- is performed on girls aged 4-12 years. Approximately two million girls are so mutilated every year, mainly in Egypt, Ethiopia, Kenya, Nigeria, Somalia and Sudan.5 It is designed to preserve virginity and ensure marriageability. Giving birth is extremely painful -- the scarred vaginal opening cannot stretch to allow passage of the fetal head -- and results in injury and extensive tearing, often causing permanent damage.5 In developing countries women not uncommonly have up to 10 pregnancies during their lifetime. Based on the probability that some will suffer more than one obstetric injury during their lifetime, the total number of women affected can be conservatively estimated at some 300 million, more than a quarter of the adult women now alive in the developing world.5 Consequences of maternal death The 585 000 women in the world who die in pregnancy each year leave behind them at least one million motherless children. The death of a mother is almost twice as dangerous for her surviving children as the death of a father, and her daughters are almost twice as likely to die as her sons. 6 Women in developing nations are the major producers of food. They are responsible for 60%-80% of all food production in Africa, and 40% in Latin America. 7 Furthermore, unpaid household labour by women is worth about four trillion (10 12 ) US dollars per year, or about a third of world economic production (1993 global figures). 8 Clearly, addressing maternal health in developing nations is also sound economics. Causes of unsafe motherhood To find solutions we need to know and understand the causes of maternal mortality and morbidity: Poverty; Poor access to health services; Pregnancies -- too many, too close, too early, too late; Poor nutrition and health; and Low social and economic status of women. All of these are interlinked; a positive change in one is likely to lead to positive changes in all of the others. 1. Poverty There has been no significant decline in poverty rates throughout most of the developing world over the past decade.9 In developing countries the individual family is likely to be impoverished, with no resources for emergencies. When daily survival of the family is at risk, mothers will use fewer resources for their own health. Moreover, most developing countries spend less on health and welfare than they do on servicing their debts.7 However, poverty does not necessarily mean poor maternal health. India, although a nation making economic progress, is still beset by the problems of the developing world -- a dense population and widespread poverty and illiteracy. Kerala State, in south-west India, however, has achieved a maternal mortality rate a third of the rate in the rest of India (Box 2). 2. Access to maternal health services In general, most women in the developing world, particularly in rural areas, have no access to adequate maternal health services. Only low cost strategies unlikely to make a major impact on overall maternal health have been introduced to combat this problem. These are: More antenatal care: Most major obstetric complications occur without warning and can kill within hours. Appreciable delay between the onset of the complication and the initiation of effective treatment can be fatal. Most women in the developing world who die in childbirth do so remote from a hospital. In most instances they would not have attended for antenatal care, and neither would their death have been prevented by it. A study in Zimbabwe in 1994 showed that a lack of antenatal care contributed to only 7% of all rural and 10% of all urban maternal deaths.12 Traditional birth attendants: It is claimed that 55% of women in the developing world are assisted in labour by trained birth attendants,13 and that there is a correlation between countries with high mortality rates and a low percentage of trained birth attendants.13 However, many birth attendants have had no formal medical training and their actions may be guided by cultural prejudice. Government training programs have often been inadequate or ineffectual, and many graduates can neither predict nor cope with serious complications.5 Screening: The screening of pregnant women to determine high and low risk groups, although useful, will not detect a no-risk group. Every pregnancy, irrespective of risk category, may develop a life-threatening complication and needs prompt access to skilled obstetric intervention. Recognition of the limitations of these low cost strategies has led to the concept of "essential obstetric care". Essential obstetric care: Essential obstetric care incorporates the provision of properly trained and skilled birth attendants able to recognise abnormality in labour, able to deal with unpredictable complications as they arise, and able to arrange transfer to a facility which can cope with obstetric emergencies. In India, about three-quarters of the 150 000 women who die each year in childbirth live within a few kilometres of a health unit or district hospital, but those in attendance often fail to recognise complications early enough or arrange for transport to a health facility. Such facilities, even if acces sible, are often inadequately staffed or equipped. Even in the United Kingdom, despite good standards of nutrition, health and hygiene, maternal mortality rates did not fall until the advent of skilled obstetric care, surgery and anaesthesia for the treatment of haemorrhage, obstructed labour and sepsis. Cultural barriers: Often cultural barriers exist that militate against the use of whatever obstetric services are in existence. Many women expect to deliver at home and many refuse to see a male doctor. Many husbands refuse to provide money for medical treatment, or won't allow their wives to be removed from the family compound. Ignorance of potential complications of labour is widespread: obstructed labour can be regarded as a consequence of a wife's infidelity.5 3. Pregnancies too early, too late, too many, too close Frequent pregnancies interspersed with long lactation periods deplete maternal energy, iron, and calcium stores. Women in Bangladesh and Pakistan spend more than half of their time between the ages of 15 and 45 either pregnant or breastfeeding.5 The greater the number of pregnancies, the greater the risk of complications. Teenage pregnancy and pregnancy in the 40s likewise increase maternal risk. Cultural determinants and inequality of the sexes mean that many women have no reproductive choice. If all women who did not want any more children were able to stop becoming pregnant, the birth rate would drop by 57% in Latin America, 23% in Africa and 43% in Asia.14 Of all maternal deaths, 58% could be prevented by a combined approach of general fertility reduction, abortion services, and family planning targeted at high risk groups.15 Almost 50% of couples in the developing world have little or no access to family planning;6 less than 2% of all government health spending and less than 2% of international aid goes to family planning.5 Contraceptive technology is well advanced, and research into distribution methods shows that even poor societies can afford good family planning programs.16 Furthermore, it is possible to supply contraception in ways that are acceptable to all countries and cultures.5 The most important ingredient is the will of governments (rather than resources) to provide these services (Box 3, below). 4. Poor nutrition and health Most women in developing countries suffer from malnutrition during pregnancy and lactation. Custom and tradition have ensured that women have a clearly defined provider role. They are the labourers in the field, and their toil provides the family with food, but men and boys are fed before women and girls.17 About a third of women in Sub-Saharan Africa have an inadequate daily calorie intake,18 while 60%-70% of pregnant women in developing countries are anaemic19,20 and therefore more likely to die from postpartum haemorrhage.21 Protein, mineral and vitamin deficiencies are also widespread, but these can be easily rectified by health authorities with relatively cheap intervention programs. R educing protein-energy malnutrition is more complex.7 5. The low socioeconomic status of women In developing countries, on average, women earn 50%-70% of the income earned by men for similar work, and in Asia the wage gap reaches 50%.22 Women often do the tasks which require considerable physical exertion, regularly working 15 hours a day.23,24 Strenuous physical activity contributes to poor pregnancy outcomes, but women's health is seen by women and by others as a low priority. This acceptance comes from a lack of knowledge and education. Knowledge is power, and they have little knowledge. Illiteracy rates may be almost 50% higher for women than for men,25 and women without formal education have a greater risk of maternal mortality than educated women.26,27 Although education and social welfare are not aimed at improving maternal health, increased spending in these areas leads to sustained reduction in maternal mortality and morbidity.10 The solution -- empowerment of women At the Safe Motherhood conference in Nairobi, Kenya, in 1987, the world set itself the target of reducing maternal morbidity by half by the year 2000. It was considered that almost all conditions that lead directly to maternal morbidity are either preventable or treatable, and that with access to better medical facilities a reduction of unnecessary loss of life of this order was achievable. In many areas of the developing world various initiatives and programs have been implemented and it is to be hoped that some progress will be made. However, with the publication of the 1990 maternal mortality estimates,3 derived by new and improved methods, it became apparent that the magnitude of the problem was even greater than previously realised, and that major intervention would be necessary if these targets were to be realised. Better access to family planning services, widespread provision of essential obstetric care and programs to deal with malnutrition in women can be provided by making a relatively small increase in the overall health budget or by changing health care priorities. Authorities such as the World Health Organization and the World Bank 7 have clearly demonstrated that increased expenditure in these areas will produce handsome economic returns. Why, then, is women's health not given greater priority? The reason is the male-dominated culture of much of the developing world. Control can only be exercised by power and this power resides in the hands of men. This describes the lot of women in much of the Third World. Without knowledge they are powerless, and will remain so. Just as we have found with Australian Aboriginal women, women in the developing world will never achieve satisfactory health outcomes until they themselves, through the acquisition of knowledge and learning, are able to compete, at all levels of society, for their fair and equitable share of power and influence. For these women, empowerment is the ultimate key, the way forward to safe motherhood. References National Health and Medical Research Council. Health Care Committee. Report on maternal deaths in Australia 1988-1990. Canberra: AGPS, 1993: 5. Day P, Lancaster P, Huang J. Australia's mothers and babies, 1992. Sydney: Australian Institute of Health and Welfare, National Perinatal Statistics Unit, 1997. World Health Organization/UNICEF. Revised 1990 estimates of maternal mortality. A new approach by WHO and UNICEF . Geneva: WHO/UNICEF, April 1996. O'Connor MC, Bush A. Pregnancy outcomes of Australian Aborginals and Torres Strait Islanders [editorial]. Med J Aust 1996; 164: 516-517. UNICEF. The progress of nations. Adamson P, editor. New York: UNICEF, 1996: 3-9. Pittrof R, Stanfield P. Raising awareness of safe motherhood. A collaborative project. Action for Safe Motherhood (UK) and Teaching Aids at Low Cost. St Albans, UK: TALC, October 1995. World Bank. World Development Report 1993. Investment in health. New York: Oxford University Press, 1993: 6, 9, 113. Freedman LP, Maine D. Women's mortality: a legacy of neglect. In: Koblinsky M, Timyan J, Gay J, editors. The health of women -- a global perspective. Boulder: Westview Press, 1993: 147-170. World Bank. World Development Report 1992. New York: Oxford University Press, 1992. Franke RW, Chasin BH. Kerala State, India: radical reform as development. Int J Health Services 1992; 22: 139-156. State of the World's Children. Oxford: Oxford University Press, 1996. Mbizvo MT, Fawcus S, Lindmark G, Nystr¿m L and the Maternal Mortality Study Group. A community based study of maternal mortality in Zimbabwe. Lund: Reprocentralen HSC, Uppsala University, 1994. World Health Organization: coverage of maternity care. A tabulation of available information, 3rd edition. Geneva: WHO: 1993 (WHO/FHE/MSM/93.7:12.) Eschen A, Whittaker M. Family planning. A base to build on for women's reproductive health. In: Koblinsky M, Timyan J, Gay J, editors. The health of women -- a global perspective. Boulder: Westview Press, 1993: 105-131. Winikoff B, Sullivan M. Assessing the role of family planning in reducing maternal mortality. Stud Fam Plan 1987; 18: 128-143. Potts M. Costs, finance and human resources. In: Senanayake P, Kleinman R, editors. Family planning, meeting challenges, promoting choices. Proceedings of the IPPF Congress, 1992. Cranforth UK: Parthenon Publishing Group, 1992: 709: 21. Government of Lesotho, Health Ministry. Lesotho country paper. Presented at the Conference on Safe Motherhood for the Southern African Development Coordinating Council (SADCC) countries. Harare, Zimbabwe: 1990. Mhloyi, M. Maternal mortality in the SADCC region. Background paper for the Conference on Safe Motherhood for the Southern African Development Coordinating Council (SADCC) countries. Harare, Zimbabwe: SADCC, 1990. DeMaeyer D, Adies-Tegman M. The prevalence of anaemia in the world. World Health Stat Q 1985; 38: 302-316. Jordan EA, Sloan LS. The prevalence of anaemia in developing countries 1979-89. An annotated bibliography. Arlington, Va: MotherCare 1991. (MotherCare Working Paper 7A.) United Nations Fund for Population Activities (UNFPA). State of the world population 1989. Investing in women: the focus of the nineties. New York: United Nations Population Fund, 1989. United Nations Department of International Economic and Social Affairs (UNDIESA). The world's women: trends and statistics 1970-1990. New York: United Nations, 1991. Bleiberg FM, Burn TA, G oihman S, Gouba E. Duration of activities and energy expenditure of female farmers in dry and rainy season in Upper Volta. Br J Nutrit 1980; 43: 71-82. Roberts SB, Paul AA, Cole TJ, Whitehead RG. Seasonal changes in activity, birth weight and lactation performance in rural Gambian women. Trans R Soc Trop Med Hyg 1982; 76: 668-678. United Nations Educational Scientific and Cultural Organization. Statistical yearbook 1992. Paris: UNESCO, 1992. Harrison KA. Approaches to reducing maternal and perinatal mortality in Africa. In: Philpott RH, editor. Maternity services in the developing world. What the community needs. London: Royal College of Obstetricians and Gynaecologists, 1980: 52-69. Briggs N. Illiteracy and maternal health: educate or die. Lancet 1993; 341: 1063-1064. This is an abridged version of the 57th Edward Stirling Memorial Lecture, given at the University of Adelaide on 21 August 1996. Authors' details 43 Walter Street, North Adelaide, SA. John O'Loughlin, FRACOG, FRCOG, Obstetrician and Gynaecologist; member of the Executive Board of the International Federation of Gynecology and Obstetrics. Reprints will not be available from the author. Correspondence: Dr J O'Loughlin, 43 Walter Street, North Adelaide, SA 5006. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia. We appreciate your comments.

John O'Loughlin

Medical log: forward command Thredbo Roger D Harris A first-hand account of the medical response to the disaster MJA 1997; 167: 627-629 Introduction - Postscript - Acknowledgements - Authors' details - - - ©MJA1997 Introduction At 2340 on Wednesday, 30 July 1997, a landslide hit the ski resort village of Thredbo, in New South Wales. Two ski lodges were destroyed, with the loss of 18 lives. There was only one survivor, rescued about 66 hours after the disaster struck. More than 30 doctors were directly involved in the rescue effort and many more covered for their absent colleagues. The NSW Ambulance Service responded with 183 officers, and hundreds of fire brigade personnel, police, State Emergency Service and volunteer rescue association personnel participated in the rescue effort. Here is a brief account taken from the "doctors' log", a medical record compiled at the site by the attending physicians during the first few days of the disaster. Entries were made in the log every few hours to assist in monitoring the medical progress of the disaster and to serve as a record for later audit. Wednesday 30 July 2340: Disaster strikes A landslide completely destroys two ski lodges within a matter of seconds. Fortunately, the first lodge has only one occupant (as it is midweek and snowfalls are light), but, tragically, the second lodge is the staff accommodation for the resort employees and as many as 20 to 30 people are feared trapped or dead. As local rescuers arrive on the scene, there are reports of cries for help from people trapped within the wreckage. A rapid assessment of the site by the Thredbo fire brigade and police reveals that it is dangerously unstable and there is a strong smell of gas and diesel fuel. The police decide to clear the site until it is declared safe enough to allow further rescue attempts. Two general practitioners who practise in Thredbo and several other doctors holidaying there are on stand-by at the disaster site, but are unable to get to people trapped within the wreckage. Thursday 31 July0030: Medical support is mobilised A regional disaster is declared (see Box below). Goulburn (in southern NSW, approximately 300 km from Thredbo) is established as the regional disaster coordination centre, but as it is feared that regional resources may be overwhelmed Sydney coordination is also notified. Teams of doctors and nurses are sent from Cooma to Thredbo and from Canberra to Jindabyne (a triage point), and a four-person specialist medical team (an emergency physician, surgeon, anaesthetist and a medical retrieval specialist) is flown to Thredbo from St George Hospital in south-eastern Sydney. (Medical retrieval specialists in NSW are either emergency physicians or anaesthetists who work for the medical retrieval unit at St George Hospital.) The medical specialist team is sent from Sydney so as not to drain the supply of medical specialists from local areas, including Canberra. At this point, it was feared that there would be mass casualties that would need to be transferred to regional hospitals. The medical retrieval unit conducts a disaster bed count and locates 25 potential intensive care beds in the State. The Thredbo landslide: a regional disaster A "disaster" is an event that overwhelms the capacity of the local resources to deal with the situation. The level of the disaster is graded according to the size of the response necessary. A disaster may involve mobilising only the resources of a single institution such as a hospital, or it may extend to involve the region, the State or the entire nation. The Thredbo landslide was classified as a regional disaster, although it did extend to involve many resources drawn from throughout New South Wales. 0730: Forward medical command post established The medical command post, along with the other emergency services, is set up in a lodge 50 m from the disaster site. The forward medical command post is responsible for coordinating the on-site medical rescue and liaising with medical command posts in Goulburn and Sydney. Telephone and fax lines, desks, chairs, stationery and white boards are organised. After consultation with the fire brigade, it is decided that the police will take overall charge of the site and coordinate all emergency personnel. The medical team from St George Hospital relieves the Thredbo and Cooma doctors, who have manned the site overnight. Their initial task is to establish a line of communication with both Goulburn and Sydney coordination centres. The Thredbo medical centre is chosen as the primary casualty treatment area because it already has the infrastructure and equipment (e.g., lighting, heating, handbasins, x-ray machines, oxygen, suction) necessary to stabilise patients before transport. A comprehensive inventory is taken of all the medical equipment and is sent to Sydney and Goulburn to help with planning of additional supplies. A temporary mortuary is set up in the Thredbo fire brigade station as it is close to both the disaster site and the medical centre. People are evacuated from homes adjacent to the landslide as there is real concern that these buildings may also slip, and also so as not to hamper the rescue. Arrangements are made for the medical team to review all evacuees to ensure that they have no special medical requirements. A second specialist medical team from Sydney is activated (from the Royal North Shore Hospital) and accommodation is organised for the medical staff in Thredbo. 1030: Medical team inspects the disaster site By mid morning, the initial tasks involved in establishing the disaster medical command are complete. Geological engineers and mine rescue experts examine the disaster site and consider it very unstable. The first inspection of the site by a medical officer is carried out. The medical team realise that they need to be prepared to treat possible mass casualties among the rescue workers, and identify several occupational health issues: Irritated eyes/throat. Rescuers to wear goggles and face masks while clearing dusty plasterboard and fibreglass insulation bats. Minor injuries, such as foreign bodies in the eye and lacerations. Medical supplies are organised from Goulburn. Exhaustion and hypothermia among the rescuers. All rescue personnel are alerted to the relevant signs and symptoms and told to report any concerns to their superiors and the medical staff. The medical team decides to inspect the disaster site every four to six hours to deal with these problems and others as they develop. Rescue shifts are limited to between four and eight hours, with adequate breaks during the shift for food and drink. The Salvation Army provides hot food and drinks around the clock and the rescuers warm themselves by fires burning in 44-gallon drums around the site. 1620: The first body is recovered As the bodies of victims are found, the medical team works with the police disaster victim identification squad. The medical officers pronounce the person deceased and tag them with a preliminary identification number. The police take video recordings and photographs of the victims both at the spot where they are found and at the temporary mortuary. This information will be submitted to the coronial investigation into the disaster. Finally, bodies are taken to Sydney for further examination and formal identification. After consultation with coronial medical officers, the police insist that no bodies are to be viewed at the scene by significant others. The coronial medical officers state that viewing the body in this setting can be more traumatic and that identification at this point is frequently wrong, leading to more confusion, delays and further trauma. 1830: Second medical specialist team arrives The St George doctors are relieved by the Royal North Shore team and are exhausted as they have not slept in 36 hours. The temperature in Thredbo drops to -14oC overnight. Friday 1 August0800: St George medical team return to Sydney It is decided that two medical teams are not necessary at the forward command post as the medical personnel at both Cooma and Canberra can be mobilised at short notice. Each medical team at the forward command post will be replaced every 24 hours by a new team from Sydney. At the forward command post, teams will divide into two groups of two and work six-hour shifts to provide 24-hour cover. The NSW Premier and the Police Commissioner are to visit the disaster site, and the medical commander is asked to attend a briefing and site inspection with them. Several public health and environmental issues arise during the day: Water and sewerage is cut off to the site and surrounding village. Some rescue personnel are staying in lodges without running water, and toilets are not flushing. One rescue worker develops abdominal pain, vomiting and diarrhoea. As there is concern about the possible cause as well as contamination of other rescuers, the patient is interviewed and returned to Sydney. Water, vomitus and stool samples are sent to Sydney. A directive is issued to drink only bottled water or cooled boiled water. Exposure by the rescue workers to decomposing bodies and body effluent. The principles of universal precautions are re-emphasised to the rescuers, decontamination posts are established at all exit points from the disaster site, and protective suits are brought in for those in direct contact with bodies. Diesel fuel seeps continuously into Thredbo creek. The leak is largely contained by the fire brigade using booms and siphons, but some oil escapes downstream. The Public Health Office, Environmental Protection Agency and Snowy Mountains Shire are all notified and asked to review the situation. 1500: Meeting the relatives The doctors meet the relatives of those still missing. The relatives, understandably distraught and angry that the rescue effort appears to be going so slowly, interpret the cautious pace of the rescue as indicating that the medical team has lost all hope of finding any survivors. The meetings are very emotional and extremely draining on the already tired doctors. 1800: The third night begins The rescue effort will continue through the night. Special helium balloons containing a light source are suspended over the rescue area to provide a very bright light with minimal shadowing. Saturday 2 August 0530: A possible survivor is located. The medical team is notified by the ambulance paramedics at the site that a survivor has been found. The patient is believed to be a male with minimal injuries. The initial action is to ensure that the relatives are given the known facts about the survivor before possibly misleading media reports filter through to them. A rescue helicopter is activated from Sydney and is to stand-by in Thredbo ready to transfer the patient to a tertiary hospital. The information from the site is that the survivor is trapped in a confined space surrounded by concrete slabs and underneath two further slabs. The only access to him is through a small hole and it is estimated that extrication will take eight to 12 hours. Attempting intravenous access is not feasible, but an oxygen mask is passed down to him by paramedics. The medical team discusses the clinical problems likely to be affecting the survivor: dehydration, hypothermia, rhabdomyolysis and possibly vascular instability if he is moved or sat up. A doctor goes down to the site and crawls under the concrete slabs to assess the patient as best he can. He can only talk to him and see his hand reaching up through the hole, but cannot reach it. As extrication will take some time and he appears in relatively good health (from his own reports), it is decided a trial of warm oral fluids should be tried. Glucose 25 g is added to normal saline 1000 mL, and the fluid warmed with a small Biegler fluid warmer (ATOM, Austria) plugged into a fire brigade power supply. A giving set is lowered to him through the hole and he sips 20 mL every 20 minutes to see if he can tolerate it. Surprisingly, he states that the warm saline tastes fine and even "compliments the chef". A Warm Touch air warmer (Mallinckrodt, USA) is modified by connecting a domestic vacuum cleaner hose to the outlet pipe in order to extend its length. The hosing is insulated by wrapping multiple foil sheets around the tubing. The warmer is plugged into the power source at the site and generates a steady flow of slightly warm air through the end of the long hose. The hose is fed down to the patient, who uses the warm air to dry his soaking wet jumper and shorts. During this time, a lengthened pulse oximeter probe from a Criticare oximeter (Criticare Systems, Inc., Waukesha, Wisconsin, USA) is applied by the patient to monitor pulse rate and oxygen saturation. 1700: The survivor is rescued The access hole to the patient is enlarged significantly. An ambulance paramedic goes down inside the hole with the patient and a doctor leans into it to perform a saphenous-vein cutdown by torchlight to establish intravenous access. Two litres of warmed Hartmann's solution to which has been added 100 mEq of sodium bicarbonate is infused. A cardiac rhythm strip shows slow atrial fibrillation, but there are no QRS, ST or T-wave changes to suggest hyperkalaemia. The patient is slowly removed from the hole and all efforts are made to maintain him in a horizontal position, as prolonged hypothermia and immobilisation might impair his ability to autoregulate his blood pressure, and sudden movements might cause his blood pressure to fall precipitately. He is taken to the Thredbo medical centre, where a "trauma team" conducts a primary survey (airway, breathing, circulation) and secondary survey (full head-to-toe examination) and initial resuscitation before transferring him by helicopter to Canberra 50 minutes later. Amazingly, he has minimal injuries other than extensive frostbite to both feet. A relief medical team arrives from Westmead Hospital, in Sydney, and, after aiding with resucitation, proceed to the forward command post and disaster site. More specialists arrive from the Prince of Wales Hospital and St Vincent's Hospital in Sydney. Victim identification, monitoring of occupational health and public health problems and general medical cover continue for another three days. Tragically, no other survivors are found. Postscript From a medical perspective, the Thredbo disaster was unusual in that there were no mass casualties. However, there was a considerable workload for the doctors, who, in addition to carrying out medical duties, had to cope with exhaustion, certifications of death and dealing with grieving relatives, as well as exposing themselves to danger while attending to a patient who was still trapped. The biggest stressor was probably the environment itself. At night the disaster site was lit with floodlights and helium light balloons. Anyone approaching the site had to pass through two checkpoints. The first, "perimeter", checkpoint was manned by the State Emergency Service, and the second, "central", checkpoint was manned by the police. At each checkpoint (and at other positions around the site), fires burned in 44-gallon drums for the rescuers to warm themselves by. The lights, the fires, the checkpoints and the devastation of the hillside created an atmosphere similar to a war zone. One medical officer commented: "It's like being in a Mad Max movie!". Acknowledgements On behalf of the medical team that attended the disaster site, acknowledgement should be given to the leadership shown by Dr Ronald Manning (Emergency Physician). Credit should also be given to those who "held the fort" while their colleagues were in Thredbo. Photography: Dr Roger Harris, Trevor Lee (NSW Ambulance Service), and Dr Michael King. Authors' details Department of Emergency Medicine, Royal North Shore Hospital, St Leonards, NSW. Roger D Harris, MB BS, FACEM, Research Fellow in Emergency Medicine. Reprints: Dr R D Harris, Department of Emergency Medicine, Royal North Shore Hospital, St Leonards, NSW 2065. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Roger D Harris

The crossing "Come quick, Doc -- I think he's dead!" MJA 1997; 167: 630-631 I had not been looking forward to this trip right from the start. If you've got to spend a night in an aircraft seat, it's preferable if the seat is in an aircraft, not on the Liverpool-Dublin ferry. But the crossing had to be made, so I had asked my nearly-new Irish bride to book a cabin to make the journey almost tolerable. But she forgot. This led to an interesting discussion on the gangplank, during which she accused the medical profession in general, and me in particular, of bullying helpless midwives (surely a classic oxymoron?), whose only aim in life was to please their God-like masters. I refrained from pointing out that this view was somewhat different from the one she had been known to postulate on other occasions. We put our names down, with two hundred others, for a cancellation, but only a fool would have held any hope. While some passengers went to the bar for their sleeping draught, I took a couple of orange pills. By midnight, things were settling down in the "aircraft" area, with the significant exception of the two-year-old boy sitting next to me. He appeared set on staying awake for the night, and keeping me entertained too. Fortunately, his mother had no problem sleeping. I tried negotiating with him, but he seemed to share the Midwife's reluctance to concede any ground. Soon the pills overcame my homicidal instincts and I drifted off, despite the increasing motion of the ship. The next thing I knew an eyelid was being prised open and a voice a million miles away said, "Wake up, they're looking for a doctor!" She seemed to be confusing me with someone else. I muttered something about "only a medical student", but then the fog lifted. That was last month -- this month I was a doctor, albeit one with just two weeks' experience on the wards. I dragged the brain into gear. Already I was learning the knack of answering silly questions five seconds after being wakened. Irish explained patiently (she had had considerable experience in speaking slowly and clearly to half-awake doctors) that the ship's public address system was broadcasting the names of several doctors, obviously taken from the passenger list. I took her point: if I rendered some sort of service to the ship, they were bound to find us a cabin. So, trying to look both wide-awake and widely experienced, I set off for the Purser's office. I guess I failed in my attempts to rearrange my demeanour. "Are you looking for a doctor?" I asked the Purser in his little booth. He looked me up and down suspiciously, and conceded that he was. "Do you know where there is one?" he asked. "Well . . . actually, I'm a doctor." Frank disbelief crossed his face for a moment, then the solution dawned on him. "No, no, son -- a medical doctor, not music or anything." He seemed reassured when I told him I was tone deaf, and that I also had a first-aid certificate. We moved into his office, where he explained that the Captain had insisted that he get a doctor to look at a steward who had burnt his arm some days earlier. The Purser gave the impression that he was only following orders by getting medical attention. (I was later to see the same look on the faces of senior non-commissioned officers as they marched young men into my office -- several of whom were saved from the charge of "wasting the medical officer's time" only by urgent surgery.) The steward had a full thickness burn, badly infected. I thought I made a reasonable stab at cleaning it up and dressing it, although the Midwife clearly felt there was room for improvement. I wrote a note for the Mater casualty department in Dublin. Then I said that a good start to clearing the infection would be some intramuscular penicillin, if there was any on board. By this time the Purser had recovered his good humour (with the help of a glass of Jameson's Irish whiskey). "We've got the standard Board of Trade Medical Kit on the bridge, Doc. It's got everything you can think of -- even a big book that tells you how to use it all." Obviously, Irish's helpful critique during the dressing had rekindled the Purser's interest in my musical prowess. "I'm sure it'll have some penicillin," I said. And so we climbed six pitching ladders to the bridge, where the Navigating Officer unlocked the drug cupboard, and the first thing to hit the deck was a Webley .38 pistol. ("Well, where else would the Captain keep it?") A quick glance through the cupboard revealed the Board of Trade's thoroughness-- there were remedies for all of mankind's known ailments, even including some penicillin for injection, as well as penicillin tablets. Resisting the temptation to take the easy way out (I was very young), I lifted the penicillin G and some sterile water and started to look for syringes and needles. I found a bottle of Primaquine and couldn't help myself asking, "Good heavens, man, why have you got an antimalarial aboard the Liverpool-Dublin ferry?" The Navigating Officer looked me straight in the eye and said, "Well, to be sure, Doc, if we miss Ireland the next stop's the West Indies." I eventually unearthed a case of glass syringes, and asked for some place to sterilise them. (I didn't, at that stage of my career, have an anaesthetist's concept of asepsis -- that a wipe with an alcohol swab kills all known household germs.) Everyone looked a bit nonplussed at my request, until the Purser had an idea. "I know, we'll speak to Sean in the engine-room -- you could use his steam hose." By this time I was only too aware that the bridge was the furthest point from the ship's centre of gravity and that the Irish Sea was beginning to get angry. I succumbed to commonsense and took some penicillin tablets to give the patient. Once the needful had been done with the tablets, the Purser remembered his manners. "You'll be having a dram with me, Doctor -- and your good lady," he added hastily, as she subjected the poor man to most probably his very first feminist glare. So we both joined him in a very large Jameson's. As a Scot, I had never been able to take Irish whiskey seriously, but this didn't seem to be the time to discuss the finer points of "the water of life", as our host was obviously one of Jameson's better customers. I knew my "good lady" hated spirits of any sort, but there was no way she was going to let it show in front of what she now saw as a veritable pack of male chauvinist pigs, so she downed her drink (with tears in her eyes) as she broached the subject of a cabin for us. It seemed that all the cabins were genuinely taken, but our new friend offered us the use of some crew quarters when the watch changed at 0200. This was a great improvement on the aircraft seats with built-in toddlers, so we gratefully accepted. As he showed us to the quarters -- desperately needed now that the whiskey had combined with the sleeping pills -- my last conscious words were, "Well, you know where to find me if you need me again." Hence my rude awakening at 0415. As I groped for my shoes, I mumbled to Irish, who was already heading for the door, "I'll bet he was allergic to penicillin; I forgot to ask. Did you?" She gave me one of her withering looks in reply, and I ruled out anaphylaxis as a cause of death. I followed the Purser, swaying now with what I hoped was the ship's motion, along the corridor to the gents' toilets, where a large crowd was forming. Irish came too. Never one to stand on ceremony, she followed me into the toilets, where customers were using the facilities, washing, shaving, etcetera, as though nothing had happened. Mind you, there was some hasty zipping-up at her arrival. The Purser, who was showing the effects of a serious heart-to-heart with the Jameson's while we had been asleep, pointed to one of the stalls. "There he is, Doc -- looks pretty dead to me!" I couldn't fault his clinical judgement. The toilet door was closed, but from the eight-inch gap underneath it bulged a deeply cyanosed face. "It's not the boy with the burn!" I said to my wife, with relief in every word. "You're right," she replied. "Did you treat anyone else on this boat when I wasn't around?" What do you do with a body found face-down in a toilet stall on the Liverpool-Dublin ferry? Could it be foul play? Were we on the "high seas"? Did my Defence Union cover this? Had they even got my cheque yet? We were helped by a burly Irishman who had his ten-year-old son with him, but didn't see that as any sort of handicap to dislodging trapped bodies. We managed to open the stall door. Perhaps it was the position of the patient (he had fallen forward off the pedestal with his buttocks skyward) that made me think of my forensic lectures and the need to take the victim's temperature to establish the time of death. "Don't suppose the Board of Trade included a low- reading rectal thermometer in its box of tricks?" I muttered, more to myself than to anyone in particular. "What's that, Doc?" asked an increasingly confused Purser. "Never mind," I replied, when I saw the scathing look on the Midwife's face. Bang went my ambitions to be the young coroner. I assured myself that there were no bullet holes, assegai wounds or bottles clearly marked "poison" on the unfortunate man. We extricated him from the plumbing, restored his modesty and called for a stretcher. This gave the Purser something to do other than shake, and allowed Herself to take over traffic control at the door. I heard one or two interesting discussions between her and some potential patrons, intent on gaining access. I put it down to the Guinness, and the fact that Herself didn't acknowledge desperate men. None gained entry. The Purser returned in a few minutes with one of those terribly useful (in theory) stretchers that looks like a cricket pad on steroids. With help from the Irish father, I managed to lash the body into this, although it protruded at both ends, like a hot dog. We each took an end and, half-carrying, half-dragging the horrific-looking corpse, made our way through what seemed to be the entire passenger complement. "Next time, Irish, let me sleep," I warned. "Even a night of toddler-taming in the aircraft seats is easier than this." "Let this be a lesson to you," she replied, totally illogically. Before I could remind her whose idea it was to "volunteer", an agitated-looking man with a red face pushed through the crowd. He rushed up to her as she walked alongside me, and asked, "Is he a doctor?". Although the novelty of being the young doctor's wife was wearing thin, she nodded. "Well, I wonder if he could have a look at my wife -- I think she's gone into labour." Irish's face lit up, despite the long night with little sleep: "Now what would you want a doctor for? They know nothing about babies -- what you want is a good Irish midwife." And she strode off with him to run her own show at last. Douglas N Gow Specialist Anaesthetist, Valley Heights, NSW - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Douglas N Gow

On the water's edge Rock-a-bye paralysis MJA 1997; 167: 632 The soporific benefits of waterbeds have been known for thousands of years, since Persian nomads first slumbered on sun-warmed goatskin waterbags. Cleopatra is said to have slept on a waterbed, and Leonardo da Vinci sketched designs for their construction. Their therapeutic value was championed by Neil Arnott in 1833, who visualised the ideal state of "repose on the surface of the water, like a swan on its plumage, without sensible pressure anywhere".1 In the late 1960s, waterbeds became commercially available, and they were soon popular for both restful and romantic reasons. There appear to have been few complaints on either score. However, some inherent perils deserve to be highlighted. I report three patients for whom sleeping on a waterbed was associated with the development of compression palsy of the common peroneal nerve. Clinical record Case one: A 45-year-old truck driver, with an unremarkable previous medical history, woke one Sunday morning "unable to walk". His wife described him, intoxicated after a Christmas party the night before, flopping into their waterbed with his legs lying across the edge of the bed for most of the night. On examination, he had a significant foot drop, owing to a left common peroneal nerve palsy. There was tenderness over the nerve at the level of the head of fibula. He was managed symptomatically and made a good functional recovery in five days, although reporting a "weak ankle" persisting for some weeks. Case two: A 55-year-old man with well controlled diabetes, with no history of neuropathy, retinopathy or nephropathy, woke on a Sunday morning alongside his wife and stumbled out of bed "unable to walk properly". He denied any alcohol intake the previous evening but had had "an uncomfortable night's sleep". On examination, he had a left common peroneal nerve palsy. Nerve conduction studies demonstrated a focal conduction block in the common peroneal nerve but no evidence of generalised peripheral neuropathy. At six months, he still has a "weak ankle" but has little evidence of a foot drop. Case three: A 33-year-old male physician woke with a "dead foot" after sharing a "smallish waterbed" with his partner one Saturday night. He had taken a small amount of alcohol before going to bed and had enjoyed a good night's rest. On examination, he had a right common peroneal nerve palsy, which symptomatically resolved over five days with no subjective residual ankle weakness. The physician and his partner are now married and have bought a conventional bed. Discussion There have been few documented medical complications arising from waterbed use. I found only four reports of complications (in the 61 articles published between 1966 and August 1997, accessed through MEDLINE, that include "waterbed" as a text word). Both hypothermia and hyperthermia have been described, the latter caused by an elevated heater setting on a waterbed and initially thought to be a nosocomial fever.2,3 In another case, a leaking waterbed mimicked prematurely ruptured fetal membranes.4 Other case descriptions have implicated waterbeds in the sudden death of some infants.5 There is no evidence that waterbeds cause seasickness or lead to increased gastro-oesophageal reflux.6 All three patients reported here had slept on waterbeds with a rigid "wooden-box" frame. It is likely that the firm edge of the bed contributed to their focal compression palsy. All had slept with a partner and developed weakness in the leg on the side of the bed that they normally slept on. It is possible that as a person rolls towards the middle of the bed and their body sinks, the near leg rides up and over the firm edge. Further "tidal movement" by the person or their partner damages the nerve at the fulcrum. Alternatively, if the legs are crossed on a waterbed, the weight of the top leg may push the near leg under and across into the submerged edge. Peroneal nerve palsy is usually caused by external compression, and may be seen after anaesthesia, intoxication, coma or prolonged bed rest. Many case reports, however, give no clear history of compression. The nerve palsy is often ascribed to abnormal sleep postures, as symptoms are usually first noticed on awakening.7 It is not clear how many of these patients may have slept on waterbeds. The intoxication in the first patient described here and the Sunday-morning onset in all three patients suggest similarities with compression neuropathy of the radial nerve (so-called "Saturday-night palsy"). Waterbeds certainly have benefits in some circumstances but we have every reason to be apprehensive about the cutting edge of technology. For, despite the evolution of "soft edge models", we have not yet realised Neil Arnott's ambitious hopes of slumber "without sensible pressure". Until we do, peroneal nerve palsy will continue to remain a matter of gravity. Merlin C Thomas Senior Registrar, Department of Medicine University of Otago, Dunedin, New Zealand E-mail: mdorbell AT es.co.nz Arnott N. Elements of physics or natural philosophy, vol 1. London: Longman, Rees, Orme, Brown and Green, 1833. Gonzalez EB, Suareze L, Magee S. Nosocomial (water bed) fever. Arch Intern Med 1990; 150: 687. Jones RF, Hatzidoulis C, Chestnutt U, Stewart L. The "Coast" hydrostatic bed. Med J Aust 1975; 1: 333-335. Merritt D. Leaking waterbed mimicking prematurely ruptured foetal membranes. New Engl J Med 1991; 324: 274. Ponsonby AL, Lyons TJ, Dwyer T, Carmichael A. Free-flow waterbeds are potentially dangerous to infants [letter]. Med J Aust 1995; 162: 391-392. Wang JC, Castell DU, Sinclair JW, Wu WC. Does sleeping on a waterbed promote gasto-oesophageal reflux? Dig Dis Sci 1989; 34: 1585. Berry H, Richardson PM. Common peroneal palsy: a clinical and electrophysiological review. J Neurol Neurosurg Psychiatry 1976; 39: 1162-1171. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Merlin C Thomas

MJA Practice Essentials, Mental Health: 7. Crisis management in the community Alan Rosen "Paradoxically, if you survive them, it's in the bad conditions that you learn most about yourself." -- Tim McCartney-Snape, mountaineer (quoted in The Weekend Australian, 18-19 May 1996) MJA 1997; 167: 633-638 Synopsis - Introduction - What is a crisis? - Types of crisis - Contention in the crisis literature - Stages of a crisis - When to intervene - Practical management of a crisis - Practical points in intervention - A crisis is different from an emergency - The place of crisis intervention in psychiatric services - Who should manage crises? - Gaps in services - Conclusion - Acknowledgements - References - Authors' details - Box 1: Stages of crisis - Box 2: The process of crisis assessment and intervention - Box 3: Useful crisis resources - Case history: Stages of crisis and "depathologising" - Case history: Crisis intervention early in the course of a psychiatric illness - - - ©MJA1997 Synopsis A psychological crisis is a brief, non-illness response to severe stress. When maladaptive responses to crisis are detected, crisis intervention is employed to achieve a more adaptive resolution and a more effective learning experience. Psychiatric services cannot provide the entire range of crisis interventions required in our society. As communities, we should be encouraged to "look after our own" partly through a network of formal and informal crisis support structures. These should be carefully distinguished from emergency services. General practitioners and others in a good position to do crisis intervention require higher levels of awareness of and training in its uses, with support from specialty services. Crises can precipitate or be a consequence of mental illness. There is strong evidence that more specialised 24-hour crisis response services are needed for individuals with mental illness and their families. Evidence is emerging for the importance of early detection and intervention for young people who may be developing signs of mental illness or suicidal intention for the first time, which may manifest as a life crisis. If there is a potential or existing mental illness, good outcomes are more likely to result from good teamwork between general practitioners, other clinicians and specialist mental health services. (MJA 1997; 167: 633-638) Introduction "Crisis" was first used as a specific term in psychiatry by Gerald Caplan1,2 after considering earlier evidence that survivors of severe trauma, such as those in Lindemann's study of the "Cocoanut Grove" nightclub fire in Boston in 1942, had much better outcomes if they received immediate psychiatric help.3 A "crisis" was seen as a brief non-illness response to severe stress, and "crisis intervention" emerged to detect maladaptive responses to crises and to convert them into effective coping and learning experiences. Caplan's concept of crisis was influenced by the theories of his time. It relied on concepts of disease rather than health, and on mechanistic theories from Freud and General Systems Theory regarding "homeostasis" and "equilibrium". But these limitations were far outweighed by Caplan's contribution in emphasising the importance of preventive care, achieving mastery of the crisis, the social, cultural and material "supplies" necessary to avoid or resolve a crisis, and his pioneering advocacy of a community mental health approach.1,2,4 What is a crisis? Caplan's1,2 classic definition of crisis is an upset in the person's steady state provoked when an individual finds an obstacle to important life goals. This obstacle seems insurmountable, at least for a good while, by use of customary methods of problem solving. A crisis is a period of transition in the life of the individual, family or group, presenting individuals with a turning point in their lives, which may be seen as a challenge or a threat, a "make or break" new possibility or risk, a gain or a loss, or both simultaneously. Most crises are part of the normal range of life experiences that most people can expect, and most people will recover from crisis without professional intervention. However, there are crises outside the bounds of a person's everyday experience or coping resources which may require expert help to achieve recovery. Types of crisis Developmental crises: These are the transitions between the stages of life that we all go through. These major times of transition are often marked by "rites of passage" at clearly defined moments (e.g., those surrounding being born, becoming adult, getting married, becoming an elder, or dying). They are crises because they can be periods of severe and prolonged stress, as described by Tyhurst, another pioneer in this field,5 particularly if there is insufficient guidance and support to prevent getting stuck while in transit.6 In small-scale cultures, there is a sense of continuity and retained value in transiting from before birth to beyond death (e.g., becoming an ancestral resource). In Western societies, rites of passage between these stages have become blurred, the extended kinship networks they depend upon for clear expression have become scattered, the cultural value ascribed to such transitions varies with occupational and economic status, and events surrounding birth and death tend to be experienced as clinical termini.6 Situational crises: Sometimes called "accidental crises", these are more culture- and situation-specific (e.g., loss of job, income and/or home, accident or burglary, or loss through separation or divorce). Complex crises: These are not part of our everyday experience or shared accumulated knowledge, so we find them harder to cope with. They include: Severe trauma , such as violent personal assault, natural or man-made disasters, often directly involving and affecting both individuals and their immediate and extended support network, observers and helpers. 3,7,8 Crises associated with severe mental illness , which can increase both the number of crises a person experiences and sensitivity to a crisis. Reciprocally, the stress of crises can precipitate episodes of mental illness in those who are already vulnerable. Post-traumatic stress syndromes similar to those resulting from a disaster have been reported in some individuals 9 after emergency treatment of acute episodes of mental illness. Developmental, situational and complex crises may overlap, and one may lead to the other (e.g., a train driver distracted by being in crisis may make an error, causing a disaster). Contention in the crisis literature Controversy still surrounds the concept of crisis. The term defies consistent definition, and "crisis theory" is just that: mainly theoretical speculation based on descriptive accounts, with the cultural and clinical concepts of crisis deriving from seemingly different fields of inquiry. A personal crisis is not a clinical disorder. However, a severe or protracted response to crisis may lead to one (e.g., major depression, or, more commonly, an "adjustment disorder",10 defined as the development of clinically significant emotional or behavioural symptoms in response to an identifiable psychosocial stressor). Adjustment disorder should be distinguished from bereavement and other non-pathological reactions to crises which do not lead to marked distress in excess of what is expected, and which do not cause significant or lasting impairment in social or occupational functioning. Stress is not a synonym for crisis11 as all people face stress as part of the human condition. By no means all stressful experiences produce crises and the same type of stressor may be linked to crises, or even clinical disorders, in some but not in others. In contrast to crisis theory, some crisis interventions have been subjected to rigorous empirical study, demonstrating their effectiveness with specific problems (e.g., individuals and families seriously affected by mental illness).12,13 Crisis intervention can no longer be seen as a unified strategy for care, as many divergent practices in different settings have developed since its origin, from walk-in clinics to mobile home intervention, but Waldron has identified a number of common features.14 These include rapid service, intense work in the short term, and a practical here-and-now therapeutic focus. Stages of a crisis Box 1 presents a summary of the main stages, from the pre-crisis steady state, to crisis disequilibrium, to re-establishment of a new steady state, hopefully at an equal or higher level of organisation.11 It is often reported that a crisis state lasts several weeks, usually subsiding within one to two months, if successful resolution occurs. (See also "Case history: Stages of crisis") When to intervene Primary prevention: Strategies aimed at preventing the development of psychiatric illness altogether may be appropriate for people experiencing developmental or situational crises who have limited personal, social or cultural resources. Bereavement counselling, telephone counselling services and "How to survive Christmas" seminars18 are examples of practical primary prevention interventions in the community. Critical incident counselling may be offered to survivors or witnesses of traumatic events and disasters to prevent emergence of protracted grief reactions or post-traumatic stress disorder (PTSD),8 although efficacy in preventing PTSD remains unclear. Secondary and tertiary prevention: Secondary prevention implies that a psychological disorder has already emerged, and aims at reducing the severity, duration or the risk of recurrent relapse. Tertiary prevention is aimed at reducing the disability attendant on a disorder that is already prolonged. Indications include: People with early or acute mental illness -- preventing suicide and promoting recovery for individuals whose constitutional vulnerability and life stressors may have tipped them into an episode of mental illness, which can be highly responsive to timely crisis intervention and appropriate treatment.9,10 So-called "chronic outpatient attenders" or "chronic crisis repeaters", unnecessarily pejorative terms highlighting the frustration and attitudes of clinical staff towards these individuals who make frequent demands on services. It is often more economical and effective to provide intensive intervention at times of acute crisis rather than continuing unchallenging support of a long term sickness role. Many of these individuals have been severely traumatised in childhood. Specific interventions to deal with the sequelae of past abuse are still being developed and researched. Patients with severe or prolonged psychiatric disorders presenting with an acute exacerbation that may be precipitated by or cause a situational crisis. Defusing stressors by prompt crisis management (in conjunction with timely treatment, continuity of care and psychosocial rehabilitation) may prevent the build-up of disturbing symptoms, repeated life-disrupting hospitalisations, or suicide.9,12,13,15,17 Practical management of a crisis Crisis management is the entire process of working through the crisis to the point of resolution (Box 2). It usually includes not only the activities of the individual in crisis but also the members of the person's social network.4 Not all crises require crisis intervention, which is that aspect of crisis management carried out by crisis workers (e.g., clinicians, counsellors, police or chaplains). Practical points in intervention: Intervention frequently involves a general practitioner and a community mental health team, possibly including a psychiatrist or inpatient unit. Negotiate early in the process to formally clarify who will coordinate it, and who will do which components of the assessment and intervention (whether general practitioner, mental health worker or psychiatrist). The hospital or community crisis service should carefully identify the general practitioner's needs, especially for prompt or extra support, while the general practitioner should respond promptly to the crisis worker's liaison calls. Include family or other social or cultural supports in both the assessment and the intervention if possible. Collaborate with the individual or family in crisis ("doing with" rather than "doing to") to promote their "ownership" of the crisis, and learning of new coping and communi cation skills. Allow tension -- allowing or even encouraging a tolerable degree of arousal, tension or dependence for a limited time is sometimes functional in promoting crisis resolution. The clinician's role in a crisis can sometimes involve undoing previous inappropriate or excessive clinical interventions (e.g., inappropriate diagnoses or types of treatment, or general overmedication causing unnecessary sedation and/or other side effects). When referring a person in crisis to a hospital psychiatric unit, ask for a crisis assessment rather than insisting on hospital admission, as home-based community management often results in a better outcome. Home visits, within defined parameters of safety, should be considered for accurate assessment and review, and more direct access to all participants in the crisis. A small list of the most important specific goals for the crisis intervention which are realistic and achievable within a limited time frame should be agreed in advance between all participants, with a copy to each, and with an interactive process and date for review. If acute inpatient psychiatric care is needed, the same mental health professional(s) who engaged with the person in the community should be involved in the inpatient team (if possible) to make the transition easier and to ensure consistency of the clinical management plan agreed with the individual and family. A crisis is different from an emergency An emergency is a life-threatening situation demanding an immediate response. A crisis is often not immediately life-threatening and the timing of the response should be such as to include all participants in the crisis and existing or potential personal supports. Appropriate personnel to respond to an emergency are Police, Ambulance, Fire or Hospital Emergency Departments and/or State Emergency Services. Appropriate people to call in a crisis include general practitioners, community mental health professionals, community services officers, or lay crisis response organisations. The appropriate type of early response in an emergency is life preserving: securing physical safety, removing the person from the source of danger, and defusing physical violence. In a crisis, the early response should be crisis assessment and support, defusing stress and interpersonal strife. The use of the terms "crisis intervention" and "emergency psychiatry" are often confused by clinicians, and used interchangeably in the names and descriptions of services.17 But what difference does it make to patients and their families when they feel distressed and just know they need help now?19 In fact, they benefit by more appropriate referrals and settings for intervention when these distinctions are clearly made, while professionals are able to deliver such services more safely and effectively when they know the difference between a crisis response and an emergency response. Sometimes there is an overlap between a crisis and an emergency. When there is any hint of a crisis turning into an emergency, it is considered a skill, not a failure, if a mental health professional or general practitioner chooses not to work alone and calls for expert advice, police assistance, or other emergency services. The place of crisis intervention in psychiatric services The evidence indicates that 24-hour home-visiting crisis response services should be integrated into local comprehensive services for people seriously affected by mental illnesses and their families. 9,12,13,15,20 The potential for new learning and personal growth in this population and their families has probably been vastly underestimated, often by the clinicians involved.17 Systematic interventions to promote such new learning out of "using the crisis" of acute psychiatric episodes are being developed to reverse the potentially erosive effects of early psychosis on self-esteem, identity and related maturational tasks.9,19 Family problem-solving techniques aimed at acquiring new coping techniques in crisis have been shown to prevent relapses.20,21The principles of effective crisis intervention are consistent with current good practice in mental health services, regardless of the phase of care. There is evidence that people severely affected by psychiatric illnesses are much more likely to cooperate with interventions which are tailored to their individual needs, and when they feel listened to, are consulted and offered choices regarding types of proposed interventions. Cooperation is further enhanced when they and their families are provided with sufficient information and explanation, when time is taken to negotiate intervention goals, when low-key and low-dose interventions are offered (at home on their own "turf", if possible, rather than ours) and when the traumatising effects of involuntary hospital admission and heavy sedation are avoided.6,9,12,13,22 Inpatient psychiatric care is sometimes essential but should be arranged on a voluntary basis if possible. (See also "Case history: Crisis intervention early in the course of a psychiatric illness") Who should manage crises? General practitioners, community workers, police, ministers of religion, counsellors, as well as mental health professionals, are all in a position to be involved in crisis intervention. General practitioners are particularly well placed to help people in crisis and their families. Should all crises be referred to psychiatric services? Emphatically no, although psychiatric services are most appropriate for people in crisis who have diagnosable psychiatric illnesses and who may be suicidal. Firstly, psychiatric services do not have the resources or mandate to handle all crises in the community. There are community services for domestic abuse, children at risk, and sexual assault crises, non-government and church organisations dealing with couple, family, existential and spiritual crises, and networks for bereavement and disaster counselling. Secondly, many people requiring help with crises do not wish to be seen by a psychiatric service or professional, which they may perceive as stigmatising, and therefore adding to their troubles. When the crisis is not complicated by significant psychiatric symptoms, it may be managed with significantly better outcome by a general practitioner who has the person's trust and does not need to label the person with a psychiatric diagnosis.23 Thirdly, some communal voluntary organisations run crisis hotlines (e.g., Lifeline) which may produce more timely referrals to clinical services, or care for people who would not present clinically . Whether they reduce the number of suicides is a more contentious issue. Peer-group and consumer-driven mutual support lines are developing further, via telephone "warm-lines", interactive radio, computer bulletin board chat-lines and the Internet. While these are a potential wellspring of support, they may make the caller feel more vulnerable through public exposure, and the recipients may feel helpless if their concern is ignored or abused by an anonymous caller. Arguably, basic training in crisis support and coping skills should be adopted as essential components of community and school education.14 Gaps in services There is still a lack of child and adolescent mobile crisis services operating extended hours to augment outpatient nine-to-five mental health services for these age groups. Adolescents are at a time of developmental transition and are particularly vulnerable to crisis. Early intervention services available on a 24-hour mobile basis which are specifically designed to deal with the crises and psychiatric problems of young people, their families and peers may help to reduce the exceptionally high youth suicide rates in Australia. Conclusion The National Mental Health Strategy24 has provided impetus to develop extended-hours mobile community psychiatric services integrated with local inpatient services in both urban and rural centres across Australia. Yet it is by no means possible, nor appropriate, for psychiatric services to provide the full range of crisis intervention services needed by our community. A broad network of formal and informal crisis support structures is required to enable us to more effectively "look after our own". Some useful crisis resources. Acknowledgements I thank Dr Kai Lin Lie, Dr Dorothy Kral, Dr Gary Walter, Mr Paul Clenaghan, Ms Vivienne Miller and Ms Sylvia Hands for advice on the text. References Caplan G. Principles of preventive psychiatry. London: Tavistock 1964. Caplan G. Support systems and community mental health. New York: Behavioural Publications, 1974. Lindemann F. Symptomatology and management of acute grief. Am J Psychiat 1944; 101: 141-148. Hoff LA. People in crisis: understanding and helping. 2nd ed. Menlo Park, California: Addison Wesley, 1984. Tyhurst JS. The role of transitional states -- including disaster -- in mental illness. Symposium on Preventive and Social Psychiatry, Walter Reed Army Institute of Research. Washington DC: US Government Printing Office, 1958. Rosen A. The stigmatized stand up: active involvement in our own mental health services . Mental Health Aust 1985; 4: 3-17. Rosen A. Review of Raphael B. When disaster strikes. ASW Impact 15-16 March 1988. Raphael B. When disaster strikes: a handbook for the caring professions. London: Hutchison, 1986. McGorry P, Rosen A, Carr V, Pantelis G. Innovations in the treatment of psychosis. In: Andrews G, editor. Specialization in Psychiatry. Geigy Psychiatric Symposium Proceedings 1994; XV. Diagnostic and statistical manual of mental disorders. 4th ed. (DSM-IV). Washington DC: American Psychiatric Association, 1994. Parad HJ, Parad LG. Crisis intervention: yesterday, today and tomorrow. In: Punukollu NR, editor. Recent advances in crisis intervention. Vol I. Thuddersfield: International Institute of Crisis Intervention, 1992. Hoult J, Rosen A, Reynolds I. Community orientated treatment compared to psychiatric hospital orientated treatment. Soc Sci Med 1984; 18: 1005-1010. Stein LI, Test MA. Alternative to mental hospital treatment. I. Conceptual model, treatment programme and clinical evaluation. Arch Gen Psychiatry 1980; 37: 392-397. Waldron J. Crisis intervention. Br J Hosp Med 1984; 31: 4283-4287. Scott RD. A family oriented psychiatric service to the London Borough of Barnet. Health Trends 1980; 12: 66-68. Bassuk E, Gerson S. Chronic crisis patients: a discrete clinical group. Am J Psychiat 1980; 137: 1513-1517. Szmuckler G. The place of crisis intervention in psychiatry. Aust N Z J Psychiatry 1987; 21: 24-34. Dunsmore J. "On surviving Christmas" Seminars. Sydney: Department of Health Promotion and Education, Royal North Shore Hospital, 1990, 1995. Phelan M, Strathdee G, Thornicroft G, editors. Emergency mental health services in the community. Cambridge: Cambridge University Press, 1995. (See chapters by Katschnig, Emergency mental health services; Birchwood et al, Using the crisis; Kingdon and Jenkins, Suicide prevention; Sutherby and Szmuckler, Safe community assessments of crisis). Falloon IRH, Fadden G. Integrated mental health care. Cambridge: Cambridge University Press, 1993. McFarlane WR, Lukens E, Link B, et al. Multiple-family groups and psychoeducation in the treatment of schizophrenia. Arch Gen Psychiat 1995; 52: 679-687. Hambridge J, Rosen A. Impact of a mobile community intensive case management team in surburban Sydney. Aust N Z J Psychiatry 1994; 28: 438-445. Goldberg D. A classification of psychological distress for use in primary care settings. Soc Sci Med 1992; 35: 189-193. National Mental Health Strategy, 3rd annual report. Canberra: Department of Health, Housing and Community Services, 1995. Authors' details Royal North Shore Hospital and Community Health Services, Sydney, NSW. Alan Rosen, FRANZCP, DPM, Director; Associate Professor, University of Wollongong; Clinical Senior Lecturer, University of Sydney. Reprints: Dr Alan Rosen, Royal North Shore Hospital and Community Health Services, St Leonards, NSW 2065. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Alan Rosen

From shunned to shining: doctors, madness and psychiatry in Australian and New Zealand cinema Alan Rosen, Garry Walter, Tom Politis and Michael Shortland The histories of psychiatry and the cinema are eerily intertwined MJA 1997; 167: 640-644 Introduction - A psychiatrist's perspective - Films and psychiatric stigma - Conclusions - Acknowledgements - References - Authors' details - - - ©MJA1997 Introduction The motion picture industry has had a long-standing interest in doctors and medicine generally and with psychiatry in particular. Cinema's fascination with modern psychiatry has been intense, with the two fields emerging at about the same time -- movies were first demonstrated publicly by the Lumière brothers, Edison and others in 1895, the same year that Freud wrote Project for a scientific psychology, the prototype of his later theories.1 In 1924, the producer Samuel Goldwyn was keen to exploit the association between sex and psychoanalysis on screen and tried unsuccessfully to enlist Freud's help in making a film with an offer of $US100 000.2 Psychiatric professionals in films have been variously venerated, demonised and marginalised (classified by Schneider as, respectively, "Dr Wonderful", "Dr Evil" and "Dr Dippy"3). Hyler offers an even more elaborate and colourful classification for psychiatric patients in films: rebellious free spirit, homicidal maniac, female seductress, enlightened member of society, narcissistic parasite, and zoo specimen.4 Schneider contends that there has been a welcome shift over the years in the way film has treated madness and psychiatry, with oppressive psychiatrists and zombified victims giving way to more human encounters and ambiguous, even hopeful, outcomes.2 Arguably, however, the complete range of favourable and unfavourable stereotypes of psychiatrists and patients continues to appear -- 1991 saw the psychiatrists Dr Wonderful (Prince of Tides), Dr Evil (Silence of the Lambs ) and Dr Dippy (What about Bob?). Although the vast majority of "psychiatric" films are American (partly because the discipline is embedded in that country's culture), some of the most incisive movies, especially recently, have come from Australia and New Zealand. A chronology of antipodean films with psychiatric themes is shown in Box 1. While doctors and nurses have long been represented in antipodean films (e.g., Sister Kenny [1946]), the "psychiatric" film made its début only in 1974 with Between Wars. Michael Thornhill's first feature, a pioneer in the revival of Australian cinema, Between Wars traces the career of Dr Edward Trenbow (played by Corin Redgrave), who becomes a well-respected Sydney psychiatrist. In the 1920s, he takes up residence at Callan Park Asylum. The film touches on issues of psychoanalysis and physical treatments, such as fever treatment. In another 1974 release, 27A , a middle-aged "metho" drinker joins Alcoholics Anonymous and undergoes a psychiatric examination. As a consequence, he is committed to a hospital for the criminally insane, to be detained indefinitely under the notorious Section 27A of the Queensland Mental Health Act . Nevertheless, apart from these two films, the psychiatrist figure receives scant attention in the 1970s. When it appears, it is usually as either a peripheral character or a stereotype. The 1980s saw some clichéd psychiatric themes. For example, in An Indecent Obsession (1985) Sister Honour Langtree, in charge of a military hospital for psychiatric patients, transgresses boundaries by developing a sexual attraction for a new patient. Wrong World (1985) has the almost mandatory escape from a psychiatric hospital, and Contagion (1987) features a homicidal person with schizophrenia. The 1980s also saw the emergence of a film category which has been called "the company of eccentrics".5 Perversely non-conformist, it often foregrounded quirky protagonists and against-the-grain themes. For example, the hero in John Laurie's Stroker (1987) is "a kind of mad, Chelmsford psychologist", 5 and all the central characters in Bliss (1984) and Pandemonium (1987) seem in dire need of psychiatric evaluation. Some of Jane Campion's films also thrive on borderline heroines (e.g., the volatile Dawn in Sweetie [1989]). These eccentric personalities paved the way for the more stigmatised protagonists in the films of the next decade. An Angel at my Table (1990) depicts the life story of the award-winning novelist Janet Frame. The image of an apparently hopeless mental patient shimmers with that of a somewhat odd creative genius. Similarly, Heavenly Creatures (1994), about the relationship of two New Zealand girls who murder one of their mothers, provides a counterpoint between eccentricity and premeditated evil. Bad Boy Bubby (1994) also extends the "eccentric cinema's" preoccupation with idiosyncratic characters and offbeat themes. Except for the "soft" ending, it is totally uncompromising -- about an "uncivilised" innocent, Bubby, and his mother, who have been caught in an incestuous, symbiotic web for 35 years. On the return of his estranged father, Bubby is freed into a world which he cannot comprehend, a contemporary society which he views through an unsocialised, childlike perspective. Although there is no psychiatric intervention in Bad Boy Bubby and in other 1990s films such as The Piano (1993) and Once Were Warriors (1994), the relentless playing out of dark psychopathology might nevertheless be included in the "psychiatric" film category. Common to Australian and New Zealand "psychiatric" films in the 1990s is the more compassionate, sensitive handling of many types of intellectual and psychiatric disability,6 as illustrated by Domaradzki's Struck by Lightning and McKenzie's On the Waves of the Adriatic (named for the ancient Greek custom of casting mentally ill people adrift in boats on the Adriatic Sea). There is also a greater emphasis on more realistic, character-driven studies of madness -- Angel Baby, Cosi, Lilian's Story and Shine all strive for the narrative/dramatic depiction of alienated or troubled people for human interest. For example, Michael Rymer, the director of Angel Baby (about two people with psychoses, Harry and Kate, who fall in love), states that his film "is not about crazy people. It's about people who have an illness". 7 Cosi, based on Louis Nowra's play8 about a group of patients in an asylum who rehearse for and perform Mozart's Cos" fan tutte, has its American parallel in One Flew Over the Cuckoo's Nest (1975). We warm to many of the patients in both. Lilian's Story and Shine were inspired by real-life personalities supposedly driven mad by aggressive, possessive fathers. Lilian's Story is based loosely on the life of legendary eccentric Bea Miles, who recited Shakespeare for a dollar on the streets of Sydney and rode taxis for a sonnet. In Shine, Geoffrey Rush's portrayal of the pianist David Helfgott endears him to us, and the character ultimately triumphs in both his personal and professional life. Angel Baby, Cosi, Lilian's Story and Shine are not centrally critiques of institutions, but, rather, reinforcements of humanism and faith. The ambiguity of Angel Baby 's ending, in which we are unsure whether the hero suicides, is both tragic and potentially uplifting. Even so, we are left with a nagging feeling that this film missed its chance to instil hope because of the assumption that real-life mental illness must end in tragedy. Unfortunately, alongside the greater humanism and faith depicted in recent Australian and New Zealand "psychiatric" films, negative stereotypes about people with mental illness persist. These include the "homicidal maniac" (Doug, to staff member Lewis, in Cosi : "Hope you've made out your will, Lewis . . . you're mine"), "female seductress" (Cherry, in Cosi, also to Lewis: "I really like you", as she leans forward to kiss him), and the "zoo specimen" (Kate, in Angel Baby, resembles a feral animal as she hisses to frighten off shoppers at a mall). In addition, An Angel at my Table and Shine link madness with creative genius. While the general public may see this as instilling hope, or even as inspirational, people with mental illness may conclude that someone with a mental illness needs an exceptional creative talent to be accepted. A psychiatrist's perspective How accurately have films portrayed mental illness in terms of presentation, aetiology and treatment? From a psychiatrist's perspective, it is gratifying that the most recent Australian and New Zealand "psychiatric" films (Cosi, Angel Baby, Lilian's Story and Shine) have dealt with psychoses, which need better public understanding. However, better understanding is also needed for a range of stereotypically less bizarre disorders, such as depression and anxiety disorders, that are seemingly harder for film-makers to dramatise. Nevertheless, psychopathology has been displayed creatively and vividly in the recent films, including: auditory hallucinations (a tormented Harry clutching his head in Angel Baby); pressure of speech and flight of ideas (David Helgott, at a frantic pace in Shine : "I remember Margaret. She called me a pig. All very complicated; complicato in Israel, a battleground. A war zone, a war; what a bore it's a war . . . war"); delusions of reference (Kate, in Angel Baby, watching Wheel of Fortune on television, suggests that "Astral [on the television] sends me messages no-one else can understand"); poor social skills (Kate again, on first meeting Harry's family, flicks a whole chicken leg onto her dress and later suggests to Harry's sister-in-law, whom she has just met: "[Harry's the] best lay I've ever had . . . [he's got] a side manoeuvre from hell"); and lack of insight (Kate again: "I don't hang around with psychos -- I'm not psycho"; on the other hand, it could be seen as very sensible not to associate with stigmatised people if you wish to avoid being stigmatised yourself). The cinema imputes both genetic and environmental factors in the development of mental illness, consistent with current belief, but tends to emphasise environment. In Angel Baby, when Kate becomes pregnant she is advised by her doctor that "there's a chance that the child will inherit your illness". In contrast, Shine suggests that David's harsh upbringing contributed to his psychiatric illness, an oversimplification of the underlying themes and contribution of David's father. Nevertheless, while parenting practices are no longer thought to be instrumental in the later expression of psychoses, there is validity in the notion that stress can precipitate relapses and takes a toll on all family members. A range of treatments, both physical and psychological, have been portrayed. Lust and Revenge (1996) draws parallels between psychotherapists, religious gurus and market forces in the arts and, in the process, satirises all three. There is ambivalence about physical treatments. In Cosi, a patient about to perform in the opera reassures its director: "I'll be on top of it . . . I purposely didn't take my medication." In contrast, Kate, in Angel Baby, begs: "I want my Stelazine." However, psychotropic medication is also depicted as society's means of controlling undesirable behaviour and individuals, as attested by the comments of head nurse Errol Greer in Cosi : "The patients are on varying degrees of medication . . . don't let that worry you -- just worry about the ones who aren't." Electroconvulsive therapy (ECT) is represented neutrally in Shine but negatively in Cosi, where smoke billows from the ECT machine, and the patients are threatened: "Start making our sets [for the opera] or else it's back to shock treatment." Involuntary admission or sedation is also depicted. In Lilian's Story, the heroine is incarcerated for 20 years on the word of her sexually abusive father, and in Cosi the wrong person ("normal" Lewis) is injected with a tranquilliser without adequate assessment or consent. The community psychiatry movement has been discussed only briefly but disparagingly. Errol, in Cosi, states: "Half-way houses, community care . . . come on, the Government cuts the cost and chucks them [the patients] on the street." This negative misrepresentation of contemporary, integrated 24-hour community and hospital care can be partly explained by Nowra having drawn on his early work experiences in a psychiatric hospital in 1971. While this is made explicit in the introduction to the play, the film fudges the historical time frame so that the audience can easily assume this is current practice. Films and psychiatric stigma Recently, the National Mental Health Policy9 and the Burdekin Report10 have highlighted the need for attention to psychiatric stigma, and community surveys have revealed many public misconceptions about people with mental illness.11 Does the cinema influence psychiatric stigma, or is stigma so deeply ingrained in society that films cannot make a difference either way? Do film makers have a responsibility to teach or to change attitudes, or should we resign ourselves to the fact that films are essentially entertainment? Possible consequences of cinema depictions of mental illness and psychiatry (positive and negative) are shown in Box 2. Disturbing findings from the Glasgow Media Group12 show that public attitudes to mental illness are influenced more by media accounts of mental illness, which instil fear, rather than by direct contact with people with mental illness. Mindful that films and other media often depict people with mental illness as unpredictably violent, the Royal College of Psychiatrists organised a petition (signed by 3000 members) asking the media to alter their practices in the portrayal of mental illness and to develop guidelines.12 However, the response from producers and media managers was a deafening silence. So, is there any good news in film psychiatry? The relatively large number and appeal of recent "psychiatric" films from Australia and New Zealand is encouraging, as are the new messages of hope, resilience, rebellion, self-determination and triumph. In the most recent films, not only are people with mental illness portrayed as real characters capable of expressing the gamut of human emotions, but also a positive stereotype appears to have emerged -- the patient as hero or role model. The recognition of Janet Frame as a great writer in An Angel at my Table and David Helfgott's relationship with Gillian and celebrated return to the concert stage in Shine are a far cry from Kate in Angel Baby, who, sedated, make-up running and generally looking worse for wear, attracts the comment from her nurse: "She looks cute, doesn't she?". Moreover, An Angel at my Table and Shine show that mentally ill people can be examples for the community at large in how to persevere and transform adversity. Film makers and actors may assume that with the gradual improvements in psychiatric settings and treatments, which are becoming more sensitive to the individual, less intrusive and less disruptive to life, psychiatry will not offer sufficiently dramatic screen images. However, as Simon Champ, chair of the Australian Mental Health Consumer Network, pointed out (at a School on Psychiatry and the Cinema at the University of Sydney, New South Wales, in April 1997): "There is plenty enough drama available if you care to accurately tune into the subjective experience of an individual or family who has survived mental illness." Doctors, psychiatrists and other mental health professionals can help promote positive depictions of mental illness and psychiatry (see Box 3). Further, if there is some truth in the negative depictions of psychiatry in film, we can only hope that mental health professionals, rather than muttering darkly and dismissing the images, will reflect thoughtfully and use this as a stimulus to change their practice. Conclusions Ignored for so long, psychiatry and mental illness are now the subject of many films produced in Australia and New Zealand. These films should not be rejected simply as "quirky" or "harmless fun", but should be critically appraised to ascertain attitudes to patients, their families, their doctors and mental health professionals. Speaking in a Hippocratic vein, if a "psychiatric" film does no undeserved harm to these stakeholders and also entertains and has artistic merit, this is for the good. If the film is also accurate and informative, challenges prevailing attitudes and transforms your life, so much the better. Acknowledgements We thank Ronin Films, Roadshow Entertainment and REP Distribution for providing images from their films. We are also grateful to Karen Barfoot, Anne Deveson, Simon Champ and Julie Rigg. References Schneider I. Images of the mind: psychiatry in the commercial film. Am J Psychiatry 1977; 134: 613-620. Shortland M. Screen memories: towards a history of psychiatry and psychoanalysis in the movies. Br J Hist Sci 1987; 20: 421-452. Schneider I. The theory and practice of movie psychiatry. Am J Psychiatry 1987; 144: 996-1002. Hyler SE, Gabbard GO, Schneider I. Homicidal maniacs and narcissistic parasites: stigmatisation of mentally ill persons in the movies. Hosp Community Psychiatry 1991; 42: 1044-1048. Dermody S, Jacka E (editors). The imaginary industry: Australian film in the late 1980s. Sydney: Australian Film, Television and Radio School, 1988: 132-154. Hall S. Method in the madness. The Bulletin 1996 May 28: 80-81. Urban A. Angel baby. Cinema Papers 1995; 104: 12. Nowra L. Cosi. Sydney: Currency Press, 1992. Australian Health Ministers. National Mental Health Policy. Canberra: AGPS, 1992. Human Rights and Equal Opportunity Commission. Human rights and mental illness: report of the national inquiry into the human rights of people with mental illness. Canberra: AGPS, 1993. Commonwealth Department of Health and Family Services. Community attitudes to mental illness: qualitative research report. Canberra: AGPS, 1993. Philo G. Changing media representations of mental health. Psychiatr Bull 1997; 21: 171-172. Walter G, Rosen A. Psychiatric stigma and the role of the psychiatrist. Australas Psychiatry 1997; 5: 72-74. (Received 12 Sep, accepted 28 Oct, 1997) Authors' details Royal North Shore Hospital and Community Mental Health Services, Sydney, NSW. Alan Rosen, FRANZCP, MRCPsych, Director; Associate Professor, University of Wollongong; and Senior Clinical Lecturer, University of Sydney. Central Sydney Area Health Service, Sydney, NSW. Garry Walter, FRANZCP, Staff Specialist Psychiatrist and Inpatient Director, Rivendell Unit; and Clinical Lecturer, Department of Psychological Medicine, University of Sydney. WEA Film Study Group, Sydney, NSW. Tom Politis, President. University of Sydney, Sydney, NSW. Michael Shortland, PhD, Associate Professor of History of Science. Reprints: Dr G Walter, Psychiatric Stigma Study Group, Rivendell Unit, Hospital Road, Concord West, NSW 2138. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Alan Rosen · Garry Walter

A tremendous amount of research has been done in the past decade into the pathogenesis and management of skin diseases. From this has come greater understanding of skin function and disease mechanisms, with the development of new drugs, new technology and new methods of treatment. Dermatologists have even started to subspecialise, into areas such as dermatopathology and dermatological surgery. Australians are no slouches when it comes to innovation and investigation, as evidenced by their contributions at the huge 19th World Congress of Dermatology in Sydney in June 1997. As editor of MJA Practice Essentials -- Dermatology, Robin Marks (one of only two professors of dermatology in Australia) has obtained contributions from those with international reputations as leaders in their fields. All contributors are excellent communicators who are very practical in their outlook. The book was first published as a series of articles in The Medical Journal of Australia. It was written with general practitioners in mind: after all (according to Professor Marks' introduction), nearly 13% of Australians suffer a skin (or subcutaneous tissue) disease, and over 17% of patient encounters with general practitioners are related to skin disorders. The general practitioner is the first, and sometimes only, port of call for most patients. Each chapter is set out in a very clear, structured way, with logical subheadings, helpful summaries, illustrated case histories and excellent colour photographs throughout. The update on the uses and capabilities of laser therapy is particularly interesting. This topic fascinates the media, and unfortunately it is very easy to create an environment of unrealistic expectations. Yet quite outstanding results are being achieved with some of the newer lasers.

Alan J Cooper

A five-year-old boy drew this "monster". After his father and grandmother (and the family dog) died within a 12-month period, the child made many drawings of monsters, which his mother thought was not "normal". His mother, herself depressed, brought him to an art therapist when he began "hitting himself on the head". During art therapy sessions, the monster drawings were accepted and freely talked about. The self-injurious behaviour stopped after the boy's third individual session.

Peter L Beagley

With December comes the now-traditional MJA Christmas competition. This year, our call for "Strange cases, freakish accidents, implausible imagery and irreproducible results" brought a flood of entries that included poetry, case reports, humorous images, historical observations and unlikely research papers. Our editorial staff rose to the task of judging these with their usual demands for bribes and Christmas bonuses, but as none were forthcoming they were forced to be impartial. With difficulty, the field was narrowed to 17 finalists, whose entries will appear in this and future issues of the Journal. Thanks to all our contributors. The winner -- for the second year running -- is Dr Douglas Gow for The crossing. He claims that his entry for this year's MJA Pulitzer Prize is essentially true, although he admits that his wife says it has been embellished by the retelling over many years and several glasses of Jameson's! He also assures us that she turned out better than the story might lead you to expect (but asks you not to quote him on that). Congratulations, Dr Gow. Your prize of two bottles of Jameson's Irish Whiskey (or would you prefer scotch?) is on its way to inspire your next literary effort. Second place was a dead heat between other regular competition contributors. Dr Craig Hore wins two bottles of a fine drop for Effect of postgraduate exams on putting performance, a subject sure to require further extensive research -- perhaps comparing Port Douglas with St Andrew's. Two bottles of wine also go to Dr Nicholas Buckley and Dr Janelle McDonald for "Hale-Bopp" and "Knocking on Heaven's Gate" -- hits of the Net, 1997: the Christmas issue would not be complete without their latest thoughtful insights into celestial and calendrical influences on self-poisoning. Dr Tim Green wins third prize of a bottle of wine for Out of the blue and into the pink, a new application for the trusty blue Y-fronts.

Faith healing or Russian roulette? MJA 1997; 167: 649 To the Editor: In 1995, a Brisbane woman visited a renowned faith healer in Manila for treatment of chronic tinnitus. The treatment involved the removal of what appeared to be a clot of blood from below her left ear and also one from her abdomen. The operation was performed seemingly by way of incisions at those sites without instruments or anaesthetic and using bare hands. During both procedures, blood was released which spilled onto her skin and stained her clothing. The woman's husband and brother-in-law, who witnessed and photographed the proceedings in close proximity, were convinced that what they had seen was genuine. However, following treatment her condition remained unchanged. To explore the facts more closely, the woman brought her bloodstained clothing to the Forensic Biology Laboratory in Brisbane. Examination of the clothing confirmed the presence of splashes and stains of human blood, but most appeared diluted. These findings were corroborated by photographs which showed the blood to be far less viscous than usual (Figure). Blood samples taken from her clothing were examined using three independent genetic tests: HLA DQA1, D1S80, and HUMTH01. These tests are commonly used in forensic practice to identify the origins of biological materials and stains such as blood, hair, saliva and semen; they distinguish individuals based on their genetic make-up. The results unequivocally showed that the blood on her clothing was not her own but a mixture of blood from at least two other individuals. As a precaution, she was tested for HIV and hepatitis B antibodies, both of which were negative after three months. Hundreds of people are treated by this faith healer every day. He is revered in the Philippines and people travel from all over the world to attend his "clinic". He also claims to travel frequently to other countries to perform his services. His healing power appears to be based on illusion. No doubt, the wellbeing of patients can be influenced by their confidence in their physician ("the placebo effect"). Judging by this man's reputation, it would seem that many have felt that they benefited from his treatment. However, it is a serious health concern that he uses blood to "convince" people that his practice is authentic, considering the number of people that he treats and the diversity of their backgrounds. The possible transmission of diseases such as hepatitis B and HIV to Australian citizens during these procedures would be of interest to Australian health authorities. Paul E Roffey Formerly, Forensic Scientist, Queensland Health Department; now Lecturer, School of Biomedical Sciences, Charles Sturt University, PO Box 588, Wagga Wagga, NSW 2678 E-mail: proffey AT csu.edu.au Leo C Freney Supervising Scientist Anthony J Ansford Director, John Tonge Centre for Forensic Sciences, Queensland Health Scientific Services, Brisbane, QLD - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Paul E Roffey · Leo C Freney · Anthony J Ansford

"Irukandji" syndrome: a risk for divers in tropical waters MJA 1997; 167: 649 To the Editor: Envenomation by the cubozoan jellyfish Carukia barnesi causes "Irukandji" syndrome (named by Dr Hugo Flecker after an Aboriginal tribe near Cairns).1 I report a case of Irukandji syndrome in a scuba diver for whom appropriate therapy was delayed because it was not initially considered as a possible cause of the patient's symptoms. A 28-year-old experienced diver was diving off Brampton Island in Queensland. During his second dive, at a depth of 6 m, he had a feeling of disequilibrium and so made a controlled ascent and removed his gear. His vague malaise was accompanied by aching pain in the groin and thighs, with numbness in the fingers and toes. This rapidly progressed to severe pain in the skin, muscles, face, jaw, testes and lumbar region, with profuse sweating and agitation. By the time he presented to the emergency department (after a delay of six hours because of transport difficulties), he was in great pain, with tachycardia (90 beats/min) and hypertension (170/100 mmHg). He was treated with 100% oxygen and pethidine (intramuscular and intravenous). At this stage, there were no diagnostic clues, except that symptoms had developed rapidly within minutes of his ascent. Decompression sickness was therefore considered, but after two conversations with the consultant at the Townsville General Hospital Hyperbaric Unit, an interview with the dive buddy, and in view of the patient's diving experience and the dive history, this diagnosis was dismissed. Irukandji syndrome was suggested and, when prompted, the patient recalled seeing a small jellyfish while descending and feeling a slight irritation on his right arm. A 3 cm x 4 cm oval inflamed area was evident on his right antecubital fossa and the patient provided a sketch of the jellyfish (Figure). He was commenced on an intravenous morphine infusion over 10 hours. Although a dull chest pain and lower-limb pain persisted, he did not require further analgesia. His serum creatine phosphokinase level peaked at 7317 IU/L (normal range, 10-60 IU/L) and his serum lactate dehydrogenase level reached 349 IU/L (normal range, 120-300 IU/L). Echocardiography after two days showed mild mitral valve regurgitation. Fortunately, the patient escaped the more sinister complications of Carukia envenomation (myocardial failure and pulmonary oedema).2-4 This is the first reported case where a patient with Irukandji syndrome identified the jellyfish. It has been reported that the syndrome may be mistaken for decompression sickness,5,6 thus evading rapid diagnosis and triggering costly evacuation and recompression procedures (J Williamson, Director of Hyperbaric Medicine, Royal Adelaide Hospital, personal communication). This case is a reminder that Irukandji syndrome can be a "diving-related illness", and should always be considered in the differential diagnoses of an ill diver in tropical waters. John C Hadok Senior Medical Officer, Emergency Department, Mackay Base Hospital PO Box 5580, Mackay, QLD 4740 E-mail: jchadokAThealth.qld.gov.au Fenner PJ, Williamson J, Callanan VI, Anderley I. Further understanding of, and a new treatment for, "Irukandji" (Carukia barnesi) stings. Med J Aust 1986; 145: 569-574. Fenner PJ, Williamson JA, Burnett JW, et al. The "Irukandji syndrome" and acute pulmonary oedema. Med J Aust 1988; 149: 150-156. Martin JC, Audley I. Cardiac failure following Irukandji envenomation. Med J Aust 1990; 153: 164-166. Herceg I. Pulmonary oedema following an Irukandji sting. SPUMS J (South Pacific Underwater Medicine Society Journal) 1987; 17: 95-97. Williamson J. Scuba diving perspective. In: Williamson JA, Fenner PJ, Burnett JW, Rifkin JF, editors. Venomous and poisonous marine animals. Sydney: University of New South Wales Press, 1996: 423-427. Williamson J. "Irukandji" syndrome or decompression sickness or cerebral arterial gas embolism? A differential diagnostic trap for practitioners of diving medicine in north Queensland. SPUMS J 1985; 15: 38-39. My thanks to Drs Bruce Todd, Bert Sadleir and Associate Professor John Williamson. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

John C Hadok

Papilloedema and coma in a child: undescribed symptoms of the "Irukandji" syndrome MJA 1997; 167: 650 To the Editor: The "Irukandji" syndrome, so named in 1952,1 refers to the severe systemic symptoms that follow envenomation by the jellyfish Carukia barnesi,2,3 named by Dr Jack Barnes in 1964.4 Here, we report papilloedema and coma in a seven-year-old child who developed Irukandji syndrome after a jellyfish sting in the tropical waters of Cairns, in far north Queensland. The child was treated by one of us (R J H) in 1981, but not reported at the time and only recently described to colleagues. The boy was admitted to hospital with the severe systemic symptoms of Irukandji syndrome, including generalised muscle cramps, anxiety and sweating. Ten hours later, he was confused, disoriented, tachycardic and tachypnoeic, and had several episodes of profound sweating, cyanosis and agitation. Bilateral crepitations (more marked on the left) were heard on chest auscultation, and a chest x-ray showed increased interstitial markings consistent with pulmonary oedema. He had 4+ glycosuria, Dextrostix of 130 mg/100 mL (normal range, 80-120 mg/100 mL), and periodic auditory and visual hallucinations. The boy was pale and in obvious respiratory distress, requiring oxygen 6 L/min via facemask to maintain his central colour. Examination of his fundi showed blurring of the disc margins. Initial management consisted of an intravenous dexamethasone infusion and intermittent intravenous frusemide (exact doses not known). His symptoms persisted through the first 24 hours of admission, and by the second evening he was more disoriented and unresponsive to commands. He was given 100 mL of 20% mannitol intravenously and within two hours had a huge diuresis with a wet bed. Three hours later, he was answering questions with a grunt, and shortly after was obeying commands and was easily rousable. Ten hours later, he was talking freely and answering questions, and subsequently made a complete recovery with no neurological sequelae. To our knowledge, this is the first reported case of papilloedema and unconsciousness associated with the Irukandji syndrome. We believe this indicates cerebral oedema, but no cerebral scan was done to confirm this. Recently, a case of cerebral oedema was reported after a chirodropid (multitentacled box jellyfish) sting.5 We suggest that the patient's level of consciousness be carefully monitored in all serious jellyfish envenomations, and that any deterioration of consciousness be appropriately investigated. Peter J Fenner Honorary Medical Officer, Surf Life Saving Association, PO Box 3080, Mackay, QLD 4740 RJ Heazlewood Visiting Medical Officer, Cairns Base Hospital, QLD Flecker H. "Irukandji" sting to north Queensland bathers without production of wheals but with severe general symptoms. Med J Aust 1952; 1: 89-91. Fenner PJ, Williamson JAM, Callanan V, Audley I. Further understanding of, and a new treatment for, "Irukandji" (Carukia barnesi) stings. Med J Aust 1986; 145: 569-574. Fenner PJ, Williamson JA. World wide deaths and severe envenomation from jellyfish stings. Med J Aust 1996; 165: 658-661. Barnes JH. Cause and effect in Irukandji stingings. Med J Aust 1964; 1: 897-904. Fenner PJ, Williamson JA, Burnett JW, et al. The "Irukandji syndrome" and acute pulmonary oedema. Med J Aust 1988; 149: 150-156. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Peter J Fenner · RJ Heazlewood

European wasps: an emerging hazard in Australia MJA 1997; 167: 650 To the Editor: The Victorian Department of Natural Resources and Environment has predicted a surge in European wasp (Vespula germanica) numbers this summer (6 August 1997, press release).1 This is expected to result in an increase in serious and potentially life-threatening injuries from wasp stings.2 Since arriving in mainland Australia in 1977, the European wasp has spread dramatically,3 and is now found in all States and Norfolk Island. It has so far resisted biological and chemical control measures, and the wasp population is expected to explode.3 The toxicity of wasp venom, their multiple stinging capacity, aggressiveness and tendency to build hidden subterranean nests2,3 mean that increased morbidity from wasp stings is likely. According to the Victorian Minimum Inpatient Dataset, hospitalisations as a result of wasp stings have increased in Victoria in recent years (1992-1996),4 and wasp stings were among the top 10 poisons exposure inquiries in Victoria for 1996.4 Fatalities have been reported in other countries.5 The current paradigm is that most serious reactions to wasp stings are allergic in nature, so that only a small percentage of the population is at risk. However, as in the case of a Melbourne child who disturbed a wasp nest,2 the large number of stings sustained from an attack by a swarm of wasps (often 30 to 200 stings) can result in a massive life-threatening envenomation. Therefore, not only those with wasp allergy are at risk. Unfortunately, this issue has not been studied, despite the important implications for patient management. Allergic effects, which may be managed by immunotherapy and early administration of adrenaline, need to be distinguished from the toxic effects of envenomation, which require alternative management. We support the initiative of the Victorian Conservation Minister to develop a national European wasp strategy and recommend that it include a national surveillance system, through the Australian Venom Research Unit (AVRU), to monitor the health impact of the growing wasp population. We also encourage doctors to report serious wasp-related injuries to the AVRU: telephone (03) 9344 7753 or facsimile (03) 9348 2048. Interdisciplinary collaborative research involving entomological, toxicological, public health and emergency medicine professionals is needed to address this increasing threat to our health and enjoyment of the great outdoors. Nadine R Levick Faculty, Division Pediatric Emergency Medicine, Johns Hopkins Medical Institutions 600 North Wolfe Street, CMSC 144, Baltimore, MD, USA 21287-3144 E-mail: nlevickATwelchlink.welch.jhu.edu Ken D Winkel Deputy Director, Australian Venom Research Unit, Department of Pharmacology University of Melbourne, VIC Gordon Smith Associate Professor, Center for Injury Research and Policy, School of Hygiene and Public Health Johns Hopkins University, Baltimore, MD, USA Alexander C. Wasp plague on the way. Herald Sun 1997 Aug 8. Levick N, Braitburg G. Massive European wasp envenomation of a child. Emerg Med 1996; 8: 239-245. Spradbery JP, Maywald GF. The distribution of the European or German wasp in Australia, past, present and future. Aust J Zool 1992; 40: 495-510. Royal Children's Hospital, Pharmacy Department. Keeping tabs. Newsletter. Melbourne: Royal Children's Hospital, 1997; 3: 1. Man dies after attack by wasps. The Washington Post 1997 Aug 29: D06. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Nadine R Levick · Ken D Winkel · Gordon Smith

Choking after inhaling a foreign body through a Ventolin puffer MJA 1997; 167: 651 To the Editor: A 10-year-old boy awoke with asthma. His mother, also an asthmatic, took her salbutamol inhaler from her purse and gave the boy a puff. The boy immediately became extremely distressed and was unable to speak. He mouthed to his mother, "I cannot breathe". His mother performed the Heimlich manoeuvre, during which a white object was expelled from the boy's mouth, immediately relieving his distress. The object was a cigarette filter. His mother is a cigarette smoker and rolls her own cigarettes. Loose cigarette filters and uncapped asthma inhalers were found in the clutter at the bottom of her purse (Figure). As she had previously propelled a filter into her own airway from an inhaler, with less severe consequences, she recognised the likely cause of her son's sudden inability to breathe. This frightening and potentially lethal episode illustrates the importance of keeping caps on asthma aerosol inhalers when not in use, so preventing objects from lodging in the aerosol mouthpieces. Michael J Mackay Senior Medical Officer, Emergency Department, Mackay Base Hospital Bridge Road, Mackay, QLD 4741 - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Michael J Mackay

Out of the blue and into the pink A new litmus test for chlorine gas exposure MJA 1997; 167: 651 To the Editor: A 40-year-old man arrived at the emergency department by ambulance in respiratory distress. In his duties as a hotel maintenance worker, he had been mixing swimming pool chemicals in a dark, confined space. Inadvertently, he had mixed liquid pool "chlorine" (sodium hypochlorite) with a hydrochloric acid solution, forming an irritating yellow-green gas. Despite a brief exposure, he rapidly developed eye irritation, burning in his oropharynx, cough and chest pain. He noticed that the keys in his pocket had turned a dull colour. On arrival, about 20 minutes after the exposure, he had an irritating cough, but his vital signs were normal, oxygen saturation was 99%, and his chest was clear to auscultation. His clothing smelt of chlorine and was removed to prevent skin irritation. On removing his white overalls, it was noticed that his blue underpants had changed colour to a pink-mauve hue. Although he suffered acute embarrassment, he developed no acute clinical or radiographic signs and was discharged well after several hours' observation. Chlorine gas exposure is not an uncommon hazard of mixing household cleaners or pool chemicals. The addition of an acid to a chloride-containing base releases chlorine gas in an exothermic reaction. Chlorine gas is highly water soluble and on moist surfaces is transformed into hydrochloric acid and an oxygen radical. This mechanism explains the clinical manifestations, with the hydrochloric acid causing immediate irritation to mucosal surfaces, leading to lacrimation, burning sensations and cough. These symptoms usually serve as a warning to the victim to move away from the gas to prevent the more serious sequelae of laryngeal oedema, bronchospasm and adult respiratory distress syndrome. Presumably in this case, the elaboration of acid in the sweaty confines of his true-blue Y-fronts mimicked the classic pH indicator reaction of litmus paper. Perhaps he should have worn his underpants on the outside! Tim C Green Staff Specialist, Emergency Department, Royal Prince Alfred Hospital Missenden Road, Camperdown, NSW 2050. E-mail: timgreenATmpx.com.au Reference: Hoffman RS. Toxic inhalations. In: Rosen P, Barkin R, et al., editors. Emergency medicine -- concepts and clinical practice. 3rd ed. 1992: 2673-2682. - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Tim C Green

A sad stool MJA 1997; 167: 654 To the Editor: With greater attention being given to improving communication between healthcare professionals and the public, the following incident is a simple yet worthy reminder that effective communication depends not only on the information that is transmitted but, more importantly, on the information that is received. A young woman came into my pharmacy with a prescription for Ferro-Gradumet (ferrous sulfate, Abbott), and it was obvious that she was reluctant to have it dispensed. During our conversation, she remarked that she was very concerned about becoming depressed because the doctor had told her that while taking this medicine her emotions would be black. This certainly wasn't the message that the doctor intended to transmit (viz. her motions would be black), and it could have led her to abandon the treatment. How can we ensure that the correct message is received? Failures in communication like this can be avoided if plain, straightforward words are used instead of outdated euphemisms. In this instance, the more direct word "faeces" is less likely to be misinterpreted and, if not understood, is more likely to prompt the question, "What do you mean by that?". Richard M Worrell Pharmacist, PO Box 274, Rose Bay, NSW 2029 - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Richard M Worrell

"Hale-Bopp" and "Knocking on Heaven's Gate" Hits of the Net, 1997 MJA 1997; 167: 654 "If anyone comes to Me and does not hate his father and mother and his wife and children and brothers and sisters -- and even his own life also -- he cannot be My disciple". Luke 14:261 To the Editor: This Christmas, as we renew old family quarrels, we should remember we are celebrating the birth of Christ, who, according to the Heaven's Gate cult, was the first visitor from TELAH -- The Evolutionary Level Above Human.1 On 22 March 1997, when the Hale-Bopp comet was nearest to Earth, 39 members of this cult left earth to link up with the comet's "companion spaceship" bound for TELAH,2 wearing black Nike sneakers. Their transport to TELAH began with deliberate self-poisoning. Although we previously found no relationship between self-poisoning and celestial or occult events,3 this event combined both and suggested that we might have overlooked a synergistic mechanism. We also examined the possibility that traffic was going in the opposite direction that day, with ancient astronauts escaping their spaceship to appear on earth as newborn babies. We used two databases to test our hypothesis: a register of births in the Canberra Hospital (which we felt would closely resemble the sterile environment of a spaceship) and the Hunter Area Toxicology Service database of presentations to hospital with self-poisoning in the Lower Hunter Valley of New South Wales. To examine for evidence of massive successful and attempted soul migrations, we compared the number of births and self-poisonings between 21 and 23 March with those for the rest of the month. There did not appear to be any significant surge in self-poisonings or births at this time. On those three days, there were eight self-poisonings, compared with 51 on all the other days in March (P = 0.24, Mann-Whitney test), and 13 births compared with 141 (P = 0.61). However, we did note a surprisingly strong correlation between self-poisonings and the Nike share price4 (P = 0.005, Spearman) (Figure). In the three months after the Heaven's Gate tragedy, the share price of Nike fell by 20%, despite a 15% increase in the market index and a 28% increase in sales.4 This could either be a suicide prevention strategy or evidence that people are reducing their Nike stocks to invest in futures. When surfing the Internet, it is quickly apparent that data-dredging is not confined to medicine and there is no statistical refereeing. Significance can be found everywhere on the Net: a place to publish and perish. Nicholas A Buckley Visiting Fellow,National Centre for Epidemiology and Population Health The Australian National University, Canberra, ACT 0200 E-mail: mdnabATcc.newcastle.edu.au Janelle A McDonald Obstetric Registrar, National Centre for Epidemiology and Population Health The Australian National University, Canberra, ACT 0200 Do, Ti, et al. How and when Heaven's Gate may be entered (The door to the Physical Kingdom Level Above Human). Phoenix (Ariz): TELAH Services, 1997. On the Internet: http://www5.zdnet.com/yil/higher/heavensgate/ http://www.neosoft.com/~cshramek/comet.htm Buckley NA, Whyte IM, Dawson AH. There are days . . . and moons. Self-poisoning is not lunacy. Med J Aust 1993; 159 (11/12): 786-789. http://quote.yahoo.com/ - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Nicholas A Buckley · Janelle A McDonald

Effect of postgraduate exams on putting performance MJA 1997; 167: 655 Objective: To test the hypothesis that examination stress adversely affects golf putting performance. Participant: An advanced trainee of a learned specialist college, with moderate golfing skills and about to undertake final fellowship examinations. Methods: A week before the exams, the subject was asked to perform 50 consecutive 60 cm putts on the practice putting green, under standard conditions. The hole was cut on a flat portion of the green, with negligible borrow or irregularities. The number of successful putts was recorded. Two weeks after successfully completing the exams, the subject was asked to repeat the test. The hole and the weather conditions were similar. Results: Test one. Successful putts: 40 (including three mulligans); unsuccessful putts: 10. Test two. Successful putts: 46 (including one mulligan); unsuccessful putts: 4. Mulligans were putts that, while not successfully "holed", were deemed by the subject to have been so close that they were considered "holed". Reasons included: "The wind changed direction at the last minute" and "The hole moved after I had putted". Statistical analysis: Two new techniques relevant to golfing data were used. The Norman Index of the sum of rank performances (n value) was multiplied by the Tiger Woods covariant of superior performances (t value). The resulting score was divided by the square root of the subject's handicap, giving a dubious value (d) which was statistically feasible (d < 0.05). Like all golfing data, these values need to be treated with suspicion. Discussion: The adverse affects of examination stress on putting performance could be a result of physical impairment (tremors and sleep deprivation) and psychological impairment (distraction and fear of failure). As putting is a vital component of a golfer's repertoire, it is reasonable to extrapolate that examination stress would be detrimental to overall golfing performance. It may be that poor golfing performances adversely impact upon examination performances. This requires further testing, preferably over a long period of time (several months would be fine), at a suitable golf course (perhaps Port Douglas in far north Queensland) and with appropriate funding (to cover travel expenses!). Conclusion: Examination stress adversely affects putting performance. Postgraduate examinations should be scheduled to avoid significant golfing fixtures, such as club championships. (Disclosure: Any resemblance between the author and subject is purely coincidental.) Craig T Hore Clinical Fellow, CareFlight, NSW Medical Retrieval Services PO Box 159, Westmead, NSW 2145 - ©MJA 1997 Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Craig T Hore